Psychosis pdf - د.إلهام

Fifth stage

Psychiatry

Lec-1

الهام الجماس

4/10/2015

Psychosis

What is Psychosis?

 Generic term

 “Break with Reality”

 Symptom, not an illness

 Caused by a variety of conditions that affect the functioning of the brain.

 Includes hallucinations, delusions and thought disorder

P
S
Y
C
H
O
S

“Functional” disorders

“Organic” mental disorders

Substance induced

Delirium

Dementia

Amnestic d/o

Mood disorders

Schizophrenia “spectrum” disorders

Differential Diagnosis

Workup of New-Onset Psychosis:
“Round up the usual suspects”



Good clinical history



Physical exam, ROS



Labs/Diagnostic tests:



Medical/surgical/ substance-induced:

Psychotic d/o due to GMC

Dementia

Delirium

Medications

Substance induced:

Amphetamines

Cocaine

Withdrawal states

Hallucinogens

Alcohol



Mood disorders:

Bipolar disorder

Major depression with psychotic features



Personality disorders:

Schizoid

Schizotypal

Paranoid

Borderline

Antisocial



Miscellaneous:

PTSD

Dissociative disorders

Malingering

Culturally specific phenomena:

Religious experiences

Meditative states

Belief in UFO’s, etc

Metabolic panel
CBC with diff
B12, Folate
RPR, VDRL
Serum Alcohol
Urinalysis
Thyroid profile

urine drug screen!!!

CSF/LP
HIV serology

CT or MRI
EEG

Talking Points:

 Schizophrenia is not an excess of dopamine.

 The differentiation between “functional” and “organic” is artificial.

 Schizophrenia and other psychiatric illnesses are syndromes.

Definition:

The schizophrenic disorders are characterized in general by fundamental and
characteristic distortions of thinking and perception, and affects that are inappropriate
or blunted. Clear consciousness and intellectual capacity are usually maintained
although certain cognitive deficits may evolve in the course of time.

The most important psychopathological phenomena include:

1. thought echo

2. thought insertion or withdrawal

3. thought broadcasting

4. delusional perception and delusions of control

5. influence or passivity

6. hallucinatory voices commenting or discussing the patient in the third person

7. thought disorders and negative symptoms.

Talking Points:

 1% prevalence

 Early onset, M>F

 Early, aggressive treatment decreases long-term problems

 Multiple subtypes- catatonic, disorganized, paranoid, undifferentiated, residual

Schizophrenia Diagnostic features (1

Rank symptoms):

 1950’s - Schneider’s 1st Rank Symptoms:

Primary Delusion = ‘delusional percept’

Own thoughts spoken aloud = ‘thought echo’

Voices arguing or discussing

running commentary voices

thought withdrawal and/or thought block

Thought insertion

thought broadcasting (others are thinking it at the same time as you)

Made to feel… ‘passivity of affect’

Made to want… ‘passivity of impulse’

10. Made to do… ‘passivity of volition’

11. Done to my body ‘somatic passivity’ eg probed by aliens

Some may occur in illnesses other than schizophrenia eg mania

DSM-IV Diagnosis of Schizophrenia:

1. Psychotic symptoms (2 or more) for at least one month:

Hallucinations

Delusions

Disorganized speech

Disorganized or catatonic behavior

Negative symptoms

2. Impairment in social or occupational functioning

3. Duration of illness at least 6 mo.

4. Symptoms not due to mood disorder or schizoaffective disorder

5. Symptoms not due to medical, neurological, or substance-induced disorder

Formal Thought Disorders
Clinical features:

  Neologisms
  Tangentiality
  Derailment
  Loosening of associations (word salad)
  Private word usage
  Perseveration
  Nonsequitors

Delusions
Clinical features:

  Paranoid/persecutory
  Ideas of reference
  External locus of control
  Thought broadcasting
  Thought insertion, withdrawal
  Jealousy
  Guilt
  Grandiosity
  Religious delusions
  Somatic delusions




Religious
delusions



Somatic
delusions

Hallucinations
Clinical features:

  Auditory
  Visual
  Olfactory
  Somatic/tactile
  Gustatory

Behavior
Clinical features:

  Bizarre dress, appearance
  Catatonia
  Poor impulse control
  Anger, agitation
  Stereotypies

Mood and Affect
Clinical features:

  Inappropriate affect
  Blunting of affect/mood
  Flat affect
  Isolation or dissociation of affect
  Incongruent affect

Positive vs. negative symptoms:

Psychotic Disorders:

Onset

Symptoms

Course

Duration

Schizophrenia

Usually insidious

Many

Chronic

>6 months

Delusional
disorder

Varies
(usually insidious)

Delusion only

Chronic

>1 mo.

