4. Psychotic Disorders Flashcards
(40 cards)
1
Q
Define psychotic disorders (2)
A
- characterized by a significant impairment in reality testing
- positive and negative symptoms
2
Q
Name positive symptoms (3)
A
- delusions or hallucinations (with or without insight into their pathological nature)
- disorganized behaviours
- formal thought disorder
3
Q
Name negative symptoms (5)
A
- affective flattening
- anhedonia
- avolition
- alogia
- asociality
4
Q
Differentiate delusions vs hallucinations
A
- Delusions: fixed, false beliefs
- Hallucinations: perceptual experiences without an external stimulus
5
Q
Duration of Time Differentiates the following 3 Psychotic Disorders:
- Brief Psychotic Disorder
- Schizophreniform Disorder
- Schizophrenia
A
- Brief Psychotic Disorder: < 1 month
- Schizophreniform Disorder: 1-6 month
- Schizophrenia: >6 month
6
Q
Describe the approach to psychosis (5)
A
- differentiate among psychotic disorders and distinguish them from other primary diagnoses with psychotic features
- consider symptoms, persistence, and time
- symptoms: the primary diagnosis needs full criteria to be met
- mood: depressive episodes with psychotic features, manic episodes with psychotic features
- psychotic: consider symptoms in Criterion A of schizophrenia
- persistence: is there a time when certain symptom clusters are present without other clusters?
- i.e. if there is a period of time with mood symptoms but not psychotic symptoms, consider mood disorder
- i.e. if two weeks during which psychotic symptoms persist in the absence of mood symptoms, consider schizoaffective disorder
- i.e. if long periods with psychotic symptoms and brief or rare mood symptoms, consider schizophrenia
- time: how long have the symptoms been present?
7
Q
Differentiating Psychotic Disorders
A
8
Q
Name relevant investigations for psychosis (4)
A
- CBC, electrolytes (including extended lytes), creatinine, glucose, urinalysis, urine drug screen, TSH, Vit B12
- Liver function tests, fasting lipids, HbA1C to obtain baseline levels prior to antipsychotic initiation
- ECG (several antipsychotics affect cardiac conduction)
- If clinically indicated, order infectious work-up, inflammatory markers, brain imaging
9
Q
Name DDX for psychosis (23)
A
- Primary psychotic disorders:
- schizophrenia
- schizophreniform
- brief psychotic
- schizoaffective
- delusional disorder
- Mood disorders:
- major depressive disorder with psychotic features,
- bipolar disorder (manic or depressive episode with psychotic features)
- Personality disorders:
- schizotypal
- schizoid
- borderline
- paranoid
- obsessive-compulsive (they predispose to psychosis but presence of psychotic symptoms require another diagnosis)
- General medical conditions:
- tumour
- head trauma
- dementia
- delirium
- metabolic
- infection
- stroke
- temporal lobe epilepsy
- Substance-induced psychosis:
- intoxication or withdrawal
- prescribed medications
- toxins
10
Q
Describe: Management of Acute Psychosis and Mania (7)
A
- Ensure safety of self, patient, and other patients
- Have an exit strategy
- Decrease stimulation
- Assume a non-threatening stance
- IM medications (benzodiazepine + antipsychotic) often needed as patient may refuse oral medication
- Physical restraints may be necessary
- Do not use antidepressants or stimulants
11
Q
Name DSM-5 diagnostic criteria for schizophrenia (7)
A
- two (or more) of the following, each present for a significant portion of time during a 1 mo period (or less if successfully treated). At least one of these must be (1), (2), or (3)
- delusions
- hallucinations
- disorganized speech (i.e. frequent derailment or incoherence)
- grossly disorganized or catatonic behaviour
- negative symptoms (i.e. diminished emotional expression or avolition)
- decreased level of function: for a significant portion of time since onset, one or more major areas affected (i.e. work, interpersonal relations, self-care) is markedly decreased (or if childhood/adolescent onset, failure to achieve expected level)
- at least 6 mo of continuous signs of the disturbance. Must include at least 1 mo of symptoms (or less if successfully treated) that meet Criterion A (i.e. active-phase symptoms) and may include periods of prodromal or residual symptoms, during which, disturbance may manifest by only negative symptoms or by two or more Criterion A symptoms present in an attenuated form (i.e. odd beliefs, unusual perceptual experiences)
- rule out schizoaffective disorder and depressive or bipolar disorder with psychotic features because either 1) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness
