Download Psychosis 2016

Tabitha Rogers MD, MSW, FRCPC
Schizophrenia Program, ROMHC
Assistant Professor, University of Ottawa
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Discuss the differential diagnosis for
psychosis
Review the primary psychotic disorders
Review the treatment guidelines and
pertinent clinical information for
Schizophrenia
Provide an overview of antipsychotic
medications
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Primary Psychotic Disorders
(Schizophrenia, Brief Psychotic Episode, Schizophreniform d/o, Schizoaffective d/o,
Delusional Disorder)
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Mood Disorders (Depression with Psychotic features, Mania)
Substance-related disorders
Mental disorders due to a general medical condition
Dementia
Delirium
Anxiety Disorders- OCD
Personality Disorders, dissociative disorders
Pervasive developmental disorder
ID: 19 yr male, recently homeless. Unemployed,
limited social supports.
RFR: brought to your office by a friend. His
friend was concerned about bizarre behaviour
(wearing a winter coat during the heat wave,
wandering through traffic, talking/yelling to
self).
History:
Pt is a difficult historian, however you determine that he is from the
Toronto area but moved to Ottawa 6 months ago to participate in
Parliament as he believes he is the “vice minister”. He reports
hearing the voice of God commenting on his actions and commanding
him to do things. He believes parliament is infiltrated with demons
and he has been appointed to save Canada.
He is estranged from his family and has no supports in Ottawa other than
staff at the shelter.
He was an average student until grade 12 when he became isolative,
stopped playing sports, and started smoking marijuana. He did
poorly in grade 12 but managed to graduate high school. He enrolled
in a local college but did not attend his courses.
He has not seen a physician in 4 years, but states he has no medical issues.
He has never seen a psychiatrist.
He takes no medication.
MSE:
“ASEPTIC”
Appearance and Behaviour: Dishevelled, malodorous, wearing excessive
layers of dirty clothing. Poor eye contact, psychomotor agitation
(pacing, talking to self, punching the air)
Speech: loud in volume, somewhat monotonous
Mood: irritable
Affect: restricted affect with some lability
Perception: auditory hallucinations – command hallucinations, running
commentary
Thought process: Moderately to severely disorganized with loosening of
associations, neologisms, and tangentiality
Thought content: bizarre, grandiose, and religious delusions
Insight and Judgment: poor
Cognition: oriented X3 but attention and concentration poor
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Primary Psychotic Disorders
(Schizophrenia, Brief Psychotic Episode, Schizophreniform d/o, Schizoaffective d/o,
Delusional Disorder)
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Mood Disorders (Depression with Psychotic features, Mania)
Substance-related disorders
Mental disorders due to a general medical condition
Dementia
Delirium
Anxiety Disorders- OCD
Personality Disorders, dissociative disorders
Pervasive developmental disorder
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Schizophrenia
Brief Psychotic Episode
Schizophreniform Disorder
Schizoaffective Disorder
Delusional Disorder
Schizophrenia
A) One month with 2 of:
(only one if running commentary, bizarre delusions, 2 voices conversing):
- delusions
-hallucinations
- negative symptoms
-disorganized speech
-disorganized behaviour or catatonic behaviour
Schizophrenia:
B) social/occupational dysfunction
C) 6 months continuous disturbance
D) Not better accounted for by Mood d/o or
schizoaffective d/o
E) not GMC, substance
F) if PDD, SCZ only if prominent halluc/delus.
Subtypes:
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Catatonic:
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Disorganized:
2 of:
-motor immobility (catalepsy or stupor)
-excessive purposeless motor
- extreme negativism or mutism
-peculiar voluntary movement
-echolalia or echopraxia
All of: disorganized speech, disorganized behaviour, flat/inappropriate affect
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Paranoid: Characterized by delusions or auditory hallucinations
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Residual
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Undifferentiated
Schizophreniform Disorder
Criteria A,D, E of Schizophrenia are met
>1month, <6months.
