Psychotic Disorders

Question 1

Overview

Answer 1

I. Psychosis is generally defined to mean “loss of contact with reality” and can involve firmly held false beliefs and/or sensory experiences involving any of the five senses that do not have corresponding environmental stimuli.

Question 2

History

Answer 2

a. Historical
i. The term psychosis was first used in 1841 to indicate a “disease of the mind” in contrast to neurosis which meant “disease of the nervous system”.
ii. Two notable individuals who shaped our understanding of psychotic disorders
1. Emil Kraepelin
a. Founder of modern psychiatry who developed the classification system for psychiatric diseases
b. Called schizophrenia “dementia praecox” with belief that schizophrenia was neurodegenerative illness
2. Eugene Bleuler
a. Contemporary of Kraeplin’s who recognized that individuals with different “dementias” had different ultimate outcomes. Coined term “schizophrenia” to describe individuals with less severe cognitive symptoms whose illness progressively worsened to a point then plateaued.

Question 3

II. Epidemiology

Answer 3

a. Lifetime prevalence of schizophrenia is roughly 1.1% per the Epidemiologic Catchment Area (ECA) study
b. Male to female ratio of 1:1

Question 4

Schizophrenia: Diagnosis

Answer 4

a. Two (or more) of the following, each present for a significant portion of time during a 1-month period. At least one of these must be (1), (2), or (3):
i. Delusions
ii. Hallucinations
iii. Disorganized speech
iv. Grossly disorganized behavior or catatonic behavior
v. Negative symptoms
b. For a significant portion of time level of functioning in one or more life areas is markedly below level prior to disease onset.
c. Continuous signs of disturbance for 6 months or more.

Question 5

Schizo Etiology

Answer 5

d. Etiology - many etiologic processes appear relevant and what we currently consider “schizophrenia” almost certainly represents a heterogeneous group of illnesses with a common presenting phenotype
i. Developmental and Psychological Factors
ii. Genetic Factors
1. Familial transmission
a. Risk of disease in 1st degree relative ~10%
b. Identical twins – 40-65% risk
c. Both parents with schizophrenia
i. Risk 40-50%
d. One parent or one sibling
i. Risk 5-20%

Question 6

Suceptible genes in schizo.

Answer 6

2. Dozens of susceptibility genes have been discovered implicating numerous functions both within and outside the CNS. The most consistent genetic relationship at a population level is associated with the MHC locus on chromosome 6. Gene codes for alleles of CD4 which are associated with different levels of expression of C4A and C4B. Overactivity of C4A in the brain may lead to excessive pruning of synapses during adolescence and early adulthood. This may contribute to the development of schizophrenia for some individuals.

Question 7

Schizophrenia: 22q11 deletion syndrome

Answer 7

– “DiGeorge Syndrome” or velo-cardio-facial syndrome

a. Only recurrent, clinically recognizable, genetic cause of schizophrenia with currently available laboratory testing
b. ~90% spontaneous mutation, 10% inherited
c. 1% of patients with schizophrenia have this deletion
d. 20-30% of 22q11 patients develop schizophrenia or schizoaffective disorder
e. Symptoms of schizophrenia are indistinguishable though 22q11 patients are more likely to have intellectual impairment

Question 8

Schizophrenia: Neurotransmitters: Dopamine (DA)

Answer 8

a. Higher than normal number of D-2 receptors
b. PET scans show elevated activity of DA neurons in limbic system which correlate with positive symptoms
c. PET scans show diminished activity of DA neurons in frontal and prefrontal areas with correlate with negative symptoms

Question 9

Schizophrenia: Neurotransmitters: Serotonin (5-HT)

Answer 9

a. Serotonergic neurons are widely distributed and often inhibit dopaminergic neurons
b. Decreased levels of 5-HT metabolites are often found in patients with schizophrenia

