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Psychotic Disorders (lec 3) Flashcards

Lecture objectives: Define psychosis • Identify the DSMIV criteria for the five most common psychotic disorders and be able to differentiate between them • Describe the medications used to treat psychotic disorders • Understand the common side effects of these medications and their management

1
Q

Disorganized Speech types (5)

A
  1. derailment, tangentiality
  2. incoherence, world salad
  3. neologism
  4. echolalia
  5. blocking, paucity
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2
Q

Disorganized or Catatonic Behavior def

A

activity is not goal directed
inability to complete simple tasks
immobility
waxy flexibility

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3
Q

causes of psychosis (12)

A
  1. substance intox/withdrawal
  2. med SEs: steroids, stimulants, dopamine agonists, anticholinergics
  3. delirium
  4. dementia
  5. denocrine (thyroid)
  6. CNS infection (syphilis)
  7. epilepsy (temporal)
  8. Vit deficiency (b12)
  9. Autoimmune (SLE)
  10. Huntigton’s
  11. Wilson’s
  12. Psychiatric d/z: psychotic, mood, personality
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4
Q

Evaluation of Psychosis (10 elements)

A
  1. HPI
  2. Past psych hx
  3. substance use hx
  4. family hx
  5. social hx
  6. PMH
  7. physical exam (neuro)
  8. MSE
  9. labs: UDS, UA, CBC, CMP, TSH, RPR, B12
  10. EEG, imaging
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5
Q

Psychotic Disorders (7)

A
  1. Schizophrenia
  2. Schizophreniform disorder
  3. Schizoaffective disorder
  4. Delusional disorder
  5. Brief psychotic disorder
  6. Shared psychotic disorder
  7. substance induced, due to general medical condition or not otherwise specified
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6
Q

Schizophrenia: prevalence, affects who, when?

A

lifetime prevalence 0.5% to 1.5% worldwide (high heritability: 1st degree relative’s risk is 10x the general population)
males=females for prevalence and:
earlier age of onset
Smales early 20s, females late 20s

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7
Q

Pathophysiology of schizophrenia

A

progressive gray matter deficits (slide 12?)

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8
Q

Schizophrenia: negative sxs

A

alogia (poverty of speech) affective blunting
anhedonia
avolition
attentional impairment

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9
Q

Schizophrenia: positive sxs

A

hallucinations
delusions
disorganized behavior
disorganized speech

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10
Q

Schizophrenia course

A
  • chronic
  • abrupt onset vs. prodrome
  • negative sxs appear first
  • complete remission is uncommon
  • decreased life expectancy
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11
Q

Schizophrenia disorder life expectancy

A

men die 15 yrs earlier, women 12 (primarily due to ischemic heart disease & cancer)

  • 5% will commit suicide
  • 10% of completed suicides are schizophrenia pts
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12
Q

Schizophrenia DSM-IV dx criteria

A

A. at least 1 MONTH of 2+ of the following: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative sxs (only 1 sx if bizarre delusions or AH or running commentary or 2+ voices conversing)

B. significant social/occupational DYSFUNCTION in 1+ area

C. duration 6 MONTHS: 1 mo criterion A + prodrome/residual period

D. schizoaffective & mood d/o are ruled out (mood episodes are brief if present)

E. not due to substance or general medical condition
-if autistic/PDD must have prominent delusions/hallucinations at least 1 mo

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13
Q

Schizophrenia paranoid subtype

A

1+ delusion or frequent AH

not prominent: disorganized speech/behavior, inappropriate affect

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14
Q

Schizophrenia disorganized subtype

A
  • prominent disorganized speech & behavior
  • flat or inappropriate affect
  • not catatonic
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15
Q

Schizophrenia catatonic subtype

A

clinical picture dominated by at least 2:

  • motoric immobility/catalepsy, waxy flexibility, stupor
  • excessive motor activity (purposeless)
  • extreme negativism (resists movement), mutism
  • inappropriate/bizarre posturing, stereotypies, prominent mannerisms/grimacing
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16
Q

Schizophrenia undifferentiated subtype

A

meets criteria for schizophrenia, but no subtype

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17
Q

Schizophrenia residual subtype

A

ABSENCE of prominent hallucinations, delusions or disorganized speech/behavior or catatonia

PRESENCE of negative symptoms or 2+ attenuated positive symptoms

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18
Q

Mental Status Exam (MSE)Appearance

A

age, hygiene/clothing (disheveled, malodorous, unkempt)

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19
Q

MSE: Behavior (3)

