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Define psychosis?

- broadly defined as a loss of contact with reality


Why are psychotic states high risk periods?

pt is experiencing:
impulsivity (suicide)
other forms of behavioral dysfxn


Clinical manifestations of psychosis - delusions?

- strongly held false beliefs that are not part of the pt's cultural or religious backgrounds
- they may be bizarre or non-bizzare
- types:
delusions of reference
delusions of control


clinical manifestations of psychosis - hallucinations?

- wakeful experiences of content that isn't actually present
- any of the 5 senses
- auditory most common
- followed by visual, tactile, olfactory, and gustatory


clinical manifestations of psychosis - thought disorganization (speech)?

- alogia/poverty of content
- thought blocking - suddenly losing train of thought
- loosening of assoc - sequences not well connected
- tangentiality: answers to questions veering off topic
- clanging or clang association: using rhyming words
- word salad - real words linked incoherently
- perseravation - repeating words or ideas even when topic is changed


Psychotic disorders - differential?

- schizophrenia
- bipolar disorder with psychotic features
- major depression w/ psychotic features (at same time)
- schizoaffective disorder (depression or bipolar at diff time then psychosis)
- schizophreniform disorder (not long enough to be called schizophrenia)
- brief psychotic disorder
- substance induced psychotic disorder
- delusional disorder
- psychosis secondary to a medical condition


Work up of psychosis?

- thorough mental status exam - note grooming, mannerisms, reactions
- PE
- labs:
urine drug screen
more as indicated by hx


How do you dx schizophrenia?

- dx is based entirely on psychiatric hx and mental status exam
- there is no lab test for schizophrenia


epidemiology of schizophrenia?

- lifetime prevalence is 1%
- found in all societies and geographical areas
- equally prevalent in men and women
- over 50% male pts first admitted to psych hopstial b/f 25
- only 1/3 of female schizophrenic pts admitted b/f 25
- peak ages of onsets:
men - 12-25
women - 25-35
- women get it later in life than men and men tend to have worse outcome
- onset b/f 10 and after 60 extremely rare


Why is it so hard for the patient with schizophrenia?

- for most it is highly disabling
- generally persists throughout a pts life
- pts and their families often suffer from poor care and social ostracism
- only about half of all pts with schizophrenia obtain tx, in spite of the severity of the disorder


How does genetics play a role in schizophrenia?

prevalence of having schizophrenia:
- child with one affected parent - 12%
- 2 affected parents - 40%
- monozygotic twin - 47%


DSM-5 of schizophrenia?

2 or more of the following, each present for a significant portion of time during a 1 month period (or less if successfully tx):
-disorg. sppech (frequent derailment, incoherence)
-grossly disorganized or cataonic behavior
- negative sxs (affective flattening or poverty of speech)

only one of these criterion are necessary if:
- delusions are bizzare
- hallucinations consist of a voice keeping up running commetery, or 2 or more voices conversing
theses are all considered active phase sxs

more keys to dx:
- social or occupational dysfxn
- continuous signs of disturbance persisting for at least 6 months and w/in this at least 1 month of active phase sxs


Positive sxs of schizophrenia?

- dellusions
- hallucinations


Negative sxs of schizophrenia?

- affective flattening
- poverty of speech (alogia)
- blocking
- poor grooming
- lack of motivation
- anhedonia
- social withdrawal


diff b/t positive and negative sxs of schizophrenia?

- pts that predominantly have postive sxs have a relatively good response to tx
- pts that have negative sxs have poor responses to tx


What is paranoid subtype of schizophrenia?

- preoccupation with one or more delusions or frequent auditory hallucinations
- no disorganized speech, disorganized speech, disorganized or catonic behavior, or flat or inappropriate affect


What is the disorganized subtype of schizophrenia?

- disorganized speech, disorganized behavior, flat or inappropriate affect


What is the catatonic subtype of schizophrenia?

- motoric immobility
- excessive purposeless motor activity
- extreme negativism or mutism
- pecularities of voluntaray movement (bizarre posturing, stereotyped movements)
- echolalia or echopraxia: mimic what you say or do


Components of mental status examination? description, mood, feelings, affect, perception?

