Psychotic disorders Flashcards
(37 cards)
What is a delusion?
a fixed, false belief
What is a hallucination?
perceptual experiences (sight/touch/smell, etc) without external stimulus
How do you differentiate schizophrenia, schizophreniform, and brief psychotic disorder?
Based on time
- Brief Psychotic Disorder <1 month
- Schizophreniform 1-6 months
- Schizophrenia Disorder >6 months
DSM criteria for schizophrenia
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)
- *1. delusions
2. hallucinations
3. disorganized speech** (e.g. frequent derailment or incoherence)
4. grossly disorganized or catatonic behaviour
5. negative symptoms (i.e. diminished emotional expression or avolition)
B. decreased level of function: for a significant portion of time since onset, one or more major areas affected (e.g. work, interpersonal relations, self-care) is markedly decreased (or if childhood/adolescent onset, failure to achieve expected level)
C. 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 (e.g. odd beliefs, unusual perceptual experiences)
D. 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
E. rule out other causes: substances (e.g. drug of abuse, medication)
F. 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)
Management of acute psychosis and mania? (toronoto notes)
- 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
Name some disorganised behaviours in schizophrenia
- Catatonic stupor: fully conscious, but immobile, mute, and unresponsive
- Catatonic excitement: uncontrolled and aimless motor activity, maintaining bizarre positions for a long time
- Stereotypy: repeated but non-goal-directed movement (e.g. rocking)
- Mannerisms: goal-directed activities that are odd or out of context (e.g. grimacing)
- Echopraxia: imitates movements and gestures of others
- Automatic obedience: carries out simple commands in robot-like fashion
- Negativism: refuses to cooperate with simple requests for no apparent reason
- Inappropriate affect, neglect of self-care, other odd behaviours (random shouting)
Typical age of onset of schizophrenia?
mean age of onset: females late-20s; males early-to mid-20s
Suicide risk in schizophrenia?
10% die by suicide
30% attempt suicide
Signs + symptoms of schizophrenia
- POSITIVE
- hallucinations (eg hearing voices)
- delusions (eg persecutory, bizarre, grandiose)
- impaired insight
- disorganised thinking and speech
- NEGATIVE
- lack of motivation
- poor self-care
- blunted affect
- reduced speech output
- social withdrawal
- COGNITIVE
- impaired planning
- reduced mental flexibility
- impaired memory
- impaired social cognition
- EXCITEMENT
- disorganised behaviour
- aggression
- hostility
- MOOD
- depression
- anxiety
Psychosocial treatment for schizophrenia
- psychotherapy (individual, family, group), supportive, CBT
- 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, resources
- social skills training, employment programs, disability benefits
- housing (group home, boarding home, transitional home)
Pathophysiology of schizophrenia
- neurodegenerative theory: natural history may be a rapid or gradua ldecline 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 apoptose in later life
Good prognostic factors for schizophrenia
- 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
DSM criteria for schizophreniform disorder
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):
- *1. Delusions.
2. Hallucinations.
3. Disorganized speech** (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or avolition).
B. An episode of the disorder 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.”
C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out 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.
D. The disturbance is not attributable to the physiological effects
DSM criteria for brief psychotic disorder
A. presence of ONE of the following symptoms (must be from 1, 2, or 3)
- delusions
- hallucinations
- disorganized speech
- grossly disorganised/catatonic behaviour
B. duration 1 day - 1 month, returns to premorbid level of functioning
C. disturbance is not better explained by MDD or BPD with psychotic features
Treatment of first psychotic episode
First line:
- amisulpride
- aripiprazole
- olanzapine
- paliperidone
- quetiapine
- risperidone
- ziprasidone
Second line:
- asenapine
- sertindole
Which patients should be started on clozapine?
- A trial of clozapine should be offered to all patients who have not responded to an adequate trial of two or more alternative antipsychotic drugs
- strong evidence demonstrating the efficacy of clozapine for treatment-resistant schizophrenia
Counselling points for clozapine?
- You will need to have regular blood tests and other checks while taking clozapine to help your doctor look out for serious side effects.
