Psychotic Disorders Flashcards
What is psychosis?
General term used to describe distorted perception of reality
Poor reality testing may be accompanied by delusions, perceptual disturbances (illusions or hallucinations), and/or disorganized thinking/behavior
Can be a symptom of schizophrenia, mania, depression, delirium, and dementia
Can be substance or medication-induced
What are delusions?
Fixed, false beliefs that remain despite evidence to the contrary & can’t be accounted for by the cultural background of the individual
Can be categorized as bizarre or nonbizarre
What are bizarre delusions?
False belief that is impossible
Ex: “A martian fathered my baby & inserted a microchip in my brain”
What aree nonbizarre delusions?
False belief that is plausible, but is not true
Ex: “The neighbors are spying on me by reading my mail”
How are delusions categorized?
By theme:
Delusions of persecution / paranoid delusions:
- Irrational belief that one is being persecuted
- Ex: “The CIA is after me and tapped my phone”
Ideas of reference:
- Belief that cues in the external environmental are uniquely related to individual
- Ex: “The TV characters are speaking directly to me”
Delusions of control:
- Includes thought broadcasting (belief that one’s thoughts can be heard by others” & thought insertion (belief that others’ thoughts are being placed in one’s head)
Delusions of grandeur:
- Belief that one has special powers beyond those of a normal person
- Ex: “I am the all-powerful son of God and I shall bring down my wrath on you if I don’t get my way”
Delusions of guilt:
- Belief that one is guilty / responsible for something
- Ex: “I am responsible for all the world’s wars”
Somatic delusions:
- Belief that one is infected w/ a disease or has a certain illness
What are examples of perceptual disturbances?
Illusion:
- Misinterpretation of an existing sensory stimulus (e.g. mistaking a shadow for a cat)
Hallucination:
- Sensory perception without an actual external stimulus
- Auditory: most commonly exhibited by schizophrenic patients (auditory hallucinations that directly tell the patient to perform certain acts are called command hallucinations)
- Visual: occurs, but less common in schizophrenia; may accompany drug intoxication, drug & alcohol withdrawal, or delirium
- Olfactory: usually an aura associated w/ epilepsy
- Tactile: usually secondary to drug use / alcohol withdrawal
Differential diagnosis of psychosis
Psychotic disorder due to another medical condition
Substance / medication-induced psychotic disorder
Delirium / dementia
Bipolar disorder, manic / mixed episode
Major depression w/ psychotic features
Brief psychotic disorder
Schizophrenia
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
What are causes for psychotic disorder due to another medical condition?
CNS disease: cerebrovascular disease, MS, neoplasm, Alzheimer’s disease, Parkinson’s disease, Huntington’s disease, tertiary syphilis, epilepsy (often temporal lobe), encephalitis, prion disease, neurosarcoidosis, AIDS
Endocrinopathies: Addison/Cushing disease, hyper/hypothyroidism, hyper/hypocalcemia, hypopituitarism
Nutritional/vitamin deficiency states: B12, folate, niacin-
Other: connective tissue disease (SLE, temporal arteritis), porphyria
DSM-V criteria for psychotic disorder due to another medical condition
Prominent hallucinations or delusions
Symptoms do not occur only during an episode of delirium
Evidence from history, physical, or lab data to support another medical cause (i.e. not psychiatric)
Elderly, medically ill patients who present w/ psychotic symptoms (e.g. hallucinations, confusion, paranoia) should be carefully evaluated for delirium, which is far more common finding in this population
What are causes for substance/medication-induced psychotic disorder?
Prescription medications: anesthetics, antimicrobials, corticosteroids, antiparkinsonian agents, anticonvulsants, antihistamines, anticholinergics, antihypertensives, NSAIDs, digitalis, methylphenidate, chemotherapeutic agents
Substances: alcohol, cocaine, hallucinogens (LSD, ecstasy), cannabis, benzodiazepines, barbiturates, inhalants, PCP (can cause psychosis either in intoxication or withdrawal)
DSM-V criteria for substance/medication-induced psychotic disorder
Hallucinations &/or delusions
Symptoms do not occur only during episode of delirium
Evidence from history, physical, or lab data to support a medication or substance-induced cause
Disturbance is not better accounted for by a psychotic disorder that is not substance/medication-induced
What is schizophrenia?