-General description: ranges from completely disheveled, screaming, and agitated to obsessively groomed, completely silent and immobile.
behavior: may be talkative and exhibit weird postures, may become agitated or violent in an unprovoked manner or in response to hallucinations, may be in catatonic stupor, tics, echopraxia
-mood, feelings, affect: reduced emotional responsiveness to overly active and inappropriate emotions such as extremes of rage, happiness, and anxiety
- perception: all 5 senses may be affected by hallucinatory experiences (MC: auditory and visual).
Illusions: diff from hallucinations in that illusions are distortions of real images


MSE: thought components?

- most difficult sxs to understand
- likely the CORE sxs of schizophrenia:
*thought content:
what is the person thinking (ideas, beliefs, and interpretations of stimuli)
delusion (4 components):
false belief
based on incorrect inference about external reality.
not consistent with pt's intelligence and cultural background.
can't be corrected by reasoning

*thought form and process:
how is person thinking what they're thinking?
flight of ideas
thought blocking
poverty of content
poor abstraction abilities


MSE: sensorium and cognition?

- usually oriented to person, time and place (lack of such orientation should prompt clinicians to investigate the possibility of medical or neuro brain disorder)
- memory usually intact (may be difficult however to get pt to attend closely enough to the memory tests for adequate assessment)
- classically described as having poor insight into the nature and severity of the disorder - pt doesn't understand that they are sick (fully believe in delusions)


MSE - impulsiveness?

- may be agitated and have little impulse control when ill
- along with this - may have decreased social sensitivity - may throw food on floor, grab other person's belongings


Etiology of schizophrenia?

- NOT a single disease
- likely a group of disorders with differing causes leading to somewhat similar sxs


How is dopamine affected in schizophrenia?

- decreased dopamine in prefrontal cortex (D1 receptor) may be responsible for some of cognitive and negative sxs in schizophrenia
- all drugs with antipsych properities block dopaminergic D2 receptor
- despite adequate tx many people with schizophrenia continue to exhibit positive sxs, so likely that there are other NTs involved


How is glutamate affected in schizophrenia?

- major CNS excitatory NT
- hypofxn of NMDA glutamate receptor may contribute to pathology of schizophrenia
- clinical trials with agents that enhance glutamategic NT are being done with varied results depending on the agent


GABA's role in schizophrenia?

- major CNS inhibitory NT
- GABA-ergic interneurons are impt in regulation of prefrontal cortical fxn through their modulation of glutamatergic pyramidal cells
- evidence suggests that these interneurons are dysfxnl in people with schizophrenia


Acetylcholine's role in schizophrenia?

- increased smoking in pts with schizo has led to hypothesis that nicotine which stimulates acetylcholine receptors, is correcting a fundamental neurochemical problem in schizophrenia
- tx with nicotine or nicotine cholinergic drug can tx some abnormalities in schizo
- Unsure relationship still


Serotonin's role in schizophrenia?

- antagonism at the serotonin 5-HT2 receptor has been emphasized as impt in reducing psychotic sxs
- serotonin dopamine antagonists have high affinity for serotonin 5-HT2 receptors (even higher than D2 receptors)


Course of schizophrenia?

premorbid pattern of sxs may be first evidence of illness (usually not discovered right a way):
- quiet, passive, and introverted personality
- usually few friends growing up
- adolescents may have no close friends, no dates, and may avoid team sports
- oten enjoy movies and TV or listening to music to exclusion of social activities


Prognosis of schizophrenia?

- over 5-10 yr period after 1st psych hospitalization - only approx 10-20% of pts have a good outcome
- more than 50% have poor outcome:
repeated hosp
exacerbation of sxs
episodes of major mood disorders
suicide attempts
- doesn't always run a deteriorating course - est that 20-30% of pts are able to live somehwhat normal lives


What kind of behavior is common among untx schizo pts? Why is this dangerous?

- violent behavior (excluding homicide) is common in untx pts:
emergency tx may include restraints and seclusion
- acute sedation with ativam 1-2 mg IM may be repeated q hr prn to prevent pt from harming others
- ***approx 50% of all schizo pts attempt suicide (often due to misdx depression as flat affect or as med SE)


What type of delusion is this:
"I cant believe that they sabotaged my car, last week they stole my mail, they are following me when I leave my house"?

- delusion of persecution


Example of delusion:
"God hs chosen me to be the world's rep at the meeting at Mars "?

- delusion of grandeur


Example of delusion:
"invaders from space have infiltrated my testicles so I can't father kids"?

- bizzare delusion


Example of delusion:
"It doesn't matter anyway with how my thoughts are controlled by the govt"?

