Psychotic Disorders (Ch 3) Flashcards
Psychosis
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
it can be substance or medication induced
Delusions
fixed, false belief that remain despite evidence to the contrary and cannot be accounted for by cultural background of the individual
bizarre - false belief that is impossible
non bizarre - false belief that is plausible but not true
Delusions of persecution/paranoid delusions
irrational belief that one is being persecuted
“The CIA is after me and tapped my phone”
Ideas of reference
Belief that cues in the external environment are uniquely related to the individual
“The TV characters are speaking directly to me.”
Delusions of control
Thought broadcasting - belief thoughts can be heard by others
Thought insertion - belief other’s thoughts are being placed in one’s head
Delusions of grandeur
Belief that one has special powers beyond those of a normal person
“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 or responsible for something
“I am response for all the world’s wars”
Somatic delusions
Belief that one is infected with a disease or has a certain illness
Illusion
misinterpretation of an existing sensory stimulus (mistaking a shadow for a cat)
Hallucinations (including types)
Sensory perception without an actual external stimulus
Auditory: Most commonly in schizophrenic pts
Visual: less common in schizophrenic pts, may accompany drug intoxication, drug and alcohol withdrawal, or delirium
Olfactory: aura associated with epilepsy
Tactile: secondary to drug use or alcohol withdrawal
Differential diagnosis of psychosis
Psychotic disorder due to another medical condition Substance/Medication-induced psychotic disorder Delirium/Dementia Bipolar disorder, manic/mixed episode Major depression with psychotic features Brief psychotic disorder Schizophrenia Schizophreniform disorder Schizoaffective disorder Delusional disorder
Medical causes of psychosis - CNS
Cerebrovascular disease, MS, neoplasm, Alzheimer’s dz, Parkinson’s dz, Huntington’s dz, tertiary syphilis, epilepsy (often temporal lobe), encephalitis, prion dz, neurosarcoidosis, AIDS
Medical causes of psychosis - endocrinopathies
Addison/Cushing dz, hyper/hypothyroidism, hyper/hypocalcemia, hypopituitarism
Medical cases of psychosis - Nutritional/vitamin deficiency
B12, folate, niacin
Medical cases of psychosis - other systemic
connective tissue disease - SLE, temporal arteritis
porphyria
DSM5 criteria for psychotic disorder d/t another medical condition
Prominent hallucinations or delusions
Sxs do not occur only during an episode of delirium
Evidence from hx, physical, or lab data to support another medical (non psychiatric) cause
Medications known to induce psychosis
anesthetics anticholinergics anticonvulsants antihistamines antihypertensives antimicrobials antiparkinsonian agents chemotherapeutic agents corticosteroids digitalis methylphenidate NSAIDs
Substances known to induce psychosis
Alcohol barbiturates benzodiazepines cannabis cocaine hallucinogens (LSD, ecstasy) inhalants phencyclidine (PCP)
caused by intoxication or withdrawal
DSM5 criteria for substance/medication-induced psychotic disorder
Hallucinations and/or delusions
Sxs do not occur only during episode of delirium
Evidence from hx, 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
delusion vs illusion, vs hallucination
Delusion: false belief
Illusion: misinterpretation of external stimulus
Hallucination: perception in absence of an external stimulus
Positive symptoms of schizophrenia
ADDED onto normal behavior
Hallucinations, delusions, bizarre behavior, disorganized speech
Respond more robustly to antipsychotic medications
Negative symptoms of schizophrenia
SUBTRACTED or missing from normal behavior
Flat or blunted affect, anhedonia, apathy, logia, lack of interest in socialization
More often treatment resistant and contribute significantly to social isolation or schizophrenic patients
Cognitive symptoms of schizophrenia
impairment in attention, executive function, working memory
may lead to poor work and school performance
Three phases of schizophrenia
Prodromal: decline in functioning precedes first psychotic episode - e.g.: socially withdrawal, irritable, physical complaints, declining school/work performance, new found interest in religion or the occult
