Psychotic Disorders - Psychiatry - Lecture Slides, Slides of Psychology

Download Psychotic Disorders - Psychiatry - Lecture Slides and more Slides Psychology in PDF only on Docsity! Psychotic Disorders Docsity.com At the end of this session you will be able to: • Appreciate the prevalence of various psychotic illnesses • Describe the key features of various psychotic illnesses • Understand how to differentiate between psychotic illnesses • Select psychopharmacologic treatment for various psychotic illnesses • Apply general principles on how to approach a patient with psychosis Docsity.com • The patient appears psychotic • Given the information you have what diagnoses are on your differential? Docsity.com Cast a broad differential dx net Docsity.com Differential Diagnoses for psychotic disorders • Mood Disorders with Psychotic Features • Schizophrenia and Schizophreniform Disorder • Substance-Induced Psychotic Disorder • Delusional Disorder • Psychotic Disorder due to General Medical Condition • Shared Psychotic disorder (Folie a’ Deux) • Psychotic Disorder NOS Docsity.com So how do you figure out how to identify the diagnosis? Docsity.com ? • Are psychotic sx only present when mood symptoms present? • Does the patient have a medical condition that can cause psychosis? Docsity.com ? • Is the patient using drugs/ETOH- if yes need to have sx present after at least a month of sobriety otherwise is attributed to substance(s) Docsity.com A word about delusions • Delusions are defined as a false believe based on incorrect inference about external reality that is firmly held despite what most everyone else believes and despite what constitutes incontrovertible and obvious proof of evidenced to the contrary. • Always keep in mind cultural norms Docsity.com ? Mood incongruent • Mood incongruent themes include delusions of control, persecution, thought broadcasting and thought insertion. Mood congruent  Delusions or hallucinations consistent with themes of a depressed mood such as personal inadequacy, guilt, disease, death, deserved punishment. For manic mood themes of worth, power, knowledge, special relationship to a deity. Docsity.com Psychotic illnesses Docsity.com Treatment- Meds • Cornerstone of treatment is initiation of antidepressants but need antipsychotic as well • Antidepressant-antipsychotic cotreatment was superior to monotherapy with either drug class in the acute treatment of psychotic depression. • See psychopharm lecture for how to select an antidepressant and antipsychotic Docsity.com Treatment- ECT • ECT is very effective for psychotic depression- particularly in elderly and pregnant. Docsity.com ECT • ECT in nonpsychotic depression versus psychotic depression and found a remission rate of 95% in patients with psychotic depression compared with an 83% remission rate in patients with nonpsychotic depression. • ECT treatments with bilateral or right unilateral electrode configuration can be superior to combination Docsity.com Schizophrenia A BEAUTIFUL MATH Docsity.com Schizophrenia • Two or more of the following present for a significant portion of the time during a 1 month period: – Delusions* – Hallucinations* (See link on website for examples) – disorganized speech* – grossly disorganized or catatonic behavior* – negative symptoms (affect flattening, alogia, avolition, apathy) Docsity.com Schizophrenia • Only one criteria needed if delusions bizarre or hallucinations consist of a voice keeping a running commentary or two voices talking to each other • Must cause significant social/occupational dysfunction • Continuous signs of disturbance for 6 months • < 6 months = schizophreniform Docsity.com Etiology  Studies of monozygotic twins suggest approximately 50% schizophrenia risk genetic as there is 40-50% concordance  Estimated: the other 50% due to as of yet unidentified environmental factors including in utero exposure Docsity.com Pathophysiology • Possibly due to aberrant neuro-developmental processes such as increase in normal age- associated pruning frontoparietal synapses that occur in adolescence and young adulthood • Excessive activity in mesocortical and mesolimbic dopamine pathways Docsity.com Schizophrenia and addiction • 47 percent have met criteria for some form of a drug/ETOH abuse/addiction. • The odds of having an alcohol or drug use disorder are 4.6 times greater for people with schizophrenia than the odds are for the rest of the population: the