- delusion of control


Example of delusion:
"The DJ is really giving me instructions on what to do. He just disguises it so no one will pick up on it"?

- delusion of reference


Case 1:
Woman with hx of depression brought to ER after attempting to run into traffic
hx- Has depressive episodes 2x a year, each lasting 2 months. during depressive episodes she talks about odd beliefs, seems disorganized. She scribbles disorganized thoughts that are ilelgible in her journal. She isn't pregnant but she is convinced that she is pregnant.
MSE - calm yet guarded, has auditory hallucinations - told her to run into traffic, insists she is preg. with divine child, she describes her mood as fine

-schizoaffective disorder
- diff from schizophrenia:
prominently features both affective and psychotic sxs
- for dx: criteria for either a major depressive or manic episode must be met, and pt must have also experienced delusions or hallucinations in the absence of the mood sxs
- prognosis is better than schizophrenia, depending on subtype (depressed vs bipolar) - pts may benefit from other drugs other than neuroleptics


Case 2:
police officer brought in to ER by colleagues who are concerned about recent change in behavior
- HPI: for 2 weeks convinced that other officers are trying to frame him, he thinks that they want to kick him off the force because they can read his dirty thoughts, he has had a short fuse and seems paranoid, has been suspicious of colleagues for less than a month since being passed up for a promotion
- MSE: pt acts bizzare and answers ?s loose and disorganized manner


- brief psychotic disorder
- diff than schizo:
dx made when sxs of delusions, hallucinations, disorganized speech, or disorganized behavior persists for more than 1 day but less than 1 month
- impt to diff b/c:
50-80% of pts dx with brief psychotic disorder NEVER have another psychotic episode. Brief psychotic disorder is assoc w/ increased risk of suicide - high impulsivity in brief time of psychotic break


Case 3:
Man goes to police complaining that the FBI has been following him for a month
- HPI: pt believes that FBI has placed him on surveillance since visit to white house earlier in the year. He thinks FBI is listening in on phone conversations. His fxning hasn't been markedly impaired by distractions. He doesn't feel particulary threatened but requests the police intervene.

- delusional disorder
- diff than schizo:
powerful, well-circumscribed delusion w/o other signs or sxs of psychosis
delusions are nonbizzare in quality (address situations that occur in everyday life)
- impt to diff: most cases are refractory to tx, be careful to assess pts risk of endangering self or others


Case 4:
29yo woman presents for f/u following 3 week remission from 4 month period of psychotic episodes
- HPI: during 4 month period pt heard voices conversing with one another and suspected her mind was being controlled by a voice on the radio. Auditory hallucinations were much more intrusive in the morning. At the time of visit, pt denies hearing voices, and no longer hold delusion of mind control, reporting that work performance has improved significantly

- schizophreniform disorder
- diff from schizo:
based on schizophrenia like sxs for more than 1 month but less than 6 months
- impt to diff: 1/3 of pts recover w/in 6 months (remainder progress to dx of schizo)


Case 5:
24yo woman brought to ER late at night b/c she was on street corner proclaiming her plan to sell miracle machines
-HPI: pt hasn't had previous episodes such as this, no hx of depression, over past week hasn't been sleeping much and has felt energized. Has had delusions of grandeur and believes she has come with the plans for a great labor saving device that will maker her rich
MSE: A&Ox3, pressured speech, flight of ideas with loose associations. Easily distracted, denies visual hallucinations although she does state she has heard a voice giving her the plans to her machine

- Manic phase of bipolar disorder
- diff than schizo b/c hx of depression, first episode of this - hasn't been sleeping much, delusion of grandeur, has pressured speech, easily distracted - all hallmarks of bipolar

- tx with mood stabilizer not antipsychotic - have to tx manic episode as well as depression


What are likely the core sxs in pt with schizo?

- disorders of thought


What are FGAs? Examples of these? SEs?

- examples - haldol, thorazine
- MOA: strong antagonism of D2 receptors in both cortical and striatal areas
- highly protein and tissue bound
- all are subject to extensive metabolism via cytochrome P450 and can interact with drugs that effect that system
- oral absorption erratic b/c of 1st pass effect
-tardive dyskinesia
-hyperprolactinemia -antag dopamine
-neuroleptic malignant syndrome (NMS)
- QT prolong
- sudden death
- increased risk of mortality when tx elderly pts with dementia


FGAs: phenothiazines

- thorazine
- haldol (used in acute aggressive behavior)
- mellaril

parkinsonian syndrome
acute dystonias
- tardive dyskinesia
- wt gain/hyperprolactinemia


Examples of SGAs? MOA, SE?