- rule out other causes: GMC, substances (i.e. drug of abuse, medication)
- if history of autism spectrum disorder or communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least 1 mo (or less if successfully treated)
- specifiers: type of episode (i.e. first episode, multiple episodes, continuous), with catatonia, current severity based on quantitative assessment of primary symptoms of psychosis (in acute episode, in partial remission, in full remission)
12
Q
Describe epidemiology: Schizophrenia (3)
A
- prevalence: 0.3-0.7%, M:F = 1:1
- mean age of onset: females late-20s to 40s; males early- to mid-20s (some cases with late onset)
- suicide risk: 10% die by suicide, 30% attempt suicide
13
Q
Describe Disorganized Behaviours in Schizophrenia (8)
A
- Catatonic stupor
- Catatonic excitement
- Stereotypy
- Mannerisms
- Echopraxia:
- Automatic obedience
- Negativism
- Inappropriate affect, neglect of self-care, other odd behaviours (random shouting)
14
Q
Describe: Catatonic stupor (1)
A
fully conscious, but mute, and unresponsive, immobile, maintaining bizarre positions for a long time
15
Q
Describe: Catatonic excitement (1)
A
uncontrolled and aimless motor activity, extreme agitation
16
Q
Describe: Stereotypy (1)
A
repeated but non-goal- directed movement (i.e. rocking)
17
Q
Describe: Mannerisms (1)
A
goal-directed activities that are odd or out of context (i.e. grimacing)
18
Q
Describe: Echopraxia (1)
A
imitates movements and gestures of others
19
Q
Describe: Automatic obedience (1)
A
carries out simple commands in robot-like fashion
20
Q
Describe: Negativism (1)
A
refuses to cooperate with simple requests for no apparent reason
21
Q
Describe epidemiology: Schizophrenia (3)
A
- prevalence: 0.3-0.7%, M:F = 1:1
- mean age of onset: females late-20s to 40s; males early- to mid-20s (some cases with late onset)
- suicide risk: 10% die by suicide, 30% attempt suicide
22
Q
Describe etiology: Schizophrenia (6)
A
multifactorial: disorder is a result of interaction between both biological and environmental factors
- genetic: 40% concordance in monozygotic (MZ) twins; 46% if both parents have schizophrenia; 10% of dizygotic (DZ) twins, siblings, children affected; vulnerable genes include Disrupted-in-Schizophrenia 1 (DISC1); neuregulin 1 (NRG 1); dystrobrevin binding protein / dysbindin (DTNBP1); catechol-O-methyltransferase (COMT); d-amino acid oxidase activator (DAOA); metabotropic glutamate receptor 3 (GRM3); and brain-derived neurotrophic factor (BDNF)
- neurochemistry (“dopamine hypothesis”): excess activity in the mesolimbic dopamine pathway may mediate the positive symptoms of psychosis, while decreased dopamine in the prefrontal cortex may mediate negative and cognitive symptoms. GABA, glutamate, and ACh dysfunction are also thought to be involved
- neuroanatomy: decreased frontal lobe function; asymmetric temporal/limbic function; decreased basal ganglia function; subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities
- neuroendocrinology: abnormal growth hormone, prolactin, cortisol, and ACTH
- neuropsychology: global defects seen in attention, language, and memory suggest disrupted connectivity of neural networks
- environmental: indirect evidence of cannabis use, geographical variance, winter season of birth, obstetrical complications, and prenatal viral exposure
23
Q
Describe pathophysiology: Schizophrenia (2)
A
-
neurodegenerative theory: natural history may be a rapid or gradual decline in function and ability to communicate
- glutamate system may mediate progressive degeneration by excitotoxic mechanism which leads to production of free radicals
-
neurodevelopmental theory: abnormal development of the brain from prenatal life
- neurons fail to migrate correctly, make inappropriate connections, and apoptosis in later life
24
Q
Name comorbidities: Schizophrenia (3)
A
- substance-related disorders
- anxiety disorders
- reduced life expectancy secondary to medical comorbidities (i.e. obesity, diabetes, metabolic syndrome, CV/pulmonary disease)
25
Describe Management of Schizophrenia (7)
* biological / somatic
* acute treatment and maintenance: antipsychotics (risperidone, aripiprazole, haloperidol, paliperidone; clozapine if resistant); regimens of IM q2-4 wk used in severe cases to improve adherence
* adjunctive: ± mood stabilizers (for aggression/impulsiveness - lithium, valproate, carbamazepine) ± anxiolytics ± ECT
* treat for at least 1-2 years after the first episode, at least 5 years after multiple episodes (relapse causes severe deterioration)
* psychosocial
* psychotherapy (individual, family, group), supportive, CBT (see Table 14, PS41)
