Psychotic Disorders Flashcards
Psychosis
Psychosis is a break from reality involving delusions, perceptual disturbances, and/or disordered thinking. Schizophrenia and substance-induced psychosis are examples of commonly diagnosed psychotic disorders.
Delusions
Fixed false beliefs that cannot be altered by rational arguments and cannot be accounted for by the cultural background of the individual. Types include paranoid delusions, ideas of reference (belief that some event is uniquely related to the individual, like that jesus is speaking to me through tv characters), thought broadcasting, delusions of grandeur, and delusions of guilt.
Hallucinations
Sensory experiences without an actual external stimulus.
TYPES:
Auditory– most commonly exhibited by schizophrenic patients.
Visual– commonly seen with drug intoxication.
Olfactory– usually an aura associated with epilepsy.
Tactile– usually secondary to drug abuse or alcohol withdrawal.
Illusion
Misinterpretation of an existing sensory stimulus (like mistaking a shadow for a cat).
Differential diagnosis of psychosis
- Psychosis secondary to a general medical condition
- substance-induced psychotic disorder
- delirium/dementia
- bipolar disorder
- major depressive disorder with psychotic features
- brief psychotic disorder
- schizophrenia
- schizophreniform disorder
- delusional disorder
Psychosis secondary to a general medical condition
Medical causes of psychosis include:
- CNS DISEASE (cerebrovascular disease, MS, neoplasm, Parkinson’s disease, Huntington’s chorea, temporal lobe epilepsy, spinocerebellar degeneration encephalitis, prion disease)
- ENDOCRINOPATHIES ) Addison’s/Cushing’s disease, hyper/hypothyroidism, hyper/hypocalcemia, hypopituitarism.
- NUTRITIONAL/VITAMIN DEFICIENCY STATES: B12, folate, niacin
- OTHER: (porphyria, connective tissue disease like SLE, temporal arteritis)
DSM IV criteria for psychotic disorder secondary to a general medical condition include:
- Prominent hallucinations or delusions
- Symptoms do not occur only during episode of delirium
- evidence to support medical cause from lab data, history or physical
Psychosis secondary to medication or substance abuse
Causes of medication/substance-induced psychosis include antidepressants, antiparkinsonian agents, antihypertensives, antihistimines, anticonculsants, digitalis, beta blockers, antituberculosis agents, corticosteroids, hallucinogens, amphetamines, opiates, bromide, heavy metal toxicity and alcohol.
DSM-IV criteria:
- Prominent hallucinations or delusions
- Symptoms do not occur only during episode of delirium
- Evidence to support medication or substance-related cause from lab data, history or physical
Schizophrenia
Psychiatric disorder characterized by a constellation of abnormalities in thinking, emotion and behavior. There is no single symptom that is pathognomonic, and the disease can produce a wide spectrum of clinical pictures. it is usually chronic and debilitating.
Positive and negative symptoms
POSITIVE: hallucinations, delusions, bizarre behavior or thought disorder.
NEGATIVE: blunted affect, anhedonia, apathy, and inattentiveness.
Although negative symptoms are the less dramatic of the two types, they are considered by some to be at the “core” of the disorder.
Three Phases of Schizophrenia
- PRODROMAL– decline in functioning that precedes the first psychotic episode. The patient may become socially withdrawn and irritable. He or she may have physical complaints and/or newfound interest in religion or in the occult.
- PSYCHOTIC– perceptual disturbances, delusions and disordered thought process or content.
- RESIDUAL– occurs between episodes of psychosis. It is marked by flat affect, social withdrawal, and odd thinking or behavior (negative symptoms).
Definition / Dx of schizophrenia in DSM-IV
Two or more of the following must be present for at least 1 month.
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior.
- Negative symptoms (such as flattened affect)
- Must cause significant social or occupational functional deterioration.
- Duration of illness for at least 6 months (including prodromal or residual periods in which above criteria may not be met).
- Symptoms not due to medical, neurological or substance-induced disorder.
Subtypes of schizophrenia
- PARANOID TYPE–highest functioning, older age of onset. Must meet the following criteria:
- preoccupation with one or more delusions or frequent auditory hallucinations
- No predominance of disorganized speech, disorganized or catatonic behavior or inappropriate affect. - DISORGANIZED TYPE–poor functioning type, early onset. Must meet the following criteria:
- disorganized speech
- disorganized behavior
- flat or inappropriate affect - CATATONIC TYPE– rare. Must meet at least 2 of the following criteria:
- Motor immobility
- excessive purposeless motor activity
- extreme negativism or mutism
- peculiar voluntary movements or posturing
- echolalia or echopraxia - UNDIFFERENTIATED TYPE–characteristic of more than one subtype or none of the subtypes.
- RESIDUAL TYPE–prominent negative symptoms such as flattened affect or social withdrawal, with only minimal evidence of positive symptoms such as hallucinations or delusions.
