Psychosis

Psychiatry sept.2015

Introduction Etiology of mental disorders Scizophrenia Prof.elham Aljammas

What is Psychosis?

Generic term“Break with Reality”Symptom, not an illnessCaused 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

PSYCHOSIS

Mood disorders
Schizophrenia “spectrum” disorders “organic” mental disorders Substance induced
Delirium Dementia Amnestic d/o
“Functional”disorders

Differential Diagnoses: (Cont)

Personality disorders Schizoid Schizotypal Paranoid Borderline Antisocial
Miscellaneous PTSDDissociative disordersMalingeringCulturally specific phenomena:Religious experiencesMeditative statesBelief 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..

Definition

The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. The most important psychopathological phenomena include thought echo thought insertion or withdrawal thought broadcasting delusional perception and delusions of control influence or passivity hallucinatory voices commenting or discussing the patient in the third person thought disorders and negative symptoms.

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

1st Rank symptoms

1950’s - Schneider’s 1st Rank Symptoms:Primary Delusion = ‘delusional percept’Own thoughts spoken aloud = ‘thought echo’Voices arguing or discussingrunning commentary voicesthought withdrawal and/or thought blockThought insertionthought broadcasting (others are thinking it at the same time as you)Made to feel… ‘passivity of affect’Made to want… ‘passivity of impulse’Made to do… ‘passivity of volition’Done to my body ‘somatic passivity’ eg probed by aliensSome may occur in illnesses other than schizophrenia eg mania

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 flatteningAlogiaAvolitionAnhedoniaAttentional impairment

Psychotic Disorders

Schizo-phrenia
Usually insidious
Many
Chronic
>6 months
Delusional disorder
Varies (usually insidious)
Delusions only
Chronic
>1 mo.
Brief psychotic disorder
Sudden
Varies
Limited
<1 mo.
Onset
Symptoms
Course
Duration

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

Nigro-striatal
Substantia Nigra
Caudate and putamen
Move-ment
Extrapyramidal symptoms, dystonias, Tardive dyskinesia
Meso-limbic
Ventral tegmental area, subst. nigra
Accumbens amygdala Olfactory tubercle
Emotions, affect, memory
Positive symptoms
Meso-cortical
Ventral tegmental area
Prefrontal Cortex
Thought, volition, memory
Blockade here can worsen negative symptoms.
Cell bodies
Projections
Functions
Clinical implications

Typical Neuroleptics

Low potency: Chlorpromazine Thioridazine Mesoridazine
High potency: 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