Schizophrenia and other psychotic disorders Flashcards
PSYCHOSIS
Disruption in the experience of reality
** Psychosis is a symptom, not a diagnosis
Delusion:
fixed, false belief not consistent w/cultural or religious background. Can be bizarre or non-bizarre (thought broadcasting, ideas of reference, grandiose, alien chips, erotomanic, persecutory, partner cheating, etc)
Hallucination:
false sensory perception not associated with real external stimuli (auditory, visual, tactile, gustatory, olfactory- epilepsy)
PSYCHOSIS details
Medical workup may be indicated (esp in first episode, ie,“first break”) or in later years with no psych hx
Personality disorders do not have hallucinations (exception for Borderline)
What’s eccentric? What’s “normal”…? (eg, alien kidnapping)
A partial differential dx of psychosis:
SLE, acute intermittent porphyria, Major Depressive Disorder, Bipolar Disorder, seizures (esp TLE), Schizophrenia, Schizoaffective disorder, substance intoxication, Delirium, Dementia, adverse drug reaction, etc.
SCHIZOPHRENIA: HISTORY
Some mention of these types of disturbances date back to first-century AD and throughout the world
“dementia praecox” is a term borrowed by Emil Kraepelin and he begins to classify symptoms
Eugen Bleuler: “schizophrenia” (“split mind”) and the “4 As”: Associations Autism Ambivalence Affect
Kurt Schneider “first-rank” symptoms (hallucinations and delusions, odd thought content) used to assist in diagnosis. Many of his ideas would be incorporated into the newly-devised DSM (Diagnostic & Statistical Manual)
SCHIZOPHRENIA: SOME BASICS
NOT “split personality”
**** est. 1% of population, men=women **
Typical onset: late teens to late 20s, men earlier than women
Wide range of various mental disturbances
Increased suicide risk (est 1/3 can attempt, 1/10 succeed); higher medical co-morbidities
REMEMBER: More likely to be victim of violence
A diagnosis of exclusion
Prodromal period typical; “first break” can be mild to severe
$62.7 billion spent in 2002 (= approximately $78 billion in 2012 dollars). Roughly the same amount spent on cancer
SCHIZOPHRENIA: DIAGNOSIS
Basic DSM V Criteria:
≥2 of the following, each present for a significant portion of a 1-month period (or less if successfully treated):
delusions
hallucinations
disorganized speech (e.g., frequent derailment or incoherence)
grossly disorganized or catatonic behavior
negative symptoms
Social/occupational dysfunction
- Signs persist for at least 6 months (incl at least 1 month of above symptoms [or less if successfully treated]); may include periods of prodromal or residual symptoms, during which negative sx may prevail
The following have been ruled out: Schizoaffective, Mood Disorders, substances, general medical conditions, autism spectrum
SCHIZOPHRENIA: POSITIVE symptoms
Hallucinations and delusions
- Hallucinatory content varies greatly and usually auditory (AH)
Disorganized speech/behavior
SCHIZOPHRENIA: NEGATIVE symptoms
Lack of motivation
Affective blunting
Cognitive blunting
Impaired social functioning and social withdrawal
SCHIZOPHRENIA: PATHOPHYSIOLOGY
Cause unknown
Some hypotheses: inflammatory, viral, birth season, infectious (T. gondii), nutritional deficiency, genetic (50% concordance rate in monozygotic twins, 12.5% rate in dizygotic; ↑ risk in families, >100 gene variants identified, may be as many as 8,000)
Role of marijuana, esp brain changes?
