Psychotic disorders


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a short talk about psychotic disorders,, best wishes

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  • Family Studies Inherit a tendency for schizophrenia, not a specific form of schizophrenia Schizophrenia in the family increases risk for schizophrenia in other family members Twin Studies Risk of schizophrenia in monozygotic twins is 48% Risk of schizophrenia drops to 17% for fraternal (dizygotic) twins Adoption Studies Risk of schizophrenia remains high in adopted children with a biological parent suffering from schizophrenia - One parent >> risk is 15%, both>>25%
  • Bleuler’s 4 A’s: Affect Associative Looseness Autism Ambivalence
  • Alterations in thinking can take many forms. Delusions are false fixed beliefs that cannot be corrected by reasoning, it is a false belief that is held and maintained as true, even with evidence to the contrary. Most commonly, delusional thinking involves the following themes: (Table 20-1 has a summary of Delusions) Ideas of reference – Example – “The headline of the New York Times told me that I have been assigned to stop crime. I am issuing a nationwide bulletin telling people to turn in their guns and knives. I take my assignments very seriously.” Persecution – “My neighborhood wants me dead or alive. They think I hold all their secrets. They have tapped my phone and peek through my windows 24 hours a day.” Grandiosity – “Within one month, I am going to be a billionaire and own 14 hourses and 20 cars. I will be so rich and successful that Bill Gates and Allen Greenspan are going to call me for financial advice.” Bodily Functions Jealousy Control “My mother put a voodoo curse on me. She can control all of my thoughts and emotions through a remote control car. I am completely under her spell.”
  • Most Common Types of Hallucinations: Auditory – hearing voices or sounds *How do you know if someone is hearing voices? Turing or Tilting of head, as id the patient is talking to someone, frequent blinking of the eyes, and grimacing. Visual – seeing persons or things (More often reported in individuals with Organic Disorders – 20% of Schizophrenics experience visual hallucinations) Olfactory – smelling odors (10%) Gustatory – experiencing tastes (10%) Tactile – feeling body sensations (10%) Difference between Illusions and Hallucinations A hallucination is a false sensory perception for which no external stimulus exist. They are different from Illusions in that Illusions are misperceptions or misinterpretations of a real experience. For example, a man saw his coat hanging on a coat rack and believed it to be a bear about to attack him. He did see something real but misinterpreted what it was. * Command Hallucinations must be assessed carefully because the voices may command the person to hurt himself or someone else. Command hallucinations may be a psychiatric emergency. REMEMBER SAFETY! Personal Boundary Difficulties – People with Schizophrenia often lack a sense of their body to the rest of the world. Depersonalization – is a nonspecific feeling that a person has lost his or her identity, that the self is different or unreal. People may be concerned that body parts do not belong to them. People describe feeling like robots or feeling like they are living a dream. Derealization – is the false perception by a person that the environment has changed. For example, everything seems bigger or smaller, or familiar surroundings seem strange.
  • The negative symptoms of schizophrenia develop over a long period of time. These are the symptoms that most interfere with the individual’s adjustment and ability to survive. The presence of negative symptoms interfere with the person’s ability to: Initiate and maintain relationships Initiate and maintain conversations Hold a job Make decisions Maintain adequate hygiene and grooming During an acute psychotic episode, the negative symptoms may be difficult to assess because the positive symptoms are more obvious – meaning the hallucinations or delusions may dominate. Negative symptoms include: poverty of speech content, thought blocking, anergia, anhedonia, affective blunting, and lack of volition. (Refer to Table 20-3, p. 535 Negative Phenomena) Be sure to be able to distinguish between the positive and negative symptoms of schizophrenia (Table 20 - 4, p. 535).
  • * Depression is often seen in people with schizophrenia. Attempted suicide is a frequent event in the lives of people with schizophrenia. Actual deaths occurs in at least 10% to 13%, this is 20 times higher than in the general population. Suicide is the leading cause of premature death among people with schizophrenia. * Water Intoxication - Excessive Water or psychosis induced polydipsia is though to occur in 3 to 6% of hospitalized clients (I have seen this). Clients may ingest 10 to 15 L of fluid per day. When this disorder is not treated, it can lead to cerebral edema, seizures, brainstem herniation, and even death. WHAT TO LOOK FOR: these clients are often seen constantly carrying a cup of fluid, a coke and taking frequent trips to the water fountain. These clients have also been observed drinking from the toilet, sink, and shower. The client that I took care of was found drinking from the toilet. Must rule out medical causes. * Substance Abuse - Cannabis, alcohol, and cocaine are the drugs used most frequently by people with schizophrenia. - Clients report that all three drugs increase their happiness and decrease their feelings of depression. * Violent Behavior - Threats of violence and aggressive outbursts are common in acute schizophrenic states. Risk factors for violence may include: previous arrests, presence of substance abuse, presence of hallucinations, delusions, or bizarre behavior.