Specify if good prognostic features:
Rapid onset, confusion at peak, good premorbid function,
no affective flattening
Brief Psychotic Disorder
One of: delusions, hallucinations, disorg speech, disorg beh
>1day, <1month.
Specify: with/without stressor, or post-partum onset, +/- good
prognostic features
Schizoaffective Disorder
Uninterrupted illness where both criteria A for
SCZ and mood episode
 2 weeks delusions/halluc in the absence of
mood symptoms
 Mood symptoms present for a “substantial”
portion of total duration of illness
Specify: depressive type or bipolar type
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Nonbizarre delusions for one month.
Never met criteria for SCZ.
Other than delusion, function generally unimpaired.
If mood, duration of mood brief in relation to delusion.
Can have tactile or olfactory hallucinations if consistent with delusion.
Generally “breeds true”—does NOT progress to SCZ.
Types:
-persecutory= most common
-erotomanic
-grandiose
-somatic- ex infestation, olfactory
-jealous
Risks:
↑age, recent immigration, sensory impairment, brain injury, social isolation.
(NOT fmhx SCZ or mood)
Tx= low dose atypical antipsychotic medication
The pt is quite agitated, yelling, punching the air.
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Consider Form 1 (request for Psychiatric assessment, 72 hours)
Low stimulation environment
Restraints PRN- minimize use, use pharmacologic
restraints first, reassess frequently, see hospital policies
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Pharmacologic interventions:
Antipsychotic + Benzodiazepine
Ex. Haloperidol 5-10mg PO/IM + Lorazepam 1-2mg PO/IM or
Olanzapine 10mg IM, 10mg IM in 2 hours if needed max 3 in 24
hours. (do not give IM olanzapine with IM benzo)
(note, lower dose in the elderly. Note caution for EPS with haldol)
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Reassess risk regularly
The pt was given Olanzapine 10 mg po and
Lorazepam 2 mg po, and was sent to the ER on
a Form 1.
While in hospital he agreed to take Risperidone
2mg qHS daily, and acute psychotic symptoms
improved gradually.
Dx- Schizophrenia
Epidemiology: ~ 1%. NIMH catchment 0.6-1.9%, geographical variation
(higher in urban, industrialized)
Core Symptoms: Positive and negative symptoms, mood
symptoms, cognitive symptoms
Onset:
M:10-25 yrs
F: 25-35yrs, bimodal with 2nd peak middle age
“late onset”: onset >45yrs- 10% (more women)
“very late onset”: onset >60. Rare, more women. Little negative
or cognitive symptoms
Genetics: MZ 47%, DZ 12%, one parent 12%, both parents 40%
Genetic linkage: 22q, 11
Etiologic Hypotheses:
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Dopamine hypothesis
5HT (atypical APs are 5HT2A antagonists)
NA (low-anhedonia)
neurodevel: viral-2nd trimester, nutrition,obstetrical
complications
ACh (↓ACh receptors in caudate, hippocampus, PFC)
glutamate (NMDA antag→psychosis, agonists can help neg)
Mesocortical
pathway1,2
• Associated
with cognition
and motivation
Negative symptoms
• Alogia
• Affective flattening
• Avolition
Tuberoinfundibular
pathway1,2
• Controls prolactin secretion
• Hyperprolactinemia
Nigrostriatal
pathway1,2
• Controls motor
movement
• EPS
Mesolimbic
pathway1,2
• Associated
with memory
and emotional
behaviors1
Positive symptoms
• Delusions
• Hallucinations
• Disorganized speech/
thinking
• Disorganized or
catatonic behavior
1. Kandel ER et al. Principles of Neural Science. 3rd ed. St. Louis, MO: Elsevier; 1991.
2. Stahl SM. Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 2nd ed.
New York, NY: Cambridge University Press; 2000.
