Psychotic Disorders Flashcards
What is the definition of psychosis?
- A break from reality involving delusions, perceptual disturbances, and/or disordered thinking.
- Ex: schizophrenia & substance-induced psychosis
Disorders of thought include thought ______ and _____.
content
process
What are disorders of thought content?
- Reflect the patient’s belief’s, ideas and interpretations of his and her surroundings
- Examples
- Paranoid delusions
- Ideas of reference
- Loss of ego boundaries
What are disorders of thought process?
- Involve the manner in which the patient links ideas and words together
- Examples
- Tangentiality
- Circumstantiality
- Loosening of associations
- Thought blocking
- Perseveration
What is the definition of a delusion?
- Fixed, false beliefs that cannot be altered by rational arguments and cannot be accounted for by the cultural background of the individual
What are the 5 types of delusions?
- Paranoid delusion
- Ideas of reference
- Thought broadcasting
- Delusions of grandeur
- Delusions of guilt
Paranoid delusion
- Irrational belief that one is being persecuted
- “The CIA is after me and taps my phone”
Ideas of reference
- Belief that some event is uniquely related to the individual
- “Jesus is speaking to me through TV characters”
Thought broadcasting
- Belief that one’s thoughts can be heard by others
Delusions of grandeur
- Belief that one has special powers beyond those of a normal person
- “I am the all-powerful son of God and I shall bring down my wrath on you if I cannot have a smoke”
Delusions of guilt
- False belief that one is guilty of responsible for something
- “I caused the flood in Mozambique”
What is the definition of a hallucination?
sensory perception without an actual external stimulus
What are the 4 types of hallucinations?
When are they commonly seen?
- 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
What is the definition of an illusion?
- Misinterpretation of an existing sensory stimulus
- Ex: mistaking a shadow for a cat
Loss of ego boundaries
unawareness of where one’s mind and body end and those of others begin
What is the differential diagnosis of psychosis?
- Psychosis secondary to general medical condition
- Substance-induced psychotic disorder
- Delirium/Dementia
- Bipolar disorder
- Major depression with psychotic features
- Brief psychotic disorder
- Schizophrenia
- Schizophreniform disorder
- Schizoaffective disorder
- Delusional disorder
What are 4 medical causes of psychosis?
-
CNS disease
- Cerebrovascular disease, MS, neoplasm, Parkinson’s disease, Huntington’s chorea, temporal lobe epilepsy, encephalitis, prion disease
-
Endocrinopathies
- Addison’s/Cushing’s disease, hyper/hypothyroidism, hyper/hypocalcemia, hypopituitarism
-
Nutritional/Vitamin deficiency status
- B12, folate, niacin
-
Other
- Connective tissue disease (SLE, temporal arteritis), porphyria
What is the DSM IV criteria for psychotic disorder secondary to a general medical condition?
- Prominent hallucinations or delusions
- Symptoms do not occur only during episode of delirium
- Evidence to support medical cause from lab data, history or physical
What are the causes of medication/substance-induced psychosis?
- Anti-depressants
- Anti-parkinsonian agents
- Anti-hypertensives
- Anti-histamines
- Anti-convulsants
- Digitalis
- Beta blockers
- Anti-TB agents
- Corticosteroids
- Hallucinogens
- Amphetamines
- Opiates
- Bromide
- Heavy metal toxicity
- Alcohol
What is the DSM IV criteria for psychosis secondary to medication of substance use?
- 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
- Disturbance is not better accounted for by a psychotic disorder that is not substance-induced
What is Schizophrenia?
- Psychiatric disorder characterized by constellation of abnormalities in thinking, emotion and behavior
- No single symptom is pathognomonic
What are the positive symptoms of Schizophrenia?
- Hallucinations
- Delusions
- Bizarre behavior
- Thought disorder
What are the negative symptoms of Schizophrenia?
- Blunted affect
- Anhedonia
- Apathy
- Inattentiveness
What are the 3 phases of schizophrenia?