Question 10

Schizophrenia: Neurotransmitters: Glutamate

Answer 10

a. Decreased in schizophrenia
i. Glu receptor antagonists (ie, PCP) cause schizophrenia-like psychotic symptoms
b. MRI and post-mortem studies show decreased Glu in prefrontal cortex
c. Glu neurons interact with both DA and 5-HT neurons
d. Linked to cognitive deficits in schizophrenia

Question 11

Schizophrenia: Neuroanatomy

Answer 11

1. Structural
   a. Over-activity in limbic areas – positive symptoms
   b. Under-activity in frontal lobes – negative symptoms
2. Functional
   a. Enlargement of the lateral ventricles
   i. Loss of brain mass due to developmental failure of cell death

Question 12

Schizophrenia: Symptomotology

Answer 12

i. Positive symptoms – added to the presentation
1. Hallucinations
2. Delusions
3. Catatonia
4. Agitation

ii. Negative symptoms – absent from the presentation
1. Flattened affect
2. Apathy
3. Social withdrawal
4. Anhedonia
5. Poverty of thought
6. Poverty of speech

Question 13

Schizophrenia: Symptomotology 2

Answer 13

iii. Thought process/Thought Form
1. Loosening of associations – connections among ideas become absent or obscure
2. Neologisms – creation of words
3. Verbigerations – persistent repetition of words/phrases
4. Echolalia – repetition of word or phrase of examiner
5. Mutism – functional inhibition of speech
6. Word salad – unintelligible mixture of random words
7. Poverty of thought and Poverty of speech – speech may be complex or limited but overall content is devoid of much information
8. Thought blocking – sudden interruption in speech (and presumably flow of thought)
a. Possibly secondary to hallucination but patient may be unwilling or unable to acknowledge the cause

Question 14

Schizophrenia: Thought content: Delusion

Answer 14

1. Delusions – “fixed, false beliefs”; cannot be changed by logical reasoning and are inconsistent with beliefs typical for the patient’s cultural group (though they may have cultural content); may be pervasive to patient’s life or may be circumscribed and difficult to locate on typical interview
   a. Delusions of persecution – others are trying to harm, spy on, interfere with affairs of patient
   b. Delusions of reference – random events have special meaning to patient
   c. Delusions of influence – belief patient’s thoughts are controlled by outside sources
   d. Thought broadcasting – patient’s thoughts are being sent directly to an outside source
   e. Grandiose delusions – patients belief they are elevated in importance; more common in psychotic mania
   f. Somatic delusions – belief the body has been manipulated in some way; device inserted, body controlled by others, etc.

Question 15

Schizophrenia: Thought content: Hallucinations

Answer 15

2. Hallucinations – sensory experiences that occur without corresponding environmental stimuli
   a. Auditory hallucinations – range from indistinct/muffled sounds to complex and multiple voices
   i. Command hallucinations – voice(s) tell patient to perform an action; may be so persistent that they are difficult to resist
   b. Visual hallucinations – occur in schizophrenia but are more common in “organic” (non-psychiatric) disorders such as delirium
   c. Other hallucinations – tactile, gustatory, olfactory; more common in non-psychiatric illnesses but in schizophrenia often connected to delusional system

Question 16

Schizophrenia: Thought content: Illusions

Answer 16

3. Illusions – misperceptions of real environmental objects or events; occur in disordered and healthy individuals
   a. “Déjà vu” – happened when hasn’t
   b. “Jamais vu” – hasn’t happened when has
   c. Hypersensitivity – to light, sound, etc.
   d. Distorted perception of time
   e. Misperception of movement

Question 17

Schizophrenia: Cognitive symptoms

Answer 17

1. Impaired executive functioning – planning, decision-making, mental flexibility
2. Impaired attention and memory
   a. Working memory
3. Impaired learning
   a. Loss of educational and occupational progress

Question 18

Schizophrenia: Other Negative symptoms

Answer 18

1. Affect – flattened, blunted, inappropriate; confounded by Parkinsonian effect of drugs
2. Sense of self – lost perception of separateness from others/community
3. Avolition – difficulty initiating and maintaining goal-directed activities

