1 Psychotic Disorders Source of answers, unless otherwise noted are DSM-IV-TR or APA Practice Guideline on schizophrenia, Supplement to AJP, February,

1

Psychotic Disorders

Source of answers, unless otherwise noted are DSM-IV-TR or APA Practice Guideline on schizophrenia, Supplement to AJP, February,

2004.As of 10July2012

2

Dx criteria

Q. What are the dx criteria for schizophrenia?

3

Dx criteria

Ans. Two or more of five:

1] delusions

2] hallucinations

3] disorganized speech

4] disorganized behavior or catatonia

5] deficit signs of flat affect, apathy, alogia, and so on [“negative” signs].

4

Delusions - exception

Q. Under what circumstances can you give a person a dx of schizophrenia when delusions is the only one of the five supra that the pt has?

5

Delusions -exception

Ans. When the delusions are “bizarre.” By bizarre, DSM means that the idea could not be true. It could be true, for example, that someone is poisoned, but it could not be true that the pt’s father lives on the planet Jupiter. [Thus, one does not need to dx psychotic disorder NOS when faced with a six month illness that only has bizarre delusions, but can dx “schizophrenia.”]

6

Hallucinations - exception

Q. What characteristics of hallucination allows one to dx a person with schizophrenia even when the individual lacks any of the other four signs of schizophrenia listed supra?

7

Hallucinations -- exceptions

Ans. Two exceptions:

1] “Hearing” a voice constantly reflecting on the pt’s behavior or thoughts.

2] “Hearing two voices conversing with each other.

8

Catatonia v. paranoid

Q. Your pt has the signs of catatonic type and has the signs of the paranoid type, what is the dx?

9

Catatonic v. paranoid

Ans. Catatonic Type. The catatonic type trumps all the other types. Disorganized type also trumps paranoid type.

10

Deficit signs

• Q. Your pt has developed deficit [negative] signs. Besides being part of schizophrenia, what are two other possibilities common in psychiatric practice?

[These slides avoid the terms “positive” and “negative” and instead use “psychotic” and “deficit.”]

11

Deficit signs

Ans. While the list could be long, two will probably reach the exam question:

• -- Parkinsonian signs from the meds.

• -- Depression

12

Schizoaffective Disorder

• Q. Criteria for schizoaffective disorder?

13

Schizoaffective Disorder

Ans. Someone who has:

• -- signs of a mood disorder

• AND

• -- delusions or hallucinations for at least two weeks when mood disorder is not present. [note, not “schizophrenia,” but “delusions or hallucinations.”]

14

Structural Neuroimaging studies

Q. Most consistent structural neuro-imaging finding of these pts with schizophrenia in comparison to general population?

15

Structural Neuroimaging studies

Ans. Enlargement of lateral ventricles.

16

Functional neuroimaging studies

Q. What has been the most consistent finding as to functional neuroimaging studies in pts with schizophrenia?

17

Functional neuroimaging studies

Ans. Hypofrontality.

18

Schizophrenia - death

• Q. People with schizophrenia death rate compared with the general population is?

19

Schizophrenia - death

Ans. Die a decade or more earlier. [since 2007, “25 years” has become a common figure.]

20

Death rate - why

Q. List the three reasons why the death rate is higher.

21

Death rate - why

• Suicide rate is much higher

• Accidents are much more common

• Medical care is more inadequate.

• [Side effects of meds that are used to treat the mentally ill may become the fourth.]

22

Suicide

Q. What is rate of suicides?

23

Suicides

Ans. DSM-IV says 10%. More recent studies say 5%.

24

Suicide risks

• Q. What five suicide risk factors DIFFER from the suicide risk factors of the general populations? That is, if you are doing a risk assessment on a pt with schizophrenia, what findings would increase the suicide risk chances with pt with schizophrenia, findings that would not increase the suicide risk in the general population.

25

Suicide – risk factors

Ans. Risk factors that are different from the general population include:

• 1. Young• 2. High socioeconomic status• 3. High IQ• 4. Good scholastic record• 5. High aspirations• [This is a pretty common question on Boards,

consistent with the focus on passing a safe psychiatrist.]

26

Proven to reduce suicide in people with schizophrenia

• Q. Med/meds proven to reduce suicide rate?

27

Proven to reduce suicide rate

Ans. Clozapine

• [Lithium’s use might be an acceptable answer too, but clozapine has a specific FDA approval for suicidal risk in pts with schizophrenia. Li does not.]

28

Suicide - prediction

• Q. Status of clinicians ability to predict suicide?

