Psychosis in Women: The Hidden Challenge in Primary Care (PPT)


Published on

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • 75% - 90% psychiatric illnesses treated in PC
  • used in treatment of mood disorder related psychosis in conjunction with antipsychotic in acute phase used in treatment of mood disorder related psychosis in conjunction with antipsychotic in acute phase Mood stabilizers, antidepressants, ECT used in treatment of mood disorder related psychosis, oftentimes in conjunction with antipsychotics in acute phase of illness
  • 20 RCT compared efficacy of CBT to antipsychotic medication, case management, supportive counseling, befriending, routine psychiatric care follow-up – CBT superior to these in short-term but consistent improvement in global psychiatric symptoms not produced over the long-term
  • Psychosis in Women: The Hidden Challenge in Primary Care (PPT)

    1. 1. Psychosis in Women: The Hidden Challenge in Primary Care National Nursing Centers Consortium 6 th Annual Conference Carla J. Groh, PhD, APRN, BC
    2. 2. Prevalence of Psychotic Symptoms <ul><li>Schizophrenia & related disorders 0.4% - 1.0% in primary care </li></ul><ul><li>Psychotic symptoms may be far more common </li></ul><ul><li>2-3% respondents in ECA study reported auditory hallucinations; more frequent among women and increased with age (N = 18,572). </li></ul><ul><li>75-90% psychiatric illnesses treated in PC </li></ul><ul><li>More than 25% PCP regularly prescribe antipsychotics </li></ul>
    3. 3. Prevalence of Psychotic Symptoms <ul><li>Occur in a variety of psychiatric disorders: </li></ul><ul><ul><li>Schizophrenia </li></ul></ul><ul><ul><li>Bipolar disorder (manic phase) </li></ul></ul><ul><ul><li>Major depression with psychotic features </li></ul></ul><ul><ul><li>Substance-induced psychosis </li></ul></ul><ul><li>Occur in general medical conditions: </li></ul><ul><ul><li>Neurological disorders </li></ul></ul><ul><ul><li>Endocrine disorders </li></ul></ul><ul><ul><li>Metabolic disorders </li></ul></ul><ul><ul><li>Autoimmune disorders </li></ul></ul>
    4. 4. Prevalence of Psychotic Symptoms <ul><li>Studies results vary from 3.7% (sample of middle-class patients to 20.9% (sample of poor, little formal education, Hispanic patients) of primary care patients reporting 1 or more psychotic symptoms. </li></ul><ul><li>Prevalence of voice hearing found to be 32.8% in sample of cognitively intact but hearing impaired adults >65 years of age </li></ul><ul><li>Major concern are persons who present with sub-threshold psychotic symptoms and first episode of psychosis </li></ul>
    5. 5. Common Psychotic Symptoms <ul><li>Auditory hallucinations </li></ul><ul><li>Paranoia (being spied on or followed by others) </li></ul><ul><li>Visual hallucinations </li></ul><ul><li>Belief that people are plotting to poison them </li></ul><ul><li>Able to hear other people’s thoughts </li></ul><ul><li>Thought insertion </li></ul>
    6. 6. Comorbidities with Psychosis <ul><li>Panic disorders </li></ul><ul><li>Generalized Anxiety Disorder </li></ul><ul><li>Major Depressive Disorder </li></ul><ul><li>Alcohol use disorder </li></ul><ul><li>Borderline personality </li></ul><ul><li>Suicidal ideation** </li></ul>
    7. 7. Sequelae of Psychotic Symptoms <ul><li>Low self esteem </li></ul><ul><li>React to voices with suspicion </li></ul><ul><li>Work (either not working or missing work) </li></ul><ul><li>Family (marital discord, parent/child problems) </li></ul><ul><li>Social (isolative, fearful) </li></ul>
    8. 8. Schemata Content: Verbal Auditory Hallucinations <ul><li>Ego dystonic: </li></ul><ul><ul><li>Aggression </li></ul></ul><ul><ul><li>Dependency </li></ul></ul><ul><ul><li>Indecision </li></ul></ul><ul><ul><li>Self-punishment </li></ul></ul><ul><ul><li>Sexual identity or character </li></ul></ul>
