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Overview of psychotic disorders

Overview of psychotic disorders

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  • 1. Overview of PSYCHOTIC DISORDERS
    • Zimri Yaseen, MD
    • With thanks to Hyacinth C. Manood, MD, DPBP
    • References:
    • Kaplan & Sadock -Synopsis of Psychiatry
    • Schatzberg - Manual of Clinical Psychopharmacology,
    • Stahl - Essential Psychopharmacology
  • 2. What is psychosis?
    • Grossly impaired reality testing:
      • (contrast with neurotic disorders; reality testing intact)
    • What is reality/How do we test it?
      • Accurate sensory perception (I see it when its there)
      • Coherence across modalities (It walks like a duck, talks like a duck, smells like a duck…)
      • Coherence with context (“Is that a duck on your head or am I psychotic?”)
        • -Falsifiability (That big rock you threw at the duck didn’t injure it at all: “Must be one of those foam rocks” vs. “OMG, its Super Duck!”)
      • Big Implication: Psychosis involves perceptual and cognitive disruption
  • 3. The Prototypical Psychotic D/O: Schizophrenia (what we will talk about most). Typically involves more than just psychosis: Disorganization/cognitive deficits often prominent (leaving the patient vulnerable to psychosis)
  • 4. Associative Process (where disorganization/impoverishment happens): Stimulus Response: “ monkey see monkey do” MON A Lisa Key Banana See Monkey Do Lock
  • 5. Schizophrenia -Historical development 1st historical concept: dementia precox
    • Benedict Morel (1809-1873)
      • deteriorated patients whose illness began in adolescence
    • Emil Kraepelin (1856-1926)
      • the change in cognition (dementia) and early onset (precox) of the disorder.
      • long-term deteriorating course and the clinical symptoms of hallucinations and delusions
      • paranoia - persistent persecutory delusions; lacked the deteriorating course of dementia precox and the intermittent symptoms of manic-depressive psychosis.
      • Distinct from manic-depressive psychosis - distinct episodes of illness alternating with periods of normal functioning, not deteriorating
  • 6.
    • Eugene Bleuler (1857-1939)
    • coined the term schizophrenia, expressing presence of schisms (splits) between thought, emotion, and behavior in affected patients. Not necessarily deteriorating
      • four As:
        • Associations (loose), affect (abnormal), autism (lack of ability to/interest in relating to others), and ambivalence.
        • accessory (secondary) symptoms - hallucinations and delusions
  • 7. Kurt Schneider (1887-1967): Criteria for Schizophrenia
    • First-rank symptoms
      • Audible thoughts
      • Voices arguing or discussing or both
      • Voices commenting
      • Somatic passivity experiences
      • Thought withdrawal and other experiences of influenced thought
      • Thought broadcasting
      • Delusional perceptions
      • All other experiences involving volition made affects, and made impulses
    • Second-rank symptoms
      • Other disorders of perception
      • Sudden delusional ideas
      • Perplexity (ambivalence)
      • Depressive and euphoric mood changes (affect disordered)
      • Feelings of emotional impoverishment (affect disordered/autism)
      • (Schneiderian Sx - distorted perceptions of internal processes/ego boundaries in red)
  • 8. DSM-IV-TR Diagnostic Criteria for Schizophrenia
    • A. Characteristic symptoms : Two (or more) of the following, each present for a significant portion of time during 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, i.e., affective flattening, alogia, or avolition
    • Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.
    • B. Social/occupational dysfunction : deteriorated function or expected development arrested in 1 or more major areas
    • C Duration : > 6 months
  • 9.
    • The fine print:
    • D. Schizoaffective and mood disorder exclusion : Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.
    • E. Substance/general medical condition exclusion : The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
    • F. Relationship to a pervasive developmental disorder : Prominent delusions or hallucinations must be present for at least 1 month (or less if successfully Tx-ed)
  • 10. SUBTYPES:
    • Paranoid type A type of schizophrenia in which the following criteria are met:
    • Preoccupation with one or more delusions or frequent auditory hallucinations.
    • None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.
    • Disorganized type A type of schizophrenia in which the following criteria are met:
    • All of the following are prominent:
      • disorganized speech
      • disorganized behavior
      • flat or inappropriate affect
    • The criteria are not met for catatonic type
  • 11.