Prognosis:
20-30% live reasonably normal lives
50% moderate to poor prognosis
Good prognostic factors: late and acute
onset, precip stressor, good premorbid
funct, mood, (+)symptoms, supports
Poor prognostic factors: male, early onset,
insidious onset, single, fmhx SCZ, negative
symptoms, no remission, relapses
Substance use:
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>80% smoke
50% lifetime prevalence other substance use
Suicide:
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10-13% complete suicide, 30% attempt
risk suicide: depression, within 6 years of 1st
hospitalization, young age, high IQ, high premorbid
achievement, awareness of loss of function, command
AH, recent dc from hospital, tx nonadherence
Assessment:
Acute Phase:
- baseline assessment:
Positive+Negative symptoms, mood symptoms, SI/HI, disorganization,
level of function, substance use screen, CBC, lytes, BUN+CR, LFTs, TSH,
lipids, fasting glucose, BMI, endocrine functional inquiry, screen for EPS,
cataracts/ocular exam
- as clinically indicated: STDs, ECG, genetic testing (22q11 deletion), CT,
neuropsych testing
Stabilization/Stable Phase:
BMI: qmonthly for 6 months, then q3months
EPS: weekly for 2-4 weeks, then q6months
Blood sugar: 4 months after starting AP, then q yearly
Lipids: at least q 2yearls. (q6months if LDL high)
Eye exam: q 2 years up to age 40, then q yearly
Pharmacotherapy
No difference between FGAs and SGAs in regard to
treatment response for positive symptoms, (except
clozapine for treatment-resistant patients)
SGAs have a small but significant effect size
superiority in the treatment of negative symptoms
and cognitive impairment
Tx resistance
20% multiple episode pts have NO positive symptom
response to AP
30% respond partially
Tx refractoriness= failed trials of 2 AP
Clozapine is tx of choice
First generation = typical neuroleptics
ex. Haloperidol
block Dopamine D2 receptors
Second generation = atypicals
Ex. Clozapine, Risperidone, Paliperidone, Olanzapine,
Quetiapine, Ziprasidone, Asenapine.
Block D2 receptors + 5HT2a receptors
Less EPS
Aripiprazole: 5HT2a antagonist + partial agonist at D2, 5HT1A
Choice of antipsychotic:
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Start with an atypical antipsychotic
Previous response
Side effect profile
Medical history
Issues around compliance (consider long acting
injection)
Response, treatment resistance
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Risperidone: 0.5-1 mg/day start, (2-8mg/d)
Risperidone IM: 25-75 mg IM q 2 weeks
Paliperidone 3-12 mg po daily (in the morning)
Sustenna 75-150 mg IM q 4 weeks
Olanzapine: 5-10 mg/d start, (10-20 mg/d)
Olanzapine IM: 10mg IM can repeat in 2 hours, max 3
doses/24h
Quetiapine: 50mg BID with increments of 25-50mg BID
each day until 600-800mg is reached
Quetiapine XR: 300mg day1, 600mg day2, 800mg day3
Aripiprazole: 10-15 mg/d start, (15-30mg/d)
Ziprasidone: 40mg BID, 60mgBID, 80mg BID, (40-200
mg/d)
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Haloperidol:
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Range 1-40 mg/d, start low, go slow, watch for EPS
Emergency use 10mg IM q 4-6h with ativan and
cogentin prn
Chlorpromazine:
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Prn use 25-75mg BID-TID, 200-800mg/d possible
Usually 25-50mg IM q 4-6 h prn
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25 mg qhs and increase nightly in 25 mg
increments as tolerated
Target dose: 300-400 mg/d
Monitor HR, BP, Temperature, weekly WBC
Weekly WBC x 6 months
Biweekly WBC x 6 months
Monthly WBC as tolerated from then on
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Low potency
(chlorpromazine)
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Sedation
Postural hypotension
Elevated heart rate
Constipation
Dry mouth
Cognitive dulling
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High Potency
(Haloperidol)
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Parkinsonism
Dystonic reactions
Akithesia
Higher TD incidence
Atypicals
(Olanzapine etc..)