29

Suicide - prediction

Ans. Not able to predict.

[This will be correct answer to almost any question as to ability to predict suicide, not just the psychotic disorders.]

30

Aggressive behavior

• Q. List three co-morbid disorders that increase risk of aggressive behavior in pts with schizophrenia.

31

Aggressive behavior

Ans.

• 1. Substance abuse/dependence [especially PCP, but alcohol, cocaine, and sedatives]

• 2. Neurological disorders

• 3. Antisocial personality

32

Prognosis – family hx

• Q. Does a hx of mood disorders in the family hx suggest a poorer prognosis for your pt with schizophrenia?

33

Prognosis – family hx

Ans. A family hx that has a mood disorder has a better prognosis.

34

Prognosis - gender

• Q. Does gender make a difference as to prognosis?

35

Gender

Ans. Women have a better prognosis.

36

Prognosis – age of onset

• Q. What about prognosis and age of onset?

37

Prognosis - age

Ans. The later the onset of the illness, the better the prognosis.

38

Prognosis – Mental Status

• Q. What two mental status findings have a good prognosis?

39

Prognosis – mental status

• A. Good prognostic signs are:

• -- Lack of anosognosia

• -- Signs of mood disorder

[If neither of the above two are among the choices, seems confused may be the correct answer.]

40

Prognosis – Course of illness

• Q. What course of illness suggests a good prognosis?

List two as to onset.

List one as inter-episode functioning.

41

Prognosis - course

Ans. The following suggest a relatively good prognosis:

• -- acute onset

• -- precipitating, traumatic, event

• -- good prior-episode or good inter-episode functioning

42

Stages

• Q. APA Practice Guideline has what stages for schizophrenia?

43

Schizophrenia - stages

• Ans.

• -- Acute

• -- Stabilization

• -- Stable [“maintenance” also used]

44

Acute phase

• Q. Definition of acute phase?

45

Acute phase

Ans. Beginning with the onset of the episode until the pt reaches what the clinician believes is to be the pt’s baseline.

46

Course

• Q. You are treating a pt during his first break, age 21. What are the chances he will never have another schizophrenic episode?

47

Course

Ans. 10-20%

48

Maintenance

• Q. Indefinite maintenance of antipsychotic meds is recommended when?

49

Maintenance

• Ans. If the pt has had two psychotic episodes within five years.

50

Stable phase – relapse rate

• Q. Within one year, in a pt who responds adequately to meds in the acute phase, what percentage will relapse if continued on meds? What percentage if meds are discontinued?

51

Stable phase - relapse

Ans.

• 1/3 with meds within one year

• 2/3 without meds within one year

52

Predicting who doesn’t need meds

• Q. Is there a very reliable way to predict which of your pts with schizophrenia will never need meds again after stable stage is reached?

53

Predicting who will not need meds

• Ans. No reliable way to identify this minority.

54

Poor prognosis

• Q. What factors suggest a poor prognosis as to treatment response? Use the following outline.

GenderPre-natal factorsPeri-natal factorsPre-morbid functioningSeverity of signs of delusion and hallucinationsDuration of untreated psychosisEPS side effectsFamily setting

55

Poor prognosis - 1

• Ans. Any of the following ten factors decreases the chances of a good prognosis:

• 1. male

• 2. pre-natal injury

• 3. peri-natal injury

• 4. severe hallucinations

• 5. [see next slide]

56

Poor prognosis - 2

• 5. Severe delusions

• 6. Attentional impairment

• 7. Poor premorbid functioning

• 8. Long duration of untreated psychosis

• 9. Prominent EPS side effects to meds

• 10. High levels of expressed emotions in family setting.

57

Schizophrenia – treatmentdeficit signs

• Q. Proven treatment in controlled studies for deficit [“negative”] signs?

58

Treatment – deficit signs

• Ans. None proven for deficit [negative] signs. When pt does dramatically improve as to deficit signs, may be a function of the switch of meds as to less side effects, not an improvement in the schizophrenia per se.

59

Treatment - psychosocial

• Q. What are the psychosocial approaches to the psychiatric management of schizophrenia?

60

Treatment - psychosocial

Ans. • -- supportive psychotherapy• -- CBT• -- group therapy• -- family therapy• -- social skills training• -- supportive employment• -- ACT/PACT

61

Treatment – family therapy

• Q. During which phase should family therapy begin?

62

Treatment – family therapy

• Ans. Acute phase.

63

ACT/PACT

• Q. What is ACT/PACT?

64

ACT/PACT

Ans.

• ACT = Assertive Community Treatment

• PACT = Program for Assertive Community Treatment.