* ACT (Assertive Community Treatment): mobile mental health teams that provide individualized treatment in the community and help patients with medication adherence, basic living skills, social support, job placements, ressources
* social skills training, employment programs, disability benefits
* housing (group home, boarding home, transitional home)
26
Describe course and prognosis: Schizophrenia (4)
* majority of individuals display some type of prodromal phase
* course is variable: some individuals have exacerbations and remissions while others remain chronically ill; accurate prediction of the long-term outcome is not possible
* positive symptoms typically diminish with treatment; negative symptoms may be prominent early in the illness or may become more prominent and more disabling later on
* over time: 1/3 improve, 1/3 remain the same, 1/3 worsen
27
Name good prognostic factors of schizophrenia (10)
* Acute onset
* Shorter duration of prodrome
* Female gender
* Good cognitive functioning
* Good premorbid functioning
* No family history
* Presence of affective symptoms
* Absence of structural brain abnormalities
* Good response to drugs
* Good support system
28
Describe diagnosis: Schizophreniform Disorder (3)
* criteria A, D, and E of schizophrenia are met; an episode of the disorder lasts for at least 1 mo but less than 6 mo
* if the symptoms have extended past 6 mo the diagnosis becomes schizophrenia
* specifiers:
* with/without good prognostic features (i.e. acute onset, confusion, good premorbid functioning, absence of blunt/flat affect)
* with catatonia
* current severity based on quantitative assessment of primary symptoms of psychosis
29
Describe tx: Schizophreniform Disorder (1)
* similar to acute schizophrenia
30
Describe prognosis: Schizophreniform Disorder (1)
* better than schizophrenia; begins and ends more abruptly; good pre- and post-morbid function
31
Describe diagnosis: Brief Psychotic Disorder (3)
* criteria A1-A4, D, and E of schizophrenia are met;
* an episode of the disorder lasts for at least 1 d, but less than 1 mo with eventual full return to premorbid level of functioning
* specifiers: with/without marked stressors, with postpartum onset, with catatonia, current severity
* can occur after a stressful event or postpartum
32
Describe tx: Brief Psychotic Disorder (1)
* secure environment, antipsychotics, and anxiolytics
33
Describe prognosis: Brief Psychotic Disorder (1)
good, self-limiting, should return to pre-morbid function within 1 mo
34
Name DSM-5 diagnostic criteria for schizoaffective disorder (4)
1. concurrent psychosis (criterion A of schizophrenia) and major mood episode - uninterrupted period of illness
2. delusions or hallucinations for 2 or more wk in the absence of a major mood episode during the lifetime duration of the illness
3. major mood episode symptoms are present for the majority of the total duration of the active and residual periods of the illness
4. the disturbance is not attributable to the effects of a substance or another medical condition
* **specifiers**: bipolar type, depressive type, with catatonia, type of episode, severity
35
Describe epidemiology: Schizoaffective disorder (2)
* one-third as prevalent as schizophrenia; schizoaffective disorder bipolar type more common in young adults, schizoaffective disorder depressive type more common in older adults
* depressive symptoms correlated with higher suicide risk
36
Describe tx: Schizoaffective disorder (1)
* antipsychotics, mood stabilizers, and antidepressants
37
Describe prognosis: Schizoaffective disorder (1)
* between that of schizophrenia and of mood disorder
38
Name DSM-5 diagnostic criteria: Delusional Disorder (7)
1. the presence of one (or more) delusions with a duration of 1 mo or longer
2. criterion A for schizophrenia has never been met
Note: hallucinations, if present, are not prominent and are related to the delusional theme
1. apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour is not obviously bizarre or odd
2. if manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods
3. the disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder
* **subtypes**: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified
* **further specify**: bizarre content, type of episode (i.e. first episode, multiple episode), severity
39
Describe tx: Delusional Disorder (3)
* antipsychotics, psychotherapy, and antidepressants
40
Describe prognosis: Delusional Disorder (1)
* may respond well to antipsychotics but most patients refuse them and have chronic, unremitting course; some maintain a high level of functioning; some progress to schizophrenia