Psychiatric exam of schizophrenic patients
look for: disheveled appearance, flattened affect, disorganized thought process, intact memory and orientation, auditory hallucinations, paranoid delusions, ideas of reference, concrete understanding of similarities/proverbs, lack of insight into their disease
Pathophysiology of schizophrenia
Theorized Dopamine Pathways affected in Schizophrenia:
- prefrontal cortical– responsible for the negative symptoms
- mesolimbic– responsible for the positive symptoms
Other important dopamine pathways affected by neuroleptics:
- tuberoinfundibular– blocked by neuroleptics, causing hyperprolactinemia
- nigrostriatal–blocked by neuroleptics, causing extrapyramidal side effects
Prognostic Factors in Schizophrenia
Assc’d with Better prognosis:
- later onset
- good social support
- positive symptoms
- mood symptoms
- acute onset
- female sex
- few relapses
- good premorbid functioning
Assc’d with Worse prognosis:
- early onset
- poor social support
- negative symptoms
- family Hx
- gradual onset
- male sex
- many relapses
- poor premorbid functioning (social isolation, etc)
Typical Antipsychotics/neuroleptics
chlorpromazine (Thorazine), thioridazine, trifluoperazine, haloperidol.
These are dopamine (mostly D2) antagonists. They are classically better at treating positive symptoms than negative. They have important side effects and sequelae such as extrapyramidal symptoms, neuroleptic malignant syndrome, and tardive dyskinesia.
Other neurotransmitter abnormalities Implicated in Schizophrenia
Elevated serotonin– the newest antipsychotics (such as risperidone and clozapine) antagonize serotonin (in addition to their effects on dopamine).
Elevated norepinephrine– long-term use of antipsychotics has been shown to decrease activity of noradrenergic neurons.
Decreased GABA– recent data support the hypothesis that schizophrenic patients have a loss of GABAnergic neurons in the hippocampus; this loss might in turn activate dopaminergic and noradrenergic pathways.
Atypical antipsychotics/neuroleptics
risperidone, clozapine, olanzapine, quetiapine.
These antagonize serotonine receptors (5HT2) as well as dopamine receptors. Atypical neuroleptics are classically better at treating negative symptoms than the traditional neuroleptics. They have a much lower incidence of extrapyramidal side effects.
Important side-effects and sequelae of antipsychotic medications
- Extrapyramidal symptoms (esp with high potency traditional antipsychotics)
–dystonia (spasms) of face, neck and tongue
–pseudoparkinsonism
–akasthesia (feeling of restlessness)
Treatment: antiparkinsonian agents (benztropine, amantadine, etc), benzos. - Anticholinergic symptoms (esp w/ low potency traditional antipsychotics and atypicals)
–dry mouth, constipation and blurred vision
Treatment: as per symptom (eye drops, stool softeners, etc) - Tardive dyskinesia (high potency antipsychotics)
– writing movements of face, tongue and head
Treatment: discontinue offending agent and substitute atypical neuroleptic. Benzos, betablockers and cholinomimetics may be used short term. - Neuroleptic malignant syndrome (high potency antipsychotics)
- confusion, high fever, elevated BP, tachycardia, “lead pipe” rigidity, sweating, and greatly elevated CPK levles - Weight gain, sedation, orthostatic hypotension, ECG changes, hyperprolactinemia, hematologic effects (like agranulocytosis with clozapine, nec weekly WBC), ophthalmologic conditions (thioridazine may cause irreversible retinal pigmentation at high doses; chlorpromazine causes deposits in lens and cornea), dermatologic conditions (rashes, photosensitivity).
Schizophreniform disorder
Dx is made using the same criteria as schizophrenia, the only difference is that in schizophreniform disorder, the symptoms have lasted between 1 and 6 months, whereas in schizophrenia, they have lasted for more than 6 months.
PROGNOSIS: 1/3 pts recover completely; 2/3 progress to schizoaffective disorder or schizophrenia.
TREATMENT: hospitalization, 3-6 month course of antipsychotics, supportive psychotherapy.
Schizoaffective disorder
Dx:
- Pts who meet the criteria for either major depressive episode, manic episode or mixed episode, during which the criteria for schizophrenia are also met.
- Have had delusions or hallucinations for at least 2 weeks in the absence of mood disorder symptoms (nec. to differentiate schizoaffective disorder from mood disorder with psychotic symptoms).
- Have mood symptoms present for a substantial portion of psychotic illness.
- Symptoms not due to general medical condition or drugs.
PROGNOSIS: better than schizophrenia, worse than mood disorder
TREATMENT: hospitalization and supportive psychotherapy. Medical therapy with antipsychotics for short-term control of psychosis, mood stabalizers, antidepressants or electroconvulsive therapy (ECT) as needed for mania or depression.
Brief Psychotic Disorder
Pt w/ psychotic symptoms as defined for schizophrenia; however symptoms last from 1 day to 1 month. Sx must not be due to general medical condition or drugs. Rare Dx, much less common than schizophrenia.
Prognosis: 50-80% recovery, 20-50% may eventually be Dxed w/ schizophrenia or mood disorder.
Treatment: brief hospitalization, supportive psychotherapy, course of antipsychotics for psychosis itself and/or benzos for agitation.
Time course /Prognoses for psychotic disorders
6 months– schizophrenia
PROGNOSIS
Mood disorder > brief psychotic disorder> schizoaffective disorder>schizophrenia