    • Catatonic type
    • A type of schizophrenia in which the clinical picture is dominated by at least two of the following:
      • motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor
      • excessive motor activity (that is apparently purposeless and not influenced by external stimuli)
      • extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism
      • peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing
      • echolalia or echopraxia
  • 12.
    • Undifferentiated type
    • A type of schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the paranoid, disorganized, or catatonic type .
    • Residual type
    • A type of schizophrenia in which the following criteria are met:
    • Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.
    • There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).
  • 13. Clinical Features
    • no clinical sign or symptom is pathognomonic for schizophrenia
    • patient's symptoms change with time.
    • clinicians must take into account the patient's educational level, intellectual ability, and cultural and subcultural membership
  • 14. Making the diagnosis
    • Premorbid Signs and Symptoms:
      • patients had schizoid or schizotypal personalities characterized as quiet, passive, and introverted; as children, they had few friends; sudden onset of obsessive-compulsive behavior as part of the prodromal picture. The signs may have started with complaints about somatic symptoms, such as headache, back and muscle pain, weakness, and digestive problems; develop an interest in abstract ideas, philosophy, and the occult or religious questions.
  • 15. Mental Status Examination
    • Orientation : usually oriented to person, time, and place
    • Appearance : a patient with schizophrenia can range from that of a completely disheveled, screaming, agitated person to an obsessively groomed, completely silent, and immobile person
    • Relatedness : often impaired e.g. Precox Feeling - an intuitive experience of their inability to establish an emotional rapport with a patient
  • 16.
    • Mood/Affect : reduced emotional responsiveness, sometimes severe enough to warrant the label of anhedonia, and overly active or inappropriate emotions such as extremes of rage, happiness, and anxiety.
    • flat or blunted affect can be a symptom of the illness itself, of the parkinsonian adverse effects of antipsychotic medications, or of depression
    • Cognition: relatively subtle basic cognitive deficiencies (eg. mild visual processing or working memory impairments, Folstein mini-mental within normal limits)
  • 17.
    • Perception : most common hallucinations are auditory , with voices that are often threatening, obscene, accusatory, or insulting;
    • Cenesthetic hallucinations - are unfounded sensations of altered states in bodily organs; also fairly common
    • ( Blending into) Thought content : may believe/experience that an outside entity controls their thoughts or behavior or, conversely, that they control outside events in an extraordinary fashion
  • 18.
    • loss of ego boundaries describes the lack of a clear sense of where the patient's own body, mind, and influence end and where those of other animate and inanimate objects begin: eg. ideas of reference, cosmic identity
    • Thought process/speech :
      • looseness of associations: circumstantiality, tangentiality, derailment, incoherence,
      • abnormal speech: neologisms, verbigeration, word salad, echolalia, and mutism
      • Abnormal prosody (e.g. mechanical, monotonous, weird)
  • 19. Risk, c ourse/prognosis
    • Violence - Delusions of a persecutory nature, previous episodes of violence, substance abuse, and neurological deficits are risk factors for violent or impulsive behavior
    • Suicide is the single leading cause of premature death among people with schizophrenia. (~25% make lifetime attempts, ~10% of Schizophrenia deaths)
  • 20.
    • cognitive impairment is a better predictor of level of function than is the severity of psychotic symptoms;
    • poor insight - poor compliance with treatment
    • Nonlocalizing signs ( soft signs) include dysdiadochokinesia, astereognosis, primitive reflexes, and diminished dexterity
  • 21.
    • The classic course of schizophrenia is one of exacerbations and remissions
    • Further deterioration in the patient's baseline functioning generally follows each relapse of the psychosis
    • Sometimes, a clinically observable postpsychotic depression follows a psychotic episode
  • 22.
    • vulnerability to stress is usually lifelong
    • 10 to 20 % - good outcome; >50 % - poor outcome
  • 23. EPIDEMIOLOGY
    • lifetime prevalence of schizophrenia is about 1 percent
    • equally prevalent in men and women; Typical onset is earlier in men than in women ( M = 15 – 25; F= 25 – 35)
    • Onset of schizophrenia before age 10 or after age 60 is extremely rare; When onset occurs after age 45, the disorder is characterized as late-onset schizophrenia.
  • 24.