    9. 9. Schemata Content: Verbal Auditory Hallucinations <ul><li>Ego syntonic: </li></ul><ul><ul><li>Companionship </li></ul></ul><ul><ul><li>Entertainment </li></ul></ul><ul><ul><li>Evaluation </li></ul></ul><ul><ul><li>Role identity & self care </li></ul></ul><ul><ul><li>Self-importance </li></ul></ul><ul><ul><li>Attenuation of distress Source: Larkin, A.R. (1979). The form and content of schizophrenia hallucations. American Journal of Psychiatry, 136(7 ), 940-943. </li></ul></ul>
    10. 10. Assessment of Psychosis: Neurological Disorders <ul><li>Epilepsy </li></ul><ul><li>Neoplasm </li></ul><ul><li>Cerebral trauma </li></ul><ul><li>Multiple sclerosis </li></ul><ul><li>Huntington’s disease </li></ul><ul><li>Infections, especially viral </li></ul><ul><li>Cerebrovascular disease </li></ul><ul><li>Other space occupying lesions </li></ul>
    11. 11. Assessment of Psychosis: Endocrine, Metabolic, Autoimmune Disorders <ul><li>Porphyria </li></ul><ul><li>Systematic lupus </li></ul><ul><li>Wilson’s disease </li></ul><ul><li>Hyperparathyroidism </li></ul><ul><li>Vitamin B 12 deficiency </li></ul><ul><li>Cushing’s syndrome (20%) </li></ul><ul><li>Hyperthyroidism and hypothyroidism </li></ul>
    12. 12. Assessment of Psychosis: Screening Tests <ul><li>First psychotic episode: </li></ul><ul><ul><li>Electrolytes </li></ul></ul><ul><ul><li>Erythrocyte sedimentation rate </li></ul></ul><ul><ul><li>Thyroid function tests </li></ul></ul><ul><ul><li>Live function tests </li></ul></ul><ul><ul><li>Full blood examination </li></ul></ul><ul><ul><li>Iron studies </li></ul></ul><ul><ul><li>Vitamin B 12 and folate levels </li></ul></ul><ul><ul><li>Syphilis serology </li></ul></ul><ul><ul><li>EKG </li></ul></ul>
    13. 13. Assessment of Psychosis: Prodromal Symptoms <ul><li>Suspiciousness </li></ul><ul><li>Anxiety </li></ul><ul><li>Depression </li></ul><ul><li>Irritability </li></ul><ul><li>Restlessness </li></ul><ul><li>Change in appetite </li></ul><ul><li>Sense of change in self </li></ul><ul><li>Social isolation </li></ul><ul><li>Marked impairment: </li></ul><ul><ul><li>role functioning </li></ul></ul><ul><ul><li>personal hygiene </li></ul></ul><ul><li>Peculiar behavior </li></ul><ul><li>Blunted, flat affect </li></ul><ul><li>Odd or bizarre ideation </li></ul><ul><li>Lack of initiative, interests or energy </li></ul>
    14. 14. Assessment of Psychosis: Psychiatric Evaluation <ul><li>Comprehensive history, including (goal is to differentiate between primary versus secondary psychosis : </li></ul><ul><ul><li>Family history </li></ul></ul><ul><ul><li>Prodromal symptoms </li></ul></ul><ul><ul><li>Past medications </li></ul></ul><ul><ul><li>Substance use/abuse/misuse </li></ul></ul><ul><ul><li>Description of the voices, content, degree to which voices distress patient </li></ul></ul>
    15. 15. Treatment Options <ul><li>Treatment based on diagnosis </li></ul><ul><li>Pharmacological management </li></ul><ul><ul><li>Atypical antipsychotics </li></ul></ul><ul><ul><li>Mood stabilizers, antidepressants, ECT </li></ul></ul>
    16. 16. Treatment Options <ul><li>Non-pharmacological management: </li></ul><ul><ul><li>Cognitive behavioral therapy </li></ul></ul><ul><ul><ul><li>In 20 RCT, CBT found to be superior in short-term but not over the long-term </li></ul></ul></ul>
    17. 17. When to Refer <ul><li>First time psychotic episode </li></ul><ul><li>Suicidal or homicidal </li></ul><ul><li>Person refractory to treatment </li></ul><ul><li>Non-adherent to treatment </li></ul><ul><li>Complicated psychiatric and medical picture </li></ul>
    18. 18. Case Study