Brief psychotic
disorder

Sudden

Varies

Limited

<1 mo.

Psychosocial Factors:

 Expressed emotion

 Stressful life events

 Low socioeconomic class

 Limited social network

Some factors rejected as causal

 “Schizophrenogenic Mother”

 “Skewed” family structure

Genetic factors: (The evidence mounts…)

 Monozygotic twins (31%-78%) vs dizygotic twins

 4-9% risk in first degree relatives of schizophrenics

 Adoption studies

 Linkage, molecular studies

Positive symptoms

  Delusions
  Hallucinations
  Behavioral dyscontrol
  Thought disorder

Negative symptoms (Remember Andreasen’s “A”s)

  Affective flattening
  Alogia
  Avolition
  Anhedonia
  Attentional impairment

Genetics of Schizophrenia:
The take-home message

 Vulnerability to schizophrenia is likely inherited

 “Heritability” is probably 60-90%

 Schizophrenia probably involves dysfunction of many genes

Anatomical abnormalities:

 Enlargement of lateral ventricles

 Smaller than normal total brain volume

 Cortical atrophy

 Widening of third ventricle

 Smaller hippocampus

Physiologic studies:
PET and SPECT

 Generally normal global cerebral flow

 Hypofrontality

 Failure to activate dorsolateral prefrontal cortex (problem-solving, adaptation, coping

with changes)

Biochemical factors:
The dopamine hypothesis

 All typical antipsychotics block D

with varying affinities

 Dopamine agonists can precipitate a psychosis

Amphetamines

Cocaine

L-dopa

Dopamine systems:

Cell bodies

Projections

Function

Clinical
implications

Nigro-striatal Substantia nigra

Caudate and
putamen

Movement

Extrapyramidal
symptoms,
dystonias,
Tardive
dyskinesia

Meso-limbic

Ventral
tegmentalarea,
subst. nigra

Accumbens
amygdala
olfactory
tubercle

Emotion, affect,
memory

Positive
symptoms

Meso-cortical Ventral tegmental

area

Prefrontal
cortex

Thought,
volition,
memory

Blockade here
can worsen
negative
symptoms

Typical Neuroleptics

Neuroleptic (typicals) Side effects:

Acute dystonia

2.  Parkinsonian side effects (EPS)
3.  Akathisia
4.  Tardive dyskinesia
5.  Sedation, orthostasis, QTC prolongation, anticholinergic, lower seizure threshold,

increased prolactin

 Low potency:

o  Chlorpromazine
o  Thioridazine
o  Mesoridazine



High potency:



Haloperidol



Fluphenazine



Thiothixene



Loxapine (mid)

 High potency:

o  Haloperidol
o  Fluphenazine
o  Thiothixene
o  Loxapine (mid)

Atypical Antipsychotics:

 Risperidone

 Olanzapine

 Quetiapine

 Clozapine

 Ziprasidone

 Aripiprazole (new-partial DA agonist)

Atypical antipsychotics:

 Broader spectrum of receptor activity (Serotonin, dopamine, GABA)

 May be better at alleviating negative symptoms and cognitive dysfunction

 Clozaril (clozapine) associated with agranulocytosis, seizures

Atypical Antipsychotics (Side Effects):

1. Sedation

2. Hyperglycemia, new-onset diabetes

3. Anticholinergic effects

4. Less prolactin elevation

5. QTC prolongation

6. Some EPS

7. Increased lipids

Psychosocial Treatment:

 Education, compliance #1

 Hospitalize for acute loss of functioning

 Outpatient treatment is rehabilitative

 Psychoanalysis, exploratory therapies have limited value

 Families should be involved