- Prodromal
- Psychotic
- Residual
Prodromal phase of schizophrenia
- Decline in functioning that precedes the first psychotic episode
- The patient may become social withdrawn and irritable
- He/she may have physical complaints and/or newfound interest in religion or the occult
Psychotic phase of schizophrenia
- Perceptual disturbances
- Delusions
- Disordered thought process/content
Residual phase of schizophrenia
- Occurs btwn episodes of psychosis
- Marked by flat affect, social withdrawal, and odd thinking or behavior (negative symptoms)
- Patients can continue to have hallucinations even with treatment
What is the DSM IV Criteria for Schizophrenia?
-
2 or more of the following must be present for at least 1 month:
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms (flat affect)
- Must cause significant social or occupational functional deterioration
- Duration of illness for at least 6 mo (including prodromal or residual periods in which above crteria may not be met)
- Symptoms not due to medical, neurological, or substance-induced disorder
What are the 5 subtypes of Schizophrenia?
- Paranoid type
- Disorganized type
- Catatonic type
- Undifferentiated type
- Residual type
Paranoid type of schizophrenia
- Highest functioning type, older age of onset
- Must meet the following criteria:
- Preoccupation w/ one or more delusions or frequent auditory hallucinations
- No predominance of disorganized speech, disorganized or catatonic behavior, or inappropriate affect
Disorganized type of schizophrenia
- Poor functioning type, early onset
- Must meet the following criteria:
- Disorganized speech
- Disorganized behavior
- Flat or inappropriate affect
Catatonic type of schizophrenia
- 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 (repeats words or phrases) or Echopraxia (mimics behavior)
Undifferentiated type of schizophrenia
- Characteristic of more than one subtype or non of the subtypes
Residual type of schizophrenia
- Prominent negative symptoms
- Flattened affect or social withdrawal
- Minimal evidence of positive symptoms
- Hallucinations or delusions
What are the typical findings in schizophrenic patients on exam?
- Disheveled appearance
- Flattened affect
- Disorganized thought process
- Intact memory & orientation
- Auditory hallucinations
- Paranoid delusions
- Ideas of reference (references made to them by TV, newspaper, etc)
- Concrete understanding of similarities/proverbs
- Lack insight into their disease
Schizophrenia affects __% of people over their lifetime.
Men tend to present around ___ yrs of age.
Women tend to present around ___ yrs of age.
(Men/Women) have a more severe course.
1%
20
30
Men
People born in these two seasons have a higher incidence of schizophrenia?
What is the explanation for this?
- Winter & early spring
- Seasonal variation in viral infections of mothers during pregnancy
Schizophrenia rarely presents before age ___ or after age ___.
(Strong/Weak) genetic predisposition.
Strong association with _______.
15, 45
Strong
substance use
What is the “downward drift hypothesis”?
- Lower socioeconomic groups have higher rates of schizophrenia
- People suffereing from schizophrenia are unable to function well in society and hence enter lower socioeconomic groups
- Ex: homeless people in urban areas
What is the “dopamine hypothesis”?
- Most antipsychotics that successfully treat schizophrenia are dopamine receptor antagonists
- Cocaine & amphetamines lead to schizophrenic-like symptoms
What are the theorized dopamine pathways affected in schizophrenia?
- Prefrontal cortical - responsible for negative symptoms
- Mesolimbic - responsible for positive symptoms
What are some other important dopamine pathways affected by Neuroleptics?
- Tuberoinfundibular - blocked by neuroleptics, causing hyperprolactinemia
- Nigrostriatal - blocked by neuroleptics, causing extrapyramidal side effects
CT scans of patients with schizophrenia show…
- Enlargement of the ventricles
- Diffuse cortical atrophy
What are 3 neurotransmitter abnormalities implicated in schizophrenia?
-
Elevated serotonin
- Atypical antipsychotics antagonist serotonin
- Risperidone, clozapine
-
Elevated NE
- Long-term use of antipsychotics decreases activity of noradrenergic neurons
-
Decreased GABA
- Loss of GABAergic neurons in the hippocampus; may indirectly activate dopaminergic & noradrenergic pathways
Schizophrenia
What factors are associated with a better prognosis?
