Download Psychotic and somatoform disorders

Shawn Hersevoort MD MPH
UCSF-Fresno Psychiatry
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PART 1: PSYCHOTIC DISORDERS
Describe the clinical significance of psychotic disorders
List and described the different psychotic disorders and how to differentiate between them
List the most commonly used antipsychotic medications and describe the general
characteristics of each
 Describe the ongoing health monitoring parameters associated with using these medications
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PART 2: SOMATOFORM DISORDERS
List and described the different somatoform disorders and how to differentiate between
them
 List the medications and treatment strategies most commonly used in treatment of
somatoform disorders
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Clinical significance:
 Lifetime prevalence is 3% in the general population
 20% of primary care patients exhibit symptoms
 Those who do have higher co-morbid anxiety, depression, sociality,
and substance use
 Morbidity and mortality form general medical conditions are at least
2-3 times as high in these patients
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A primary psychotic disorder of cognitive and sensory disturbances
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6 months or more
Significant portion of the time
2/5 or more of
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Delusions: fixed false beliefs that a difficult or impossible to disprove
Hallucinations: sensory abnormalities, usually auditory
Disorganized speech: strange, frequent derailment, or incoherence
Grossly disorganized behavior or catatonia: minimal or bizarre activity,
mutism, repetitive behaviors
 Negative symptoms: emotionlessness, mutism, or limited movement or action
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Types: (no longer used)
Paranoid: prominent delusions of hallucinations (1,2)
Disorganized: disorganized/nonsensical speech, behavior, emotions (3)
Catatonic: minimal or bizarre activity, mutism, repetitive behaviors (4,5)
Undifferentiated: Not fitting clearly into paranoid, disorganized, or catatonic
types
 Residual: Not demonstrating prominent positive symptoms (partially treated or
recovering)
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Related disorders:
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BRIEF PSYCHOTIC DISORDER: less than 1 month of symptoms
SCHIZOPHRENIFOM DISORDER: 1-6 months of symptoms
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A primary psychotic disorder including prominent mood
symptoms
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Schizophrenia and a mood episode (major depressive, manic, or mixed)
Psychosis persistent in absence of mood disorder symptoms
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May need antidepressant or mood stabilizer
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Types:
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Bipolar: schizophrenia and manic or mixed episode
Depressed: schizophrenia and major depressive episode
Related disorders:
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MDD/BPD WITH PSYCHOTIC FEATURES: psychotic symptoms only during
prominent mood symptoms
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A primary psychotic disorder including delusions only
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Delusions that are non-bizarre
1 month or more
No hallucinations or other symptoms of schizophrenia
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Often respond poorly to treatment
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Types:
Erotomanic: central theme is that another person is in love with patient
Grandiose: central theme is patient having some great (but unrecognized) talent,
insight, or relationship
 Jealous: central theme is that lover is unfaithful
 Persecutory: central theme is the patient being conspired against, cheated, spied
on, or obstructed
 Somatic: central theme is involving bodily functions or sensations
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Psychotic symptoms that are judged to be due to the direct
physiological effects of a substance
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Usually only present during intoxication or withdrawal
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Psychotic symptoms that are a direct physiological result of a
medical condition
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Physical symptoms caused by illness, not just a psychological response to a
medical problem
Identified medical illness diagnosed or observed
Proposed physiological mechanism for causing mental health symptoms
Example: psychosis due to traumatic brain injury
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Common medical conditions causing psychotic symptoms:
 Acute neurological: encephalopathies, syphilis, herpes encephalitis, HIV, lupus,
vasculitis
 Chronic neurological: seizure disorder, Parkinson disease, multiple sclerosis, stroke,
Huntington disease, traumatic brain injury
 Electroyle disturbance: hypercalcemia, hyponatremia, uremia
Related disorders:
 DELIRIUM: usually reversible, rapid onset, fluctuating mental status, with reduced
attention/focus/cognition
 DEMENTIA: rarely reversible, progressive, chronic cognitive and functional decline
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Many mild to moderate psychiatric illnesses can be treated
quite effectively in primary care.
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In addition some more severe illness which have been
stabilized and are currently in good control can be managed
as well.
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For more emergent or severe cases, psychiatric consultation
or transfer may be needed.
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Psychosis
 Medications are always the first line although psychotherapy can be added as
well
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Other psychotic disorders
 Due to a substance: treat the substance use first, then use therapy and/or
medications
 Due to a general medical condition: treat the underlying medical condition first,
then use therapy and/or medications
 Not otherwise specified: although more information is needed, treatment
should proceed along the lines of the most likely diagnosis
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Medication choice should be based upon:
 Diagnosis
 Medical health of patient and drug metabolism
 Side effect and safety profile of medications
 Cost and availability
 If patient has a positive history on a medication previously, or has a
1st degree relative successfully taking medication
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 All antipsychotics are not equally effective
 All antipsychotics have interactions – do a check for interactions
when starting medication
 First line is usually second generation antipsychotics, second line is
first generation Clozaril, third line is usually E.C.T.