odds for alcohol use disorders are over three times higher, and the odds for other drug use disorders are six times higher Docsity.com A 20th-century artist, Louis Wain, who was fascinated by cats, painted these pictures over a period of time in which he developed schizophrenia. The pictures mark progressive stages in the illness and exemplify what it does to the victim's perception. Slide courtesy of Dr. Sharon Romm Docsity.com Treatment • Positive symptoms respond better than negative Antipsychotics are mainstay of treatment. • Atypical antipsychotics: used first to reduced risk of Tardive Dyskinesia (TD) but can have weight gain, metabolic syndrome including elevated lipids and type 2 diabetes • Risk of TD approximately 3-5% per year for typical antipsychotics. Highest in older women with affective disorders • Risk of dystonic reaction highest in young males Docsity.com Schizoaffective disorder • Uninterrupted period: either major depressive, episode or mixed episode while criterion for schizophrenia met • Periods where delusions or hallucinations present for >2 weeks without prominent mood symptoms • Symptoms that meet criteria for a mood disorder are present for a substantial portion of the illness • Lifetime prevalence rates is 0.7% Docsity.com Substance induced psychotic disorder Docsity.com Substance-induced psychotic disorder (SIMD) • A. Prominent hallucinations or delusions. • B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): – (1) the symptoms in Criterion A developed during, or within a month of Substance Intoxication or Withdrawal – (2) substance use is etiologically related to the disturbance Docsity.com • The diagnosis cannot be made if the symptoms occurred before the substance or medication was ingested, or are more severe than could be reasonably caused by the amount of substance involved. • If the disorder persists for more than a month after the withdrawal of the substance, the diagnosis is less likely with the exception of methamphetamines. Docsity.com Psychotic disorders due to a General Medical Condition (GMC) • Brain tumors • Seizure disorders • Delirium • Huntington’s disease • Multiple Sclerosis • Cushing’s syndrome • Vitamin deficiencies • Electrolyte abnormalities • Thyroid disorders • Uremia • SLE • HIV • Wellbutrin • Anabolic steroids • Corticosteroids • Antimalarial drugs Docsity.com Delusional disorder • Nonbizarre delusions (i.e. involving situations that occur in real life such as being poisoned, loved at a distance, deceived by a spouse) of at least one months duration. • Criterion A for Schizophrenia never met • Apart from impact of delusions functioning not markedly impaired • Not due to mood disorder or substance • Lifetime prevalence = 0.03% Docsity.com • Mean age of onset is ~40 years • Slightly higher in females compared to males Docsity.com Psychosis NOS • If pt has psychotic sx but does not meet criteria for any diagnosis they get the Psychosis NOS diagnosis Docsity.com Getting back to our case • 29 yo woman was brought to the emergency room by the police after she started screaming at Starbucks then threw coffee at the barista. In the emergency room she stated “I need to be taken to jail. I think I contaminated someone with a virus and I need to go to jail. Don’t get near me…I will make you sick too.” • PE, VS, lab work all unremarkable Docsity.com Mental status exam  Appearance: disheveled, anxious  Behavior: mild PMR, poor eye contact  Speech: soft, constricted prosody  Mood: “beyond terrible”  Affect: mood congruent, depressed  Thought process: perseverative on belief she must go to jail because of perceived wrong doing  Thought content: +delusions she has harmed someone, +paranoia, -AH, passive SI stating she deserves to die without plan, -HI, -TI, -TB, -IOR  Cognition: fully oriented  Insight/judgement: poor Docsity.com MDD with psychotic features • Leading diagnosis given depressive themes to psychosis, depressed mood, negative utox, no abnormalities in labs, normal PE and lack of negative sx Docsity.com To rule in the DX • Pt needs to currently meet criteria for a major depressive episode and not have other reasons for psychosis for example Docsity.com What information would you need to r/o other dx? • No history of manic episodes- r/o BAD • No drug/ETOH use in recent past- r/o SIPD • No medical issues such as hypothryoidism- r/o psychotic disorder due to a GMC • Does not meet criteria for schizophrenia Docsity.com