Somatic disorder and Psychosis

Question 1

Somatic Symptoms and Related Disorders

Answer 1

• Disorders with prominent somatic symptoms. Includes somatic symptoms disorders, illness anxiety disorder, coversion disorder, psychological factors affecting other medical conditions, factitous disorders, other specificied somatic symptoms and related disorders and unspecified somatic symptom and related disorders
• Diagnosis is made based on presence of symptoms and signs rather than absence of medical explaination - presence of medical diagnosis does not exclude possibility of co-morbid mental disorder. However, medically unexplained symptoms are still a key feature in conversion disorder where you much demostrate that symptoms are not consistent with meidcal pathophysiology

Question 2

Somatic Symptoms Disorder

Answer 2

• One or more symptoms that are distressing or result in significant disruption of daily life
• Excessive thoughts, feelings, or behaviours related to somatic symptoms or associated health concern charactreized by at least one of the following:
  
  • Disproportionate and persistent thoughts about the seriousness of one’s symptoms
  • Persistently high levels of anxiety about health or symptoms
  • Excessive time and energy devoted to these symptoms or health concers
• Symptomatic >6months (type symptoms may change within this period)
• Specificy if: with predominant pain; persistent (severe, marked impairment >6months)
• Diagnosis of somatic symptom disoder and a medical disorder are not mutually exclusive
• Patient may seek care from several doctors for the same symptoms; often unresponsive to medical intervention; unusually sensitive to medication side effects.
• A diagnosis of somatic symptom disorder is not made if symptoms only occur in the context of a major depressive episode

Question 3

Associated features of somatic symptoms

Answer 3

• Attention focused on somatic symptoms
• Attributed of normal boily sensations to physical illness
• Worry about illness
• Fear that physical activity may harm them
• Repeated body checking for abnormalities

Question 4

Illness Anxiety Disorder

Answer 4

• Preoccupation with having or acquiring a serious illness
• Somatic symptoms are not present, or if present, are only mild in intensity. If there is another medical condition or high risk of developing one the preoccupation is excessive and disproportionate.
• High level of anxiety about health and individual is easily alarmed about personal health status
• Individual perfroms excessive health related behaviours or shows maladaptive avoidance
• Illness preoccupation has been present for at least 6 months
• Illness related preoccupation is not better explained by another mental disorder
• Specifiy whether it is care seeking or care avoidant types

Question 5

Associated features of illness anxiety disorder

Answer 5

• In illness anxiety disorder somatic symptoms are either NOT present or mild
• Persons distress is not around physical complaint, but anxiety about the meaning, signifance, or cause of complaint.
• Concerns about undiagnosed disease do not respond to appropriate medical reassurance
• Illness becomes a central feature of identity and self-image

Question 6

Conversion Disorder (Functional Neurological Symptom Disorder)

Answer 6

• One or more symptoms of altered voluntary motor or sensory function
• Clincal findings provide evidence of incompatibility between the symptom and recognized neurological or medical conition
• Symptom or deficit is not better explained by anothe medical or mental disoder
• Symptoms cause clinically significant distress or impairment
• *Must of clear evidence of imcompatibility of disease. While the diagnosis of conversion disorder does not require judge that symptoms are not intentionally produced. However, definite evidence of feigning would suggest factitious disorder or malingering

Question 7

Psychological Factors Affecting other Medical Condition

Answer 7

• Presence of medical symptoms or condition
• Psychological or behavioural factors adversely affecting the medical condition in one of the following ways:
  
  • Factors have influenced the course of medical condition as shown by a close temporal associated between the psychological factors and development, exacerbation, or delayed recovery from the medical condition
  • Factors interfere with treatment of the medical condition
  • Factors constitute additional well-established health risks for the individual
  • Factors influence underly pathphysiology, preciptating ore exacerbating symptoms or necessitating medical attention
• Psychological and behavioural factors above are not better explained by another medical disorder
• *Psychological factors affects medical condition via the presence of behavours that adversely affect the medical condition by increasing risk of suffering, death, or disability

Question 8

Factitious Disorder Imposed on Self (or another)

Answer 8

• Falsification of physical or psychological signs or symptoms or induction of injury or disease (flasification or induction of a disease in another), associated with identified deception
• Individual presents themself as ill, impaired, or injured
• Deceptive behaviour is evident even in absence of obvious external rewards
• Behaviour is not better explained by another mental disorder, such as delusional disorder or antohre psychotic disorder

Question 9

Treatment Somatic Symptom Disoder

Answer 9

• Initial treatment: Primary care management with regularly scheduled visitis that do no depend on active symptoms. In these visitis work to establish a therapeutic allience, acknowledge and legitmize somatic sympomts, limit diagnostic testing and referrals to specialists, reassure that grave medical diseases have been ruled out - but be careful to bot do excessive reassurance as it may exacerbate fear or cause patient to think that symptoms are not being taken seriously, provide coping strategies, assess and treat comborbid psychiatric disorders, taper and discontinue unnecessary medications.
• Treatment resistant - CBT, mindfulness (70-90% will decline psychotherapy).
  