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Weight gain
Dyslipidemia
Metabolic syndrome
Type 2 diabetes
Side effects
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Wt gain: clozapine+olanzapine significant,
risperidone+quetiapine moderate
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Glucose tolerance, diabetes: all SGAs
Dyslipidemia: ziprasidone wt and lipid neutral
QTc prolongation
α1 blockade: dizzy, postural hypotension
Seizure- reduction of SZ threshold
Endocrine and sexual side effects: FGA>SGA
quetiapine+clozapine= “prolactin sparing”
Indications for Clozapine (CPA guidelines)
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treatment resistance = 2 failed trials of
any AP
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Persistent suicidality
Persistent violence/aggression
Mechanism of Action: antagonist at D1-D5, M1, H1,5HT2a, alpha.
Side effects:
common:
sedation, sialorrhea, dizzy, wt gain, tachycardia, hypotension
Severe:
- SZ: dose>500mg (or if quit smoking—smoking induces CYP1A2)
- agranulocytosis: 0.5-1%.
Risk greatest in 1st 6 months. Not dose related.
monitor CBC+diff qweekly for 6months, then q2weekly
- myocarditis, cardiomyopathy
-venous thromboembolism, PE, sudden death
Within a few days, the patient complains of
stiffness which improves with benztropine
PRN.
After about a week, nursing staff notice that he
seems to be restless and pacing. Benztropine
has some effect, but he remains subjectively
and objectively restless.
Extrapyramidal Symptoms
(EPS)
Duration of
AP tx
EPS
treatment
Minutes –
hours
Acute Dystonic
Reaction
Benztropine or other
anticholinergic
PO/IM
Torticollis, laryngospasm,
oculogyric crisis
Days
Pseudoparkinsonism
benztropine
Bradykinesia, rigidity, masklike
facies, cogwheel rigidity, perioral
tremor
Days-weeks
Akithisia
Benzodiazepine,
Beta blocker
Long term
Tardive Dyskinesia
Switch to atypical, or
Clozapine.
Often irreversible
5%/year with 1st gen. (25-50% pts tx with 1st gen long term)
Due to long-term D2 blockade—receptor sensitivity
See when d/c or ↓dose, anticholinergic can exacerbate.
Choreoathetoid movements. Orofacial most common, tongue
fasiculations early sign. Don’t see in sleep. Stress
exacerbates.
Monitoring: AIMS (abnormal involuntary movement scale)
start, qweekly x one month, then q3months
Risk factors: elderly, female, depot, 1st gen, duration use
Tx: switch to quetiapine, clozapine, olanzapine. Some evidence
for ECT, botox, B6
Positive symptoms have resolved with
Risperidone 2mg qHS
Supportive housing was arranged prior to
discharge.
You refer him to an early psychosis intervention
team (On Track Phone: 613-737-8069) where he
will have access to SW, OT, Psychiatry. You
encourage the pt to find a family physician.
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Psychoeducation, Medication Adherence
Vocational interventions
Skills training
Family interventions
Peer support
Stigma
CBT
CPA Schizophrenia Guidelines
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development of a collaborative understanding of
the nature of the illness, which encourages the
patient’s active involvement in treatment
identification of factors exacerbating symptoms
learning and strengthening skills for coping with
and reducing symptoms and stress
reducing physiological arousal
development of problem-solving strategies to
reduce relapse
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On Track 613-737-8069
Mental Health Crisis Line 613-722-6914
Schizophrenia Society of Ottawa
613-722-6521 ext 7775, 7776
Family information support groups
613-722-6521
NAMI 613-737-7791
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Ensure a safe place to interview.
Alert staff
Meds for increased agitation.
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Olanzapine 10 mg po with Ativan 2 mg po
Haldol 10 mg po with Ativan 2 mg po
Meds for treatment
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Olanzapine 15-20 mg po qhs
Risperidone 2 mg-8 mg po q hs
Paliperidone 6-12 mg po q am
Seroquel XR 600 mg po q 18:00
Asenapine 5 mg po BID
Abilify 15 to 30 mg po daily
Zeldox 80 mg po BID with meals