A
  1. cooperativeness & relation (uncooperative/combative, guarded/suspicious)
  2. eye contact (poor, looking around room, watching door, looking over shoulder
  3. motor activity (hypo or hyper; rocking, pacing, grimacing, or other abnormal movements)
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20
Q

MSE: Affect

A

Appropriate (congruent w/mood)

Inappropriate (constricted/blunted/flat vs. labile, laughing inappropriately)

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21
Q

MSE: Mood

A

whatever pt tells you, in quotes

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22
Q

MSE: Speech

A

quantity
amplitude
rate
tone

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23
Q

MSE: thought process

A

logical vs. illogical
tangential
circumstantial

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24
Q

Hallucinations: definition

A

sensory perceptions in absence of stimulus:

  • auditory
  • visual
  • tactile
  • olfactory
  • gustatory
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25
Q

Thought content (3 possible components)

A

Hallucinations: whispering, conversing, commanding

Delusions: paranoid, religious, grandiose, ideas of reference, thought broadcasting/insertion

Suicidal & Homicidal ideation: document plan & intent, if pt denies SI/HI but has command hallucination to harm self/others, document & address it!

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26
Q

Another component of MSE

A

Insight & Judgment

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27
Q

Schizophrenia: factors indicating more positive prognosis

A
  • Female
  • Later onset
  • Acute onset w/precipitating factor
  • Brief duration, early intervention, tx compliance
  • Positive symptoms
  • mood disturbance, family hx of mood do
  • high SES, married, good support system
  • good premorbid functioning
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28
Q

Schizophreniform Disorder

A
  • Essential features identical to Schizophrenia (delusions, hallucinations, disorganization, neg sxs)
  • SHORTER duration: 1-6 months
  • social/occupational fxn may/may not be impaired
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29
Q

Schizophreniform disorder prognosis

A

1/3 recover (schizophreniform is final dx)

2/3 progress to schizophrenia or schizoaffective disorder

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30
Q

DSM-IV dx criteria for schizophreniform disorder

A

A. criteria A, D and E of schizophrenia are met (characteristic sxs, not schizoaffective or mood d/o, not due to substance or GMC)

B. Episode (prodrome + active + residual phases) lasts between 1-6 months

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31
Q

Schizoaffective disorder: essential definition and types

A

Schizophrenia + mood disorder
-Bipolar or Depressed type
delusions/hallucinations 2 wks & normal mood

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32
Q

Schizoaffective disorder: prevalence & prognosis

A

more common in women (esp depressed type)

better prognosis

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33
Q

Schizoaffective disorder->increased risk of what in 1st degree relatives

A

increased risk of schizophrenia & mood d/o in 1st degree relatives

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34
Q

DSM4 Diagnostic Criteria for SchizoAFEECTIVE d/o

A

A. meets crit A fo SCHIZOPHRENIA (charactersic sxs) & CONCURRENT MAJ. DEPRESSIVE, MANIC or MIXED episode
B. must have 2+ weeks of delusions or hallucinations w/out prominent mood sxs
C. mood sxs present for a sig portion of illness
D. not due to substance or GMC

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35
Q

Delusions: definition

A

fixed false beliefs, despite disproving evidence

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36
Q

4 types of delusions which can be one of which 2 things

A

-paranoid or persecutory
-grandiose
-reference
-somatic
BIZARRE vs. NON-BIZARRE

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37
Q

Delusional disorder: prevalence, demographics

A
  • prevalence=0.03%, males=females, but variation among subtypes
  • variable age at onset (teen-late adulthood)
  • variable course (may remit & relapse)
  • possible familial relationship to Schizophrenia
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38
Q

Non-bizzare delusions

A

plausible but false
i.e. infestations, being followed by police
(NOT alien abduction)

39
Q

Delusional disorder: can it co-occur with schizophrenia?

A

no, it does NOT meet criterion A for Schizophrenia

40
Q

Describe the following in DELUSIONAL DISORDER: hallucinations, psychosocial function, thought process, insight

A

Hallucinations could be related to delusional theme (bugs)
Psychosocial fxning NOT markedly impaired
NORMAL thought process
POOR insight

41
Q

DSM4 dx criteria for DELUSIONAL DISORDER

A

A. NON-BIZZARE delusions for at least 1 MONTH
B. crit A for schizophrenia has NEVER been met (but hallucinations rltd to delusion OK)
C. Fxning NOT markedly impaired, normal behavior
D. mood episodes, if any, are brief relative to delusion
E. not due to substance or GMC