  • * Interventions are geared toward the patient’s phase of schizophrenia. For example, in the acute phase, phase I the clinical focus is on crisis intervention. Safety is of utmost importance - protection from harm to self or others, the patient is in need of support (use supportive and direct communication when interacting with the patient), client’s need for treatment (this includes psychopharmacological administration) along with counseling. Phase I: Acute Phase - crisis intervention protection from harm (safety) need for support (supportive communication) need for treatment (psychopharmacological) counseling * Counseling is very important. For example if the client is in the acute phase of the illness, it is important to: maintain eye contact, speak simply in a loud voice than usual, and call the person by name (helps with reality orientation). When the patient is hallucinating it is important for the nurse to: Establish trust - so that the client feels safe, assess for auditory hallucinations (CUES - eyes looking around, tilting head to one side, mumbling to oneself, curling up on the bed and withdrawing), Allow the person to discuss their hallucinations - this may the first time the person has been allowed to mention about the hallucination.
  • The choice of treatment for schizophrenics is Antipsychotic medications. Medication used to treat psychotic disorders is called antipsychotics. There are two groups 1) standard (traditional) and 2) atypical. The standard or traditional antipsychotic drugs are able to block postsynaptic dopamine receptors in the central nervous system and are effective in treating schizophrenia. The choice of the drugs is based on: desired side effect (an agitated patient may be given a more sedating antipsychotic), avoiding adverse side effects for example Haldol can be used in people with cardiac problems because of its anticholinergic effects, and patient response (what drug worked well in the past). Antipsychotics reduce disruptive and violent behavior, improvement in self-care, sleep, etc. The antipsychotic agents are usually effective 3 to 6 weeks after the regimen is started. Only about 10% of schizophrenics fail to respond the drugs. *KNOW BOTH NAMES – GENERIC AND TRADE NAMES Geodon>> S/E >> weight gain
  • Antidepressants – Antidepressants are recommeneded along with antipsychotic agents for treatment of depression, which is very common in these individuals. Antimanic Agents – Lithium can be useful for suppressing violent episodes. Benzo – Adjunctive treatment especially in the acute phase – has a positive affect on anxiety, agitation, or psychosis. WHEN DO YOU CHANGE ANTIPSYCHOTIC REGIMEN? *Lack of efficacy of the current drug regimen *Occurrence of intolerable or persistent side effects Has anyone heard of ECT? HISTORY OF ECT * ECT (Electroconvulsive Therapy) - In several studies of first-admission schizophrenic patients, ECT was found to be as effective as antipsychotic medication during the acute phase. It is not as effective in chronic schizophrenia. ECT may also be useful in severly catatonic patients. It is also indicated when antipsychotic drug therapy fails or is contraindicated.
  • Paranoid Schizophrenics have hallucinations and delusions. They do not have disorganized speech, but they have disorganized behavior, catatonia, or inappropriate affect. Paranoid ideas cannot be corrected by experiences and cannot be modified by facts or reality. Projections is the most common defense mechanism used by most people who are paranoid. For example, when paranoid individuals feel self-critical, they experience others as being harshly critical toward them. When they feel angry, they experience others as being unjustly angry at them. Paranoid symptoms can be secondary to a physical illness, organic brain disease, or drug intoxication. People with paranoid schizophrenia usually have a later age of onset (late 20s to 30s). They usually have deep feelings of loneliness, despair, hopelessness, and fear of abandonment. Upon assessment, you will find the paranoid schizophrenic as guarded, tense, and reserved. They may even be hostile. During the hospitalization, the patient may make offensive criticisms, so it is important for the staff to not react to these criticisms. Self-care such as grooming, dressing, and bathing is not a problem, in fact they may be dressed meticulous. Nutrition may be a problem because they have a common delusion that the food is poisoned.