Question 19

Schizophrenia: Clinical Course

Answer 19

i. Highly variable
1. Prodromal phase vs not
2. Remission (residual phase) vs none
3. Deteriorating course vs Full remission/recovery (rare)

Question 20

Schizophrenia: Clinical Course 2

Answer 20

ii. Variability in course is one strong indicator for multi-disease/common phenotype model
iii. Onset - bimodal
1. Late teens to early 20s
a. Earlier in men than women
b. Multiple stresses including separation from parents, transition from education to work settings, marriage, children, etc.
c. Stage of neurodevelopment
2. Second smaller peak in late 40s particularly for women
3. Like many illnesses may have precipitating event (e.g., social or economic stress, trauma, drug use, etc.)
4. Initial presentation – variable and has prognostic significance
a. Abrupt onset – develops over 1-2 days in response to stressor
i. GOOD prognosis as most resolve quickly
b. Insidious prodromal phase – onset over months with social withdrawal, peculiar behavior, neglect of hygiene, blunted affect, odd beliefs, apathy
i. POOR prognosis

Question 21

Schizophrenia: Prognostics Variables

Answer 21

1. POOR – predominance of negative symptoms, insidious onset, poor cognitive performance on testing, abnormalities on CT, lack of mood symptoms
2. GOOD – predominance of positive symptoms, acute onset, late onset, female, good premorbid functioning, presence of mood symptoms, family history of mood disorders

Question 22

Schizophrenia: QOL

Answer 22

i. Small social groups (support networks)
ii. Impaired educational achievement (despite normal or high intelligence)
iii. Barriers to employment (improves outcomes but difficult to obtain and maintain)
iv. Fewer and shorter marriages
v. Criminal behavior – when services are not provided through mental health system enter justice system usually for minor, nonviolent crimes
vi. Homelessness – 5-8% are homeless
vii. High psychiatric co-morbidity – anxiety, depression, substance-use disorders

Question 23

Schizoaffective Disorder: Diagnosis: DSM 5 Criteria

Answer 23

i. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia
ii. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime of the illness
iii. Symptoms that meet criteria for a mood episode are present for a majority of the total duration of the active and residual portions of the illness.
iv. The disturbance is not attributable to the effects of a substance or another medical condition.
v. Specify type: 
Bipolar Type: if the disturbance includes a Manic or a Mixed Episode (or a Manic or a Mixed Episode and Major Depressive Episodes) 
Depressive Type: if the disturbance only includes Major Depressive Episodes

Question 24

Schizoaffective Disorder:

Differential Diagnosis

Answer 24

i. Mood Disorders with psychotic features
1. Major depressive disorder with psychotic features – psychotic symptoms are present ONLY during course of FULL major depressive episode
a. Major depressive episodes – Psychotic features are typically mood congruent. Depressive features (flat affect, anhedonia, psychomotor retardation, etc.) may resemble negative symptoms of schizophrenia.

2. Bipolar disorder with psychotic features - psychotic symptoms are present ONLY during course of FULL manic or depressive episode
   a. Manic episodes – Many individuals with severe mania experience psychotic symptoms including AVHs, delusions, bizarre behaviors, etc. Careful history will reveal additional mood symptoms. Behavioral observations and MSE will also likely reveal differentiating factors.

Question 25

a. Brief psychotic disorder

Answer 25

only requires 1 symptom (hallucinations, delusions, etc.) and duration is between 1 day and 1 month.
i. Return to premorbid functioning is required (given provisional specifier while symptomatic)

Question 26

b. Schizophreniform disorder

Answer 26

all same criteria as schizophrenia but duration is 1 month to 6 months.