42
Q

Delusional disorder: 7 subtypes

A
  1. Erotomania
  2. Grandiose
  3. Jealous
  4. Persecutory
  5. Somatic
  6. Mixed
  7. Unspecified
43
Q

Erotomania

A

delusion that another is in love with pt, usually a person of higher status (celebrity stalkers)

44
Q

Grandiose

A

delusion of inflated worth, power, knowledge, identity or special relationship to deity or famous person

45
Q

Jealous

A

delusion that spouse, significant other, sexual partner is unfaithful

46
Q

Persecutory

A

delusion that pt is being treated malevolently

conspired against, cheated, spied on, followed, poisoned, harassed…

47
Q

Somatic

A

delusion of physical defect or medical condition

48
Q

Mixed delusion

A

features of more than one, but non predominate

erotomania, grandiose, jealous, persecutory, somatic

49
Q

Unspecified delusion

A

delusion, that has not been specified

50
Q

Brief Psychotic Disorder

A
  • SUDDEN ONSET of at least 1 positive symptoms
  • lasts 1 DAY TO 1 MONTH w/RETURN TO NORMAL premorbid fxning
  • emotional, labile, confused
51
Q

Brief psychotic disorder onset

A

onset in pate 20s to early 30s

may be marked with a stressor or post-partum onset

52
Q

Brief psychotic disorder: what do you need to rule out

A

rule out culturally appropriate experience, malingering, personality disorder

53
Q

Brief psychotic disorder: DSM-IV dx criteria

A

A. 1 OR MORE of: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior

B. duration of 1 DAY TO 1 MONTH, w/eventual RULL RETURN TO PREMORBID LEVEL OF FUNCTIONING

c. not due to SCZ, schizoaffective, mood d/o, substance, or GMC

54
Q

Acute stabilization of psychotic d/os: medication

A

start antipsychotic at low dose & titrate as needed, avoid using 2 antipsychotics

55
Q

Acute stabilization of psychotic d/o: priority, sxs

A 
priority=safety,  ↓ DTO/DTS
may need hospitalization
agitation improves fast(min-hrs)
hallucinations improve in days
negative sxs, delusions, cognitive deficits take much longer, if they improve
56
Q

Indications for hospitalization in psychotic d/os (4)

A
  1. Danger to self (DTS)
  2. Danger to others (DTO)
  3. command auditory hallucinations
  4. unable to care for self
57
Q

Maintenance of psychotic d/os goal

A

symptom control and relapse prevention

58
Q

Maintenance of psychotic d/os

A

compliance is an issue

  • simplify med regimen (daily vs BID/TID dosing)
  • minimize SEs
  • day/partial hospitalization or intensive outpatient programs
  • assertive community tx, case management
  • involve social network
59
Q

Monitoring/atypical antipsychotic protocol

A
  • BMI monthly x 3 mos, then q 3 mos
  • waist circumference annually
  • lipids at 12 weeks & q 5 yrs
  • fasting glucose at 12 wks & annually
  • AIMS q 6 mos
60
Q

Clozapine monitoring

A

CBC x 6 mos
CBC biweekly x 6 mos
CBC monthly for remainder of tx

61
Q

First generation (conventional) antipsychotics (6+)

A

CHLORPROMAZINE (Thorazine)
Haloperidol (Haldol) [PO tab or elixir, IM, IV, long-acting injection, topical]
Thioridazine (Mellaril)
Prochlorperazine (Compazine)
Fluphenazine (Prolixin) [PO & inhaled]
many others: Trilafon, Navane, Orap, Moban….

62
Q

Second generation, atypical antipsychotics (9)

A 
Aripiprazole (Abilify) 
Asenapine (Saphris)
Clozapine (Clozaril)
Lurasiodone (Latuda)
Paliperidone (Invega Sustenna)
Olanzapine (Zyprexa)
Quetapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
63
Q

Aripriazole (Ability): metabolic activity

A

partial D2 agonst

metabolically neutral

64
Q

Asenapine (Saphris): unique

A

sublingual administration

65
Q

Clozapine (Clozaril): unique characteristic

A

agranulocytosis risk: requires regular CBC monitoring of WBCs & ANC (weekly initially)

66
Q

Lurasidone (Lutada): unique characteristic

A

pregnancy category B

67
Q

Olanzapine (Zyprexa): what does the presentation want you to note?

A

weight gain

68
Q

Risperidone (Risperidal): what does the presentation find unique abt this?