    • In general, the outcome for female schizophrenia patients is better than that for male schizophrenia patients
    • higher mortality rate from accidents and natural causes than the general population
    • more likely to have been born in the winter and early spring - Season-specific risk factors, such as a virus or a seasonal change in diet, may be operative .
  • 25.
    • gestational and birth complications, exposure to influenza epidemics, or maternal starvation during pregnancy, Rhesus factor incompatibility, and an excess of winter births. - neurodevelopmental pathological process
  • 26. Etiology
    • I. Genetic Factors:
    • Prevalence of Schizophrenia in Specific Populations
    • Population Prevalence (%)
    • General population 1
    • Non-twin sibling of a schizophrenia patient 8
    • Child with one parent with Schizophrenia 12
    • Dizygotic twin of a schizophrenia patient 12
    • Child of two parents with schizophrenia 40
    • Monozygotic twin of a schizophrenia patient 47
  • 27.
    • II. Biochemical Factors :
    • Dopamine Hypothesis - schizophrenia results from too much dopaminergic activity (now clearly out of date).
      • Revision: Dopaminergic activity too high in mesolimbic pathway, too low in mesocortical pathway
    • Serotonin - excess as a cause of both positive and negative symptoms in schizophrenia . 5HT-2A receptors on dopaminergic neurons inhibit dopamine release (strong mesocortical and weak mesolimbic effect)
    • Norepinephrine - selective neuronal degeneration within the norepinephrine reward neural system could account for the impaired capacity for emotional gratification and the decreased ability to experience pleasure.
  • 28.
    • GABA - GABA has a regulatory effect on dopamine activity, and the loss of inhibitory GABAergic neurons could lead to the hyperactivity of dopaminergic neurons.
    • Neuropeptides - substance P and neurotensin, are localized with the catecholamine and indolamine neurotransmitters and influence the action of these neurotransmitters.
  • 29.
    • Glutamate - ingestion of phencyclidine, a glutamate antagonist, produces an acute syndrome similar to schizophrenia. The hypotheses proposed about glutamate include those of hyperactivity, hypoactivity, and glutamate-induced neuro- toxicity .
    • Acetylcholine and Nicotine - decreased muscarinic and nicotinic receptors ; dysregulation of neurotransmitter systems involved in cognition
  • 30.
    • Neuropathology :
    • lateral and third ventricular enlargement and some reduction in cortical volume;
    • reduced symmetry in several brain areas in schizophrenia, including the temporal, frontal, and occipital lobes ;
    • decrease in the size of the region including the amygdala, the hippocampus, and the parahippocampal gyrus;
  • 31.
    • several symptoms of schizophrenia mimic those found in persons with prefrontal lobotomies or frontal lobe syndromes
    • The medial dorsal nucleus of the thalamus, which has reciprocal connections with the prefrontal cortex, has been reported to contain a reduced number of neurons
    • cell loss or the reduction of volume of the globus pallidus and the substantia nigra.
  • 32.
    • III. Psychosocial and Psychoanalytic Theories
    • Sigmund Freud - postulated that schizophrenia resulted from developmental fixations that occurred earlier than those culminating in the development of neuroses .
    • Margaret Mahler - there are distortions in the reciprocal relationship between the infant and the mother .
    • Paul Federn - the defect in ego functions permits intense hostility and aggression to distort the mother-infant relationship, which leads to eventual personality disorganization and vulnerability to stress.
  • 33.
    • Harry Stack Sullivan - schizophrenia is an adaptive method used to avoid panic, terror, and disintegration of the sense of self .
    • Karl Jaspers - existential psychoanalysis
      • trying to understand the psychological meaning of schizophrenic signs and symptoms such as delusions and hallucinations.
    • Adolf Meyer - founder of psychobiology
      • reaction to life stresses ; schizophrenic reaction
    • The useful idea in all of this:
      • All psychodynamic approaches are founded on the premise that psychotic symptoms have meaning in schizophrenia
    • Learning theory - the poor interpersonal relationships of persons with schizophrenia develop because of poor models for learning during childhood.
  • 34.
    • Family Dynamics (stressors that may reveal vulnerability to or exacerbate psychosis)
    • Double Bind - children receive conflicting parental messages about their behavior, attitudes, and feelings. In Bateson's hypothesis, children withdraw into a psychotic state to escape the unsolvable confusion of the double bind.