Psychiatric disorder characterized by constellation of abnormalities in thinking, emotion, and behavior
No single symptom that is pathognomonic & there is heterogeneous clinical presentation
Typically chronic, w/ significant psychosocial & medical consequences to the patient
What are the categories of symptoms of schizophrenia?
Positive symptoms (added onto normal behavior): hallucinations, delusions, bizarre behavior, disorganized speech - Tend to respond more robustly to antipsychotic medications
Negative symptoms (subtracted from normal behavior): flat/blunted affect, anhedonia, apathy, alogia, lack of interest in socialization
- These symptoms are comparatively more often treatment resistant & contribute significantly to social isolation
- The 5 A’s of schizophrenia: Anhedonia, Affect (flat), Alogia (poverty of speech), Avolition (apathy), Attention (poor)
Cognitive symptoms: impairments in attention, executive function, & working memory
- These symptoms may lead to poor work and school performance
What are examples of catatonia seen in schizophrenia?
Stereotyped movements
Bizarre posturing
Muscle rigidity
What are the 3 phases of schizophrenia?
- Prodromal: decline in functioning that precedes the first psychotic episode
- Patient may become socially withdrawn & irritable
- May have physical complaints, declining school/work performance, and/or newfound interest in religion or the occult - Psychotic: perceptual disturbances, delusions, & disordered thought process/content
- Residual: occurs following episode of active psychosis
- Marked by mild hallucinations/delusions, social withdrawal, & negative symptoms
DSM-V criteria for schizophrenia
2 or more of the following must be present for at least 1 month:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
(At least one symptoms must be 1, 2, or 3)
Must cause significant social, occupational, or self-care functional deterioration
Duration of illness for at least 6 months (including prodromal or residual periods in which the above full criteria may not be met)
Symptoms not due to effects of substance or another medical condition
When is clozapine considered as a treatment for schizophrenia?
Considered when patient fails both typical & other atypical antipsychotics
This is due to potential for agranulocytosis which requires patients to be monitored (WBC, ANC) counts regularly
Psychiatric exam of patients w/ schizophrenia
Typical findings:
- Disheveled appearance
- Flat affect
- Disorganized thought process
- Intact procedural memory & orientation
- Auditory hallucinations
- Paranoid delusions
- Ideas of reference
- Lack of insight into their disease
What is the difference between brief psychotic disorder, schizophreniform disorder, & schizophrenia?
Time:
- Brief psychotic disorder: <1 month
- Schizophreniform disorder: between 1 to 6 months
- Schizophrenia: >6 months
Epidemiology of schizophrenia
Affects approx. 0.3-0.7% of people over lifetime
People born in late winter & early spring have higher incidence of schizophrenia for unknown reasons
- 1 theory involves seasonal variation in viral infections, particularly second trimester exposure to influenza virus
Men and women equally affected, but have different presentations & outcomes:
- Men present in early to mid-20s
- Women present in late 20s
- Men tend to have more negative symptoms & poorer outcome compared to women
Rarely presents before age 15 or after age 55
Strong genetic predisposition:
- 50% concordance rate among monozygotic twins
- 40% risk of inheritance if both parents have schizophrenia
- 12% risk if 1 first-degree relative is affected
Substance use is comorbid in many patients w/ schizophrenia
- Most commonly abused substance is nicotine (>50%), followed by alcohol, cannabis, & cocaine
Post-psychotic depression is phenomenon of schizophrenic patients developing a major depressive episode after resolution of their psychotic symptoms
What is the downward drift hypothesis of schizophrenia?
