Download Schizophrenia and other psychotic disorders

Schizophrenia and Other
Psychotic Disorders
Anita S. Kablinger MD
Associate Professor
Departments of Psychiatry
of Pharmacology
LSUHSC-Shreveport
What is Psychosis?
Generic term
 “Break with Reality”
 Symptom, not an illness
 Caused by a variety of conditions
that affect the functioning of the
brain.
 Includes hallucinations, delusions
and thought disorder

Differential Diagnosis

Medical/surgical/
substance-induced
Psychotic d/o due to GMC
Dementias
Delirium
Medications
Substance induced
Amphetamines
Cocaine
Withdrawal states
Hallucinogens
Alcohol

Mood disorders
Bipolar disorder
Major depression with
psychotic features
Mood disorders
“Functional”
disorders
Schizophrenia
“spectrum”
disorders
P
S
Y
C
H
O
S
I
S
Substance
induced
Delirium
Dementia
Amnestic d/o
“organic”
mental
disorders
Differential Diagnoses:
(Cont)

Personality
disorders
Schizoid
Schizotypal
Paranoid
Borderline
Antisocial

Miscellaneous
PTSD
Dissociative disorders
Malingering
Culturally specific phenomena:
Religious experiences
Meditative states
Belief in UFO’s, etc
Workup of New-Onset Psychosis:
“Round up the usual suspects”
Good clinical history
 Physical exam, ROS
 Labs/Diagnostic tests:

Metabolic panel
CBC with diff
B12, Folate
RPR, VDRL
Serum Alcohol
Urinalysis
Thyroid profile
URINE DRUG SCREEN!!!
CSF/LP
HIV serology
CT or MRI
EEG
Talking Points




Schizophrenia is not an excess of
dopamine.
The differentiation between “functional”
and “organic” is artificial.
Schizophrenia and other psychiatric
illnesses are syndromes.
Schizophrenia is a diagnosis of exclusion.
Talking Points
1% prevalence
 Early onset, M>F
 Early, aggressive treatment
decreases long-term problems
 Multiple subtypes- catatonic,
disorganized, paranoid,
undifferentiated, residual

Schizophrenia
Diagnostic features
DSM-IV Diagnosis of
Schizophrenia

Psychotic symptoms (2 or more) for
at least one month





Hallucinations
Delusions
Disorganized speech
Disorganized or catatonic behavior
Negative symptoms
Diagnosis (cont.)
Impairment in social or occupational
functioning
 Duration of illness at least 6 mo.
 Symptoms not due to mood disorder
or schizoaffective disorder
 Symptoms not due to medical,
neurological, or substance-induced
disorder

Clinical features:
Formal Thought Disorders
Neologisms
 Tangentiality
 Derailment
 Loosening of associations (word
salad)
 Private word usage
 Perseveration
 Nonsequitors

Clinical features:
Delusions








Paranoid/persecutory
Ideas of reference
External locus of
control
Thought broadcasting
Thought insertion,
withdrawal
Jealousy
Guilt
Grandiosity


Religious delusions
Somatic delusions
Clinical features:
Hallucinations
Auditory
 Visual
 Olfactory
 Somatic/tactile
 Gustatory

Clinical features:
Behavior
Bizarre dress, appearance
 Catatonia
 Poor impulse control
 Anger, agitation
 Stereotypies

Clinical features:
Mood and Affect
Inappropriate affect
 Blunting of affect/mood
 Flat affect
 Isolation or dissociation of affect
 Incongruent affect

Positive vs. negative
symptoms
Positive symptoms
Delusions
Hallucinations
Behavioral dyscontrol
Thought disorder
Negative symptoms
(Remember
Andreasen’s “A”s)
Affective flattening
Alogia
Avolition
Anhedonia
Attentional impairment
Psychotic Disorders
Onset
Schizophrenia
Usually
insidious
Delusional
disorder
Brief
psychotic
disorder
Symptoms
Many
Course
Duration
Chronic
>6 months
Varies
Delusions
(usually
only
insidious)
Chronic
>1 mo.
Sudden
Limited
<1 mo.
Varies
Psychosocial Factors
Expressed emotion
 Stressful life events
 Low socioeconomic class
 Limited social network

Some factors rejected as
causal

“Schizophrenogenic Mother”

“Skewed” family structure
Genetic factors:
(The evidence mounts…)
Monozygotic twins (31%-78%) vs
dizygotic twins
 4-9% risk in first degree relatives of
schizophrenics
 Adoption studies
 Linkage, molecular studies

Genetics of Schizophrenia:
The take-home message
Vulnerability to schizophrenia is
likely inherited
 “Heritability” is probably 60-90%
 Schizophrenia probably involves
dysfunction of many genes

Anatomical abnormalities
Enlargement of lateral ventricles
 Smaller than normal total brain
volume
 Cortical atrophy
 Widening of third ventricle
 Smaller hippocampus

Physiologic studies:
PET and SPECT
Generally normal global cerebral
flow
 Hypofrontality
 Failure to activate dorsolateral
prefrontal cortex (problem-solving,
adaptation, coping with changes)

Biochemical factors:
The dopamine hypothesis
All typical antipsychotics block D2
with varying affinities
 Dopamine agonists can precipitate a
psychosis

 Amphetamines
 Cocaine
 L-dopa
Dopamine systems
Cell bodies
Projections Functions
Clinical
implications
Nigrostriatal
Mesolimbic
Substantia
Nigra
Caudate
and
putamen
Movement
Extrapyramidal
symptoms, dystonias,
Tardive dyskinesia
Ventral
tegmental
area, subst.
nigra
Accumbens
amygdala
Olfactory
tubercle
Emotions,
affect,
memory
Positive symptoms
Mesocortical
Ventral
tegmental
area
Prefrontal
Cortex
Thought,
volition,
memory
Blockade here can
worsen negative
symptoms.
Typical Neuroleptics

Low potency:


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Chlorpromazine
Thioridazine
Mesoridazine

High potency:



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Haloperidol
Fluphenazine
Thiothixene
Loxapine (mid)
Neuroleptic (typicals):
side effects
Acute dystonia
 Parkinsonian side effects (EPS)
 Akathisia
 Tardive dyskinesia
 Sedation, orthostasis, QTC
prolongation, anticholinergic, lower
seizure threshold, increased
prolactin

Atypical Antipsychotics:
Risperidone
 Olanzapine
 Quetiapine
 Clozapine
 Ziprasidone
 Aripiprazole (new-partial DA
agonist)

Atypical antipsychotics:
Broader spectrum of receptor
activity (Serotonin, dopamine,
GABA)
 May be better at alleviating negative
symptoms and cognitive dysfunction
 Clozaril (clozapine) associated with
agranulocytosis, seizures

Atypical Antipsychotics:
Side Effects
Sedation
 Hyperglycemia, new-onset diabetes
 Anticholinergic effects
 Less prolactin elevation
 QTC prolongation
 Some EPS
 Increased lipids

Psychosocial Treatment
Education, compliance #1
 Hospitalize for acute loss of
functioning
 Outpatient treatment is
rehabilitative
 Psychoanalysis, exploratory
therapies have limited value
 Families should be involved
