Psychotic Disorders (lec 3) Flashcards Preview

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Flashcards in Psychotic Disorders (lec 3) Deck (93):
1

Disorganized Speech types (5)

1. derailment, tangentiality
2. incoherence, world salad
3. neologism
4. echolalia
5. blocking, paucity

2

Disorganized or Catatonic Behavior def

activity is not goal directed
inability to complete simple tasks
immobility
waxy flexibility

3

causes of psychosis (12)

1. substance intox/withdrawal
2. med SEs: steroids, stimulants, dopamine agonists, anticholinergics
3. delirium
4. dementia
5. denocrine (thyroid)
6. CNS infection (syphilis)
7. epilepsy (temporal)
8. Vit deficiency (b12)
9. Autoimmune (SLE)
10. Huntigton's
11. Wilson's
12. Psychiatric d/z: psychotic, mood, personality

4

Evaluation of Psychosis (10 elements)

1. HPI
2. Past psych hx
3. substance use hx
4. family hx
5. social hx
6. PMH
7. physical exam (neuro)
8. MSE
9. labs: UDS, UA, CBC, CMP, TSH, RPR, B12
10. EEG, imaging

5

Psychotic Disorders (7)

1. Schizophrenia
2. Schizophreniform disorder
3. Schizoaffective disorder
4. Delusional disorder
5. Brief psychotic disorder
6. Shared psychotic disorder
7. substance induced, due to general medical condition or not otherwise specified

6

Schizophrenia: prevalence, affects who, when?

lifetime prevalence 0.5% to 1.5% worldwide (high heritability: 1st degree relative's risk is 10x the general population)
males=females for prevalence and:
earlier age of onset
Smales early 20s, females late 20s

7

Pathophysiology of schizophrenia

progressive gray matter deficits (slide 12?)

8

Schizophrenia: negative sxs

alogia (poverty of speech) affective blunting
anhedonia
avolition
attentional impairment

9

Schizophrenia: positive sxs

hallucinations
delusions
disorganized behavior
disorganized speech

10

Schizophrenia course

-chronic
-abrupt onset vs. prodrome
-negative sxs appear first
-complete remission is uncommon
-decreased life expectancy

11

Schizophrenia disorder life expectancy

men die 15 yrs earlier, women 12 (primarily due to ischemic heart disease & cancer)
-5% will commit suicide
-10% of completed suicides are schizophrenia pts

12

Schizophrenia DSM-IV dx criteria

A. at least 1 MONTH of 2+ of the following: delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative sxs (only 1 sx if bizarre delusions or AH or running commentary or 2+ voices conversing)

B. significant social/occupational DYSFUNCTION in 1+ area

C. duration 6 MONTHS: 1 mo criterion A + prodrome/residual period

D. schizoaffective & mood d/o are ruled out (mood episodes are brief if present)

E. not due to substance or general medical condition
-if autistic/PDD must have prominent delusions/hallucinations at least 1 mo

13

Schizophrenia paranoid subtype

1+ delusion or frequent AH
not prominent: disorganized speech/behavior, inappropriate affect

14

Schizophrenia disorganized subtype

-prominent disorganized speech & behavior
-flat or inappropriate affect
-not catatonic

15

Schizophrenia catatonic subtype

clinical picture dominated by at least 2:
-motoric immobility/catalepsy, waxy flexibility, stupor
-excessive motor activity (purposeless)
-extreme negativism (resists movement), mutism
-inappropriate/bizarre posturing, stereotypies, prominent mannerisms/grimacing

16

Schizophrenia undifferentiated subtype

meets criteria for schizophrenia, but no subtype

17

Schizophrenia residual subtype

ABSENCE of prominent hallucinations, delusions or disorganized speech/behavior or catatonia

PRESENCE of negative symptoms or 2+ attenuated positive symptoms

18

Mental Status Exam (MSE)Appearance

age, hygiene/clothing (disheveled, malodorous, unkempt)

19

MSE: Behavior (3)

1. cooperativeness & relation (uncooperative/combative, guarded/suspicious)