Psychotic - perceptual disturbances, delusions, disordered thought process/content
Residual - following episode of active psychosis. marked by mild hallucinations or delusions, social withdrawal, negative symptoms
DSM5 Criteria for Schizophrenia
Two or more of the following present for at least 1 month:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
(at least 1, 2, or 3)
Must cause significant social, occupational, or self-care functional deterioration
Duration of illness for at least 6 month - including prodromal or residual periods in which the above criteria may not be met
Symptoms not due to effects of a substance or another medical condition
Catatonia
stereotyped movement, bizarre posturing, and muscle rigidity
can be seen in schizophrenic patients
Clozapine
considered for treating schizophrenia when fail typical and other atypical antipsychotics
Rare adverse event: agranulocytosis - need WBC and ANC counts regularly
5 A’s of schizophrenia negative symptoms
Anhedonia Affect - flat Alogia - poverty of speech Avolition - apathy Attention - poor
Echolalia vs Echopraxia
Echolalia - repeats words or phrases
Echopraxia - mimics behavior (practices behavior)
Typical psychiatric exam findings in schizophrenic patients
Disheveled appearance flat affect disorganized thought process Intact procedural memory and orientation Auditory hallucinations Paranoid delusions Ideas of reference Lack of insight into their disease
Epidemiology of Schizophrenia
Men early-mid 20s
Women late 20s
Men more negative sis, poorer outcome
Rarely presents before 15 or after 55
Strong genetic predisposition
Substance use: over 50% nicotine, alcohol, cannabis, cocaine
Post psychotic depression
Downward drift hypothesis in schizophrenia
schizophrenic pos unable to function well in society, end up in lower socioeconomic groups - many become homeless
Dopamine hypothesis - schizophrenia
Increased dopamine activity in certain neuronal tracts cause schizophrenia
Evidence: dopamine receptor antagonists successful in treating
Cocaine and amphetamines increased dopamine activity and can lead to schizophrenic like symptoms
Prefrontal cortical dopamine pathway (schizophrenia)
inadequate dopaminergic activity responsible for negative symptoms
Mesolimbic dopamine pathway (schizophrenia)
Excessive dopaminergic activity responsible for positive symptoms
Tuberoinfundibular dopamine pathway
blocked by antipsychotics -> hyperprolactinemia -> gynecomastia, galactorrhea, sexual dysfunction, menstrual irregularities
Nigrostriatal dopamine pathway
blocked by antipsychotics -> Parkinsonism/extrapyramidal side effects: tremor, rigidity, slurred speech, akathisia, dystonia, and other abnormal movements
Serotonin abnormality in schizophrenia
Elevated serotonin
some second gen (atypical) antipsychotics (risperidone and clozapine) antagonize serotonin and wearing antagonize dopamine
Norepinephrine abnormality in schizophrenia
Elevated norepinephrine
Long term use of antipsychotics shown to decrease activity of noradrenergic neurons
GABA abnormality in schizophrenia
Decreased GABA
Decreased expression of the enzyme necessary to create GABA in the hippocampus of schizophrenic pts
Glutamate receptor abnormality in schizophrenia
Decreased levels of glutamate receptors
Schizophrenics have fewer NMDA receptors, corresponds with psychotic sis with NMDA antagonists like ketamine
Prognostic factors associated with a better prognosis in schizophrenia
later onset good social support positive sxs mood sxs acute onset female few relapses good premorbid functioning
Prognostic factors associated with a worse prognosis in schizophrenia
Early onset poor social support negative symptoms family history gradual onset male many relapses poor premorbid functioning (social isolation, etc) Comorbid substance use
First generation (typical) antipsychotic medications
Chlorpromazine
Fluphenazine
Haloperidol
Perphenazine
D2 antagonists
Treat positive sis with minimal impact on negative sis
Side effects: extrapyramidal sis, neuroleptic malignant syndrome, tardive dyskinesia
Second generation (atypical) antipsychotic medications
Aripiprazole Asenapine Clozapine Iloperidone Lurasidone Olanzapine Quetiapine Risperidone Ziprasidone