- Later onset
- Good social support
- Positive symptoms
- Mood symptoms
- Acute onset
- Female sex
- Few relapses
- Good premorbid functioning
Schizophrenia
What factors are associated with worse prognosis?
- Early onset
- Poor social support
- Negative symptoms
- Family history
- Gradual onset
- Male sex
- Many relapses
- Poor premorbid functioning (social isolation, etc)
Typical neuroleptics
- Examples
- Mechanism
- Efficacy
- Side effects
- Chlorpromazine, thioridazine, trifluoperazine, haloperidol
- Dopamine (D2) antagonists
- Positive >> Negative symptoms
- Side effects
- Extrapyramidal symptoms
- Neuroleptic malignant syndrome
- Tardive dyskinesia
Atypical neuroleptics
- Examples
- Mechanism
- Efficacy
- Side effects
- Risperidone, clozapine, olanzapine, quetiapine, aripiprazole, ziprosidone
- Antagonize serotonin receptors (5-HT2) & dopamine receptors
- Negative >> Positive symptoms
- Lower incidence of extrapyramidal side effects
Medications should be taken for a least _________ before efficacy is determined.
4 weeks
Behavioral therapy
- Attempts to improve patients’ ability to function in society
- Patients helped through a variety of methods to improve their social skills, become self-sufficient, and act appropriately in public
- Family therapy & group therapy are successful adjuncts
What are extrapyramidal symptoms?
How is it treated?
- Caused by high potency traditional antipsychotics
- Dystonia (spasms) of face, neck, tongue
- Parkinsonism (resting tremor, rigidity, bradykinesia)
- Akathisia (feeling of restlessness)
- Treatment: antiparkinsonian agents (benztropine, amantadine), benzodiazepines
What are anticholinergic symptoms?
How are they treated?
- Caused by low-potency antipsychotics & atypical antipsychotics
- Dry mouth
- Constipation
- Blurred vision
- Treatment: as per symptom (eyedrops, stool softeners, etc)
What is tardive dyskinesia?
How is it treated?
- Caused by high potency antipsychotics
- Darting or writhing movements of face, tongue and head
- Treatment: discontinue offending agent and substitute atypical neuroleptic
- Benzodiazepines, beta blockers & cholinomimetics may be used short term
- Movements often persist despite withdrawal of the offending drug
What is neuroleptic malignant syndrome?
- Caused by high potency antipsychotics
- Confusion, high fever, elevated BP, tachycardia, “lead pipe” rigidity, sweating, greatly elevated CPK levels
- Can be life-threatening, not an “allergic rxn”
What are some additional side effects of antipsychotic medications?
- Weight gain
- Sedation
- Orthostatic hypotension
- ECG changes
- Hyperprolactinemia
- Gynecomastia, galactorrhea, amenorrhea, diminished libido, impotence
- Hematologic effects
- Agranulocytosis (clozapine)
- Ophthalmologic conditions
- Thioridazine: irreversible retinal pigmentation
- Chlorpormazine: deposits in lens & cornea
- Dermatologic conditions
- Rashes, photosensitivity
- Hyperlipidemia
- Glucose intolerance
What is the difference between schizophrenia & schizophreniform disorder?
- Schizophreniform disorder
- 1-6 months
- Schizophrenia
- >6 months
Schizophreniform Disorder
___ recover completely.
___ progress to schizoaffective disorder or schizophrenia.
1/3
2/3
How is schizophreniform disorder treated?
- Hospitalization
- 3-6 month course of antipsychotics
- Supportive psychotherapy
What is the definition of schizoaffective disorder according to DSM-IV criteria?
- Meet criteria for either major depressive episode, manic episode or mixed episode (during which criteria for schizophrenia are also met)
- Have delusions or hallucinations for 2 wks in the absence of mood disorder symptoms (necessary to differentiate schizoaffective disorder from mood disorder with psychotic features)
- Have mood symptoms present for substantial portion of psychotic illness
- Symptoms not due to general medical condition or drugs
Prognosis of schizoaffective disorder is _____ than schizophrenia but _____ than mood disorder.
better, worse
How is schizoaffective disorder treated?
