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Shawn Hersevoort MD MPH UCSF-Fresno Psychiatry 1 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 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 2 3 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 4 5 A primary psychotic disorder of cognitive and sensory disturbances 6 months or more Significant portion of the time 2/5 or more of 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 6 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) Related disorders: BRIEF PSYCHOTIC DISORDER: less than 1 month of symptoms SCHIZOPHRENIFOM DISORDER: 1-6 months of symptoms 7 A primary psychotic disorder including prominent mood symptoms Schizophrenia and a mood episode (major depressive, manic, or mixed) Psychosis persistent in absence of mood disorder symptoms May need antidepressant or mood stabilizer 8 Types: Bipolar: schizophrenia and manic or mixed episode Depressed: schizophrenia and major depressive episode Related disorders: MDD/BPD WITH PSYCHOTIC FEATURES: psychotic symptoms only during prominent mood symptoms 9 A primary psychotic disorder including delusions only Delusions that are non-bizarre 1 month or more No hallucinations or other symptoms of schizophrenia Often respond poorly to treatment 10 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 11 Psychotic symptoms that are judged to be due to the direct physiological effects of a substance Usually only present during intoxication or withdrawal 12 Psychotic symptoms that are a direct physiological result of a medical condition 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 13 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 14 15 Many mild to moderate psychiatric illnesses can be treated quite effectively in primary care. In addition some more severe illness which have been stabilized and are currently in good control can be managed as well. For more emergent or severe cases, psychiatric consultation or transfer may be needed. 16 Psychosis Medications are always the first line although psychotherapy can be added as well 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 17 18 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 19 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. 20 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 21 Early benefits: first 1-2 weeks Full benefits: weeks 4-6 Side effects: worst in first week but should decrease after that 22 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 23 Metabolic syndrome: antipsychotic medications carry a class warning about weight gain and diabetes 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) 24 2-3 months: repeat after 8-16 weeks treatment, or after any significant change in treatment 6 months: then repeat after 6 months 12 months: then repeat all on an annual basis (except ECG and prolactin unless clinically indicated) 25 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. Serotonin too low = depressed and anxious too high = sex ses, sweating, emotionless Norepinephrine too high = sedation and weight gain 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 Alpha blockade too high = orthostasis Dopamine too high = psychotic too low = parkinsonism, low energy, low pleasure 26 SGA + sleep, + calming, - oversedation. - weight + energizing, - overstimulating aripiprazole (A) ziprazodone ----- (G) risperidone ----- (R) olanzapine (Z) quetiapine (S) 27 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) 28 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) 29 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 30 Clozaril/clozapine: older antipsychotic with extensive health risks, side effects, and interactions Other typical/first generation antipsychotics: extensive health risks, side effects, and interactions 31 32 Clinical significance: Primary care providers face unexplained and perplexing complaints up to 40% of 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) 33 34 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 35 Intentional production of symptoms Secondary gain YES NO YES Malingering - NO Factitious d/o Somatoform d/o 36 Intentional production of symptoms Secondary gain YES NO YES Lying - NO Exaggerating Suffering 37 1 or more unexplained distressing physical complaints Excessive thoughts, feelings, or behaviors related to complaints Modifier: With Prominent Pain (previously pain d/o) NOTE: previously somatization d/o & undifferentiated somatoform d/o 38 One or more unexplainable, voluntary motor or sensory neurological deficits Usually preceded by psychological stress AKA: Functional Neurological Symptom Disorder 39 Preoccupation with a nonexistent disease despite a thorough medical work-up Does not meet criteria for a delusion NOTE: previously Hypochondriasis 40 Purposeful and sometimes elaborate self-report of somatic complaints with the objective of assuming the “sick role” AKA: Muchausen’s Disorder referring to the elaborate and sometimes fanciful histories that are sometimes generated to describe the illness RELATED: FD Imposed on Another (AKA FD/M by proxy) 41 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 42 43 CBT/Consultation Support focused therapy Assess Rule our general medical causes (25-50% with conversion disorder have eventually) Treat co-morbid psychiatric disorders (50% have anxiety/depression/pain) 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 44 Empathy “Become the patient” for a brief time Acknowledge patient’s reported discomfort Spend more time listening than trying to solving the medical mystery 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.” 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 45 46 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 47 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 48 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 49 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? 51