Psychotic Disorders Flashcards
Psychosis basic description
Distorted perception of reality characterized by delusions hallucinations and disorganized speech/thought, catatonic behavior
Often possess negative symptoms as well
- flat affect
- impaired self-care
- avolition
Can occur in patients with medical illness, psychiatric illnesses or both
Types of hallucinations
Hallucinations = perceptions of an absent external stimuli
Auditory (more common in primary psychotic disorders)
Visual (more common with medical disorders and toxidrome consequences, rather than psychotic)
Tactile (more common in alcohol withdrawal and stimulant use)
Olfactory (more common in temporal lobe epilepsy and in brain tumors/lesions, or aura migraines)
Gustatory (usually only seen in epilepsy)
Hypnagogic (going to sleep related only)
- sometimes related to narcolepsy or sleep disorders
- often is normal though*
Hypnopompic (waking from sleep only)
- sometimes related to narcolepsy or sleep disorders
- often is normal though*
Delusions
Fixed false beliefs that are held despite presentation to the contrary. Also is NOT accounted for by cultural norms
Examples:
- paranoia
- persecutors ideation
- ideas of reference (getting messages specifically for them from some stimuli that is not there)
- thought insertion/broadcasting
- delusions of control (“there is a chip in my body controlling me”)
- grandiose delusions (false idealization about themselves)
- erotomainic delsions (belief someone is in love with the patient despite proof against that)
Disorganized thinking
Can be speech or thoughts
- tangent speech/thinking
- nonsensical transitions
- neologisms (making up words that aren’t real)
How to different wernickes aphasia from schizophrenia word Salad?
Word salad/aphasia
- Says words that make no sense but there is a common theme that they are trying to say
Schizophrenia/psychosis disorganized
- there is no idea association between the word salad
Primary vs secondary psychotic disorders
Primary = arises de novo or from an unidentified source
Secondary = arises from a medical condition or a substance induced cause usually
- the cause can be identified
Schizophrenia
Chronic progressive neurodegenerative illness causing profound functional impairment.
Includes the following catagories:
1) positive features: need at least 1 of the first 4
- hallucinations
- delusions
- unorganized thought
- disorganized speech
- “bizarre behavior”
2) negative features:
- flat/blunted affect
- apathy
- social withdrawal
- alogia (non verbal)
3) cognitive disorders
- severe functional impairment
- lack of insight into the illness
- Diagnosis requires at least two of the following active symptoms Above, with at least 1 being one of the positive features*
- also must be active for at least 1 month and present in general for over AT LEAST the past 6 months of onset
- also must rule out actual medical diagnosis/disorders
Is believed to be due to increased serotonergic activity and altered dopaminergic activity. Also decreased dendritic branching
- venticulomegaly can be present on brain imaging (not diagnostic)
Worldwide prevalence = 1% worldwide
- men = early 20s-30s
- women = late 20s -30s
- both sexes increase suicidal ideology
- *heavy cannabis use and tobacco use is associated with increased risk of schizophrenia and other anxiety disorders
- *if was a complicated birth, increases risk of developing schizophrenia
- *there is genetic predisposition, however external factors are required to activate it.
- increased risk of diabetes/hyperlipidemia/HTN/cardiovascular diseases
if schizophrenic symptoms start at elderly age, it is likely NOT SCHIZOPHRENIA, and more so medical condition
Treatment = atypical antipsychotics (risperidone)
- positive symptoms usually go away, but negative symptoms often persist even with treatment
- also tell them to stop smoking if they are smoking*
Brief psychotic disorders
Stress related pseudo-schizophrenia.
Possess at least 1 of the positive symptoms of schizophrenia that is lasting LESS than 1 month
Schizophreniform disorder
Slightly worse than brief psychotic disorder but not quite full blown schizophrenia
- middle ground
Possess at least 2 symptoms (with at least 1 positive) of the schizophrenia symptoms
- lasts between 1 month and 6 months, but NOT MORE than 6 months
treatment = still treat with antipsychotics targeting D2 receptors
Schizoaffective disorder
Is essentially schizophrenia with occasional mood disorders in conjunction (mania/bipolar and depressive)
Criteria:
1) delusions or hallucinations for at least 2 or more weeks in the absence of mania or depression episodes*
2) for rest of the disorder must also have a major mood disorder and delusions or hallucinations at some point
3) not attributable to effects of a substance or another medical condition
bipolar subtype: patient has had manic episodes
Depressive subtype: patient has had no manic episodes and/or has depression
Treatment = still treat with antipsychotics targeting D2 receptors. Also treat type related symptoms as needed.
Neurochemical pathways assoacited with schizophrenia
1) mesolimbic
- increases DA projections and causes the POSITIVE symptoms in schizophrenia
2) Mesocortical
- decreases DA projections and causes the NEGATIVE symptoms in schizophrenia
3) Nigrostriatal
- this is often a pathway affected by drugs used to treat schizophrenia
- causes dyskinesia
4) Tuberohypophyseal
- this is often a pathway affected by treatment side effects
- causes hyperprolactinemia
How to ask about delusions and hallucinations
Hallucinations = be blunt and just ask
Delusions = be less blunt and ask generalized questions that aren’t directed toward them
Delusional disorder criteria
The presence of one or more delusions with a duration of at least 1 month
DOES-NOT meet schizophrenia
- no hallucinations, negative symptoms, disorganized thinking
Function is not impaired outside of the delusion
- is actually socially active
Mood symptoms are either not present or are present in brief periods at the same time and as a result of active delusions
- pretty rare and usually only seen in patients with severe depression if seen*
- persecutory delusions are the most common
- onset is later in life and treatment is usually poor response
can be shared in individuals in close relationships “folie a deux”
Common secondary psychotic disorders causes
Substance-induced = most common
- meth/ other stimulants
- most common cause period*
- heavy cannabis
General medical contains
- paraneoplastic syndromes
- temporal epilepsy
- CNS malignancy
- MS/Huntington’s, Creutzfeldt-Jakob
- B12/B9 deficiency
- AIDS or tertiary syphilis
- Traumatic Brian injury (super rare)
- severe thyroid abnormalities
Pharmacotherapy in psychosis
Generally, always block D2 receptors and treat associated symptoms
- mood stabilizers = schizoaffective with bipolar type
- antidepressants = schizoaffective with depressive type
- benzos = acute psychotic anxiety
- Benztropine = Extrapyramidal symptoms