  • Disorganized Schizophrenia is the most regressed and socially impaired of all the schizophrenic disorders. A person diagnosed with disorganized schizophrenia may have marked looseness of associations, grossly inappropriate affect, bizarre mannerisms, incoherent speech, and socially withdrawn. Delusions and hallucinations are present but are fragmented. Onset early to middle teens and is associated with poor premorbid functioning, a positive family history of psychopathological disorders and has a poor prognosis. Need help with communication and self-care.
  • The essential feature of catatonia is abnormal motor behavior. Two extreme motor behaviors are seen in patients with catatonia: extreme motor agitation and extreme psychomotor retardation (with mutism and even stupor). Other behaviors include posturing, waxy flexibility (the ability to hold distorted postures for extensive periods for example a person may raise their arm and keep it in that position for hours - the physician may ask the patient to raise their hand above their head and if they keep it in the fixed position that is a diagnostic sign), stereotyped behavior, extreme negativism, echolalia (mimicking or imitating the speech of others), and echopraxia (mimicking or imitating the movement of others). The onset of catatonia is abrupt and the prognosis is favorable. Clients in the withdrawn phase can be so withdrawn that they appear comatose. They can be mute and may remain so for hours, days, even weeks or months IF they are not treated with antipsychotic medication. The patient may not seem like they are paying attention to the events going on around them, but don’t let that fool you - they are aware of the environment and may even remember events accurately at a later date. When a patient is withdrawn, physical needs take priority - the patient may need to be hand-fed or even tube fed in order to maintain adequate nutritional status. Other needs include assessment of urinary or bowel retention, bathing, grooming, ROM exercises to prevent muscle atrophy and contractures.
  • Loose association: Definition - thinking haphazard, illogical, and confused. Connections in thought are interrupted. Example: “I can’t go to the zoo, no money, Oh... I have a hat, these members make no sense, man…What’s the problem?” -Neolgism: Definition: Words a person makes up that have meaning only for that person, it is often part of a delusional system. Example: “I am afraid to go to the hospital because the norks are looking for me.” -Clang association: Definition: The meaningless rhyming of words, often in a forceful manner. Example: “Rain, pain, bang, clang.” -echolalia: Definition - mimicking or imitating the speech of another person. Example: The nurse says to the patient, “Tell me your name.” The patient responds, “Tell me your name, tell me your name.” -Word Salad: Definition: Mixture of words and phrases that have no meaning. Example: “I am fine…apple pie…no sale…furniture store…take it slow…cellar door…” Concrete thinking: What brought you here to the hospital? The cab “ People in glass houses shouldn’t through stones.” Don’t throw stones or the windows will break. ANSWERS ARE LITERAL Thought broadcasting: thought broadcasting - the belief that one’s thoughts can be heard by others Thought insertion: thought insertion - the belief that thoughts from other people are being inserted into one’s mind Thought withdrawal: thought withdrawal - the belief that thoughts have been removed from one’s mind by an outside agency. Delusions of being controlled: Delusions of being controlled belief that one’s body or mind is controlled by an outside agency
  • Reduced activation of the prefrontal cortex while performing “executive functions” Abnormalities in whole NT system
  • Brief psychotic disorders: Sudden onset of at least one “positive” CHARACTERISTIC SYMPTOM Duration of 1 day to 1 month Eventual return to premorbid functioning