Question 27

c. Delusional Disorder

Answer 27

1 or more delusions in setting of otherwise retained functional behavior
i. Erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified

Question 28

Miscellaneous

Answer 28

a. Postpartum psychosis
b. Posttraumatic Stress Disorder – setting of flashbacks and can include hallucinations and illusions
c. Personality Disorders – lack acute psychotic episodes and deteriorating course of schizophrenia
i. Schizoid
ii. Schizotypal
iii. Paranoid
iv. Borderline

Question 29

Miscellaneous 2

Answer 29

d. Psychotic Disorders secondary to non-psychiatric medical conditions
i. Vascular Disorders – especially older patients, cerebral vasculitis
ii. Autoimmune disorders – SLE particularly prone
iii. Nutritional deficiencies
iv. Metabolic disturbances
v. Sleep disorders
vi. Hydrocephalus – obstructive and normal pressure
vii. Drug intoxication/withdrawal
viii. Epilepsy – complex partial and absence
ix. Dementias – all can cause psychosis but Lewey-Body dementia and Parkinsonian dementia are often described with vivid hallucinations
x. Infections, TBI, neoplasms, toxicities (lead, carbon monoxide, etc.), endocrine disorders
xi. NOTE: many GMCs cause delirium which can usually be readily distinguished on mental status examination!!!

Question 30

e. Developmental Disabilities

Answer 30

PDDs include eccentric behavior, poor social skills, flat or bizarre affect, lack of empathy, etc. but do not have positive symptoms of schizophrenia

i. How to know the difference?
1. Age of onset, stable vs deteriorating course, lack of positive symptoms
2. May be co-morbid with primary psychotic illness

Question 31

f. Cultural influence and culture-specific disorders

Answer 31

i. Provider may confuse beliefs and behavior patterns associated with specific culture with schizophrenia. If unsure then consult with physicians who have knowledge or experience with culture in question.

Question 32

1. Amok (Malaysia, Indonesia, Philippines)

Answer 32

episode of dissociative brooding over perceived wrong then sudden violent behavior followed by amnesia for event. Often delusional with other psychotic features.

Question 33

Koro (South and East Asia

Answer 33

delusional belief that penis will recede inside body and cause death

Question 34

Treatment for Psychotic Disorders

Answer 34

1. Treatment takes recovery-oriented approach – goal is to achieve optimum functioning in community with as much autonomy as possible
2. Approximately 90% of individuals may live outside of hospital setting the majority of the time
3. Hospitalization – utilized for risk of SI/HI, command hallucinations of threatening nature with belief patient may act on them, extreme paranoia, significant confusion with deterioration in functioning
4. Group Therapy – a mainstay of treatment in both inpatient and outpatient settings; used in conjunction with medications
   a. Communication
   b. Symptom alleviation
   c. Social skills

Question 35

Treatment for Psychotic Disorders 2

Answer 35

5. Individual Therapy – focus on supportive therapy; attempts to build close therapeutic relationships and/or nondirective techniques cause anxiety (particularly in paranoid patients)
   a. Education, problem solving, reasonable expectations, crisis intervention, limit setting, illness self-management
6. Community Treatment
   a. Case management
   b. Help patient access community resources
   c. Treatment planning and monitoring
   d. Intensive case management (ACT, MHICM, etc.)
   i. Have fewer clients and see patient multiple times per week
   ii. Oversee med administration including transporting to medical appointments
   iii. Assist with finances – bill paying, insurance, housing issues, etc.
   e. Advocacy - NAMI
   f. Vocational training/rehabilitation

Question 36

Treatment for Psychotic Disorders 3

Answer 36

7. Pharmacotherapy (please see Psychopharmacology II lecture for more details on medication treatments)
   a. 1st generation antipsychotics – primarily block D2 receptors
   i. EPS – dystonia, akathesia, parkinsonism, tardive dyskinesia
   b. 2nd generation (atypical) antipsychotics – block D2 and 5HT2 receptors with additional unique receptor profiles for each agent
   i. Less EPS risk
   ii. Weight gain, metabolic syndrome
   c. Long-acting injections (depot formulations)
   i. 2 first-generation and 4 second-generation medications
   ii. Strongly consider for patients with history of violence and/or medication noncompliance