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