Lower socioeconomic groups have higher rates of schizophrenia which may be due to the downward drift hypothesis
Postulates that people suffering from schizophrenia are unable to function well in society & hence end up in lower socioeconomic groups
Many homeless people in urban areas suffer from schizophrenia
Pathophysiology of schizophrenia - the dopamine hypothesis
Though the exact cause of schizophrenia is not known, it appears to be partly related to increased dopamine activity in certain neuronal tracts
- Evidence to support this is that most antipsychotics that are successful in treating schizophrenia are dopamine receptor antagonists
- Cocaine & amphetamines increase dopamine activity & can lead to schizophrenic-like symptoms
Dopamine pathways affected in schizophrenia and antipsychotics
Theorized dopamine pathways affected:
- Prefrontal cortical: inadequate dopaminergic activity responsible for negative symptoms
- Mesolimbic: excessive dopaminergic activity responsible for positive symptoms
Other important dopamine pathways affected by antipsychotics:
- Tuberoinfundibular: blocked by antipsychotics, causing hyperprolactinemia, which may lead to gynecomastia, galactorrhea, sexual dysfunction, and menstrual irregularities
- Nigrostriatal: blocked by antipsychotics, causing Parkinsonism/extrapyramidal side effects such as tremor, rigidity, slurred speech, akathisia, dystonia, & other abnormal movements
What is akathisia?
An unpleasant, subjective sense of restlessness & need to move
Often manifested by inability to sit still
Other neurotransmitter abnormalities implicated in schizophrenia
Elevated serotonin: some of second-generation (atypical) antipsychotics (e.g. risperidone & clozapine) antagonize serotonin & weakly antagonize dopamine
Elevated norepinephrine: long-term use of antipsychotics has been shown to decreased activity of noradrenergic neurons
Decreased GABA: decreased expression of enzyme necessary to create GABA in the hippocampus of schizophrenic patients
Decreased levels of glutamate receptors: have fewer NMDA receptors
- This corresponds to psychotic symptoms observed w/ NMDA antagonists like ketamine
Prognostic factors of schizophrenia
Even w/ meds, 40-60% of patients remain significantly impaired after their diagnosis, while only 20-30% function fairly well in society
About 20% of patients w/ schizophrenia attempt suicide & many more experience suicidal ideation
Several factors are associated w/ better/worse prognosis: BETTER PROGNOSIS: - Later onset - Good social support - Positive symptoms - Mood symptoms - Acute onset - Female gender - Few relapses - Good premorbid functioning
WORSE PROGNOSIS:
- Early onset
- Poor social support
- Negative symptoms
- Family history
- Gradual onset
- Male gender
- Many relapses
- Poor premorbid functioning (social isolation, etc.)
- Comorbid substance use
What do CT & MRI scans of patients w/ schizophrenia show?
May show enlargement of ventricles and diffuse cortical atrophy & reduced brain volume
What is neologism?
Neologism is a newly coined word or expression that has meaning only to the person who uses it
Treatment of schizophrenia
Multimodal approach is most effective, & therapy must be tailored to the needs of specific patient
Pharmacologic treatment consists primarily of antipsychotic meds (neuroleptics):
- First generation (typical) antipsychotic medications (e.g. chlorpromazine, fluphenazine, halperidol, perphenazine):
- These are primarily dopamine (D2) antagonists
- Treat positive symptoms w/ minimal impact on negative symptoms
- Side effects: EPS, NMS, tardive dyskinesia
- Second generation (atypical) antispychotic medications (e.g. aripiprazole, asenapine, clozapine, iloperidone, lurasidone, olanzpine, quetiapine, risperidone, ziprasidone):
- These antagonize serotonin receptors (5-HT2) & dopamine (D4>D2) receptors
- Research has shown no significant difference between first- & second-generation antipsychotics in efficacy (selection requires weighing of benefits & risks in individual clinical cases)
- Lower incidence of EPS, but increased risk for metabolic syndrome
- Meds should be taken for at least 4 weeks before efficacy is determined
- Clozapine is reserved for patients who have failed multiple antipsychotic trials due to its increased risk of agranulocytosis
Behavioral therapy:
- Attempts to improve patietns’ ability to function in society
- Patients are helped through variety of methods to improve their social skills, become self-sufficient, & minimize disruptive behaviors
Family therapy & group therapy are useful adjuncts
What is the medical evaluation for metabolic syndrome?
