Psychotic Disorders Flashcards
Psychosis
Not a diagnosis in itself, but a shorthand way of describing the presence of psychotic symptom which are…
Delusions
Hallucinations
Delusion
A fixed false belief, firmly held despite evidence to the contrary, and out of keeping with the individual’s cultural background.
Delusion Subtypes
Bizarre (could not ever happen)
Non-bizarre (could happen)
Persecutory (fearing harm)
Erotomanic (loved at a distance)
Grandiose
Jealous
Somatic
Delusions of reference
Hallucination
A perception without a stimulus.
These are contrasted with illusions which are misinterpretations of a stimulus.
All sensory modalities can yield hallucinations.
Auditory (most common in psychiatry)
Visual (more common of an organic cause)
Somatic
Olfactory
Gustatory
Illusion
A misinterpretation of a stimulus.
Causes of Psychosis
- Psychiatric - schizophrenia, mood disorders, borderline personality disorder
- Organic - delirium, dementia
- “Normal” causes - hypnagogic/hypnopompic, bereavement, sensory deprivation
Thought Process in Psychiatry
A. GOAL DIRECTED (Normal) - thoughts proceed logically from one to the next
B. CIRCUMSTANTIAL - they get to the point eventually, but not without a lot of unnecessary detail
C. DISORGANISED - this is the thought disorder of schizophrenia. Subjects jump from one to the next without any apparent connection. There are many variations within this category
D. FLIGHT OF IDEAS - the thought disorder of mania. Thoughts jump from one to the next, but there are connections visible. Connections may be rhymes, jokes, or double meanings of words
Schizophrenia
A. Two or more of the following symptoms present for a significant portion of time during a 1 month period (or less if successfully treated)…
1. delusions
2. hallucinations
3. disorganized speech
4. grossly disorganized or catonic behaviour
5. negative symptoms (affective flattening, alogia or avolition)
B. One of more areas of functioning such as work, interpersonal relations, or self care are markedly below the level achieved prior to onset.
C. Continuous signs of disturbance persist for 6 months. This 6 month period must include at least 1 month of symtpoms that meet criteria A, and may include periods of prodromal or residual symptoms.
D. Schizoaffective disorder and mood disorder with psychotic features have been ruled out
E. Disturbance is not due to the direct physiological effects of a substance or general medical condition
F. If there is a history of autism, then ad additional diagnosis of schizophrenia is only made if prominent delusions or hallucinations are present for one month
Prognosis of Schizophrenia
Best 20% - single or multiple psychotic episodes but recover to baseline and maintain jobs
Middle 50% - multiple psychotic episodes, but declining baseline over time with increasing disability
Worst 30% - psychotic episode resists treatment and leads to early and severe disability
Suicide occurs in 10%, most likely in the early years and/or after hospital discharge. Violence is usually not an issue, but is rasied over the average population level but is much less than substance abuse.
Epidemiology of Schizophrenia
M = F
1% lifetime prevalence
Onset is typically in early adulthood… 15-25 in men and 25-35 in women
1% prevalence worldwide, but better outcome in undeveloped world
Single >> divorced > married
Much more common in lower SES
Etiology of Schizophrenia
Genetics is a component… 10% if first degree relative is affected and 50% if monozygotic twins
There is the dopamine hypothesis which postulates that there is an overactivity of dopaminergic transmission in SCZ, particularly in the mesolimbic projection. This is supported by the fact that dopamine releasing drugs cause psychosis.
Investigations for Schizophrenia
Often needed for initial presentation, not every time.
Urine - screen for cocaine, amphetamines, and cannabis
CT brain - dilated ventricles and small medial temporal lobes are commonly seen in schizophrenia but are not diagnostic. CT is to rule out strokes and tumors.
EEG - for temporal lobe epilepsy
Blood tests - CBC, electrolytes, liver function, glucose, cholesterol, and triglycerides. Antipsychotics affect many of these.
ECG - if the QTc interval is already long, antipsychotics can cause torsades
Treatment of Schizophrenia
Decide on the location first. Inpatient is better if the patient is dangerous or if the severity of the illness compromises the ability to self care or engage in initial treatment. Outpatient may be acceptable for minor illness or if patient cooperation won’t allow admission.
Biological treatment is antipsychotic medication which should result in the successful treatment of hallucinations and delusions in 70% of cases.
Atypical antipsychotics are the 1st choice due to a lower side effect profile.
Typical antipsychotics can also be used but have a higher side effect profile.
Relapse off of medication is 90% likely, so after 1 episode continue medication for at least 1 of stability. After multiple episodes, continue medication for at least 5 years.
Side Effects of Antipsychotics
Atypical antipsychotics…
Sedation
Weight gain
Hyperprolactinemia
Typical antipsychotics…
Sedation
Anticholinergic effects
Extrapyramidal side effects
Extrapyramidal Side Effects
These are caused by the effects of dopamine blockade in the basal ganglia. They are much more common with the typical than atypical antipsychotics and are divided into four groups.
1) Acute dystonias such as torticollis, oculogyric crisis, or (most commonly) tongue and jaw rigidity. Treat with anticholinergic drugs like benzotropine.
2) Parkinsonism. Also treat with anticholinergic drugs like benzotropine.
3) Akathisia. Motor restlessness, often more manifested in the legs than arms. Treat with dose reduction or propanolol.
4) Tardive dyskinesia. Occurs late in treatment. Usually oro-facial involuntary movements. With medication removal, two-thirds will recover and one-third is permanent.