  • Lifetime prevalence under 1% Diagnosis of exclusion: often provisional Diagnostic ambiguity may lead to overdiagnosis Prognosis intermediate between Schizophrenia and Mood Disorders It has two types Bipolar - illness includes Manic or Mixed episodes (and often Major Depression also) Depressive Type - only type of mood episodes are Major Depressive Episodes
  • B12, niacin? Thyroid, parathyroid? Pituitary? Uremia, Dementia with lewy bodys
  • Beta blockers Digitalis Antiarrythmics Sedatives: Barbiturates Benzodiazepines (withdrawal) Alcohol (withdrawal) Hormones: Oral Contraceptive Pills Prednisone Corticosteroids Anabolic steroids Stimulants: amphetamine, cocaine, ephedra Analgesics Antimicrobials Antidepressants (rarely) Antihistamines, anticholinergics Thyroid hormones Antiparkinsonian agents: L-dopa, bromocriptine, amantadine, etc
  • Psychotic disorders

    1. 1. Psychotic Disorders Al-Momtan
    2. 2. Definitions <ul><ul><li>Psychotic behavior – Cluster of disorders characterized by hallucinations and/or loss of contact with reality. </li></ul></ul><ul><li>Psychotic Symptoms </li></ul><ul><li>Presence of Delusions and Hallucinations </li></ul><ul><li>Severely disorganized behavior, speech and thought </li></ul><ul><li>Also occurs in Mood Disorders </li></ul><ul><li>May be associated with substance use </li></ul><ul><li>May be due to medication side effects </li></ul><ul><li>May be due to Delirium, GMC </li></ul><ul><li>DSM-IV </li></ul>
    3. 3. Schizophrenia <ul><li>Schizophrenia vs. Psychosis </li></ul><ul><ul><li>Psychosis – Broad term (e.g., hallucinations, delusions) </li></ul></ul><ul><ul><li>Schizophrenia – A type of psychosis </li></ul></ul><ul><ul><li>Psychosis and Schizophrenia are heterogeneous </li></ul></ul><ul><ul><li>Disturbed thought, emotion, behavior </li></ul></ul>
    4. 4. Schizophrenia <ul><li>Neurological disease that affects a person’s perception, thinking, language, emotion, and social behavior. </li></ul>
    5. 5. Facts and How common? <ul><li>Onset and Prevalence of Schizophrenia worldwide </li></ul><ul><ul><li>About 1% of the population </li></ul></ul><ul><ul><li>Usually develops in early adulthood, but can emerge at any time </li></ul></ul><ul><li>Schizophrenia Is Generally Chronic </li></ul><ul><ul><li>Most suffer with moderate-to-severe impairment throughout their lives </li></ul></ul><ul><ul><li>Life expectancy in persons with schizophrenia is slightly less than average </li></ul></ul><ul><li>Schizophrenia Affects Males and Females About Equally </li></ul><ul><ul><li>Females tend to have a better long-term prognosis </li></ul></ul><ul><ul><li>Onset of schizophrenia differs between males (earlier) and females (later) </li></ul></ul><ul><li>Schizophrenia Appears to Have a Strong Genetic Component </li></ul>
    6. 6. DSM-IV-TR Criteria for Schizophrenia <ul><li>Characteristic symptoms – </li></ul><ul><li>Two or more of the following, one month, less if treated: </li></ul><ul><ul><li>Delusions. </li></ul></ul><ul><ul><li>Hallucinations. </li></ul></ul><ul><ul><li>Disorganized Speech. </li></ul></ul><ul><ul><li>Disorganized or Catatonic Behavior. </li></ul></ul><ul><ul><li>Negative symptoms.(flat affect) </li></ul></ul>
    7. 7. Assessment of Symptoms <ul><li>Symptoms may be classified as </li></ul><ul><ul><li>Positive – “attention getter” symptoms i.e. hallucinations, delusions, bizarre behavior, disorganized speech </li></ul></ul><ul><ul><li>Negative – “crippling” symptoms i.e. apathy, lack of motivation, anhedonia </li></ul></ul><ul><ul><li>Cognitive - i.e. difficulty with attention, memory, and problem solving </li></ul></ul><ul><ul><li>Disorganized – i.e. disorganized speech, inappropriate affect </li></ul></ul>
    8. 8. Alterations in Thinking <ul><li>Delusions </li></ul><ul><ul><ul><li>Ideas of Reference </li></ul></ul></ul><ul><ul><ul><li>Persecution </li></ul></ul></ul><ul><ul><ul><li>Grandiosity </li></ul></ul></ul><ul><ul><ul><li>Bodily Functions </li></ul></ul></ul><ul><ul><ul><li>Jealousy </li></ul></ul></ul><ul><ul><ul><li>Control </li></ul></ul></ul>