Boards like to ask: Ventricular enlargement (3rd & lateral) in some
Prefrontal cortex (last cortical area to develop) connections seem to be affected; however, it’s likely that multiple neuroanatomical sites and functional brain systems are involved
SCHIZOPHRENIA: NEUROTRANSMITTERS
“Dopamine hypothesis”
- Excess dopaminergic activity
- Theory supported by efficacy of antipsychotics
- Dopaminergic drugs can cause psychosis
- Exact mechanism unknown
Serotonin
- LSD causes psychosis (serotonergic)
- Role in negative symptoms
- Modulates dopamine
Glutamate
- Hypo/hyperfunction at various receptors including NMDA
SCHIZOPHRENIA: TREATMENT
Antipsychotics are 1st line tx
- If effective, controls behavior & symptoms
- Consider likely side effect profile
- Consider metabolic consequences
- Use adjunct meds as needed for side efx
- Consider long-acting injectables
- Typicals vs. atypicals: risks/benefits of side effect profile
Medical workup as appropriate (labs, neuroimaging, H&P)
Provide safe environment
If outpatient, provide support services (ACT, clubhouses, day programs, etc)
Major side effects of antipsychotic tx to monitor for:
Movement disorders (dystonia, akathisia, parkinsonism [tremor, rigidity, bradykinesia, masked facies], tardive dyskinesia [TD])
Neuroleptic malignant syndrome (NMS)
Anticholinergic effects
Sedation
Metabolic consequences (wt gain, DM, Dyslipidemia). Recent research suggests glucose dysregulation may already be present at dx
All of the above can contribute to non-compliance with meds
Clozapine:
all of the major side effects of antipsychotics plus
agranulocytosis (& others) –> restricted use
Can ↓ suicidality
Best antipsychotic available?
SCHIZOPHRENIA: LONG TERM OUTCOMES
Typical course: prodrome → active ↔ residual
Lower life expectancy
Untreated schizophrenia has poor prognosis
Noncompliance (for many reasons) is frequent and decompensation occurs each time. Brain tissue may be lost w/each relapse.
Disability is frequently necessary
Wide variety of outcomes
Properly treated and managed, however, the brighter the quality of life
One of the major keys in distinguishing many of these is
duration of symptoms
SCHIZOPHRENIFORM DISORDER
Similar to schizophrenia * except symptom duration
Symptoms of schizophrenia lasting >1 month but <6 months
May describe the prodrome
Estimates of progression to schizophrenia: 60-80%
Recent research suggests FEP 24x more likely to die in year 1 after dx than peers
SCHIZOAFFECTIVE DISORDER
Can be a difficult dx to make
Features of both schizophrenia and depression or bipolar illness;
Requires 2 weeks of schizophrenia symptoms in the absence of mood symptoms AND the presence of mood symptoms for a substantial part of the lifetime illness course
Tx: psychosis with antipsychotics, mania with mood stabilizers, depression with antidepressants. Combine as necessary.
BRIEF PSYCHOTIC DISORDER
Psychosis >1 day but under 1 month
Must not be due to substance use or medical condition
May be in response to a stressor
R/O cultural contribution
Requires full return to premorbid function; however, approximately 50% go on to develop chronic psychiatric syndromes
Tx: antipsychotics
BRIEF PSYCHOTIC DISORDERincludes
Postpartum psychosis
- Onset usually within hours to weeks of birth
- R/O medical causes (infectious, narcotic use, etc)
- Content usually bizarre and involves the baby
- Mother may have bipolar hx
- This is a psychiatric emergency: keep mother and baby safe
- Consider breastfeeding status when treating
DELUSIONAL DISORDER
≥1 month of a delusion (erotomanic, persecutory, grandiose, jealous, somatic)
Does not meet basic schizophrenia criteria; behavior and function usu not affected
Women > men, usu mid-late life
R/O medical causes (eg, tumors, TLE, etc)
Tx: psychotherapy; poor response to antipsychotics
OTHER PSYCHOTIC DISORDERS
Psychosis due to Substance Abuse
“Delusional symptoms in partner of individual with delusional disorder,” ie, delusional transfer from one individual to another (usu from a chronically ill or dominant person to a more submissive, less intelligent individual). AKA “folie a deux”
- Tx: separation. Minimal/poor response w/antipsychotics
Psychosis due to General Medical Condition
- Just a few: TLE, neoplasm, CVA, brain trauma, Huntington’s, Neurosyphilis, HIV, NPH, Herpes encephalitis, etc.
