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Psychotic Disorders Flashcards

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1
Q

What is psychosis?

A

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

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2
Q

What are delusions?

A

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

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3
Q

What are bizarre delusions?

A

False belief that is impossible

Ex: “A martian fathered my baby & inserted a microchip in my brain”

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4
Q

What aree nonbizarre delusions?

A

False belief that is plausible, but is not true

Ex: “The neighbors are spying on me by reading my mail”

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5
Q

How are delusions categorized?

A

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

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6
Q

What are examples of perceptual disturbances?

A

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
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7
Q

Differential diagnosis of psychosis

A

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

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8
Q

What are causes for psychotic disorder due to another medical condition?

A

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

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9
Q

DSM-V criteria for psychotic disorder due to another medical condition

A

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

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10
Q

What are causes for substance/medication-induced psychotic disorder?

A

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)

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11
Q

DSM-V criteria for substance/medication-induced psychotic disorder

A

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

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12
Q

What is schizophrenia?

A

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

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13
Q

What are the categories of symptoms of schizophrenia?

A 
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

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14
Q

What are examples of catatonia seen in schizophrenia?

A

Stereotyped movements

Bizarre posturing

Muscle rigidity

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15
Q

What are the 3 phases of schizophrenia?

A
  1. 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
  2. Psychotic: perceptual disturbances, delusions, & disordered thought process/content
  3. Residual: occurs following episode of active psychosis
    - Marked by mild hallucinations/delusions, social withdrawal, & negative symptoms
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16
Q

DSM-V criteria for schizophrenia

A

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

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17
Q

When is clozapine considered as a treatment for schizophrenia?

A

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

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18
Q

Psychiatric exam of patients w/ schizophrenia

A

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
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19
Q

What is the difference between brief psychotic disorder, schizophreniform disorder, & schizophrenia?

A

Time:

  • Brief psychotic disorder: <1 month
  • Schizophreniform disorder: between 1 to 6 months
  • Schizophrenia: >6 months
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20
Q

Epidemiology of schizophrenia

A

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

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21
Q

What is the downward drift hypothesis of schizophrenia?

A

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

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22
Q

Pathophysiology of schizophrenia - the dopamine hypothesis

A

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
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23
Q

Dopamine pathways affected in schizophrenia and antipsychotics

A

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
24
Q

What is akathisia?

A

An unpleasant, subjective sense of restlessness & need to move

Often manifested by inability to sit still

25
Q

Other neurotransmitter abnormalities implicated in schizophrenia

A

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

26
Q

Prognostic factors of schizophrenia

A

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
27
Q

What do CT & MRI scans of patients w/ schizophrenia show?

A

May show enlargement of ventricles and diffuse cortical atrophy & reduced brain volume

28
Q

What is neologism?

A

Neologism is a newly coined word or expression that has meaning only to the person who uses it

29
Q

Treatment of schizophrenia

A

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

30
Q

What is the medical evaluation for metabolic syndrome?

A

Weight

BMI

Fasting blood glucose

Lipid assessment

Blood pressure

31
Q

Important side effects & sequelae of antipsychotic meds

A

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)

32
Q

What are the extrapyramidal symptoms side effects of antipsychotics? Treatment?

A

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)
33
Q

What are the anticholinergic symptoms side effects of antipsychotics? Treatment?

A

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.)

34
Q

What are the symptoms of metabolic syndrome side effects of antispychotics? Treatment?

A

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
35
Q

What are the symptoms of tardive dyskinesia side effects of antipsychotics? Treatment?

A

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
36
Q

What are the symptoms of neuroleptic malingant syndrome side effects of antipsychotics?

A

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

37
Q

Diagnosis & DSM-V criteria of schizophreniform disorder

A

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

38
Q

Prognosis of schizophreniform disorder

A

1/3 of patients recover completely

2/3 progress to schizoaffective disorder or schizphrenia

39
Q

Treatment of schizophreniform disorder

A

Hospitalization (if necessary)

6-month course of antipsychotics

Supportive psychotherapy

40
Q

Diagnosis & DSM-V criteria of schizoaffective disorder

A

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
41
Q

Prognosis for schizoaffective disorder

A

Worse w/:

  • Poor premorbid adjustment
  • Slow onset
  • Early onset
  • Predominance of psychotic symptoms
  • Long course
  • Family history of schizophrenia
42
Q

Treatment of schizoaffective disorder

A

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
43
Q

Diagnosis & DSM-V criteria of brief psychotic disorder

A

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

44
Q

Prognosis of brief psychotic disorder

A

High rates of relapse, but almost all completely recover

45
Q

Treatment of brief psychotic disorder

A

Brief hospitalization (usually required for workup, safety, & stabilization)

Supportive therapy

Course of antispychotics for psychosis

Benzodiazepines for agitation

46
Q

What is delusional disorder?

A

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

47
Q

Diagnosis & DSM-V criteria of delusional disorder

A

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
48
Q

Types of delusions

A

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

49
Q

Schizophrenia vs. delusional disorder

A

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

50
Q

Prognosis of delusional disorder

A

Better than schizophrenia w/ treatment:

  • > 50% full recovery
  • > 20% decreased symptoms
  • <20% no change
51
Q

Treatment of delusional disorder

A

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

52
Q

Examples of psychotic disorders seen within certain cultures:

A

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
53
Q

Time course of psychotic disorders

A

<1 month = brief psychotic disorder
1 months - 6 months = schizophreniform disorder
>6 months = schizophrenia

54
Q

Prognosis of psychotic disorders

A

Mood disorder w/ psychotic features > schizoaffective disorder > schizophreniform disorder > schizophrenia

55
Q

Quick and easy distinguishing features of psychotic disorders

A

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

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