Psychotic Disorders

Question 1

Fixed, false beliefs that persist despite evidence to the contrary and that do not make sense within the context of an individual’s cultural background.

Answer 1

Delusions

Question 2

Delusions of persecution/paranoid delusions:

Answer 2

Irrational belief that one is being persecuted. Example: “The Central Intelligence Agency (CIA) is monitoring me and tapped my cell phone.”

Question 3

Delusions of reference:

Answer 3

Belief that cues in the external environment are uniquely related to the individual. Example: “The TV characters are speaking directly to me.”

Question 4

Delusions of control:

Answer 4

Includes thought broadcasting (belief that one’s thoughts can be heard by others) and thought insertion (belief that outside thoughts are being placed in one’s head).

Question 5

Delusions of grandeur:

Answer 5

Belief that one has special powers beyond those of a normal person. Example: “I am the all-powerful son of God and I shall bring down my wrath on you if I don’t get my way.”

Question 6

Delusions of guilt:

Answer 6

Belief that one is guilty or responsible for something. Example: “I am responsible for all the world’s wars.”

Question 7

Somatic delusions:

Answer 7

Belief that one has a certain illness or health condition. Example: A patient believing she is pregnant despite negative pregnancy tests and ultrasounds.

Question 8

What are 2 types of perceptual disturbances?

Answer 8

1. Illusions (Misinterpretation of an existing sensory stimulus (such as mistaking a shadow for an evil spirit).)
2. Hallucinations (auditory, visual, olfactory, tactile)

Question 9

What are some differential diagnosis of psychosis

Answer 9

■ Psychotic disorder due to another medical condition.
■ Substance/Medication-induced psychotic disorder.
■ Delirium/Major neurocognitive disorder (dementia).
■ Bipolar disorder, manic/mixed episode.
■ Major depressive disorder with psychotic features.
■ Brief psychotic disorder.
■ Schizophrenia.
■ Schizophreniform disorder.
■ Schizoaffective disorder.
■ Delusional disorder.

Question 10

Medical causes that could cause psychosis:

Answer 10

1. Central nervous system (CNS) disease (cerebrovascular disease, multiple scle-
   rosis, neoplasm, Alzheimer disease, Parkinson disease, Huntington disease, tertiary syphilis, epilepsy [often temporal lobe], encephalitis, prion disease, neurosarcoidosis, AIDS).
2. Endocrinopathies (Addison/Cushing disease, hyper/hypothyroidism, hyper/ hypocalcemia, hypopituitarism).
3. Nutritional/Vitamin deficiency states (B12, folate, niacin).
4. Other (connective tissue disease [systemic lupus erythematosus, temporal
   arteritis], porphyria).

Question 11

Prescription medications that can cause psychosis:

Answer 11

Anesthetics, antimicrobials, corticosteroids, antiparkinsonian agents, anti- convulsants, antihistamines, anticholinergics, antihypertensives, nonsteroidal anti-inflammatory drugs (NSAIDs), digitalis, methylphenidate, and chemo- therapeutic agents.

Question 12

DSM 5 criteria for schizophrenia

Answer 12

Two or more of the following must be present for at least 1 month:
1. Delusions.
2. Hallucinations.
3. Disorganized speech.
4. Grossly disorganized or catatonic behavior. 5. Negative symptoms.

Note: At least one must be 1, 2, or 3.
■ Must cause significant social, occupational, or functional (self-care)
deterioration.
■ Duration of illness for at least 6 months (including prodromal or residual periods in which the above full criteria may not be met).
■ Symptoms not due to effects of a substance or another medical condition.

Question 13

What is echolalia

Answer 13

Repeating of words or phrases

Question 14

What is echopraxia

Answer 14

Mimics behavior

Question 15

When does schizophrenia usually present?

Answer 15

Men: 15-25 (mid 20s)
Women: 15-30 (late 20s)

Question 16

What are the 4 dopamine pathways in schizophrenia?

Answer 16

■ Prefrontal cortical: Inadequate dopaminergic activity; responsible for negative symptoms.
■ Mesolimbic: Excessive dopaminergic activity; responsible for positive symptoms.
■ Tuberoinfundibular: Blocked by antipsychotics, causing hyperprolactinemia, which may lead to gynecomastia, galactorrhea, sexual dysfunction, and menstrual irregularities.
■ Nigrostriatal: Blocked by antipsychotics, causing Parkinsonism/ extrapyramidal side effects such as tremor, rigidity, slurred speech, akathisia, dystonia, and other abnormal movements.