Weight
BMI
Fasting blood glucose
Lipid assessment
Blood pressure
Important side effects & sequelae of antipsychotic meds
Extrapyramidal symptoms
Anticholinergic symptoms
Metabolic syndrome
Tardive dyskinesia
Neuroleptic malignant syndrome
Prolonged QTc interval & other ECG changes
Hyperprolactinemia –> gynecomastia, galactorrhea, amenorrhea, diminished libido, & impotence
Hematologic effects (agranulocytosis seen w/ clozapine - requires frequent blood draws)
Ophthalmologic conditions (thioridazine may cause irreversible retinal pigmentation at high doses; deposits in lens & cornea w/ chlorpromazine)
Dermatologic conditions (rashes & photosensitivity)
What are the extrapyramidal symptoms side effects of antipsychotics? Treatment?
Seen especially w/ use of high-potency first-generation antipsychotics:
- Dystonia (spasms) of face, neck, & tongue
- Parkinsonism (resting tremor, rigidity, bradykinesia)
- Akathisia (feeling of restlessness)
Treatment:
- Anticholinergics (benztropine, diphenhydramien)
- Benzodiazepines / beta-blockers (specifically for akathisia)
What are the anticholinergic symptoms side effects of antipsychotics? Treatment?
Seen especially w/ low-potency first-generation antipsychotics & atypical antipsychotics:
- Dry mouth
- Constipation
- Blurred vision
- Hyperthermia
Treatment:
- As per symptom (eye drops, stool softeners, etc.)
What are the symptoms of metabolic syndrome side effects of antispychotics? Treatment?
Seen w/ second-generation antipsychotics:
- Constellation of conditions (increased BP, increased blood sugar levels, excess body fat around waist, abnormal cholesterol levels) that occur together
- Increase risk for developing cardiovascular disease, stroke, and type 2 diabetes
Treatment:
- Consider switching to first-generation antipsychotic or more “weight-neutral” second-generation antipsychotic (e.g. apiprazole, ziprasidone)
- Monitor lipids & blood glucose
- Refer patient to primary care for appropriate treatment of hyperlipidemia, diabetes, etc.
- Encourage appropriate diet, exercise, & smoking cessation
What are the symptoms of tardive dyskinesia side effects of antipsychotics? Treatment?
Seen more likely w/ first-generation antipsychotics:
- Choreoathetoid movements - usually seen in face, tongue, & head
Cumulative risk of developing tardive dyskinesia from antipsychotics is 5% per year
Treatment:
- Discontinue or reduce medication & consider substituting an atypical antipsychotic (if appropriate)
- Benzodiazepines, Botox, and vitamin E may be used
- Movements may persist despite withdrawal of drug
What are the symptoms of neuroleptic malingant syndrome side effects of antipsychotics?
Seen w/ typically high-potency first-generation antipsychotics:
- Change in mental status, autonomic instability (high fever, labile BP, tachycardia, tachypnea, diaphoresis), “lead pipe” rigidity, elevated creatine phosphokinase (CPK) levels, leukocytosis, & metabolic acidosis
Medical emergency that requires prompt withdrawal of all antipsychotic meds & immediate medical assessment & treatment
May be observed in any patient being treated w/ any antipsychotic meds at any time, but more frequently associated w/ initiation of treatment & at higher IV / IM dosing of high-potency neuroleptics
Patients w/ history of prior NMS are at an increased risk of recurrent episodes when retrialed w/ antipsychotic agents
Diagnosis & DSM-V criteria of schizophreniform disorder
Same DSM-V criteria as schizophrenia
Only difference between the 2 is that in schizophreniform disorder the symptoms have lasted between 1 & 6 months, whereas in schizophrenia the symptoms must be present for > 6 months
Prognosis of schizophreniform disorder
1/3 of patients recover completely
2/3 progress to schizoaffective disorder or schizphrenia
Treatment of schizophreniform disorder
Hospitalization (if necessary)
6-month course of antipsychotics
Supportive psychotherapy
Diagnosis & DSM-V criteria of schizoaffective disorder
Diagnosis is made in patients who:
- Meet criteria for either a major depressive or manic episode during which psychotic symptoms consistent w/ schizophrenia are also met
- Delusions / hallucinations for 2 weeks in absence of mood disorder symptoms (this criterion is necessary to differentiate schizoaffective disorder from mood disorder w/ psychotic features)
- Mood symptoms present for a majority of pyschotic illness
- Symptoms not due to effects of substance (drug / medication) or another medical condition
Prognosis for schizoaffective disorder
Worse w/:
- Poor premorbid adjustment
- Slow onset
- Early onset
- Predominance of psychotic symptoms
- Long course
- Family history of schizophrenia
Treatment of schizoaffective disorder
Hospitalization (if necessary) & supportive psychotherapy
Medical therapy:
- Antipsychotics (second-geenration meds may target both psychotic & mood symptoms)
- Mood stabilizers
- Antidepressants
- ECT may be indicated for treatment of mood symptoms
Diagnosis & DSM-V criteria of brief psychotic disorder
Patient w/ psychotic symptoms as in schizophrenia, but the symptoms last from 1 day to 1 month
There must be eventual full return to premorbid level of functioning
Symptoms must not be due to effects of substance (drug/medication) or another medical condition
Rare diagnosis - much less common than schizophrenia
May be seen in reaction to extreme stress:
- Bereavement
- Sexual assault
- Etc.
