18

Fifth stage

Psychiatry
Lec-18
د.الهام الجماس

13/3/2017

مكتب الجامعه للطباعه والاستنساخ
عدد الاوراق :5
السعر :250
Psychosis

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


PSYCHOSIS

Substance induced

Mood disorders

Delirium

Dementia
Amnestic d/o

Schizophrenia “spectrum” disorders

“Functional”disorders

“Organic” mental disorders

Differential Diagnosis:
Personality disorders:
Schizoid
Schizotypal
Paranoid
Borderline
Antisocial
Medical/surgical/ substance-induced:
Psychotic d/o due to GMC
Dementia
Delirium
Medications
Substance induced:
Amphetamines
Cocaine
Withdrawal states
Hallucinogens
Alcohol


Miscellaneous:
PTSD
Dissociative disorders
Malingering
Culturally specific phenomena:
Religious experiences
Meditative states
Belief in UFO’s, etc

Mood disorders:

Bipolar disorder
Major depression with psychotic features

Workup of New-Onset Psychosis:“Round up the usual suspects”

Good clinical history
Physical exam, ROS
Labs/Diagnostic tests:
CT or MRI
EEG
CSF/LP
HIV serology
urine drug screen!!!
Metabolic panel
CBC with diff
B12, Folate
RPR, VDRL
Serum Alcohol
Urinalysis
Thyroid profile


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


SchizophreniaDiagnostic features (1st Rank symptoms):
1950’s - Schneider’s 1st Rank Symptoms:
Primary Delusion = ‘delusional percept’
Own thoughts spoken aloud = ‘thought echo’
Voices arguing or discussing
running commentary voices
thought withdrawal and/or thought block
Thought insertion
thought 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 aliens
Some 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
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


Delusions
Clinical features:
Formal Thought Disorders
Clinical features:

Neologisms

Tangentiality
Derailment
Loosening of associations (word salad)
Private word usage
Perseveration
Nonsequitors
Paranoid/persecutory
Ideas of reference
External locus of control
Thought broadcasting
Thought insertion, withdrawal
Jealousy
Guilt
Grandiosity
Religious delusions
Somatic delusions


Religious delusions
Somatic delusions

Behavior

Clinical features:
Hallucinations
Clinical features:

Bizarre dress, appearance

Catatonia
Poor impulse control
Anger, agitation
Stereotypies
Auditory
Visual
Olfactory
Somatic/tactile
Gustatory

Mood and Affect

Clinical features:


Inappropriate affect
Blunting of affect/mood
Flat affect
Isolation or dissociation of affect
Incongruent affect

Negative symptoms(Remember Andreasen’s “A”s)

Affective flattening
Alogia
Avolition
Anhedonia
Attentional impairment
Positive symptoms
Delusions
Hallucinations
Behavioral dyscontrol
Thought disorder
Positive vs. negative symptoms:

Psychotic Disorders:

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


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
Function
Clinical implications
Nigro-striatal
Substantia nigra
Caudate and putamen
Movement
Extrapyramidal symptoms, dystonias, Tardive dyskinesia
Meso-limbic
Ventral tegmentalarea, subst. nigra
Accumbens amygdala olfactory tubercle
Emotion, affect, memory
Positive symptoms
Meso-cortical
Ventral tegmental area
Prefrontal cortex
Thought, volition, memory
Blockade here can worsen negative symptoms


High potency:
Haloperidol
Fluphenazine
Thiothixene
Loxapine (mid)
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, lowerseizure 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