Question 17

What factors are associated with a better prognosis of schizophrenia?

Answer 17

■ Later onset.
■ Good social support.
■ Positive symptoms.
■ Mood symptoms.
■ Acute onset.
■ Female gender.
■ Few relapses.
■ Good premorbid functioning.

Question 18

Important Side Effects and Sequelae of Antipsychotic Medications

Answer 18

1. Extrapyramidal symptoms (especially with the use of high-potency
   first-generation antipsychotics):
   * Dystonia (spasms) of face, neck, and tongue.
   * Parkinsonism (resting tremor, rigidity, bradykinesia).
   * Akathisia (feeling of restlessness).
   Anticholinergic symptoms (especially low-potency first-generation anti- psychotics and atypical antipsychotics): Dry mouth, constipation, blurred vision, hyperthermia.
   Metabolic syndrome (second-generation antipsychotics): A constellation of
   body fat around the waist, abnormal cholesterol levels—that occur together, increasing the risk for cardiovascular disease, stroke, and type 2 diabetes.
2. Tardive dyskinesia (more likely with first-generation antipsychotics): Choreoathetoid movements, usually seen in the face, tongue, and head.
3. Neuroleptic malignant syndrome (NMS) (typically high-potency first-generation antipsychotics):
   ● Change in mental status, autonomic instability (high fever, labile blood pressure, tachycardia, tachypnea, diaphoresis), “lead pipe” rigidity, ele- vated creatine kinase (CK) levels, leukocytosis, and metabolic acidosis. Reflexes are decreased.
4. Prolonged QTc interval and other electrocardiogram changes, hyperprolac- tinemia (gynecomastia, galactorrhea, amenorrhea, diminished libido, and impotence), hematologic effects (agranulocytosis may occur with clozapine, requiring frequent blood draws when this medication is used), ophthalmo- logic conditions (thioridazine may cause irreversible retinal pigmentation at high doses; deposits in lens and cornea may occur with chlorpromazine), dermatologic conditions (such as rashes and photosensitivity).

Question 19

Treatment of TD

Answer 19

Treatment: Discontinue or reduce the medication and consider substituting an atypical antipsychotic (if appropriate).

Question 20

Treatment of EPS

Answer 20

Treatment: Anticholinergics (benztropine, diphenhydramine), benzodiazepines/beta-blockers (specifically for akathisia).

Question 21

Treatment of anticholinergic symproms

Answer 21

Treatment: As per symptom (eye drops, stool softeners, etc.).

Question 22

Treatment of NMS

Answer 22

prompt withdrawal of all anti- psychotic medications and immediate medical assessment and treatment.

Question 23

How long do symptoms have to be present for a diagnosis of schizophreniform disorder?

Answer 23

> 6 months

Question 24

DSM 5 criteria for schizoaffective disorder

Answer 24

■ Meet criteria for either a major depressive or manic episode during which psychotic symptoms consistent with schizophrenia are also met.
■ Have delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms (this criterion is necessary to differentiate schizoaffective disorder from a mood disorder with psychotic features).
■ Have mood symptoms for a majority of the psychotic illness.
■ Have symptoms not due to the effects of a substance (drug or medication) or
another medical condition.

Question 25

How long do symptoms have to be present to be diagnosed with brief psychotic disorder?

Answer 25

1 day to 1 month

Question 26

DSM 5 criteria for delusional disorder

Answer 26

■ One or more delusions for at least 1 month.
■ Does not meet criteria for schizophrenia.

■ Usually nonbizarre delusions
■ Daily functioning not significantly
impaired

Question 27

Delusion that another person is in love with the individual.

Answer 27

Erotomanic Delusion

Question 28

Delusions of having great talent.

Answer 28

Grandiose Delusion

Question 29

Physical Delusions

Answer 29

Somatic Delusions

Question 30

Delusions of persecution

Answer 30

Persecutory Delusions

Question 31

Delusions of unfaithfulnesss

Answer 31

Jealous Delusion