    • Schisms and Skewed Families - In one family type, with a prominent schism between the parents, one parent is overly close to a child of the opposite gender. In the other family type, a skewed relationship between a child and one parent involves a power struggle between the parents and the resulting dominance of one parent.
    • Pseudomutual and Pseudohostile Families - suppress emotional expression by consistently using pseudomutual or pseudohostile verbal communication.
    • Expressed Emotion - families with high levels of expressed emotion (hostile critical and controlling), the relapse rate for schizophrenia exacerbation is high
  • 35. Treatment
    • Antipsychotics (  =weight gain/metabolic syndrome,  =depot injection available, green=weak or no association with weight gain )
    Decreasing Strength of D2 blockade, Increasing ACh blockade Increasing Strength of H2 blockade Clozaril (clozapine)  Mellaril (thioridazine)  Thorazine(chlorpromazine)  Seroquel (quetiapine)  +/-  Compazine (prochlorperazine) Abilify (aripiprazole D2 partial agonist ) Zyprexa (olanzapine)   Trilafon (perphenazine) Risperdal (risperidone)   Geodon (ziprasidone) Haldol (haloperidol)  Prolixin (fluphenazine)  2nd generation (D2 & 5HT-2a +/- ACh/H) 1st generation (D2 +/- Ach/H)
  • 36. Other Pharmacologics
    • Anxiolytics (benzodiazepines): can help reduce positive symptoms
    • Antidepressants: can help treat comorbid depression, anxiety, obsessive/compulsive Sx
    • Antiepileptics (VPA, Lamotrigine) Lithium: can be used as mood stabilizers to treat manic symptoms. Lamotrigine may be useful as an anxiolytic
  • 37. Medications to treat adverse effects
    • Tremor/Akathesia
      • Benztropine
      • Propranolol
      • Benzodiazepines
      • Amantadine
    • Dystonia
      • Diphenhydramine
    • NMS
      • Stop Antipsychotic
      • Dantrolene
      • Bromocriptine
    • Weight Gain
      • Topiramate
      • Metformin
    • Sedation
      • Stimulants (eg provigil)
  • 38. Non-Pharmacological treatments
    • Individual supportive therapy
    • Cognitive behavioral therapy
    • Art therapy
    • Group therapy
    • Family therapy
    • (Experimental Treatment: Transcranial Magnetic Stimulation)
    • ECT - controversial
  • 39. Other psychotic disorders <1mo Brief Psychotic d/o <6mo Schizophreniform d/o Duration: >6mo schizophrenia With cognitive symptoms Without major cognitive symptoms Delusional Disorders With significant mood symptoms Schizoaffective d/o
  • 40. SCHIZOPHRENIFORM DISORDER
    • acute psychotic disorder that has a rapid onset and lacks a long prodromal phase
    • similar to schizophrenia, except that its symptoms last at least 1 month but less than 6 months.
    • return to their baseline level of functioning once the disorder has resolved.
  • 41.
    • lifetime prevalence rate = 0.2 percent
    • 1-year prevalence rate of 0.1 percent
    • have more affective symptoms (especially mania) and a better outcome
    • increased occurrence of mood disorders in the relatives
    • progression to schizophrenia range between 60 and 80 percent
  • 42. DSM-IV-TR Diagnostic Criteria for Schizophreniform Disorder
    • Criteria A, D, and E of schizophrenia are met.
    • An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as provisional)
  • 43.
    • Specify if:
    • Without good prognostic features
    •     With good prognostic features : as evidenced by two (or more) of the following:
      • onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning
      • confusion or perplexity at the height of the psychotic episode
      • good premorbid social and occupational functioning
      • absence of blunted or flat affect
  • 44. Brief Psychotic Disorder
    • sudden onset of psychotic symptoms, which lasts 1 day or more but less than 1 month
    • Remission is full, and the individual returns to the premorbid level of functioning
    • occurs more often among younger patients (20s and 30s)
    • with personality disorders (most commonly, histrionic, narcissistic, paranoid, schizotypal, and borderline personality disorders).
    • precipitating stressors - major life events
  • 45. Schizoaffective Disorder
    • symptoms of both schizophrenia and mood disorders
    • onset of symptoms was sudden and often occurred in adolescence.
