Psychiatry 12/3/2017
Introduction Etiology of mental disorders Scizophrenia Prof.elham AljammasDifferential Diagnosis
Medical/surgical/ substance-induced Psychotic d/o due to GMC Dementias Delirium Medications Substance induced Amphetamines Cocaine Withdrawal states Hallucinogens AlcoholMood disorders Bipolar disorder Major depression with psychotic features
PSYCHOSIS
Mood disordersSchizophrenia “spectrum” disorders “organic” mental disorders Substance induced
Delirium Dementia Amnestic d/o
“Functional”disorders
Differential Diagnoses: (Cont)
Personality disorders Schizoid Schizotypal Paranoid Borderline AntisocialMiscellaneous 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
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, residualSchizophrenia
Diagnostic features1st 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 maniaDSM-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 disorderClinical features: Formal Thought Disorders
Neologisms Tangentiality Derailment Loosening of associations (word salad) Private word usage Perseveration NonsequitorsClinical features: Delusions
Paranoid/persecutory Ideas of reference External locus of control Thought broadcasting Thought insertion, withdrawal Jealousy Guilt GrandiosityReligious delusions Somatic delusions
Clinical features: Hallucinations
Auditory Visual Olfactory Somatic/tactile GustatoryClinical features: Behavior
Bizarre dress, appearance Catatonia Poor impulse control Anger, agitation StereotypiesClinical 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 disorderNegative symptoms(Remember Andreasen’s “A”s)Affective flatteningAlogiaAvolitionAnhedoniaAttentional impairment
Psychotic Disorders
Schizo-phreniaUsually 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 networkSome factors rejected as causal
“Schizophrenogenic Mother”“Skewed” family structureGenetic 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 genesAnatomical abnormalities
Enlargement of lateral ventricles Smaller than normal total brain volume Cortical atrophy Widening of third ventricle Smaller hippocampusPhysiologic 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-striatalSubstantia 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 MesoridazineHigh potency: Haloperidol Fluphenazine Thiothixene Loxapine (mid)