  • Amitriptyline - shows benefit for fatigue, functional symtpoms, global impairment, morning stifness, pain, sleep, and tender points.
  • Fluoxetine - benefits for functionals status, global well-being, morning stifness, sleep, and tender points.

Question 10

Schizophrenia Spectrum and Other Psychotic Disorders

Answer 10

• Includes schizophrenia, other psychotic disorders, and schizotypal personality disorder.
• Psychosis is a symptom complex characterized by abnormalities in one or more of the following - delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behaviours, and negative symptoms

Question 11

Delusions

Answer 11

• Fixed beliefs that cannot be changed even with conflicting evidence
• Persecutory - belief that one is going to be harmed, harassed, etc. by an individual or group
• Referential - belief that things in the environment are directed at onself
• Grandiose - belief thay one has exceptional abilities, wealth, or fame
• Erotomanic - when one falsely believes that another person is in love with them
• Nihilistic - conviction that a major catastrophe will occur
• Somatic - peroccupations regarding health and organ function
• *Bizarre delusion - if it is clearly implausible, not understadable, and is not derived from ordinary life experiences.
• *Non-bizarre delusion - if it is possible. Ex. under surveillance by the police.

Question 12

Hallucinations

Answer 12

• Perception like experienes that occur without an external stimulus. They are as vivide and clear as normal perceptions and not under voluntary control. Auditory are more common in schizophrenia and related disorders
• Must occur in context of clear sensorium - i.e., hypnagogic (while falling asleep) and hyponpompic (while waking up) are within range of normal experience

Question 13

Disorganized Thinking

Answer 13

Disorganized thinking is typically inferred from ones speech.

• Derailment/ loose associations - switch from topic to topic
• Tangential - answer to questions are obliquely related (never return to answer the questions)
• Word salad - nearly incomprehensible

Question 14

Grossly Disorganized or Abnormal Motor Behaviour

Answer 14

• Can manifest in a number of ways from childlike silloness to agitations
• Catatonic behaviour - decrease in reactivity to the environment. Ranges from negative (resistance to instruction); maintaining a rigid posture; lack of verbal and motor responses (mutism and stupor).

Question 15

Negative Symptoms

Answer 15

• Dimished emotional expression
• Avolition - decrease in motivated self-initiated purposeful activities
• Alogia - dimished speech output
• Anhedonia - decreased ability to experience pleasure from positive stimuli
• Asociality - lack of interest in social interactions

Question 16

Delusional Disorder

Answer 16

• Presence of one (or more) delusions with durationof 1 month or longer
• Criteria A for Schizophrenia has never been met
• Apart from impact of delusions or its ramifications, functioning is not markedly impaired and behaviour is not obviously bizarre or odd
• If manic or major depressive episodes have occured, these have been brief relative to duration of delusional periods
• Disturbance is not attributable to physiological effects of the substance or another medical condition and not better explained by another mental disoder, such as body dysmorphic disorder or OCD
• *Specify whether - erotomanic type, grandiose type, jealous type (central theem of individuals delusion that their spoutse or lover is unfaithful), persecutory type, somatic type, mixed type (when no one delusional theme predominates), unspecified type (when dominant delusional belief can’t be clearly determined or is not described in the specific type
• Specify if - with bizarre content

Question 17

Brief Psychotic Disoder

Answer 17

• Presence of one or more of the following
  
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behaviour
• Duration of epiosde is ≥ 1 day but ≤ 1 month, with eventual full return to premorbid level or functioning
• Disturbance is not better explained by major depressive or bipolar disoder with psychotic features or another psychotic disoder such as catatonia or schizophrenia and is not due to effects of a substance or another medical condition
• *Specify if - with marked stressors, without marked stressors, postpartum onset, with catatonia