2. eye contact (poor, looking around room, watching door, looking over shoulder

3. motor activity (hypo or hyper; rocking, pacing, grimacing, or other abnormal movements)

20

MSE: Affect

Appropriate (congruent w/mood)
Inappropriate (constricted/blunted/flat vs. labile, laughing inappropriately)

21

MSE: Mood

whatever pt tells you, in quotes

22

MSE: Speech

quantity
amplitude
rate
tone

23

MSE: thought process

logical vs. illogical
tangential
circumstantial

24

Hallucinations: definition

sensory perceptions in absence of stimulus:
-auditory
-visual
-tactile
-olfactory
-gustatory

25

Thought content (3 possible components)

Hallucinations: whispering, conversing, commanding

Delusions: paranoid, religious, grandiose, ideas of reference, thought broadcasting/insertion

Suicidal & Homicidal ideation: document plan & intent, if pt denies SI/HI but has command hallucination to harm self/others, document & address it!

26

Another component of MSE

Insight & Judgment

27

Schizophrenia: factors indicating more positive prognosis

-Female
-Later onset
-Acute onset w/precipitating factor
-Brief duration, early intervention, tx compliance
-Positive symptoms
-mood disturbance, family hx of mood do
-high SES, married, good support system
-good premorbid functioning

28

Schizophreniform Disorder

-Essential features identical to Schizophrenia (delusions, hallucinations, disorganization, neg sxs)
-SHORTER duration: 1-6 months
-social/occupational fxn may/may not be impaired

29

Schizophreniform disorder prognosis

1/3 recover (schizophreniform is final dx)

2/3 progress to schizophrenia or schizoaffective disorder

30

DSM-IV dx criteria for schizophreniform disorder

A. criteria A, D and E of schizophrenia are met (characteristic sxs, not schizoaffective or mood d/o, not due to substance or GMC)

B. Episode (prodrome + active + residual phases) lasts between 1-6 months

31

Schizoaffective disorder: essential definition and types

Schizophrenia + mood disorder
-Bipolar or Depressed type
delusions/hallucinations 2 wks & normal mood

32

Schizoaffective disorder: prevalence & prognosis

more common in women (esp depressed type)
better prognosis

33

Schizoaffective disorder->increased risk of what in 1st degree relatives

increased risk of schizophrenia & mood d/o in 1st degree relatives

34

DSM4 Diagnostic Criteria for SchizoAFEECTIVE d/o

A. meets crit A fo SCHIZOPHRENIA (charactersic sxs) & CONCURRENT MAJ. DEPRESSIVE, MANIC or MIXED episode
B. must have 2+ weeks of delusions or hallucinations w/out prominent mood sxs
C. mood sxs present for a sig portion of illness
D. not due to substance or GMC

35

Delusions: definition

fixed false beliefs, despite disproving evidence

36

4 types of delusions which can be one of which 2 things

-paranoid or persecutory
-grandiose
-reference
-somatic
BIZARRE vs. NON-BIZARRE

37

Delusional disorder: prevalence, demographics

*prevalence=0.03%, males=females, but variation among subtypes
*variable age at onset (teen-late adulthood)
*variable course (may remit & relapse)
*possible familial relationship to Schizophrenia

38

Non-bizzare delusions

plausible but false
i.e. infestations, being followed by police
(NOT alien abduction)

39

Delusional disorder: can it co-occur with schizophrenia?

no, it does NOT meet criterion A for Schizophrenia

40

Describe the following in DELUSIONAL DISORDER: hallucinations, psychosocial function, thought process, insight

Hallucinations could be related to delusional theme (bugs)
Psychosocial fxning NOT markedly impaired
NORMAL thought process
POOR insight

41

DSM4 dx criteria for DELUSIONAL DISORDER

A. NON-BIZZARE delusions for at least 1 MONTH
B. crit A for schizophrenia has NEVER been met (but hallucinations rltd to delusion OK)
C. Fxning NOT markedly impaired, normal behavior
D. mood episodes, if any, are brief relative to delusion
E. not due to substance or GMC

42

Delusional disorder: 7 subtypes

1. Erotomania
2. Grandiose
3. Jealous
4. Persecutory
5. Somatic
6. Mixed
7. Unspecified

43

Erotomania

delusion that another is in love with pt, usually a person of higher status (celebrity stalkers)

44

Grandiose

delusion of inflated worth, power, knowledge, identity or special relationship to deity or famous person

45

Jealous

delusion that spouse, significant other, sexual partner is unfaithful

46

Persecutory

delusion that pt is being treated malevolently
(conspired against, cheated, spied on, followed, poisoned, harassed...)

