Psychotic Disorders Flashcards
What are the Primary psychotic disorders?
Primary psychotic disorders are common and include:
Schizophrenia. Schizoaffective disorder. Brief psychotic disorder. Schizophreniform disorder.
how does psychosis present?
abnormal psychomotor behavior, delusions, disorganized speech, hallucinations, and negative symptoms
what is the cause of schizophrenia?
It is believed that the underlying cause of these abnormalities is an imbalance between neurotransmitters. Many neurotransmitters play a role, including dopamine, serotonin, and glutamate
there is modest support for the hyperdopaminergic theory, which proposes that hyperactivity of dopaminergic neurons in the mesolimbic tract is the key imbalance
Medications blocking dopamine decrease psychotic symptoms,
what are the differentials for schizophrenia?
Schizoaffective disorder
Combination of psychosis (i.e., delusions, hallucinations) and affective symptoms that are closely related in time but present, almost independent of each other, as clusters of symptoms. The affective symptoms are present for a significant amount of the total duration of illness.
Substance-induced psychotic disorder
Delusions are not crystallized as in schizophrenia, but auditory hallucinations may still be present. The drugs most often associated with psychosis are heavy and persistent use of marijuana; stimulant drugs such as methamphetamine, cocaine, and amphetamines; psychotomimetics such as LSD and ketamine-like drugs; and inhalants such as toluene, gasoline, and various types of glues.
Dementia with psychosis
Delusions may be similar, but are without a history of psychosis prior to dementia onset. An older age, family history of dementia, and gradual cognitive decline suggests dementia.
what is the DSM criteria for schizophrenia?
Schizophrenia can be diagnosed if the following conditions are met:
Two or more of the following symptoms are present: delusions, hallucinations, disorganized speech, disorganized/catatonic behavior, or negative symptoms. At least one of the symptoms must be a positive symptom.
Symptoms occur for a period of at least 1 month (less, if treated) and are associated with at least a 6-month period of functional decline.
Symptoms do not occur concomitantly with substance use or with a mood disorder episode.
____________
Negative symptoms
affective flattening, avolition, anhedonia, attention deficit, or impoverishment of speech and language
how do you manage schizophrenia?
CBT - if at risk of developing psychosis
If a person is considered to be at increased risk of developing psychosis, it is recommended to offer cognitive behavioral therapy and to not start any antipsychotic medication.
Emotional, psychosocial, and other stressors should be addressed. Anxiety, depression, substance misuse, and personality disorders should be screened for and treated.
for the acute psychotic episode
Risperidone - 1mg twice daily initially - max 16mg/day
or olanzapine
5-10mg once daily - max 20mg/day
or tertiary options - haloperidol
0.5-2mg 3x a day
what are the indications for hopsitalization of a schizophrenic patient?
Indicators of the need for hospitalization include violence, decreased control of behavior, poor judgment, and suicidality.
Having the patient in a safe and predictable environment is important.
what is the DSM criteria for Schizoaffective disorder
An uninterrupted period of illness, during which there is a major mood episode (major depressive or manic) concurrent with a schizophrenia episode characterized by two or more of the following symptoms present for a considerable part of a 1-month period (at least one of these must be delusions, hallucinations, or disorganized speech):
Delusions
Hallucinations
Disorganized speech (e.g., frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
Negative symptoms (i.e., diminished emotional expression or avolition).
During this time, there should be a period of at least 2 weeks with delusions and hallucinations, in the absence of a major mood episode (depressive or manic) during the lifetime duration of illness.
Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual period of illness.
Other possible etiologies such as substances (e.g., illicit drugs, medication) or general medical conditions have been ruled out.
Specify whether bipolar type (if manic episode is part of the presentation; major depressive episodes may also occur) or depressive type (if only major depressive episodes are part of the presentation).
Specify if: with catatonia.
Specify if: (the following course specifiers are only to be used after a 1-year duration of the disorder and if they are not in contradiction to the diagnostic course criteria)
what are the differentials for Schizoaffective disorder
Schizophrenia
Mood symptoms are either of shorter duration relative to the total duration of the episode of illness, limited to the prodromal phase or residual phases, or fail to satisfy the criteria for a mood episode
Substance-induced psychotic disorder
Delusions are not crystallized, and the patient may have auditory hallucinations and a high level of suspiciousness. Use of substances
Dementia with psychosis
Delusions may be similar to those in schizoaffective disorder, but usually there has been no history of psychosis before the onset of dementia.
How do you manage Schizoaffective disorder
For the acute psychotic episode
First line
Paliperidone 6mg
or Risperidone 1mg once a day (max 30mg)
Secondary line
Olanzapine 5-10mg once daily (max 20mg)
Third line
Haloperidol 0.5-5mg 3x/day (max 100mg/day)
If depressive symptoms
Fluoxetine 20mg once/day (max 80)
or
Paroxetine 20mg once/day (max 50mg)
If manic symptoms
lithium 300mg orally 3x/day (max 2400mg/day)
carbamazepine 200mg 2x/day (max 1600mg/day)
last resort: lamotrigine (dose depends)
what are the most common side effects you get with antipsychotics?
akathesia
postural hypotension
dystonia
tardive dyskinesia - Characterized by repetitive, involuntary, purposeless movements
NMS
parkinsonism
What is the DSM criteria for brief psychotic disorder
Psychotic symptom(s)
The presence of one or more of the following psychotic symptoms: delusions, hallucinations, disorganized speech, or grossly disorganized or catatonic behavior (with at least one of the following symptoms present: delusions, hallucinations or disorganized speech).
Duration of episode
For at least 1 day, but <1 month, before a full return to premorbid level of functioning.
No better accounted for by other conditions
The disturbance must not be better accounted for by either a general medical condition, the direct physiologic effects of a substance (drug use or medication), a mood disorder with psychotic features, schizoaffective disorder, or schizophrenia.
What are the differentials for brief psychotic disorder?
Schizophrenia
Period of psychosis lasts >1 month. Diagnosis based on patient history and family history and medical records.
Delusional disorder
Period of psychosis lasts >1 month. Diagnosis based on patient history and family history and medical records.
Major depressive disorder with psychotic features
Period of psychosis lasts >1 month. Diagnosis based on patient history and family history and medical records.
Syphilis
History of sexual contact with infected person.
Central nervous system involvement: may be associated with cranial nerve palsy, stroke, dementia, sensory loss, Argyll Robertson pupil.
What is the management of brief psychotic disorder?
2nd gen antipsychotic:
olanzepine 2.5 - 10mg (max 20mg/day) - cn give IM if no oral
or
Risperidone 0.5 - 3mg/day
Adjunct w Lorazepam 1-2mg 8 hourly when needed
Psychosocial treatments (psychotherapy and family support) should be offered to all patients presenting with BPD. Family support is crucial to help assure structure and safety to patients who may be experiencing psychotic symptoms for the first time. However, it is important to identify individual perceptions and needs for nonpharmacologic treatments, which may be influenced by cultural and religious origins.
When do you diagnose schizophreniform disorder
diagnosed when symptoms of schizophrenia are present for a significant portion of the time within a one-month period, but signs of disruption are not present for the full six months required for the diagnosis of schizophrenia.