Question 18

Schizophreniform Disorder

Answer 18

• 2 or more of the following (one must be first 3), each present for a significant portion of time during a 1 month period (or less if treated)
  
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorgaized or catatonic behaviour
  • Negative symptoms
• An episode lasts at least 1 month but less than 6 months - if diagnosis is made without waiting for recovery it should be “provisional”
• Schizoaffective disorder and depressive or bioplar disorder with psychotic features have been ruled out because either no major depressive or manic episodes have occured concurrently with active phase symptoms or, if mood episodes have occured during acite phase they have been present for a minority of the total duration
• Disturbance is not attributable to physiological effects of a substance or another medical condition
• *Specificy if with good prognostic features - requries presence of at least 2 of the following - onset of prominent psychotic symptoms within 4 weeks of first noticeable change in usual behaviour or functioning; confusion or perplexity; good premorbid social and occupational functioning, absence of blunted or flat affect or without good prognostic features
• If disturbance persists beyond 6 months person is given diagnosis of schizophrenia

Question 19

Schizophrenia

Answer 19

• 2 or more of the following (one must be first 3), each present for a significant portion of time during a 1-month periof (or less if treated)
  
  • Delusions
  • Hallucinations
  • Disorganized speech
  • Grossly disorganized or catatonic behaviour
  • Negative symptoms
• For significant portion of time since onset of disturbance level of functioning in one or more major areas such as work, interpersonal relations, or self-care, is markedly below level achieved prior to onset
• Continuous signs of disturbance persist for at least 6 months. At least 1 month of symptoms must meet criterion above. May include periods od predromal or residual symptoms where signs may be manifested by only negative symptoms or by 2 or more symptoms listed above present in an attentuated form
• Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either no major depressive or manic epsiodes have occured concurrently with active phase symptoms or if mood episodes have occured during active phase symptoms, they have been present for a minority of the total duration of active and residual periods of illness
• Disturbance is not attributable to physiological effects of a substnace or another medical condition
• If there is a history of autism or a communication disorder, the additional diagnosis of schizophrenia is made only is prominent delusions or hallucinations, in addition to the other requried symptoms are also present for at least 1 month.

Question 20

Development and Course of Schizophrenia

Answer 20

• Psychotic features tends to emerge between late teens and mid 30s with peak onset being early to mid 20s for males and late 20 for females.
• Onset is usually insidious, but it can be abrupt
• Males tends to have worse prognosis - poorer premorbid adjustment, lower educational achievement, more prominents negative symptoms and cognitive impairment, and genrally worse outcome
• Imparied cognition is common and may persist when other symptoms are in remission
• Psychotic symptoms tend to diminish over life course (may be due to age related declines in dopamine0

Question 21

Biological Factors that Contribute to Schizophrenua

Answer 21

• Genetics - risk is 13X higher if one parent has schizophrenia
• Birth related complcations - hypoxia during delivery, greater paternal age, perinatal and prenatal adversities (stress, infection, malnutrition, maternal diabetes, and other medical conditions).

Question 22

Brain Abnormalities Schizophrenia

Answer 22

• Frontal lobe is believed to be implicated
  
  • Imaging studies show abnormally reduced frontal brain volumes and reduced blood flow in frontal region when engaged in a mental task (in 25-50%).
• Some also show abnormalities in the left temporal lobe - specifically deficients in memory and selective attention in this region (again it is inconclusive)

Question 23

Neurochemical Imbalance Schizophrenia

Answer 23

• Dopamine hypothesis - abnormal acitivty of dopamine is involved in schizophrenia. Evidenced by the fact that
  
  • Antipsychotic drugs block effects of dopamine
  • Imaging studies show elevated densities of dopamine receptors
  • Drugs that increase dopamine can cause psychosis (cocaine, amphetamine)
• However, it is likely more complex - not just a straight increase in dopamine. Some theories that dopmaine interacts with teh true culprits - GABA and glutamate
• Serotonin - may cause positive and negative symptoms
• Norephinephrine - may cause anhedonia

Question 24

Schizoaffective Disorder

Answer 24

• An uninterrupted period of illness during which there is a mjor mood episodes (major depressive or manic) cocurrent with criteria A of schizophrenia.
• Delusions or hallucinations for 2 or mroe weaks in absence of major mood episode (dperssive or manic) during the lifetime duration of the illness
• Symptoms that meet criteria for a major mood episode are present for majority of total duration of active and residual portions of the illness
• Disturbance is not due to effects of a substance or another medical condition
• *Specify whether - bipolar type or depressive type
• *Critieria about social dysfunction does not have to be met - although it is frequently impaired

