Psychotic disorders

Question 1

What is Psychosis?

Answer 1

1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly Disorganized or catatonic behavior
5. Negative symptoms

Question 2

psychosis

Delusions

Answer 2

Fixed beliefs that one holds despite evidence to the contrary
Think - cognitive distortion
Various themes - see Delusional Disorder specifiers
The distinction between a delusion and a strongly held idea is sometimes difficult - delusions typically cannot be broken

Ex. A patient has delusions that she won a house, she fully believes this despite lack of evidence. She packs her things, tells her family she is moving, etc.

Question 3

psychosis

Hallucinations

Answer 3

Perception-like experiences that occur without an external stimulus.
Think - sensory based

Vivid, clear, with the full force and impact of normal perceptions, and not under voluntary control
Auditory is most common in psychotic disorders - usually in the form of a voice, not just a noise

Others include: visual, tactile. Olfactory and gustatory typically medical cause involving temporal lobe.

Be sure to distinguish Inner dialogue (intrusive thoughts) vs perceived sounds

Hallucinations while falling asleep or waking up are normal (Hypnagogic Hallucinations)

Question 4

psychosis

Disorganized Thinking (Speech)

Derailment, thought blocking, tangentially, incoherence, word salad

Answer 4

Disorganized thinking is typically seen in the presentation of disorganized speech

Derailment - switching from topic to topic with no logical connection

Thought blocking- sudden and involuntary interruption

Tangentiality - answers to questions are seem to be unrelated and gradually deviate

Incoherence - unintelligible sounds that may or may not be words

Word salad - mix of seemingly random words strung together in a “sentence”

Symptoms must be severe enough to impair effective communication, but may be mild if in prodromal or residual phases of psychosis

Question 5

psychosis

Grossly Disorganized Behavior

Answer 5

Behavior that seems bizarre, without purpose or inappropriate.
Ex: childlike silliness, unprovoked agitation, pacing aimlessly, inappropriate giggling, poor hygiene

Included catatonic behavior, which is marked decrease in reactivity to the environment

Can range from….
Resistance to instructions (negativism)
Maintaining a rigid, inappropriate or bizarre posture (waxy flexibility)
Complete lack of verbal and motor response (mutism and stupor)
Purposeless and excessive motor activity without obvious cause (catatonic excitement)

Question 6

psychosis

Negative Symptoms

Answer 6

Like it sounds - lacking “something”

Diminished emotional expressions - reductions in the expression of emotions in the face, eye contact, intonation of speech and movements of the hand, head, and face that normally give an emotional emphasis to speech

Avolition - decrease in motivated self-initiated purposeful activities
Alogia- diminished speech output
Anhedonia - lack of interest, happiness
Asociality- apparent lack of interest in social interactions

Account for a substantial portion of the morbidity associated with psychotic disorders

Question 7

Delusional Disorder

general
Time frame

Answer 7

The presence of 1 or more delusions with a duration of 1 months or longer

Criteria A for schizophrenia have never been met
Apart from the impact of the delusions, or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd

If mania or MDD episodes have occurred, these have been brief relative to the duration of delusions

Disturbance is not attributable to the physio effects of a substance or another medical condition and is not better explained by another mental condition (OCD, BDD)

Question 8

Delusional Disorder

Erotomanic type and Grandiose type

Answer 8

Erotomaniac type: delusion that another person is in love with the individual

Grandiose type - delusional or conviction of having some great or unrecognized talent or insight or having made some important discovery

Question 9

Delusional disorder

Jealous type and Persecutory type (MC)

Answer 9

Jealous type - delusion that his or her spouse or partner is unfaithful

Persecutory type (MC) - delusion that one is being conspired against, cheated, spied on, followed, poisoning, or drugged, maliciously maligned, harassed, or obstructed in pursuit of long-term goals

Question 10

delusional disorder

Somatic type

Answer 10

Somatic type - delusions involving bodily functions or sensations

Question 11

delusional disorder

With bizarre content

Answer 11

Must be clearly implausible, not understandable, and not derived from ordinary life experiences