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Antipsychotic dosing and schedule:
Starting dose: ½ of the standard minimum dose if possible
Increasing dose: every week if needed
Timing: at night as they are all usually sedating
Discontinue medication: 2-4 week taper if possible
Cross-taper: if changing medication, cross taper by starting
new med at low dose to test for side effects then increase
weekly while lowering other medications weekly
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Early benefits: first 1-2 weeks
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Full benefits: weeks 4-6
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Side effects: worst in first week but should decrease after
that
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Most common side effects for all antipsychotics are:
 Feeling stimulated and/or sedated  change dosing time between am/pm
 Nausea or diarrhea or constipation  take with food, hydrate, OTC meds
 Dry mouth  hydrate or use Xylitol gum
 Weight gain  motivate health behaviors, change med
 Motor Side effects: Scale: A.I.M.S. (abnormal involuntary movement scale)
▪
▪
▪
▪
▪
Akathisia: distressing inner restlessness  wait, lower, or give propranolol 10-40mg BID
Dystonia: rapid painful muscles contraction  diphenhydramine 50mg (preferably IM)
Parkinsonism: rigidity, tremor, shuffling gate  benztropine 1-2mg BID
Tardive Dyskinesia: long term permanent motor symptoms  consult psychiatry
Neuroleptic Malignant Syndrome: rare life threatening hyperthermia and rigidity  ER
 Splitting/dividing doses  improves/decreases side effects but also worsens compliance
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Metabolic syndrome: antipsychotic medications carry a class warning about weight gain
and diabetes
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For antipsychotic medications it is helpful to have baseline labs within 2 weeks of starting
medication
 REQUIRED
▪ HA1C, Fasting Lipids, Glucose
 RECOMMENDED
▪
▪
▪
▪
Complete metabolic panel
Complete blood count
TSH
Physical exam: blood pressure, BMI, and waist circumference
 IF INDICATED
▪ EKG (especially ziprazadone or if hx arrhythmia)
▪ Serum prolactin (especially risperidone)
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2-3 months: repeat after 8-16 weeks treatment, or after any
significant change in treatment
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6 months: then repeat after 6 months
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12 months: then repeat all on an annual basis (except ECG
and prolactin unless clinically indicated)
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Monoamine hypothesis: abnormal CNS levels of serotonin, norepinephrine, and dopamine are responsible
for most types of mental illness. If we can modulate these chemicals, we can correct the defects.
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Serotonin
 too low = depressed and anxious
 too high = sex ses, sweating, emotionless
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Norepinephrine
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 too high = sedation and weight gain
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Anticholinergic
 too high (ACh blockade) = confusion,
 too low = depressed, lethargic, and difficulty
with concentration
 too high = anxious, overstimulated, possibly
manic and/or psychotic
Antihistamine
constipation, dry mouth
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Alpha blockade
 too high = orthostasis
Dopamine
 too high = psychotic
 too low = parkinsonism, low energy, low
pleasure
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SGA
+ sleep, + calming,
- oversedation. - weight
+ energizing,
- overstimulating
aripiprazole (A) ziprazodone ----- (G) risperidone ----- (R) olanzapine (Z) quetiapine (S)
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SGA
SSRI
fluoxetine (P) sertraline (Z) ----- escitalopram (L) citalopram (C)
paroxetine (P)
+ sleep, + calming,
- oversedation. - weight
+ energizing,
- overstimulating
aripiprazole (A) ziprazodone ----- (G) risperidone ----- (R) olanzapine (Z) quetiapine (S)
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SGA
SSRI
fluoxetine (P) sertraline (Z) ----- escitalopram (L) citalopram (C)
paroxetine (P)
+ sleep, + calming,
- oversedation. - weight
+ energizing,
- overstimulating
aripiprazole (A) ziprazodone ----- (G) risperidone ----- (R) olanzapine (Z) quetiapine (S)
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Generic
Dose (starting)
titrate weekly
Sedation,
weight gain
EPS
Special positive
Special negative
Seroquel
quetiapine
400-800 (100)
*****
*
best elderly
long titration, orthostasis
Zyprexa
olanzapine
10-30 (5)
*****
***
Strongest?
Risperdal
risperidone
1-6 (1)
***
*****
Strongest?
hyperprolactinemia
Abilify
aripiprazole
10-30 (5)
*
*
least weight
worst akathisia, weakest?