    9. 9. Also observed! <ul><ul><li>Thought broadcasting </li></ul></ul><ul><ul><li>Thought insertion </li></ul></ul><ul><ul><li>Thought withdrawal </li></ul></ul><ul><ul><li>Being controlled </li></ul></ul><ul><ul><li>Loose Association </li></ul></ul><ul><ul><li>Neologisms </li></ul></ul><ul><ul><li>Concrete Thinking </li></ul></ul><ul><ul><li>Echolalia </li></ul></ul><ul><ul><li>Clang Association </li></ul></ul><ul><ul><li>Word Salad </li></ul></ul>
    10. 10. Alterations in Perception <ul><li>Hallucinations - auditory, visual, olfactory, gustatory, and tactile </li></ul><ul><ul><li>90% of schizophrenics experience hallucinations - auditory most common </li></ul></ul><ul><ul><li>Difference between Illusions and Hallucinations </li></ul></ul><ul><ul><li>Depersonalization and Derealization (loss of ego boundaries) </li></ul></ul><ul><li>Bizarre Behavior </li></ul>
    11. 11. Negative Symptoms <ul><li>Develop over time </li></ul><ul><li>May not be detected (masked by positive symptoms </li></ul><ul><li>Negative symptoms include: poverty of speech content, thought blocking, anergia, anhedonia, affective blunting, and lack of avolition. </li></ul>
    12. 12. Associated symptoms <ul><li>Depression and Suicide </li></ul><ul><li>Water Intoxication </li></ul><ul><li>Substance Abuse </li></ul><ul><li>Violent Behavior </li></ul>
    13. 13. Management <ul><ul><li>Phases of presentation: </li></ul></ul><ul><ul><li>Acute. </li></ul></ul><ul><ul><li>Maintenance. </li></ul></ul><ul><ul><li>Stable. </li></ul></ul><ul><ul><li>Psychopharmacology : </li></ul></ul><ul><li>- Typical (Traditional) Antipsychotics – target the positive symptoms </li></ul><ul><ul><ul><li>Older drugs – Watch for signs of EPS </li></ul></ul></ul><ul><li>- Atypical (Novel) Antipsychotics – diminish the positive and negative symptoms </li></ul>
    14. 14. Pharmacology <ul><li>Typical ones!! </li></ul><ul><ul><li>Thorazine (chlorpromazine) </li></ul></ul><ul><ul><li>Mellaril (thioredazine) </li></ul></ul><ul><ul><li>Stelazine ( Trifluoperazine) </li></ul></ul><ul><ul><li>Trilafon (perphenazine) </li></ul></ul><ul><ul><li>Serentil ( Mesoridazine) </li></ul></ul><ul><ul><li>Prolixin ( Fluphenazine) </li></ul></ul><ul><ul><li>Navane ( Thiothixene) </li></ul></ul><ul><ul><li>Haldol (Haloperidol and Haloperidol deconate) </li></ul></ul><ul><ul><li>Loxapine </li></ul></ul><ul><ul><li>Moban (molindon) </li></ul></ul><ul><li>A typicals !! </li></ul><ul><li>Clozapine (Clozaril) agranulocytosis and seizures </li></ul><ul><li>LOWER SIDE EFFECTS: </li></ul><ul><ul><li>Risperidone (Risperdal). </li></ul></ul><ul><ul><li>Olanzapine (Zyprexa). </li></ul></ul><ul><ul><li>Quetiapine (Seroquel) </li></ul></ul><ul><ul><li>Ziprasidone (Geodon) </li></ul></ul>
    15. 15. Side Effects of antipsychotics <ul><li>Anticholinergic Symptoms </li></ul><ul><li>Extrapyramidal Symptoms (EPS): </li></ul><ul><ul><li>Pseudoparkinsonism. </li></ul></ul><ul><ul><li>Acute dystonic reactions </li></ul></ul><ul><ul><ul><li>Opisthotonos </li></ul></ul></ul><ul><ul><ul><li>Oculogyric Crisis. </li></ul></ul></ul><ul><ul><li>Akathisia. </li></ul></ul><ul><ul><li>Tardive Dyskinesia </li></ul></ul>
    16. 16. Adjuncts to Antipsychotic Therapy <ul><li>Antidepressants </li></ul><ul><li>Antimanic Agents </li></ul><ul><li>Benzodiazepines </li></ul><ul><li>ECT </li></ul>
    17. 17. Sub-types of Schizophrenia <ul><li>Paranoid Type </li></ul><ul><li>Disorganized Type </li></ul><ul><li>Catatonic Type </li></ul>
    18. 18. Paranoid type <ul><li>Any intense and strongly defended irrational suspicion </li></ul><ul><li>Most common symptoms - hallucination and delusions </li></ul><ul><li>Defense Mechanism - Projection </li></ul>
    19. 19. Disorganised type <ul><li>Most regressed and socially impaired </li></ul><ul><li>Symptoms - loose association, inappropriate affect, bizarre mannerisms, incoherent speech and withdrawn </li></ul><ul><li>Onset? </li></ul><ul><li>Prognosis </li></ul>