- WBC + neutrophil counts for at least the first 18 weeks
- cardiac parameters, including regular measurement of temperature, HR, BP and RR. Troponins and C-reactive protein should be measured weekly for the first 4 weeks. ECG recommended at baseline and should be repeated on the basis of the other observations and results
- metabolic parameters, including weight, body mass index (BMI), waist circumference, blood glucose concentration and lipid profile
- Do not stop taking this medicine suddenly unless your doctor tells you to.
- Your clozapine dose may need changing if you vary your caffeine intake (eg tea, coffee, cola drinks) or if you start or stop smoking tobacco; tell your doctor if any of these habits change.
Common adverse effects of clozapine?
Common (>1%)
- drowsiness (occurs in 40%), hypersalivation (can cause aspiration pneumonia), constipation (may result in obstruction, paralytic ileus and death), seizures, headache, tachycardia, hyperpyrexia (5%), hepatitis, neutropenia, vomiting, urinary incontinence, nocturnal enuresis
Infrequent (0.1–1%)
- myocarditis (usually in the first month of initial treatment but rarely may occur when starting after a break in treatment), agranulocytosis, eosinophilia, priapism, EPSE
Rare (<0.1%)
- cardiomyopathy, hypertension, myoclonic jerks, interstitial nephritis, respiratory arrest, fulminant hepatic necrosis
Constipation
Leaky mouth
O - myocarditis, tachycardia
Z- seiZures
Agranulocytosis
Priapism
Incontinence
Neutropenia
EPSE
DSM criteria for schizoaffective disorder
A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia.
Note: The major depressive episode must include Criterion A1: Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.
C. Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness.
D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
Treatment of schizoaffective disorder
- combination of an antipsychotic with an antidepressant (when depressed), and/or lithium or sodium valproate (when manic)
- Drugs used for prophylaxis of bipolar disorder can also be used for prophylaxis of the mood component of schizoaffective disorder
MOA of antipsychotics
Antipsychotic actions are thought to be mediated (at least in part) by blockade of dopaminergic transmission in various parts of the brain (in particular the limbic system). Evidence suggests:
- all effective antipsychotics block D2 receptors
- differential blockade of other dopamine receptors (eg D1) may influence therapeutic and adverse effects
- antagonism of other receptors may influence antipsychotic activity, eg 5HT2antagonism with some agents.
Indications for antipsychotics
- Acute and chronic psychoses (eg schizophrenia)
- Bipolar disorder
Common adverse effects of antipsychotics?
- sedation, anxiety, agitation, EPSE, orthostatic hypotension, tachycardia, blurred vision, mydriasis, constipation, nausea, dry mouth, urinary retention, sexual adverse effects, weight gain, hyperprolactinaemia (may result in galactorrhoea, gynaecomastia, amenorrhoea or infertility)
Infrequent or rare
allergic reactions, including urticaria, Stevens-Johnson syndrome; intra-operative floppy iris syndrome, SIADH, hyperthermia, hypothermia, neuroleptic malignant syndrome, anaemia, thrombocytopenia, neutropenia, agranulocytosis, VTE, stroke, ECG changes (reversible, broadened QT interval), arrhythmias, cardiac arrest, sudden death, hepatic fibrosis, priapism, systemic lupus erythematosus, seizures, increased blood glucose, dysarthria, dysphagia, new-onset or worsening obsessive-compulsive symptoms (most often reported with clozapine; may respond to stopping/dose reduction)
Explain some extrapyramidal symptoms?
-
dystonias - continuous spasms and muscle contractions
- torticollis - abnormal, asymmetrical head or neck position (crick in the neck)
- carpopedal spasm - involuntary contraction of the feet or (more commonly) the hands
- trismus - lockjaw
- perioral spasm
- oculogyric crisis - prolonged involuntary upward deviation of the eyes
- laryngeal spasm
- opisthotonos - spasm of the muscles causing backward arching of the head, neck, and spine
- onset = within 5 days
- treatment = benztropine or diphenhydramine
- akathisia - motor restlessness
- onset = within 10 days
- treatment = lorazepam, propanolol, or diphenhydramine
- parkinsonism - tremor, rigidity or bradykinesia
- onset = within 30 days
- treatment = benztropine, reduce or change antipsychotic to a lower potency
- tardive diskinisea - Involuntary movements of the face, mouth or tongue, and sometimes head and neck, trunk or limbs
- onset = over 90 days
- no good treatment; may try clozapine; discontinue drug or reduce dose
