Download PSYCHOTIC DISORDERS - Eleanor L. Ronquillo MD October 13

PSYCHOTIC DISORDERS - Eleanor L. Ronquillo MD
October 13, 2010
When you encounter a patient with behavioral problems, the first question in assessment should be:
 IS THIS PATIENT PSYCHOTIC OR NOT?
What is Psychosis?
 State in which the person’s thoughts, affective response, ability to recognize reality, and ability
to communicate and relate to others are sufficiently impaired = OUT OF TOUCH WITH REALITY.
 Common characteristics of psychosis are: impaired reality testing, hallucinations, delusions
Psychotic Disorders
 Schizophrenia
 Schizophreniform Disorder
 Brief Reactive Psychosis
 Delusional Disorder
 Schizoaffective Disorder
 Substance-Induced Psychosis
 Psychotic features of Mood Disorders
 Psychosis of Organic Mental Disorders
A. SCHIZOPHRENIA
 Disruptive psychopathology - cognition, emotion, perception, behavior
 Severe, chronic, usually begins before age 25, affects persons of all social classes
 Diagnosis is based entirely on the psychiatric history and mental status examination
 There is no laboratory test for schizophrenia
 Occurrence of psychosis for at least 6 months
 Theories about etiology
o Dopamine Hypothesis (Biochemical Factor)
 Too much dopamine
 Antipsychotic drugs act as antagonists of the dopamine type 2 (D2) receptor
 Drugs like cocaine and amphetamine increase dopaminergic activity
 Too much release of dopamine, too many dopamine receptors, hypersensitivity
of the dopamine receptors to dopamine, or a combination of these mechanisms
o Neuropathology
 Neurochemical abnormalities in limbic system, basal ganglia, cerebral cortex,
the thalamus, brainstem
 Loss of brain volume - reduced density of the axons, dendrites, and synapses
that mediate associative functions of the brain
 Lateral and third ventricular enlargement and some reduction in cortical
volume
o Psychoanalytic Theories
 Sigmund Freud - early developmental fixations, defects in ego development, ego
disintegration, impaired ego functions
 Margaret Mahler - distortions in the reciprocal relationship between the infant
and the mother, the person's identity never becomes secure.
 Harry Stack Sullivan - disturbance in interpersonal relatedness > sense of
unrelatedness > distortions >usually but not always, persecutory
o
o
Learning Theory
 Child learned irrational reactions and ways of thinking by learning from parents
with significant emotional problems and adverse circumstances > poor
interpersonal relationships
Family Theory
 Schisms and Skewed Families (Theodore Lidz)
1. Schism (division) between the parents - one parent is overly close to a
child of the opposite gender.
2. Skewed (distorted) relationship between a child and one parent - power
struggle between the parents, resulting dominance of one parent,
tenuous adaptive capacity of the schizophrenic person.
DSM-IV-TR Diagnostic Criteria for Schizophrenia
A. Characteristic symptoms: Two (or more) of the following, each present for a significant portion
of time during a 1-month period
o Delusions
o Hallucinations
o Disorganized speech
o Grossly disorganized or catatonic behavior
o Negative symptoms, i.e. affective flattening, alogia, or avolition
B. Social/occupational dysfunction: major areas of functioning like work, interpersonal relations,
or self-care are markedly low
C. Duration: at least 6 months
D. Schizoaffective and mood disorder are ruled out
E. Substance/general medical condition exclusion: The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical
condition.
 From APA DSM-4 TR: American Psychiatric Association
DSM-IV-TR classifies the subtypes of schizophrenia as:
1. Paranoid
 Delusions = paranoia, persecutory or grandiose
 Less deterioration than other types, intelligence can remain intact
 Tense, suspicious, guarded, reserved, and sometimes hostile or aggressive, but they can
occasionally conduct themselves adequately in social situations
2. Disorganized
 Formerly called hebephrenic
 Marked regression to being primitive, disinhibited and unorganized
 Laughing to self, gesturing, silly affect
3. Catatonic
 Marked disturbance in motor function
 Stupor, negativism, rigidity, posturing
 Waxy flexibility or catalepsy - person who can be molded into a position that is then
maintained; when an examiner moves the person's limb, the limb feels as if it were
made of wax
 Mutism is particularly common.
