Psychotic disorders

Question 1

Differential diagnosis of psychosis

Answer 1

• Schizophrenia
• MDD with psychotic symptoms
• Delirium or Dementia
• Substance use
• Bipolar disorders
• Due to medical condition (CNS diseases, MS, B12 deficiency…)

Question 2

What is the prevalence of schizophrenia?

Answer 2

0.3 - 0.7%
- onset at 20-50s years old

Question 3

What are the comorbidities of schizophrenia?

Answer 3

Substance abuse (mc nicotine > 50%) followed by alcohol

Question 4

What are the positive symptoms and why do they occur?

Answer 4

• Due to high dopamine (meso-limbic)
• Hallucination
• Delusions
• Disorganized behavior
• Disorganized speech (Word salad)

Question 5

What are the negative symptoms and why do they occur? “5 A’s”

Answer 5

• Due to high serotonin and low dopamine (prefrontal cortex)
  5 A’s:
• flat Affect (no reaction)
• Alogia (answer with one word to Qs)
• Anhedonia
• Apathy
• Avoidance

Question 6

What are the cognitive symptoms?
“Memory, Learning, Understanding”

Answer 6

• Impaired attention
• Impaired working memory
• Impaired executive function
  “Poor in work and school performance”

Question 7

What are the 3 phases of schizophrenia?

Answer 7

1- Prodromal > depression-like
2- Psychotic
3- Residual > social withdrawal, negative symptoms, mild hallucinations or delusions)

Question 8

Diagnosis criteria for Schizophrenia:

Answer 8

• Symptoms > 6 months (including prodromal and residual)
• > 2 of these must be present for 1 month at least:
  1- Delusion
  2- Hallucination
  3- Disorganized speech
  4- Disorganized or catatonic behavior
  5- Negative symptoms
• at least 1 must be 1,2,3
• Significant occupational, functional deterioration
• Not due to substance use or other medical condition

Question 9

What does CT/MRI shows on schizophrenic patients?

Answer 9

Enlarged ventricles & diffuse cortical atrophy & reduced brain volume

Question 10

What is the first, second, third line of treatment in schizophrenia?

Answer 10

1st: Antipsychotics
2nd: CBT
3rd: ECT (electroconvulsive therapy)

Question 11

Typical (1st generation) antipsychotics work on which receptors?

Answer 11

Dopamine (D2) antagonist

Question 12

Atypical (2nd generation) antipsychotics work on which receptors?

Answer 12

Dopamine (D4 > D2) antagonist
Serotonin (5-HT2) antagonist

Question 13

Main ADRs of typical antipsychotics?

Answer 13

• Extrapyramidal symptoms:
  Spasms of face, neck, tongue.
  Parkinsonism (resting tremor, rigidity)
  Akathisia (inability to remain still)
  Tx: Anticholinergic, benzodiazepines
• Neuroleptic malignant syndrome
• Tardive dyskinasia

Question 14

Main ADRs of atypical antipsychotics?

Answer 14

• Metabolic syndrome (monitor Lipids, BP, BG)

Question 15

Clozapine (2nd generation antipsychotic) has risk of ……………………

Answer 15

Agranulocytosis

Question 16

What are the typical and atypical agents?

Answer 16

Typical: chlorpromazine, haloperidol
Atypical: Quetiapine, risperidone, clozapine, olanzapine (pines)

Question 17

What is neuroleptic malignant syndrome?

Answer 17

• Unstable mental status (e.g. delirium)
• Autonomic instability (tachypnea, tachycardia, fever, diaphoresis, fluctuating BP)
• Lead-pipe rigidity
• Lab: High CK, leukocytosis, metabolic acidosis

Question 18

What is the management of neuroleptic malignant syndrome?

Answer 18

Dantrolene + immediate stopping of antipsychotics

Question 19

What is the management of metabolic syndrome?

Answer 19

Switch to 1st generation OR use Aripiprazole (2nd generation weight-neutral medication)
+ encourage exercise & healthy diet & smoking cessation

Question 20

What is the difference between schizoaffective disorder & mood disorders with psychotic symptoms?

Answer 20

Schizoaffective: psychosis + mood disorder syndrome
- Delusions and hallucinations for two weeks occur before or after mood symptoms NOT AT THE SAME TIME AS MOOD DISORDER WITH PSYCHOTIC SYMPTOMS
- Treat mood disorder first (mood stabilizers + atypical antipsychotics)