Geodon
ziprazidone
40-160 (20)
Usually BID
*
*
haloperidol
1-10 (1)
***
*****
Class/brand
Atypical/SGA
cards risk, must be taken with food
Typical/FGA
Haldol
best preg
EPS worst
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Clozaril/clozapine: older antipsychotic with extensive health
risks, side effects, and interactions
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Other typical/first generation antipsychotics: extensive health
risks, side effects, and interactions
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Clinical significance:
 Primary care providers face unexplained and perplexing complaints up to 40% of
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their patients
Medical explanations for common complaints such as malaise, fatigue,
abdominal discomfort, an dizziness are only found 15-20% of the time
Studies indicate that 16-20% of primary care patients fit criteria for a
somatoform disorder
May result in more disability and unemployment than nay other physical illness
These patients utilize outpatient services at least 2 x as often
This accounts for as much as 10% of all medical expenditures (>$100
billion/yr/US)
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MALINGERING
 Intentionally produced or exaggerated symptoms for external/secondary
gain (mental or physical)
 ex: obtaining controlled substances, disability, or to avoid legal
prosecution
FACTITIOUS DISORDER
 Purposeful and sometimes elaborate self-report of somatic complaints
with the objective of assuming the “sick role”
SOMATOFORM DISORDER
 Unintentional production of symptoms that are related to psychosocial
stressors and unhealthy coping strategies
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Intentional production
of symptoms
Secondary
gain
YES
NO
YES
Malingering
-
NO
Factitious d/o
Somatoform d/o
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Intentional production
of symptoms
Secondary
gain
YES
NO
YES
Lying
-
NO
Exaggerating
Suffering
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1 or more unexplained distressing physical complaints
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Excessive thoughts, feelings, or behaviors related to complaints
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Modifier: With Prominent Pain (previously pain d/o)
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NOTE: previously somatization d/o & undifferentiated somatoform d/o
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One or more unexplainable, voluntary motor or sensory
neurological deficits
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Usually preceded by psychological stress
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AKA: Functional Neurological Symptom Disorder
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Preoccupation with a nonexistent disease despite a thorough
medical work-up
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Does not meet criteria for a delusion
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NOTE: previously Hypochondriasis
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Purposeful and sometimes elaborate self-report of somatic
complaints with the objective of assuming the “sick role”
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AKA: Muchausen’s Disorder referring to the elaborate and
sometimes fanciful histories that are sometimes generated to
describe the illness
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RELATED: FD Imposed on Another (AKA FD/M by proxy)
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Psychological factors adversely affect the medical condtion
directly or indirectly
Ex: poor compliance with medications b/c of depressive sx or
ignoring the symptoms of MI b/c of delusions
Modifiers: Mild, moderate, severe, extreme
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CBT/Consultation
 Support focused therapy
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Assess
 Rule our general medical causes (25-50% with conversion disorder have
eventually)
 Treat co-morbid psychiatric disorders (50% have anxiety/depression/pain)
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Regular visits
 Short frequent visits with focused exams
 Discuss recent stressors and healthy coping strategies
 Over time – the patient should agree to stop over using medical providers
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Empathy
 “Become the patient” for a brief time
 Acknowledge patient’s reported discomfort
 Spend more time listening than trying to solving the medical mystery
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Med-psych interface
 Help the patient learn about the mind-body connection (stress  illness)
 Avoid comments like: “there is nothing medically wrong with you,” or “this is all
psychological.”
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Do no harm
 Avoid unnecessary diagnostic procedures
 When possible avoid referrals to specialists
 Once a reasonable medical workup has been done, feel comfortable with a somatoform
disorder diagnosis and initiate treatment
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 Usually wait until after the 1st encounter
▪ Too quick might endanger rapport
 Treat underlying anxiety, depression, insomnia, or pain
▪ Use safe and reasonable medications starting at low dosages
▪ Try to avoid those with extensive physical side effects, lethality, or addiction
▪ Attempt to use medications that target multiple symptoms simultaneously
 If a co-morbid psychiatric diagnosis is not clear, consider SNRI medications
▪ Evidence shows that SNRIs may be more beneficial than SSRIS in these cases
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PART 1: PSYCHOTIC DISORDERS
Describe the clinical significance of psychotic disorders. uncommon but
serious med/psych
 List and described the different psychotic disorders and how to differentiate
between them. Schizophrenia, schizoaffective, DD, subst/due to AMC
 List the most commonly used antipsychotic medications and describe the
general characteristics of each. Aripiprazole/ziprazidone, risperidone,
olanzaine/quetiapine
 Describe the ongoing health monitoring parameters associated with using
these medications. DM related & general health: 1/3/6/12 months
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PART 2: SOMATOFORM DISORDERS
List and described the different somatoform disorders and how to
differentiate between them. Somatic symptom d/o, conversion d/o, illness
anxiety d/o, factitious d/o, Psychological factors affecting other medical
conditions
 List the medications and treatment strategies most commonly used in
treatment of somatoform disorders. CARE MD
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1.
2.
3.
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Arlington, VA:
American Psychiatric Publishing.
Robert M. McCarron, Glen L. Xiong, James Bourgeois. Lippincott's Primary Care Psychiatry
Hardcover . Lippincott Williams & Wilkins, 2009
Questions?
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