 Has become rare, is seen in seriously ill and untreated cases
4. Undifferentiated and Residual
a) Undifferentiated Type
 Clearly schizophrenic, cannot be easily fit into one type or another
b) Residual Type
 Continuing evidence of the schizophrenic disturbance in the absence of a
complete set of active symptoms
 Emotional blunting, social withdrawal, eccentric behavior, illogical thinking,
and mild loosening of associations
Brief Psychotic Disorder
 Sudden onset of psychotic symptoms
 Acute and transient
 <1 month
 Remission is full
 Return to the premorbid level of functioning
 Not associated with a mood disorder, a substance-related disorder, or a psychotic disorder
caused by a general medical condition
Schizophreniform Disorder
 1-6 months
 Return to their baseline level of functioning
 Cause - not known; stressor?
 Lacks a long prodromal phase
 Functional impairment at the time of an episode
 No decline in social and occupational functioning
Schizoaffective Disorder
 As the term implies, schizoaffective disorder has features of both schizophrenia and
affective disorders
Delusional Disorder
 Great variety of false beliefs that can be held by so many people
 They are so difficult to treat
 Diagnosis is made when a person exhibits nonbizarre delusions of at least 1 month duration
that cannot be attributed to other psychiatric disorders
 Person remains generally functional with some relationships
Culture-Bound Syndromes
 Unique behavioral phenomena observed only in particular cultures or sociocultural contexts
 Readily recognized as illness behavior by most participants in that culture and given
culturally sanctioned explanations and interpretations
 Assessment must start with recognition that each human society has an indigenous body of
beliefs and practices
 Not all are psychotic
 Amok “naghuramentado”
o Dissociative episode characterized by an outburst of violent, aggressive, or
homicidal behavior directed at persons
o
o
o
o
Precipitated by a perceived slight or insult
Prevalent only among men
Accompanied by exhaustion and a return to premorbid state following the episode
May occur as a brief psychotic episode
How can we tell if a person has psychosis?
 Psychotic Features
1) Perceptual disturbances
o Hallucination - false sensory perception occurring in the absence of any
relevant external stimuli
a. Auditory (most common) - hearing voices (ex. command)
b. Visual
c. Tactile (ex. formication - insects crawling on skin)
d. Olfactory
e. Gustatory
2) Disturbance in form/flow of thoughts
o Neologisms - new words coined by patient or old words with new meaning
o Word Salad/Looseness of Association - unrelated and unconnected ideas
shift from one subject to another
o Perseveration - repetition of the same response to different stimuli,
repetition of the same verbal response to different questions.
o Circumstantiality/tangentiality - patient digresses into unnecessary details
and inappropriate thoughts before communicating the central idea.
o Clang association - speech/words are associated by the sound of a word
rather than by its meaning; words have no logical connection; punning and
rhyming
o Echolalia - psychopathological repeating of words or phrases of one person
by another; repetitive; persistent; seen in severe types
3) Disturbance in content of thoughts
o Delusion - false belief, firmly held, unshakable, despite objective and
obvious contradictory proof; other members of his group/culture do not
share the belief
o Kinds
 Delusion of control - false belief that a person’s will, thoughts, or
feelings are being controlled by external forces
 Delusion of grandeur - exaggerated conception of one’s importance,
power, or identity
 Delusion of infidelity/jealousy - false belief that one’s lover is unfaithful;
pathological jealousy
 Delusion/ideas of reference - false belief that the behaviour of other
refers to oneself; events/objects/people have a particular meaning to
him usually of a negative nature, people on television or radio are
referring to them
o Erotomania - false belief that someone is deeply in love with them; more
common in women than in men (also known as de Clerambault syndrome).
o Folie a deux - mental illness shared by two persons, usually involving a
common delusional system; if it involves three persons, it is referred as folie
a trois, and so on. Also called shared psychotic disorder.
o
Illogical thinking - thinking containing erroneous conclusions or internal
contradictions; psychopathological only when it is marked and not caused
by cultural values or intellectual deficit.
o Magical thinking - words or actions assume power (e.g., to cause or prevent
events)
4) Grossly disorganized behaviour
o Catatonia - voluntary assumption of an inappropriate or bizarre posture,
generally maintained for long periods of time
o Hebephrenia - wild or silly behavior or mannerisms, inappropriate affect,
incoherence
o Coprophagia - Eating of filth or feces
Other symptoms of psychosis:
 Thought broadcasting - one's thoughts are being broadcast or projected into the
environment.
 Thought withdrawal - one's thoughts are being removed from one's mind by other people or
forces.
 Thought insertion – one’s thoughts are being implanted in one's mind by other people or
forces.
Treatment
1. Combined psychotherapy and pharmacology
2. The use of psychotropic drugs in combination with psychotherapy has become widespread. In
fact, it has become the standard.