Question 25

Substance Medication induced psychotic disorder

Answer 25

• Presence of one or both of the following:
  
  • Delusions
  • Hallucinations
• Evidence from history, physical examination, or laboratory findings of both of the following:
  
  • Symptoms of criteria A developed during or soon after substance intoxication or withdrawal or after exposure to medication
  • Involved substance/medication is capable of producing the symptoms criteria A
• Disturbance is not better explained by a psychotic disorder that is not substance/medication induced
• Disturbance does not occur exclusively during course of delirium
• The disturbances causes clinically significant distress or impairment in functioning
• Substances - alcohol, cannabis, phencyclidine, other hallucinogens, inhalant, sedative, hypnotic, amphetamines, cocaine, etc.

Question 26

Psychotic disorder due to another medical condition

Answer 26

• Prominent hallucinations or delusions
• Evidence that it is due to another medical condition
• Not better explained by another medical disorder
• Disturbance does not occur exclusively during course of a delirium
• Cases clinically significant distress or impairment
• *Not diagnosed if individual apprecipates that hallucinations are due to a medical disorder
• Disoders- hyper-and hypo-thryoid, hyper-and hypo-parathyroidism, hyper- and hyp-adrenocroticism, autoimmune disorders (SLE, NMDA receptor autoimune encephalitis), temporal lobe epilespy, Huntingtons, MS, migrans, etc.

Question 27

THC and the developing Brain

Answer 27

• High TCH levels alter brain strucutre, size, and function, especially for frequent, heavy users.
• Neurons in brain areas that are rich in cannabinoid receptors (CB1) are damaged or destroyed by THC.
• Can result in neuronal damage in critical brain areas like the prefrontal cortex, hippocampus, amygdala and cerebellum. The amount of damage is directly correlated with smoking frequency and the age when pot use begins.
• The onset of psychotic symptoms is up to 6 years earlier in those who start smkoing pot before age 15.
• Greater emotional and social development before the onset ofsymptoms is associated with less illness related functional impairment

Question 28

EPS

Answer 28

• Extrapyamidal motor system is distinct from the pyramdial tract and is compsed of the basal ganglia, subthalamic nucleus, substantia nigra, red nucleus, and brain stem reticular function.
• D₂ blockade in nigrostriatal pathway is thought to cause EPS

Question 29

EPS types

Answer 29

• Acute - symptoms develop within hours to days of taking the medication
• Tardive - symptoms develop after chronic use of the medication
• Dsytonia - sustained posture produced by continuous muscular contraction. (Acute or tardive)
• Akathisia - feeling of internal motor restlessness. Generally present throughout body but can be confined to the legs. May be described as tension, nervousness or anxiety.
• Parkinsonism - classic triad of rigidity, bradykinesia, and tremor
• Tardive dyskinesia - choreiform movements (repetitive irregular, jerky, movements of usually short amplitude).
  
  • Involuntary movements involve muscles of lower face and distal extremities

Question 30

MOA of atypicals

Answer 30

• Clozapine - high affinity for dopamingeric, histaminergic, and muscarinic receptors, with selectivity in mesolimbic area
• Risperidone, olanzapine, quetiapine, and ziprasidone -mainly have affinity at dopaminergic D₂ and serotonergic 5-HT (antagonizing)
• Apripipazole - D₂ partial agonist

Question 31

Mechanism of EPS reduction in atypicals

Answer 31

• Still debated as to why these medications have lower incidence. Some theories include:
  
  • Suggest that atypicals have higher antagonistic affinity for 5-HT₂ serotonine receptors than the D₂ dopamine receptors. Some hypothosize that serotonin antagonism of atypicals may help alleviate EPS by lessening dopamine inhibition in the striatum. Specifically, it is thought that serotonin antagonists act as part of a feedback loop in basal ganglia, increasing dopamine release, and easing EPS. (Not likely becasue some of the typicals also habe high serotonin antagonism)
  • Another theory proposes that atypicals have faster dissociation from the D₂ dopamine receptor compared to the typicals. Supported by evidence that EPS only seems to occur once D₂ occupancy exceeds 80%

Question 32

Metabolic Syndrome and Atypicals

Answer 32

• Blocking histamine (H₁) and serotonine (5HT_2c) receptors in hypothalamus increase appetite
• Alter glucose metabolism by increasin insulin resistance