- Hospitalization and supportive psychotherapy
- Medical therapy
- Antipsychotics: short-term control of psychosis
- Mood stabilizers
- Antidepressants
- Electroconvulsive therapy (ECT): as needed for mania or depression
What is the definition of brief psychotic disorder according to DSM-IV criteria?
- Patient with psychotic symptoms as defined for schizophrenia
- Symptoms last 1 day to 1 month
- Symptoms must not be due to general medical condition or drugs
- Rare, much less common than schizophrenia
Brief psychotic disorder
___% recovery rate
___% may be eventually diagnosed with schizophrenia or mood disorder
50-80%
20-50%
How is brief psychotic disorder treated?
- Brief hospitalization
- Supportive psychotherapy
- Course of antipsychotics for psychosis itself and/or benzodiazepines for agitation
What is the time course of these disorders?
- Brief psychotic disorder
- Schizophreniform disorder
- Schizophrenia
- Brief psychotic disorder: <1 month
- Schizophreniform disorder: 1-6 months
- Schizophrenia: >6 months
Put these in order of prognosis from BEST to WORST:
- Schizophreniform disorder
- Brief psychotic disorder
- Schizophrenia
- Mood disorder
- Schizoaffective disorder
- Mood disorder (BEST prognosis)
- Brief psychotic disorder
- Schizoaffective disorder
- Schizophreniform disorder
- Schizophrenia (WORST prognosis)
In what subset of patients is delusional disorder most common?
- Older patients (>40 YO)
- Immigrants
- Hearing impaired
What is the DSM-IV criteria for delusional disorder?
- Nonbizarre, fixed delusions for at least 1 month
- Does not meet criteria for schizophrenia
- Functioning in life not significantly impaired
What are the 6 types of delusions and their definitions?
- Erotomanic type - delusions revolves around love
- Grandiose type - inflated self-worth
- Somatic type - physical delusions
- Persecutory type - delusions of being persecuted
- Jealous type - delusions of unfaithfulness
- Mixed type - more than one of the above
Prognosis of delusional disorder
___% full recovery
___% decreased symptoms
___% no change
50%
20%
30%
How is delusional disorder treated?
- Psychotherapy may be helpful
- Antipsychotics are often ineffective
- Course should be tried
- High potency traditional antipsychotic or one of the newer atypical antipsychotics
What are the fundamental differences between Schizophrenia & Delusional Disorder?
-
Schizophrenia
- Bizarre delusions (or nonbizarre)
- Daily functioning significantly impaired
- Must have 2 or more of the following:
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized behavior
- Negative symptoms
-
Delusional Disorder
- Nonbizarre delusions (never bizarre)
- Daily functioning not significantly impaired
- Does not meet the criteria for schizophrenia as described in left column
What is the DSM-IV criteria for shared psychotic disorder?
- Folie à deux
- Diagnosed when a patient develops the same delusional symptoms as someone he or she is in a close relationship with
- Most commonly family members
Shared psychotic disorder
___% will recover upon removal from the inducing person
20-40%
How is shared psychotic disorder treated?
- Separate the patient from the person who is the source of shared delusions (usualy a family member with an underlying psychotic disorder)
- Psychotherapy should be undertaken
-
Antipsychotic medications
- If symptoms not improved in 1-2 wks after separation
What is Koro?
Culture-specific psychoses
- Patient believes that his penis is shrinking and will disappear, cuasing his death
- Culture: Asia
What is Amok?
Culture-specific psychoses
- Sudden unprovoked outbursts of violence of which the person has no recollection
- Person often commits suicide afterwards
- Culture: Malaysia, Southeast Asia
What is Brain fag?
Culture-specific psychoses
- Headache, fatigue and visual disturbances in male students
- Culture: Africa
Define
Lifelong psychotic disorder
Schizophrenia
Define
Schizophrenia for <6 months
Schizophreniform
Define
Schizophrenia + mood disorder
Schizoaffective
Define
Paranoid, odd or maginal beliefs, eccentric, lack of friends, social anxiety. Criteria for true psychosis are not met.
Schizotypal (personality disorder)
Define
Withdrawn, lack of enjoyment from social interactions, emotionally restricted.
Schizoid (personality disorder)