Download PSYCHOSIS

THE PHILIPPINE COLLEGE OF
PSYCHOPHARMACOLOGY
2010
PSYCHOSIS
(Featuring the HDL method)
TEACHING MODULE FOR THE
PRIMARY CARE PHYSICIANS
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OBJECTIVES
At the end of the module, the family
physician is expected to:
1. identify the core psychotic symptoms,
specifically that of schizophrenia using the
HDL method.
2. prescribe the appropriate antipsychotic
medications using the STEPS approach.
3. refer to a psychiatrist, if needed.
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FORMAT OF ACTIVITIES
•
•
•
•
Case presentation
Lecturettes
Interactive sessions
Summary
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WHY PSYCHIATRY FOR GPs?
• Most psychiatric patients first seen by GPs
• GPs need updated skills and knowledge to
help psychiatric patients better
• More easy, quick, diagnostic tools for GPs
now available
• Presence of new drugs which are safe,
tolerable, effective, priced right, and
simple to use by GPs
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INTERACTIVE SESSION 1
• “What is your most unusual experience?”
(Unusual vs Usual)
• “What makes you different from others?
(Unique vs Common)
• “Do you hear voices?”
(Abnormal vs Normal)
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CASE PRESENTATION
• A 21-year old male, single, college
student, suddenly runs out of his
classroom. He shouts, ‘ back off ’ at a
friend who follows him. He is convinced
that his teachers and classmates intend to
kill him. He hears the mocking voices of
his teachers coming from the electric fan
and on the classroom walls, talking about
him and calling him nasty names.
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CASE PRESENTATION
• The patient is brought to a GP. PE and lab
tests for illegal drugs are normal. He looks
blankly at the walls. He is inattentive and
responds irrelevantly to questions. He
mumbles incoherently, “A,B, (ZTE) F,G”.
He accuses his parents and the doctor to
be in a plot to kill him. He cannot be
convinced otherwise.
• Judgement, impulse control, and insight
are poor. Sensorium is
t intact.
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CASE PRESENTATION
• Background: socially withdrawn and
avoids group activities; with few friends
and lacks initiative. An only child who
relates poorly to parents who are very
busy. Father is very critical and mother is
overprotective. Mother had a history of
similar difficulties.
• The current episode is his second in two
years. No meds for three months
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Case Summary
• A young man’s second episode of
behavioural changes like blank stares,
hearing voices, fixed ideas of being
harmed, and irrelevant speech. These
occur in the background of poor family
bonding and lack of social interactions.
There is a positive family history of
psychiatric illness. No maintenance meds.
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LECTURETTE
Identifying Core Symptoms of Psychosis
• Positive Symptoms: HDL method *
Hallucinations – most important ; usually
auditory, multiple voices talking about the patient
Delusions - persecutory, bizarre, systematized
Looseness of associations – irrelevant speech,
hard to understand
* hallucinations and delusions should be present 10
LECTURETTE
• Negative Symptoms: 4 As *
Alogia - limited speech ; tendency to mutism
Affective blunting – flat; blank stares; no emotion
Avolition – unexplained lack of initiative
Anhedonia – pervasive lack of interest / pleasure
unrelated to depression
* 2 or more enhance the diagnosis
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LECTURETTE
• Other Features: (exclusion criteria) *
At least six months duration
Social/occupational dysfunction
No mood disorder *
No substance abuse / medical condition *
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INTERACTIVE SESSION 2
• Positive symptoms of our patient:
What is the H?
What is the D?
What is the L?
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INTERACTIVE SESSION 3
• Negative symptoms of the patient:
Name at least 2 As:
A?
A?
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LECTURETTE
• Other features present in our patient:
Poor functioning: school, parents, peers
Positive family history (mother)
Second episode in two years
High emotional expressivity (or ‘High EE’)overcritical and overprotective parents
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PSYCHOTIC?
Positive and negative symptoms plus
impaired functioning but no mood symptoms
Due to substance ←↓→ Due to medical illness?
abuse?
If no
↓
Ask duration
< 1month ← ↓ →
< 6 months
Brief Psychotic
Schizophreniform
Disorder
Disorder
> 6 months
Schizophrenia
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LECTURETTE
• Treatment Strategies: (including the
STEPS approach)
1. Antipsychotic Drugs: Typicals
Atypicals
2. Day-to-Day Management:
family cooperation/involvement
approach of physician
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THE STEPS APPROACH IN PSYCHOSIS
• Typical Antipsychotics: Examples
chlorpromazine (Thorazine), haloperidol (Haldol)
fluphenazine decanoate (Modezine)
Safe in short-term; TD a problem in long-term
Tolerable, but EPS a concern
Effective, but less with (-) symptoms
Price inexpensive (P20-30/day)
Simple, not very (2-3x a day, except depots)
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Average Doses of Typicals
• Chlorpromazine (Thorazine)
100-400 mg/day
• Haloperidol (Serenace, Haldol)
2-4 mg/day
• Fluphenazine Decanoate (Modezine)
12.5 – 25 mg/month (0.5 -1.0 cc) IM (long-acting)
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Treatment for EPS
• Biperiden (Akineton)
One ampoule (1 cc or 5 mg) IM or slow IV
then 1 tablet/day ( 2 mg) as maintenance
(‘Cabuquit’s cocktail’)
• Diphenhydramine (Benadryl)
One ampoule ( 1cc or 50 mg) IM or slow IV
then 1 capsule/day (50 mg); sedating
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USING THE STEPS APPROACH
• Atypical Antipsychotics: Examples
aripiprazole (Abilify), clozapine (Ziproc), olanzapine (Zyprexa),
quetiapine (Seroquel), risperidone (Aspidon)
Safe in short-term and long-term
Tolerable, except for weight gain and DM; less EPS
Effective, for both (+) and (-) symptoms
Price expensive ; generics more affordable
Simple (usual OD dosing)
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USING THE STEPS APPROACH
The fine art of choosing the best drugs (PCPsych)
(5 – finest ; 1- not so fine)
Drugs
S
T
E
P
S
CLZ
3
3
5
4
3
OLZ
3
2
4
2
4
QUE
4
3
4
3
3
RIS
4
3
4
4
4
ARI
4
3
4
3
4
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LECTURETTE
• When to refer?
Diagnosis is vague or confusing
Psychiatric emergency
Need for psychotherapy
Poor response to treatment
GP feels “burnt out”/overwhelmed
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LECTURETTE
• What to say to the patient?
Do you acknowledge failure?
Should you imply referral is a “last
resort?”
Is the referral a rejection of the patient?
Is the psychiatrist the more appropriate
doctor to deal with the problem?
(suggest it is a team approach)
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SUMMARY
• Core features of psychosis are HDL:
hallucinations, delusions, and looseness of
associations
• Except for their price, atypicals can be first
line drugs for psychosis; typicals remain
good choices, inexpensive but with
tolerability issues
• Primary care physicians can be effective
partners of psychiatrists in treating patients
with psychosis
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THANK YOU FOR LISTENING
Do you hear the gears talking to you?
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