5-HT2 antagonist, as well as D4>D2 receptors
Lower incidence of extrapyramidal side effects, increased risk for metabolic syndrome
Extrapyramidal symptoms - side effect
especially seen in high potency first gen antipsychotics
Dystonia (spasms) of face, neck, and tongue
Parkinsonism - resting tremor, rigidity, bradykinesia
Akathisia - feeling of restlessness
Tx: anticholinergics (benztropine, diphenhydramine), benzodiazepines/beta-blockers(specifically for akathisia)
Anticholinergic symptoms - side effect
especially low-potency first gen antipsychotics and atypical antipsychotics)
Dry mouth, constipation, blurred vision, hyperthermia
tx: per symptom - eye drops, stool softeners, etc
Metabolic syndrome - side effect
Second gen antipsychotics
Elevated BP, blood glucose
excess body fat around waist
Abnl cholesterol levels
combined -> increased risk of CV disease, stroke, T2DM
Tx: switch to first get or a more “wt neutral” second generation antipsychotic like aripiprazole or ziprasidone
Monitor lipids and blood glucose
PCP for hld, DM, etc
Encourage diet, exercise, smoking cessation
Tardive dyskinesia - side effect
first gen antipsychotics
Choreoathetoid movements - face, tongue, head
Tx: dc or reduce medication, consider substituting an atypical antipsychotic if appropriate
Benzodiazepines, Botox, Vit E
Movements may persist despite withdrawal of drug
Neuroleptic malignant syndrome - side effect
high potency first gen antipsychotics, any antipsychotic, initiation of tx and at higher IV/IM dosing of high potency neuroleptics
Change in mental status, autonomic instability (high fever, labile BP, tachycardia, tachypnea, diaphoresis), “lead pipe” rigidity, elevated CPK, leukocytosis, metabolic acidosis
Medical emergency - requires prompt withdrawal of all antipsychotic meds and immediate medical assessment and tx
Thioridazine side effect
irreversible retinal pigmentation at high doses
Chlorpromazine side effect
deposits in lens and cornea
DSM5 criteria for schizophreniform disorder
same criteria as schizophrenia
sis last between 1-6 months
DSM5 criteria for schizoaffective disorder
Either a major depressive or manic episode during which psychotic sxs consistent with schizophrenia also met
Delusions or hallucinations for 2 weeks in absence of mood disorder sxs
Mood sxs present for majority of psychotic illness
Sis not due to effects of a substance or other medical condition
Medical Treatment of schizoaffective disorder
Second gen antipsychotics may target both psychotic and mood symptoms
mood stabilizers
antidepressants
electroconvulsive therapy (ECT)
DSM5 criteria for Brief Psychotic Disorder
psychotic sxs as in schizophrenia lasting from 1 day to 1 month with eventual full return to premorbid level of functioning
not due to effects of a substance or other medical condition
May be seen in reaction to extreme stress such as bereavement, sexual assault, etc
Prognosis and treatment of brief psychotic disorder
High rates of release, almost all completely recover
Brief hospitalization (workup, safety, stabilization), supportive tx, course of antipsychotics for psychosis, and/or benzodiazepines for agitation
Delusional Disorder
middle-aged or older patients (after 40 yo)
DSM5:
one or more delusions for at least 1 month
Does not meet criteria for schizophrenia
Functioning in life not significantly impaired, behavior not obviously bizarre
Erotomanic type (delusion)
delusion that another person is in love with them
Grandiose type (delusion)
Delusions of having great talent
Somatic type (delusion)
physical delusions
Persecutory type (delusion)
delusions of being persecuted
Jealous type (delusion)
delusions of unfaithfulness
Koro
Southeast Asia - Singapore
Intense anxiety that the penis will recede into the body, possibly leading to death
Amok
Malaysia
Sudden unprovoked outbursts of violence, often followed by suicide
Brain fag
Africa
Headache, fatigue, eye pain, cognitive difficulties, and other somatic disturbances in male students
Schizotypal
personality disorder
paranoid, odd or magical beliefs, eccentric, lack of friends, social anxiety
criteria for overt psychosis not met
Schizoid
personality disorder
solitary activities, lack of enjoyment from social interactions, no psychosis