    • good premorbid level of functioning, and often a specific stressor preceded the onset of symptoms.
    • 0.5 to 0.8 percent lifetime prevalence
  • 46.
    • depressive type of schizoaffective disorder may be more common in older persons; bipolar type may be more common in young adults;
    • age of onset for women is later than that for men
    • better prognosis than patients with schizophrenia and a worse prognosis than patients with mood disorders
  • 47.
    • DSM-IV-TR Diagnostic Criteria for Schizoaffective Disorder
    • An uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode, or a mixed episode concurrent with symptoms that meet Criterion A for schizophrenia. Note : The major depressive episode must include Criterion A1: depressed mood.
    • During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.
    • Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.
    • The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
    • Specify type:
    •        Bipolar type : if the disturbance includes a manic or a mixed episode (or a manic or a mixed episode and major depressive episodes)
    • Depressive type : if the disturbance only includes major depressive episodes
  • 48. Delusional Disorder and Shared Psychotic Disorder
    • nonbizarre delusions of at least 1 month's duration that cannot be attributed to other psychiatric disorders
    • .025 to 0.03 percent
    • mean age of onset is about 40 years
    • slight preponderance of female
  • 49.
    • Men are more likely to develop paranoid delusions
    • women are more likely to develop delusions of erotomania.
    • defense mechanisms of reaction formation, denial, and projection
  • 50. Mental Status
    • may seem eccentric, odd, suspicious, or hostile.
    • quite normal except for a markedly abnormal delusional system
    • moods are consistent with the content of their delusions
    • do not have prominent or sustained hallucinations
  • 51.
    • delusions are usually systematized and are characterized as being possible
    • no insight into their condition and are almost always brought to the hospital by the police, family members, or employers. Judgment can best be assessed by evaluating the patient's past, present, and planned behavior.
    • Men are more likely to develop paranoid delusions
  • 52. Types :
    • Persecutory Type
    • Jealous Type
    • Erotomanic Type
    • Somatic Type
    • Grandiose Type
  • 53.
    • DSM-IV-TR Diagnostic Criteria for Delusional Disorder
    • Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration.
    • Criterion A for schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme.
    • Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
    • If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.
    • The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
  • 54.
    • Shared Psychotic Disorder - shared paranoid disorder, induced psychotic disorder, folie a deux, folie impose, and double insanity)
    • characterized by the transfer of delusions from one person to another.
  • 55. DSM-IV-TR Diagnostic Criteria for Shared Psychotic Disorder
    • A delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established delusion.
    • The delusion is similar in content to that of the person who already has the established delusion.
    • The disturbance is not better accounted for by another psychotic disorder (e.g., schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
  • 56. DSM-IV-TR Diagnostic Criteria for Brief Psychotic Disorder
    • Presence of one (or more) of the following symptoms:
      • delusions
      • hallucinations
      • disorganized speech (e.g., frequent derailment or incoherence)
      • grossly disorganized or catatonic behavior
    • Note: Do not include a symptom if it is a culturally sanctioned response pattern.
    • Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.
    • The disturbance is not better accounted for by a mood disorder with psychotic features, schizoaffective disorder, or schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
  • 57.
    • Specify if:
      • With marked stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture
      •   Without marked stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture
      •     With postpartum onset: if onset within 4 weeks postpartum
  • 58. DSM-IV-TR Diagnostic Criteria for Psychotic Disorder Not Otherwise Specified
    • Examples include
    • Postpartum psychosis that does not meet criteria for mood disorder with psychotic features, brief psychotic disorder, psychotic disorder due to a general medical condition, or substance-induced psychotic disorder
    • Psychotic symptoms that have lasted for less than 1 month but that have not yet remitted, so that the criteria for brief psychotic disorder are not met
    • Persistent auditory hallucinations in the absence of any other features
    • Persistent nonbizarre delusions with periods of overlapping mood episodes that have been present for a substantial portion of the delusional disturbance
    • Situations in which the clinician has concluded that a psychotic disorder is present, but is unable to determine whether it is primary, due to a general medical condition, or substance induced
    This category includes psychotic symptomatology (i.e., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis or about which there is contradictory information, or disorders with psychotic symptoms that do not meet the criteria for any specific psychotic disorder.