47

Somatic

delusion of physical defect or medical condition

48

Mixed delusion

features of more than one, but non predominate
(erotomania, grandiose, jealous, persecutory, somatic)

49

Unspecified delusion

delusion, that has not been specified

50

Brief Psychotic Disorder

-SUDDEN ONSET of at least 1 positive symptoms
-lasts 1 DAY TO 1 MONTH w/RETURN TO NORMAL premorbid fxning
-emotional, labile, confused

51

Brief psychotic disorder onset

onset in pate 20s to early 30s
may be marked with a stressor or post-partum onset

52

Brief psychotic disorder: what do you need to rule out

rule out culturally appropriate experience, malingering, personality disorder

53

Brief psychotic disorder: DSM-IV dx criteria

A. 1 OR MORE of: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior

B. duration of 1 DAY TO 1 MONTH, w/eventual RULL RETURN TO PREMORBID LEVEL OF FUNCTIONING

c. not due to SCZ, schizoaffective, mood d/o, substance, or GMC

54

Acute stabilization of psychotic d/os: medication

start antipsychotic at low dose & titrate as needed, avoid using 2 antipsychotics

55

Acute stabilization of psychotic d/o: priority, sxs

priority=safety, ↓ DTO/DTS
may need hospitalization
agitation improves fast(min-hrs)
hallucinations improve in days
negative sxs, delusions, cognitive deficits take much longer, if they improve

56

Indications for hospitalization in psychotic d/os (4)

1. Danger to self (DTS)
2. Danger to others (DTO)
3. command auditory hallucinations
4. unable to care for self

57

Maintenance of psychotic d/os goal

symptom control and relapse prevention

58

Maintenance of psychotic d/os

compliance is an issue
-simplify med regimen (daily vs BID/TID dosing)
-minimize SEs
*day/partial hospitalization or intensive outpatient programs
*assertive community tx, case management
*involve social network

59

Monitoring/atypical antipsychotic protocol

-BMI monthly x 3 mos, then q 3 mos
-waist circumference annually
-lipids at 12 weeks & q 5 yrs
-fasting glucose at 12 wks & annually
-AIMS q 6 mos

60

Clozapine monitoring

CBC x 6 mos
CBC biweekly x 6 mos
CBC monthly for remainder of tx

61

First generation (conventional) antipsychotics (6+)

CHLORPROMAZINE (Thorazine)
Haloperidol (Haldol) [PO tab or elixir, IM, IV, long-acting injection, topical]
Thioridazine (Mellaril)
Prochlorperazine (Compazine)
Fluphenazine (Prolixin) [PO & inhaled]
many others: Trilafon, Navane, Orap, Moban....

62

Second generation, atypical antipsychotics (9)

Aripiprazole (Abilify)
Asenapine (Saphris)
Clozapine (Clozaril)
Lurasiodone (Latuda)
Paliperidone (Invega Sustenna)
Olanzapine (Zyprexa)
Quetapine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)

63

Aripriazole (Ability): metabolic activity

partial D2 agonst
metabolically neutral

64

Asenapine (Saphris): unique

sublingual administration

65

Clozapine (Clozaril): unique characteristic

agranulocytosis risk: requires regular CBC monitoring of WBCs & ANC (weekly initially)

66

Lurasidone (Lutada): unique characteristic

pregnancy category B

67

Olanzapine (Zyprexa): what does the presentation want you to note?

weight gain

68

Risperidone (Risperidal): what does the presentation find unique abt this?

