Psychotic disorders Flashcards
What is a delusion?
a fixed, false belief
What is a hallucination?
perceptual experiences (sight/touch/smell, etc) without external stimulus
How do you differentiate schizophrenia, schizophreniform, and brief psychotic disorder?
Based on time
- Brief Psychotic Disorder <1 month
- Schizophreniform 1-6 months
- Schizophrenia Disorder >6 months
DSM criteria for schizophrenia
A. two (or more) of the following, each present for a significant portion of time during a 1 mo period (or less if successfully treated). At least one of these must be (1), (2), or (3)
- *1. delusions
2. hallucinations
3. disorganized speech** (e.g. frequent derailment or incoherence)
4. grossly disorganized or catatonic behaviour
5. negative symptoms (i.e. diminished emotional expression or avolition)
B. decreased level of function: for a significant portion of time since onset, one or more major areas affected (e.g. work, interpersonal relations, self-care) is markedly decreased (or if childhood/adolescent onset, failure to achieve expected level)
C. at least 6 mo of continuous signs of the disturbance. Must include at least 1 mo of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms (during which, disturbance may manifest by only negative symptoms or by two or more Criterion A symptoms present in an attenuated form (e.g. odd beliefs, unusual perceptual experiences)
D. rule out schizoaffective disorder and depressive or bipolar disorder with psychotic features because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness
E. rule out other causes: substances (e.g. drug of abuse, medication)
F. if history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 mo (or less if successfully treated)
Management of acute psychosis and mania? (toronoto notes)
- Ensure safety of self, patient, and other patients
- Have an exit strategy
- Decrease stimulation
- Assume a non-threatening stance
- IM medications (benzodiazepine + antipsychotic) often needed as patient may refuse oral medication
- Physical restraints may be necessary
- Do not use antidepressants or stimulants
Name some disorganised behaviours in schizophrenia
- Catatonic stupor: fully conscious, but immobile, mute, and unresponsive
- Catatonic excitement: uncontrolled and aimless motor activity, maintaining bizarre positions for a long time
- Stereotypy: repeated but non-goal-directed movement (e.g. rocking)
- Mannerisms: goal-directed activities that are odd or out of context (e.g. grimacing)
- Echopraxia: imitates movements and gestures of others
- Automatic obedience: carries out simple commands in robot-like fashion
- Negativism: refuses to cooperate with simple requests for no apparent reason
- Inappropriate affect, neglect of self-care, other odd behaviours (random shouting)
Typical age of onset of schizophrenia?
mean age of onset: females late-20s; males early-to mid-20s
Suicide risk in schizophrenia?
10% die by suicide
30% attempt suicide
Signs + symptoms of schizophrenia
- POSITIVE
- hallucinations (eg hearing voices)
- delusions (eg persecutory, bizarre, grandiose)
- impaired insight
- disorganised thinking and speech
- NEGATIVE
- lack of motivation
- poor self-care
- blunted affect
- reduced speech output
- social withdrawal
- COGNITIVE
- impaired planning
- reduced mental flexibility
- impaired memory
- impaired social cognition
- EXCITEMENT
- disorganised behaviour
- aggression
- hostility
- MOOD
- depression
- anxiety
Psychosocial treatment for schizophrenia
- psychotherapy (individual, family, group), supportive, CBT
- ACT (Assertive Community Treatment): mobile mental health teams that provide individualized
- treatment in the community and help patients with medication adherence, basic living skills, social support, job placements, resources
- social skills training, employment programs, disability benefits
- housing (group home, boarding home, transitional home)
Pathophysiology of schizophrenia
- neurodegenerative theory: natural history may be a rapid or gradua ldecline in function and ability to communicate
- glutamate system may mediate progressive degeneration by excitotoxic mechanism which leads to production of free radicals
- neurodevelopmental theory: abnormal development of the brain from prenatal life
- neurons fail to migrate correctly, make inappropriate connections, and apoptose in later life
Good prognostic factors for schizophrenia
- Acute onset
- Shorter duration of prodrome
- Female gender
- Good cognitive functioning
- Good premorbid functioning
- No family history
- Presence of affective symptoms
- Absence of structural brain abnormalities • Good response to drugs
- Good support system
DSM criteria for schizophreniform disorder
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
- *1. Delusions.
2. Hallucinations.
3. Disorganized speech** (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.”
C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness.
D. The disturbance is not attributable to the physiological effects
DSM criteria for brief psychotic disorder
A. presence of ONE of the following symptoms (must be from 1, 2, or 3)
- delusions
- hallucinations
- disorganized speech
- grossly disorganised/catatonic behaviour
B. duration 1 day - 1 month, returns to premorbid level of functioning
C. disturbance is not better explained by MDD or BPD with psychotic features
Treatment of first psychotic episode
First line:
- amisulpride
- aripiprazole
- olanzapine
- paliperidone
- quetiapine
- risperidone
- ziprasidone
Second line:
- asenapine
- sertindole
