Psychotic Disorders

Question 1

Schizophrenia - general info

Answer 1

Thought disorder that impairs judgment, behavior and the ability to interpret reality

Symptoms must be present for at least 6 months and it must affect functioning.

Make sure you get UTox

Question 2

Schizophrenia Epi

Answer 2

Prevalence is 1%. Males and females affected the same.

Peak onset in men is earlier (18-25) than in women (25-35)

Increased incidence in people born in winter or early spring

Schizo in first degree relatives increases risk.

10% of those affected commit suicide.

Question 3

Etiology of schizophrenia

Answer 3

Neurotransmitter abnormalities such as dopamine dysregulation (frontal hypoactivity and limbic hyperactivity) and brain abnormalities on CT and MRI (enlarged ventricles and reduced cortical volume)

Question 4

Delusion

Answer 4

Fixed false idiosyncratic belief

Question 5

Hallucinations

Answer 5

Perception without an existing external stimulus

Question 6

Illusion

Answer 6

Misperception of an actual external stimulus

Question 7

History and exam for schizophrenia

Answer 7

2 or more of the following are present continuously for 6 or more months with social or occupational dysfunction:

1) Positive symptoms: hallucinations (usually auditory), delusions, disorganized speech, bizarre behavior, thought disorder
2) Negative symptoms: Flat affect, lower emotional reactivity, poverty of speech, lack of purposeful actions, anhedonia

Question 8

Brief psychotic disorder

Answer 8

Greater than 1 day and less than 1 month

Question 9

Schizophreniform disorder

Answer 9

Greater than 1 month and less than 6 months

Question 10

Schizoaffective disorder

Answer 10

Schizophrenia plus a major affective disorder (MDD or BPD)

Question 11

Tx for schizophrenia

Answer 11

1) Hospitalize patients who are acutely psychotic
2) Ensure patient safety and use an atypical antipsychotic as first line
3) In any emergency situation where IM meds are needed, consider short acting meds such as olanzepine or ziprazidone. Haldol is still used but given side effects, pick the atypical if given the choice.
4) If noncompliant with meds, consider long acting antipsychotics like risperidone or paliperidone as first line. Haldol still used but again pick the atypical bc of side effects.
5) Clozapine used only when patients do not respond to an adequate trial of typical or atypical antipsychotics. NEVER used as first line.

Negative symptoms are harder to treat.

Supportive psychotherapy, training in social skills and vocational rehab along with illness education can help

Question 12

Typical antipsychotics

Answer 12

Haloperidol, droperidol, fluhenazine, thioridazine, chlorpromazine

Indications:
1) Psychotic disorders, acute agitation, acute mania, Tourette’s

2) Thought to be more effective for positive symptoms of schizo. Primarily blocks D2 dopamine receptors
3) For patients in whom compliance is a major issue, consider antipsychotics that come in depot forms (haloperidol, fluphenazine)

Side effects:

1) EPS, hyperprolactinemia
2) Anticholinergic effects (dry mouth, urinary retention, constipation)
3) Seziures, hypotension, sedation, QTc prolongation
4) Irreversible retinal pigmentation (thioridizine)

5) NMS

Question 13

NMS

Answer 13

Fever, muscle rigidity, autonomic instability, elevated CK, clouded consciousness

Usually typical antipsychotics

Tx = stop med. Provide supportive care in ICU. Give dantrolene or bromocriptine

Can happen at any time point from starting meds.

Question 14

Atypical antipsychotics

Answer 14

Clozapine, risperidone (long acting depot form too), quetiapine, olanzepine, ziprasidone, aripiprazole

Currently first line treatment for schizophrenia given fewer EPS and anticholinergic effects

Clozapine is reserved for severe treatment resistance and severe TD

Question 15

General rule of thumb for atypicals side effects

Answer 15

• pines - increased risk of weight gain, metabolic syndrome, diabetes
• dones - increased risk of movement disorders, cardiac conduction problems

Question 16

Olanzepine side effects

Answer 16

Greater incidence of diabetes and weight gain

avoid in diabetic and obese patients

Question 17

Risperidone side effects

Answer 17

Greater incidence of movement disorders

Question 18

Quetiapine side effects

Answer 18

Lower incidence of movement disorders

Appropriate for use in patient with preexisting movement disorders

Question 19

Ziprasidone side effects

Answer 19

It’s atypical

Increased risk of prolongation of QT. Avoid in patients with conduction defects

Question 20

Clozapine side effects

Answer 20

High risk of agranulocytosis. Need to monitor CBC weekly.

Never use as first line

Question 21

Aripiprazole side effects

Answer 21

An Atypical

Partial dopamine agonist, approved as adjunct treatment in MDD

Question 22

Lurasidone side effects

Answer 22

An Atypical

The only antipsychotic in pregnancy category B. Safer for use in pregnant patients.

Question 23

Acute dystonia

Answer 23

1) Onset - hours to days
2) Symptoms - Prolonged, painful tonic muscle contractions or spasms (torticolis, oculogyric crisis, laryngeal spasms)
3) Tx - Anticholinergics (Benztropine, diphenhydramine, trihexyphenidyl) are acute therapy. Some patients on antipsychotics who are prone to dystonic reactions may need regular ppx dosing of benztropine.

Question 24

Dyskinesia

Answer 24

1) Onset - Days
2) Symptoms - Psuedoparkinsonism (shuffling gait, cogwheel)
3) Tx - Give an anticholinergic (benztropine) or a dopamine agonist (amantadine). Lower dose of neuroleptic or discontinue if tolerated.

Question 25

Akathisia

Answer 25

1) Onset - Weeks
2) Symptoms - Subjective/objective restlessness that is perceived as being distressing. Rocking. Inability to relax.
3) Tx - Lower neuroleptic dose and try B-blockers (propranolol). switch to atypical if applicable. Benzos or anticholinergics may help too.

Question 26

Tardive dyskinesia

Answer 26

1) Onset - Months (rare before 6 months)
2) Symptoms - Stereotypic, involuntary painless oral-facial movements. Likely from dopamine receptor sensitization from chronic dopamine blockade. Often irreversible (50%). Head, limb, trunk. Perioral movements most common though.
3) Tx - Discontinue or lower the dose of neuroleptic. Attempt treatment with more appropriate drugs; and consider changing neuroleptic (to clozapine or risperidone).

Switch to atypical if applicable.

Giving anticholinergics or decreasing neuroleptics may initially worsen TD.

Clozapine has lowest risk.

Question 27

Delusional Disorder

Answer 27

Prominence of non-bizarre delusions for more than one month and no impairment in level of functioning (may believe country is about to be invaded but still obeys laws, goes to work and pays bills)

Hallucinations are not prominent and are related (if present at all) to the delusional theme.

Treatment is with atypical antipsychotics as first line. May also consider psychotherapy to help promote reality testing.

Question 28

Evolution of EPS

Answer 28

4 and A

4 hrs: Acute dystonia
4 days: Akinesia (dyskinesia)
4 weeks: Akathesia
4 months: TD (often permanent)