3. For psychosis, always treat with anti-psychotics.
Typical antipsychotics
 Dopamine Receptor Antagonists (DRA’s): Typical Antipsychotics
 Chlorpromazine (Thorazine), which was introduced in the mid-1950s, was the first drug that
significantly and consistently reduced symptoms of psychosis.
 Antipsychotic activity was related to high-affinity antagonism of dopamine D2 receptors.
 Other terms used to refer to these drugs are first-generation, typical, traditional, or
conventional antipsychotics.
 Antipsychotic activity derives from inhibition of dopaminergic neurotransmission.
 Potency refers to the amount of drug that is required to achieve therapeutic effects.
 Low-potency drugs, such as chlorpromazine and levomepromazine, given in doses of several
hundred milligrams per day, typically produce more weight gain and sedation.
 High-potency agents, such as haloperidol are usually given in doses of less than 10 mg per day.
High-potency agents are also more likely to cause extrapyramidal side effects.
 Precautions and adverse reactions of DRA’s
o Neuroleptic Malignant Syndrome
 Potentially fatal side effect of DRA treatment
 Can occur at any time during the course of DRA treatment
 Extreme hyperthermia, severe muscular rigidity and dystonia, akinesia, mutism,
confusion, agitation, and increased pulse rate and blood pressure (BP) leading
to cardiovascular collapse

o
o
Laboratory findings include increased white blood cell (WBC) count, creatinine
phosphokinase, liver enzymes, plasma myoglobin, and myoglobinuria,
occasionally associated with renal failure
 Symptoms usually evolve over 24 to 72 hours, and the untreated syndrome lasts
10 to 14 days
Neurological side effects
 Akathisia - restlessness, jitteriness, pacing, rocking motions while sitting, and
rapid alternation of sitting and standing
 Dystonias - contractions of muscles that result in obviously abnormal
movements or postures, including oculogyric crises, tongue protrusion, trismus,
torticollis, laryngeal–pharyngeal dystonias, and dystonic postures of the limbs
and trunk.
 Neuroleptic-Induced Parkinsonism -muscle stiffness (lead pipe rigidity),
cogwheel rigidity, shuffling gait, stooped posture, and drooling
 Treatment
 Parkinsonism can be treated with anticholinergic agents, benztropine
(Cogentin), amantadine (Symmetrel), or diphenhydramine (Benadryl)
(Table 36.2-2 in Kaplan).
Tardive Dysknesia
 Adverse effect of long term antipsychotic treatment usually seen with 10-20
year treatment with typical antipsychotics
 Abnormal involuntary movements of face, mouth, neck, trunk, limbs
Atypical Antipsychotics
 Relatively new, more often used
 Selective dopamine receptors antagonists
 Minimal neurologic side effects
 More metabolic side affects – metabolic syndrome, weight gain, increased blood sugar,
cholesterol
 More expensive
 Targets both negative & positive symptoms
 Olanzapine, Clozapine, Risperidone, Quetiapine, Amisulpiride, etc.
Psychiatric Rehabilitation
 Interventions
o Family meetings
o Support groups
o Supportive psychotherapy
o Occupational/vocational therapy
o Social skills training
 Designed to help people with disabilities caused by mental illness to improve their functioning
and quality of life by enabling them to acquire the skills and support needed to be successful in
usual adult roles and in the environments of their choice. Normative adult roles:
o Living independently
o Roles - attending school or working in competitive jobs
o Relating well to family
o Having friends

o Having intimate relationships
Psychiatric rehabilitation emphasizes
o Independence rather than reliance on professionals
o Community integration rather than isolation
o Patient preferences rather than professional goals
Vocational Rehabilitation
 Impairment of vocational role performance is a common complication related to schizophrenia.
Studies across the United States show that less than 15 percent of patients with severe mental
illnesses, such as schizophrenia, are employed.
 Studies also show that competitive employment is a primary goal for 50 to 75 percent of
patients with schizophrenia. Because of patient interests and historical factors, vocational
rehabilitation has always been a centerpiece of psychiatric rehabilitation.
Social Skills Rehabilitation
 Social dysfunction is a defining characteristic of schizophrenia. People with the illness have
difficulty fulfilling social roles, such as worker, spouse, and friend, and have difficulty meeting
their needs when social interaction is required.
 The primary modality of social skills training is role play of simulated conversations. The trainer
first provides instructions on how to perform the skill and then models the behavior to
demonstrate how it is performed.
Other psychosocial interventions for schizophrenia
 Family therapy
o Defined as any psychotherapeutic endeavor that explicitly focuses on altering the
interactions between or among family members and seeks to improve the functioning of
the family as a unit, or its subsystems, and/or the functioning of individual members of
the family.