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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.