A

prolactin, EPS

69
Q

Ziprasidone (Geodon): unique feature

A

50% less bioavailable without food

70
Q

What to consider in selection of antipsychotics

A 
Dx! r/o non-psych causes
drug-drug intrxns (CYP metabolism)
personal & fam hx of response to meds
setting (ICU, ED, involuntary vs. voluntary, inpatient, outpatient)
route (PO, ODT, IV, IM, long-acting IM)
SE profiles
71
Q

Side Effects of Antipsychotics

A
  1. Extrapyramidal symptoms (EPS): acute dystonic reaction, Parkinsonism, akathesia, Tardive Dyskinesia (TD), Neuroleptic malignant syndrome (NMS)
  2. Other: anticholinergic, adrenergic, cardiac, endocrine, hepatic
72
Q

Acute dystonic rxn

A

(an extrapyramidal symptom)

torticollis, jaw spasms, dysphagia, dysarthria, tongue protrusion, oculogyric crisis, etc.

73
Q

Extrapyramidal Symptoms (5)

A 
ACUTE DYTONIC REACTION
Parkinsonism
Akathisia
Tardive dyskinesia (TD)
Neuroleptic malignant syndrome (NMS)
74
Q

Akathisia

A

restlessness, fidgeting, rocking, pacing

75
Q

Tardive Dyskinesia

A

ABNORMAL INVOLUNTARY MOVEMENTS

  1. Choreiform: rapid, jerky, non-repetitive
  2. Athetoid: slow, sinuous, continual
  3. Rhythmic: stereotypies
76
Q

Tardive dyskinesia prevalence, remission

A

prevalence: 20-30%, incidence 3-5% per year
-higher risk in older adults, longer exposure, mood d/I
ONLY 5-40% OF ALL CASES REMIT!
use AIMS to screen EVERY 6 MONTHS

77
Q

Tx of ACUTE DYSTONIA

A

benztropine, diphenhydramine

78
Q

Tx of PARKINSONISM

A

amantadine, benztropine, diphenhydromine

79
Q

Tx of AKATHISIA

A

propranolol

80
Q

Tx of TARDIVE DYSKINESIA

A

benztropine or diphenhydramine AND decrease or stop the antipsychotic

81
Q

Neuroleptic Malignant Syndrome (NMS)

A

POTENTIALLY LIFE THREATENING!

sever muscle RIGIDITY + INCREASED TEMP

82
Q

Risk factors for NMS

A
  • dehydration, ?hot/humid weather
  • agitation
  • high dose, rapid increase, IM injection
  • hx of NMS
  • Lithium use
83
Q

NMS associated features (5)

A
  1. mental status change (often 1st sx)
  2. autonomic instability(↑BP/HR)
  3. leukocytosis (>10,000)
  4. ↑CK (often >300)
  5. electrolyte abnormalities
84
Q

NMS mnemonic

A 
(FEVER)
Fever
Encephalopathy
Vitals unstable
Elevated enzyme (CK)
Rigidity
NMS
85
Q

NMS treatment

A

theory: Dantrolene
Reality: supportive/symptomatic
NO neuroleptics for at least 2 weeks

86
Q

All atypical antipsychotics black box warning

A

increased mortality when treating elderly pts for dementia-related psychosis (all atypicals)

87
Q

Other atypical antipsychotic SEs (9)

A
  1. Anticholinergic
  2. Adrenergic (alpha 1 blockade)
  3. Weight gain
  4. Endocrine
  5. Ocular
  6. Cardiovascular
  7. Hepatic: Transaminitis
  8. Neuro (decreased seizure threshold, dose dependent w/most 1st gen & clozapine)
  9. Leukocytosis & agranulocytosis
88
Q

Anticholinergic Effects

A

dry mouth, blurry vision, constipation, urinary retention, confusion, delirium

89
Q

Adrenergic effects of antipsychotics

A

(alpha 1 blockade)

-hypotension, dizziness

90
Q

Endocrine effects of antipsychotics (atypicals, 1st gen)

A

atypicals: hyperglycemia, HLP, metabolic syndrome

1st gen & Risperidone elevated prolactin, gynecomastia, galactorrhea, amenorrhea, decreased libido

91
Q

Ocular side effects of antipsychotics

A

pigmentary retinopathy (chronic Thioridazine)

92
Q

Cardiovascular effects of antipsychotics

A 
QT prolongation (can lead to torsades)
Orthostatic hypotension
Tachycardia
93
Q

Neurological side effects of antipsychotics

A

decreased seizure threshold

dose-dependent risk with most 1st gen & clozapine

Q4 Psych (14 decks)

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