Patients w/ borderline personality disorder may have transient, stress-related psychotic experiences
- These are considered part of underlying personality disorder & not diagnosed as brief psychotic disorder
Prognosis of brief psychotic disorder
High rates of relapse, but almost all completely recover
Treatment of brief psychotic disorder
Brief hospitalization (usually required for workup, safety, & stabilization)
Supportive therapy
Course of antispychotics for psychosis
Benzodiazepines for agitation
What is delusional disorder?
Occurs more often in middle-aged or older patients (after age 40)
Immigrants, the hearing impaired, & those w/ family history of schizophrenia are at increased risk
Diagnosis & DSM-V criteria of delusional disorder
Following criteria must be met:
- 1 or more delusions for at least 1 month
- Does not meet criteria for schizophrenia
- Functioning in life not significantly impaired & behavior not obviously bizarre
- While delusions may be present in both delusional disorder & schizophrenia, there are important differences
Types of delusions
Erotomanic type: delusion that another person is in love w/ the individual
Grandiose type: delusions of having great talent
Somatic type: physical delusions
Persecutory type: delusions of being persecuted
Jealous type: delusions of unfaithfulness
Mixed type: more than 1 of the above
Unspecified type: not a specific type as described above
Schizophrenia vs. delusional disorder
Delusions:
- Schizophrenia: bizarre or nonbizarre delusions
- Delusional disorder: usually nonbizarre delusions
Daily functioning:
- S: significantly impaired
- DD: not significantly impaired
Schizophrenia must have 2 or more of the following:
- Delusions
- Hallucinations
- Disorganized speech
- Disorganized behavior
- Negative symptoms
Delusional disorder does not meet criteria for schizophrenia
Prognosis of delusional disorder
Better than schizophrenia w/ treatment:
- > 50% full recovery
- > 20% decreased symptoms
- <20% no change
Treatment of delusional disorder
Difficult to treat, especially given the lack of insight & impairment
Antipsychotic meds are recommended despite somewhat limited evidence
Supportive therapy is helpful
Group therapy should be avoided given patient’s suspiciousness
Examples of psychotic disorders seen within certain cultures:
Koro:
- Psychotic manifestation: intense anxiety that penis will recede into body, possibly leading to death
- Culture: Southeast Asia (e.g. Singapore)
Amok:
- Psychotic manifestation: sudden unprovoked outbursts of violence, often followed by suicide
- Culture: Malaysia
Brain fag:
- Psychotic manifestation: headache, fatigue, eye pain, cognitive difficulties, & other somatic disturbances in male students
- Culture: Africa
Time course of psychotic disorders
<1 month = brief psychotic disorder
1 months - 6 months = schizophreniform disorder
>6 months = schizophrenia
Prognosis of psychotic disorders
Mood disorder w/ psychotic features > schizoaffective disorder > schizophreniform disorder > schizophrenia
Quick and easy distinguishing features of psychotic disorders
Schizophrenia: lifelong psychotic disorder
Schizophreniform: schizophrenia for >1 and <6 months
Schizoaffective: schizophrenia + mood disorder
Schizotypal (personality disorder): paranoid, odd / magical beliefs, eccentric, lack of friends, social anxiety)
- Criteria for overt psychosis are not met
Schizoid (personality disorder): solitary activities, lack of enjoyment from social interactions, no psychosis