- ex: resperdol, abiify
- MOA: post-synaptic blockade D2 receptors + 5HT2 receptor binding (lower risk for EPS)
- each med is unique in its rate of absorption, clearance time, and susceptibility to changes in hepatic and renal fxn, and drug interactions
- SE: wt gain, hyperglycemia, hyperlipidemia, EPS, TD, NMS, hyperprolactemia, increased mortality in elderly pts with dementia
- cost: much higher unless generic
- clozapine: can cause agranulocytosis (check CBC), not 1st line therapy


When are FGAs indicated?

- IV for emergent situations (with careful cardiac monitoring b/c they can prolong QT interval)
- haldol and prolixin are available as depot preps for ease of admin for long term use and more cost effective then atypical antipsychotics
- all are metabolized in the liver


Use of risperdal? SEs, Forms?

- most widely rx antipsychotic in US
- once a day dosing
- no anticholinergic effects
- SE: sedation, hypotension, akathisia, prolactin elevation and wt gain
- forms: disintegrating tablet, liquid and depot forms
- generic available


Use of zyprexa? SEs, forms?

- once a day dosing
- levels decreased some by cig. smoking
- SE: wt gain, sedation, akathisia, hypotension, dry mouth and constipation
- forms: coated tablets, disintegrating tabs, injectable
- more expensive than other SGAs


Use of seroquel? SEs?

- also used to tx mood and anxiety disorders, PTSD, parkinson disease
- BID dosing recommended, often give qday, comes only as tabs
- SE: sedation (improves over time), orthostatic hypotension, akathisia, dry mouth, wt gain (moderate)
- low incidence of EPS


Use of abilify? SEs, forms? Disadvantage?

- unique pharmacokinetics:
agonist at D2 receptors
partial agonist at 5HT1a receptors
antagonist at 5HT2a, H1 and alpha-1-adrenergics
- SE: HA, N/V, akathisia, tremor, constipation, and min. wt gain
- forms: std and disintegrating tabs and IM soln
- disadvantage: unpredictable effect on activity of other antipsychotics


Use of clozaril? Has high risk of? Other side effects?

- unique for its efficacy in otherwise tx resistant pts
- has high risk of AGRANULOCYTOSIS (1-2%) therefore only recommended for those resistant to tx (monitor CBC)
- SE: orthostatic hypotension, tachycardia, wt gain, metabolic syndrome, sialorrhea, sedation, constipation, and seizure risk that increases with dose


Management of EPS?

- akathisia: most common
cautious antipsychotic dose reduction, tx with bentos, bblocker, benztropine
- parkinsonian syndrome:
amantadine: cause hypotension and mild agitation
- dystonias: preferred to change to antipsychotic w/ lower EPS
benzotropine, diphenhydramine


What are examples of tardive dyskinesia? RFs? What should you monitor with? Tx?

- sucking/smacking lips
- choreaoathetoid movement of tongue
- facial grimacing
- lateral jaw movements/clenching
- choreiform or athetoid movements of body
- RFs: long use, EPS, elderly, use of other meds
- monitor for TD if occurs -change to antipsychotic with low risk of TD
- no pharm tx available


Metabolic effects of antipsychotics?

- monitor wt gain and manage
- monitor glucose and serum lipid levels and tx accordingly
- NMS: fever, rigidity, mental status changes, and autonomic instability
- anticholinergic SEs - dry mouth, constipation, careful in elderly


What is a good alt for pts who responded well to med but are habitually nonadherent to taking it?

- considered for depot med


What meds are considered 1st line in tx of schizophrenia? Downside of these drugs?

- SGAs
- downside - more expensive b/c of lower risk for EPS, and also have several more metabolic SEs and wt gain than FGAs


What psychosocial interventions are available for schizophrenic pt?

- meds are often only partially effective in tx of schizophrenia
many pts benefit form systemic rehab:
-family psychoeducational intervention:
educates family that it is a disease, factors about the disease, how to help pt, and give optimism to family
- social skills training - for pt:
deficits in skills such as personal care, cooking, paying pills, and dating which are usually result of negative sxs.
uses behaviorally based instruction, role modeling, rehearsal, corrective feedback, and positive reinforcement
- cognitive behavioral therapy: used to tx med-resistant psychosis