prolactin, EPS

69

Ziprasidone (Geodon): unique feature

50% less bioavailable without food

70

What to consider in selection of antipsychotics

Dx! r/o non-psych causes
drug-drug intrxns (CYP metabolism)
personal & fam hx of response to meds
setting (ICU, ED, involuntary vs. voluntary, inpatient, outpatient)
route (PO, ODT, IV, IM, long-acting IM)
SE profiles

71

Side Effects of Antipsychotics

1. Extrapyramidal symptoms (EPS): acute dystonic reaction, Parkinsonism, akathesia, Tardive Dyskinesia (TD), Neuroleptic malignant syndrome (NMS)

2. Other: anticholinergic, adrenergic, cardiac, endocrine, hepatic

72

Acute dystonic rxn

(an extrapyramidal symptom)
torticollis, jaw spasms, dysphagia, dysarthria, tongue protrusion, oculogyric crisis, etc.

73

Extrapyramidal Symptoms (5)

ACUTE DYTONIC REACTION
Parkinsonism
Akathisia
Tardive dyskinesia (TD)
Neuroleptic malignant syndrome (NMS)

74

Akathisia

restlessness, fidgeting, rocking, pacing

75

Tardive Dyskinesia

ABNORMAL INVOLUNTARY MOVEMENTS
1. Choreiform: rapid, jerky, non-repetitive
2. Athetoid: slow, sinuous, continual
3. Rhythmic: stereotypies

76

Tardive dyskinesia prevalence, remission

prevalence: 20-30%, incidence 3-5% per year
-higher risk in older adults, longer exposure, mood d/I
ONLY 5-40% OF ALL CASES REMIT!
use AIMS to screen EVERY 6 MONTHS

77

Tx of ACUTE DYSTONIA

benztropine, diphenhydramine

78

Tx of PARKINSONISM

amantadine, benztropine, diphenhydromine

79

Tx of AKATHISIA

propranolol

80

Tx of TARDIVE DYSKINESIA

benztropine or diphenhydramine AND decrease or stop the antipsychotic

81

Neuroleptic Malignant Syndrome (NMS)

POTENTIALLY LIFE THREATENING!
sever muscle RIGIDITY + INCREASED TEMP

82

Risk factors for NMS

-dehydration, ?hot/humid weather
-agitation
-high dose, rapid increase, IM injection
-hx of NMS
-Lithium use

83

NMS associated features (5)

1. mental status change (often 1st sx)
2.autonomic instability(↑BP/HR)
3. leukocytosis (>10,000)
4. ↑CK (often >300)
5. electrolyte abnormalities

84

NMS mnemonic

(FEVER)
Fever
Encephalopathy
Vitals unstable
Elevated enzyme (CK)
Rigidity
NMS

85

NMS treatment

theory: Dantrolene
Reality: supportive/symptomatic
NO neuroleptics for at least 2 weeks

86

All atypical antipsychotics black box warning

increased mortality when treating elderly pts for dementia-related psychosis (all atypicals)

87

Other atypical antipsychotic SEs (9)

1. Anticholinergic
2. Adrenergic (alpha 1 blockade)
3. Weight gain
4. Endocrine
5. Ocular
6. Cardiovascular
7. Hepatic: Transaminitis
8. Neuro (decreased seizure threshold, dose dependent w/most 1st gen & clozapine)
9. Leukocytosis & agranulocytosis

88

Anticholinergic Effects

dry mouth, blurry vision, constipation, urinary retention, confusion, delirium

89

Adrenergic effects of antipsychotics

(alpha 1 blockade)
-hypotension, dizziness

90

Endocrine effects of antipsychotics (atypicals, 1st gen)

atypicals: hyperglycemia, HLP, metabolic syndrome

1st gen & Risperidone elevated prolactin, gynecomastia, galactorrhea, amenorrhea, decreased libido

91

Ocular side effects of antipsychotics

pigmentary retinopathy (chronic Thioridazine)

92

Cardiovascular effects of antipsychotics

QT prolongation (can lead to torsades)
Orthostatic hypotension
Tachycardia

93

Neurological side effects of antipsychotics

decreased seizure threshold
dose-dependent risk with most 1st gen & clozapine