Psychotic disorders Flashcards
Discuss associated conditions
Neurological
- Dementia (esp. Lewy Body Dementia)
- Cerebrovascular disease
- Epilepsy (esp. complex partial seizures), peri- and post-ictal psychosis ^[DO NOT treat with anti-psychotics typically]
- Huntington’s Disease
- Wilson’s Disease
Endocrine:
- hyper and hypo para/thyroidism
- Cushing’s disease
Autoimmune:
- cerebral lupus
Toxicological:
- lead and mercury poisoning
Nutritional:
- B6 def
Trauma:
- TBI
Substances of abuse which may be associated with psychotic features
- Amphetamines
- LSD
- Phencyclidine
- MDMA (Ecstasy)
- Cocaine
- Other
Can persist post-intoxication.
Medications
- corticosteroids
- dopamine agonists
- L-DOPA
- SSRI/SNRI
- tricyclic
- anti-epileptics
- statins
Core primary psychiatric conditions associated with psychosis
- Schizophrenia and related disorders
- Delusional disorder
- Brief psychotic disorder
- Mood disorders with psychotic features
Defien psychosis and categories
Psychosis = severe impairment of reality testing
If any one (or both) of the following is present the term “psychosis” can be used:
1. Delusion, and cannot be convinced to the contrary. Common is persecutory. Also reference? receiving special messages. Grandiose. Mood congruent. Thought alienation. Capra? - doppelganger replacement.
2. Hallucination (excluding non-pathological hallucinations e.g. hypnagogic, hypnopompic). False perception but compelling enough. Any sensory modality. Most common auditory.
Broad categories of “psychosis”
1. Primary psychiatric disorder eg schizophrenia
2. Medical disorder
3. Substance/alcohol/medication related
Describe schizophrenia
Schizophrenia: Core DSM-5 diagnostic criteria
(A) Characteristic symptoms: ≥ 2 present for 1 month (less if treated); at least one must 1,2, or 3.
1. Delusions
2. Hallucinations
3. Disorganized speech (formal thought disorder)
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
(B) Reduced functioning: e.g. occupational/social/self-care
(C) Duration: continuous signs of the disturbance for at least 6 months
Clinical features of schizophrenia
- positive e.g. hallu, delus, thought disorder
- negative e.g. decreased motivation, anhedonia, altered expression of emotion, decreased amount or content of speech
- cognitive deficits e.g. impaired attention, working memory, executive function, verbal fluency…
Prevalence of schizophrenia
- Point prevalence = 4.6 per 1000 persons
- Life-time prevalence = 4.0 per 1000 persons
- No gender difference in prevalence
- Poorer countries – lower prevalence, female excess
Incidence of schizophrenia
- Incidence = 0.16 – 0.42 per 1000 persons
- Males > females (1:1.4)
- Urban > non-urban or mixed environments
- Migrant > non-migrant
Mortality in schizophrenia
- Mortality rates 2-3 X higher than the general population
- On average people with schizophrenia die 12-15 years earlier than the general population
- Most of the excess deaths are from recognized medical disorders (esp. cardiovascular disease)
- Lifestyle factors
- Psychotropic medication
- Health care access and delivery issues e.g. due to positive and negative symptoms
Genetics – family studies & twin studies - greater risk if relative has: 1st degree 5-15% chance
- pattern of inheritance non-Mendelian: polygenic, interacting with themselves and with environment, other non-genetic factors involved (identical twin risk 50%)
- susceptibility genes: support that it is a neurodevelopmental disorder, a disorder of neuronal connectivity
Genetics – genome-wide association studies
- ZNF, first identified, and other loci
- miRNA - neuronal proliferation, synapse maturation, dendrite formation
Environmental factors in schizophrenia
- obstetric complications, maternal infection or malnutrition, city birth, late winter/spring birth
Neurochemical findings in schizophrenia
- Abnormal dopaminergic neurotransmission (“hyperdopaminergic”)
- nigrostriatal: blocked = parkinsonism
- mesolimbic = blocked = reduction in delusions and hallucinations
- to cortex = cognitive side effects
- = hyperprolactinaemia
- Possible roles for glutamate, GABA, and serotonin
Dopamine hypothesis
- illicit drugs increasing dopamine
Glutamate in schizophrenia
- NMDA receptor antagonists
- Ketamine
- Decreased glutamate in CSF
- susceptibility genes
- Anti-NMDA receptor encephalitis
Describe schizophrenia management
Overview
- Thorough assessment – history (including collateral), physical and mental state examination, and appropriate investigations – Blood tests, urinary drug screen, and sometimes cerebral CT or MRI scan and ECG. Occasionally, an EEG is indicated, especially if there is a possibility of complex partial seizures.
- Psychoeducation
- Explore for comorbidity – medical, psychiatric, D&A
- Establish therapeutic rapport
- Treat using a bio-psycho-social approach
- Pharmacotherapy and psychological therapy/support
- Ongoing risk assessment
- Encourage healthy lifestyle behaviors (involve clinical manager, dietician, personal trainer, etc. if necessary)
Metabolic monitoring of antipsychotic medication
Factors associated with suboptimal adherence to treatment in schizophrenia - person: cultural and family, previous experiences, support, personalty, psychological reactance, intelligence, views of illness
- treatment: therapeutic relationship, treatment setting effectiveness, complexity, side effects,
- illness
Strategies to enhance adherence in patients with schizophrenia
- early relapse signature
- eliciting patient concerns
- giving credit
- therapeutic alliance
- uncivering non-adherence
- eliviting negative cognitions
- practical solutions
- socratic questioning
- motivational enhancement therapy
- frame treatment as trial
- correct misinformation
- giving credit
- using legal framework
List some emerging and established schozophrenia treatment
- CBT
- cRT
- etc