Ie, belief that an outside source has removed his/her organs and replaced them with someone else’s without leaving any wounds or scars

Question 12

delusional disorder

prognosis and Tx

Answer 12

Most of these patients DO NOT go on to develop schizophrenia
½ recover fully
⅓ significantly improve significantly
20% maintain the delusion indefinitely

Tx: atypical antipsychotics and therapy

Question 13

Brief Psychotic Disorder

criteria
Time frame

Answer 13

Sudden onset involving the presence of one or more of the following:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
*at least 1 of the symptoms must be 1, 2, or 3

Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning

Not better explained by MDD, mania, or another psychotic disorder and is not attributable to effects of substance or medical condition

Question 14

Brief Psychotic Disorder- Specifier

with marked stressors, with postpartum

Answer 14

With marked stressors
Symptoms occur in response to events that singly, or together, would be stressful to almost anyone in similar circumstance
Without marked stressors

With postpartum onset
If onset is during pregnancy or within 4 weeks postpartum
With catatonia

Question 15

Brief Psychotic Disorder

Epidemiology and tx

Answer 15

2x more common in females
Pre-existing personality disorder may predispose patients to the development of this disorder

Tx: antipsychotics
Response is usually rapid and complete. If complete resolution is achieved, treat for 1-3 months

Question 16

Schizophreniform Disorder

criteria
Time frame

Answer 16

2 or more of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated).
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
**at least 1 of these must be 1, 2, or 3 **

Duration must be at least 1 month but less than 6 months (use provisional specifier while waiting to determine resolution timeframe)

Schizoaffective disorder is ruled out if no major depressive or manic episodes occurring during active-phase symptoms or if mood episodes have occurred and ben present for a minority of total duration of active-phase

Not attributable to the effects of a substance or medical condition, and other psychotic disorders have been ruled out

Question 17

Schizophreniform Disorder

With good prognostic features
Without good prognostic features
With catatonia

Answer 17

With good prognostic features
Requires the presence of at least 2 of the following:
onset of prominent psychotic symptoms within 4 weeks of the first noticeable change;
confusion/perplexity;
good premorbid social and occupational functioning;
absence of blunted or flat affect

Without good prognostic features
When 2 or more of the above features are not met

With catatonia

About ⅓ of patients will experience a resolution of symptoms before the 6 month mark, and this will be their final diagnosis. The remaining ⅔ usually go on to develop schizophrenia.
Tx: antipsychotics

Question 18

Schizophrenia Disorder

criteria

Answer 18

A. 2 or more of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated).
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly Disorganized or catatonic behavior
5. Negative symptoms
*At least 1 of these must be 1, 2, or 3

B. Level of functioning in one or more major areas, such as work, interpersonal relations, or self-care, is markedly below the level achieved prior to the onset

C. Continuous signs of the disturbance persist for at least 6 months.
This period must include at least 1 month of symptoms (or less if successfully treated), that meets Criteria A and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by 2 or more symptoms listed in Criterion A

D. Schizoaffective disorder is ruled out if no major depressive or manic episodes occurring during active-phase symptoms or if mood episodes have occurred and ben present for a minority of total duration of active-phase

E. Other medical/mental disorders have been ruled out and this is not attributable to effects of a substance

Question 19

Schizoaffective Disorder

criteria

Answer 19

An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia

Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness
Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness
Disturbance is not attributable to the effects of a substance or another medical condition

Specify: bipolar type, depressive type, first episode vs multiple, remission status

Question 20

Question 21

antipsych meds in ppt

Question 22

Answer 22

Sx of antipsych meds

Question 23

AIMS

Answer 23

Screening for TD
Provider rates patient
Score of 2 indicates presence of TD
Performed every 6 months

Question 24

Answer 24

When prescribing think of
Efficacy- similar efficacy among all antipsychotics except for clozapine which is considered clearly more effective than the others
Side effects- similar side effects among all but to different degrees
Cost- there are either cheap or really expensive
Route: PO vs IM