Psychotic disorders Flashcards
Common types/themes of delusions
Persecution/paranoia (people after me)
Ideas of reference (TV talking to me)
Thought broadcasting (others can read my thoughts) or thought insertion (thoughts are being placed in my head)
Grandeur (I am the king of the mountaintop)
Guilt (I’m responsible for WWII)
Somatic delusions (I have __ disease)
What is an illusion?
Misperception of sensory stimulus
What is a hallucination?
Sensory perception without sensory stimulus
-Auditory, visual, olfactory, or tactile
Differential diagnosis (broad) of psychosis
Psychosis 2/2 medical condition Substance or medication induced Delirium/dementia Bipolar disorder, manic or mixed episode Major depression with psychotic features Brief psychotic disorder Schizophreniform disorder Schizoaffective disorder Delusional disorder
Medical causes of psychosis
CNS disease (stroke, MS, cancer, Alzheimer's, PD, HD, syphilis, epilepsy, encephalitis, HIV, etc) Endocrinopathies (Addison's, Cushing's, thyroid, hyper/hypocalcemia, hypopituitarism) Nutritional/vitamin deficiency (B12, folate, niacin) Other (Rheum disease, porphyria)
DSM-V criteria for psychotic disorder due to other medical condition
Prominent hallucinations or delusions
Sypmtoms do not occur only during an episode of delirium
Evidence from history/physical/lab support medical cause
Medications that can cause medication-induced psychotic disorder
Anesthesia, antibiotics, steroids, anti-parkinsonian drugs, anticonvulsants, antihistamines, anticholinergics, antihypertensives, NSAIDs, digitalis, methylphenidate, chemotherapy
Substance-induced: Alcohol, cocaine, LSD, PCP, ecstasy, cannabis, benzos, barbiturates, inhalants
Positive symptoms of schizophrenia
Hallucinations, delusions, bizarre behavior, disorganized speech
*Respond well to antipsychotic meds
Negative symptoms of schizophrenia
Flat or blunted affect, anhedonia, apathy, alogia, lack of interest in socialization
*Often resistant to treatment
Cognitive symptoms of schizophrenia
Impairments in attention, executive function, and working memory
Three phases of schizophrenia
Prodromal phase: decline in functioning, social withdrawal, irritability
Psychotic phase: Perceptual disturbances, delusions, and disordered thought
Residual phase: Follows an episode of active psychosis. Mild hallucinations or disturbances and negative symptoms
Diagnostic criteria for schizophrenia
Two or more of the following present for at least one month:
-Delusions
-Hallucinations
-Disorganized speech
-Grossly disorganized or catatonic behavior
-Negative symptoms
Significant social, occupational, or self-care functional impairment
Duration of illness>6mos
Symptoms not due to substance or medical condition
Typical findings on psychiatric exam in patients with schizophrnia
Disheveled appearance Flat affect Disorganized thought process Intact procedural memory and orientation Auditory hallucinations Paranoid delusions Ideas of reference Lack of insight
Difference in male vs. female presentations of schizophrenia
Men tend to present in early/mid 20s, women in late 20s
Men tend to have more negative symptoms and worse outcomes
Epidemiology of schizophrenia
Ages 15-55
Strong genetic component
Often comorbid substance abuse
Pathophysiology of schizophrenia
Increase in dopaminergic activity in mesocorticolimbic tracts (–> positive symptoms)
Decrease in dopaminergic activity in prefrontal-cortical tracts (–> negative symptoms)
Effects of antipsychotic blockade of dopaminergic activity in tuberoinfundibular pathway
Reduces tonic dopaminergic inhibition of prolactin release, leading to hyperprolactinemia (–> gynecomastia, galactorrhea, sexual dysfunction, menstrual irregularities)
Effects of antipsychotic blockade of dopaminergic activity in nigrostriatal pathway
Parkinsonism/extrapyramidal signs (tremor, rigidity, slurred speech, akathisia, dystonia, etc)
Other (besides dopamine) neurotransmitter abnormalities in schizophrenia
Elevated serotonin (some second gen antipsychotics [risperidone and clozapine] block serotonin)
Elevated norepinephrine
Decreased GABA
Decreased number of glutamate NMDA receptors
Factors associated with better prognosis in schizophrenia
Later onset Good social support Positive symptoms Mood symptoms Acute onset Females Few relapses Good premorbid functioning
Factors associated with worse prognosis in schizophrenia
Early onset Poor social support Negative symptoms Family history gradual onset Male Many relapses Poor premorbid functioning Substance use
Pharmacologic treatment of schizophrenia
Typical or atypical antipsychotics
Which antipsychotics are more likely to produce extrapyramidal signs/symptoms (EPS)?
Typical, high-potency (haloperidol) antipsychotics
Treatment for EPS
Anticholinergics (benztropine, diphenhydramine), beta-blockers for akathisia (or benzos)
Low-potency typical antipsychotic meds have what receptor activities?
HAM
Histaminergic blockade
alpha-adrenergic blockade
Muscarinic blockade
Main side effect of atypical antipsychotics?
Metabolic syndrome (insulin resistance, weight gain, increased BP, hyperlipidemia)
**Less with aripiprazole or ziprasidone
What is schizophreniform disorder?
Features of schizophrenia for <6 months but >1mo
What is brief psychotic disorder?
Features of schizophrenia for <1mo
Prognosis and treatment of schizophreniform disorder?
1/3 of patients recover completely, 2/3 progress to schizoaffective or schizophrenia
Treat with 6 month course of antipsychotics and psychotherapy
Diagnostic criteria for schizoaffective disorder
- Major depressive or manic episode during which psychotic symptoms are present
- Delusions or hallucinations for 2 weeks in the absence of mood disorder symptoms (this criterion distinguishes between schizoaffective and mood disorder with psychotic features)
- Mood symptoms present for majority of illness
- Symptoms not due to effects of a substance/medical condition
Treatment for schizoaffective disorder?
Supportive psychotherapy
Antipsychotics (atypicals may help more with mood)
Mood stabilizers, anti-depressants, or ECT may help
Diagnostic criteria for delusional disorder
One or more delusions for at least 1 month
Doesn’t meet criteria for schizophrenia
Functioning in life not significantly impaired, and behavior not obviously bizarre
Types of delusions
Erotomanic (this person is in love with me) Grandiose (I am awesome) Somatic (I have liver failure) Persecutory (they are after me) Jealous (she's cheating on me) Mixed Unspecified
Treatment for delusional disorder
Supportive therapy
Antipsychotic medications