    20. 20. Catatonia type <ul><li>Abnormal motor behavior </li></ul><ul><li>Be familiar with other symptoms </li></ul><ul><li>Prognosis? </li></ul><ul><li>Physical Needs are a Priority </li></ul>
    21. 21. Help and Support <ul><li>Educate patient and family about illness </li></ul><ul><li>Assist patient in improving his or her ability to solve problems related to environmental stress </li></ul><ul><li>Teach the patient coping strategies </li></ul><ul><li>Assist family and patient to identify sources for ongoing support </li></ul>
    22. 22. Better Prognosis <ul><li>Acute onset </li></ul><ul><li>Marked confusion while psychotic </li></ul><ul><li>Good premorbid functioning </li></ul><ul><li>No affective blunting or flattening </li></ul><ul><li>No family history of psychosis </li></ul><ul><li>Clear precipitant/stressor </li></ul><ul><li>Later onset. </li></ul><ul><li>Insight preserved </li></ul><ul><li>Female </li></ul><ul><li>Minimal residual symptoms </li></ul><ul><li>Normal neurological functioning </li></ul><ul><li>Family history of a mood disorder </li></ul><ul><li>Early treatment and good compliance </li></ul>
    23. 23. To be familiar with!! <ul><li>Loose association. </li></ul><ul><li>Neolgism </li></ul><ul><li>Echolalia </li></ul><ul><li>Clang association </li></ul><ul><li>Word salad </li></ul><ul><li>Concrete thinking </li></ul><ul><li>Thought broadcasting. </li></ul><ul><li>Thought insertion, withdrawal. </li></ul><ul><li>Delusion of being controlled! </li></ul>
    24. 24. Gross and Imaging changes! <ul><ul><li>Increased size of lateral ventricles </li></ul></ul><ul><ul><li>Decreased brain volume </li></ul></ul><ul><ul><li>Smaller Prefrontal Cortex? </li></ul></ul><ul><ul><li>Loss of asymmetry between left and right brain. </li></ul></ul>
    25. 25. Schizophreniform Disorder vs Breif psychotic disorder <ul><li>Same criteria as Schizophrenia except for duration: </li></ul><ul><ul><li>Lasts at least 1 month but less than 6 months </li></ul></ul><ul><li>Diagnosis is “Provisional” if made without waiting for recovery (ie. Before 6 months) </li></ul>
    26. 26. Schizoaffective disorder <ul><li>Mixture of Schizophrenic and Affective symptoms </li></ul><ul><ul><li>I.e. alterations in mood as well as disturbances in thought </li></ul></ul><ul><li>Thought by some to be a severe form of Bipolar (Varcarolis, 1998) </li></ul><ul><li>Treatment: Lithium used with antipsychotic therapy for treatment of manic symptoms </li></ul>
    27. 27. Other Disorders with Psychotic Features (cont.) <ul><li>Delusional Disorder </li></ul><ul><ul><li>Delusions that are contrary to reality </li></ul></ul><ul><ul><li>Lack other positive and negative symptoms </li></ul></ul><ul><ul><li>Types of delusions include </li></ul></ul><ul><ul><ul><li>Erotomanic </li></ul></ul></ul><ul><ul><ul><li>Grandiose </li></ul></ul></ul><ul><ul><ul><li>Jealous </li></ul></ul></ul><ul><ul><ul><li>Persecutory </li></ul></ul></ul><ul><ul><ul><li>Somatic </li></ul></ul></ul><ul><ul><li>Extremely rare </li></ul></ul><ul><ul><li>Better prognosis than schizophrenia </li></ul></ul>
    28. 28. Psychosis due to GMC <ul><li>R/O them 1 st . </li></ul><ul><li>PD?, tumours?, strokes? Aura of migraine? </li></ul><ul><li>DLB, MS, alzehimer? Sarcoidosis? </li></ul><ul><li>Vitamins dif.?, endocrinopathies? </li></ul><ul><li>RF?, Liver failure? </li></ul><ul><li>Infxns: syphilis, AIDS, Leprosy? Malaria? </li></ul><ul><li>Electrolyte disturbance? </li></ul>
    29. 29. Substance induced Psychosis <ul><li>toxins? </li></ul><ul><li>Drugs? </li></ul><ul><li>hormons </li></ul><ul><li>Withdrawal of sedatives/hypnotics. </li></ul><ul><li>Hormons? Bromocriptine? </li></ul><ul><li>Cannabis? </li></ul>
    30. 30. Associated mental disorders <ul><li>MR </li></ul><ul><li>OCD </li></ul><ul><li>Autism </li></ul><ul><li>Post-traumatic stress disorders. </li></ul>
    31. 31. Thank you! Best of Wishes,,