• Above is community based, 7x24, in which the team goes to where each pt is, there home, their bar, whatever.

65

ACT/PACT

• Q. For what pts is ACT/PACT indicated?

66

ACT/PACT

• Ans. two conditions:

• 1] Pt has high risk of hospital readmission.

• AND

• 2] Unable to use usual community-based [e.g., clinic] resources.

67

Treatment - benzodiazepines

• Q. Role of benzodiazepines in the management of acute phase of schizophrenia

68

Treatment - benzodiazepines

• Ans. Signs of:

• -- Agitation

• -- Anxiety

• -- Catatonia

69

Treatment - benzodiazepines

• Q. Role of benzodiazepines in management of stable phase?

70

Schizophrenia - benzodiazepines

• Ans. In stable phase:

• -- Anxiety

• -- Insomnia

• [while not in Guideline, one can probably assume that if lorazepam was a major success in abolishing catatonia in acute phase, it would be continued.]

71

Schizophrenia – beta-blockers

• Q. In pts with schizophrenia, beta-blockers are used for?

72

Schizophrenia – beta-blockers

• Ans. Recurrent signs listed below in the face of antipsychotic failure

• -- Hostility

• -- Aggression

73

Mood stabilizers

• Q. When are mood stabilizers used in this disorder?

74

Mood stabilizers

• Ans. In the face of antipsychotic medications failure to prevent RECURRENT:

• -- Aggression

• -- Hostility

75

Schizophrenia - ECT

• Q. Indications for ECT?

76

Schizophrenia - ECT

• Ans. Indications are:

• 1. Catatonia [some might say, catatonia after benzodiazepine failure]

• 2. Clozapine failures that have:a. persistent, severe psychosis

b. suicidal

77

Relapse

Q. List four causes of relapse in schizophrenia?

78

Relapse

Ans. Causes include:

• 1. non-compliant with treatment

• 2. stressful event

• 3. use of substance or alcohol

• 4. natural course of illness

79

Substance Abuse• Q. Excluding smoking, what percentage of

people with schizophrenia have a substance-related disorder?

80

Substance abuse

• Ans. 50%

81

Dual dxed pts

• Q. Best psychiatric management of pt with schizophrenia and a substance dependence?

82

Dual dxed pt

• Ans. Integrated, comprehensive and carried out by the same team.

[This is politically correct answer for all dual dx pts, not just those with schizophrenia.]

83

Treatment of first episode - meds

• Q. What meds are indicated for the first episode?

84

Treatment of first episode - meds

Ans. All atypicals except clozapine.

[This answer is pre-CATIE. Would be hard to justify this post-CATIE if someone preferred perphenazine.]

85

Medication effects on second episode

• Q. How do medications during the first episode differ from latter episodes as to impact on the pt? For example, your pt had good response to risperidone on 1 mg BID during first episode with side effects of dizziness and dry mouth in his first hospitalization. He failed to take meds after your hospital discharge and was readmitted with another episode of schizophrenia. What would you expect if you use risperidone again?

86

Medications impact on first episode

Ans. Pt is less sensitive as to the therapeutic effects AND less sensitive as to the side effects. You will probably need to use higher dose that 1 mg BID for the second hospitalization and the side effects might be less prominent.

87

Clozapine as initial medication

Q. How does clozapine compare with other antipsychotics for naïve-medication patient? Will it perform better, for example, than chlorpromazine?

88

Clozapine as initial medication

Ans. Will not do better. So, in addition to the usual side effect concerns, there is no evidence that clozapine is superior in pts in their first acute episode. Clozapine might be the correct answer in highly suicidal pt.

89

Hx of weight gain, hyperglycemia, or hyperlipidemia

• Q. With the hx of weight gain, hyperglycemia or hyperlipidemia with prior antipsychotics, what meds would now likely become first choice if they have not already been used and found wanting?

90

Hx of weight gain, hyperglycemia or hyperlipidemia

• Ans. aripiprazole or ziprasidone.

91

Weight gain

• Q. Weight gain is hypothesized to be associated with which two receptor site?

92

Weight gain

Ans. Meds blocking

• H1

• OR

• 5-HT2C

93

Weight gain & med discontinuance

• Q. When one discontinues an antipsychotic that apparently was related to gaining weight, what is the impact of discontinuance of that medication on the pt’s weight? Rapidly return to pre-med weight?

94

Weight gain & med discontinuance

Ans. Usually, no further weight gain, but what has been gained will not be automatically loss. If pt has gained 25 pounds, losing that weight is not going to take place simply because the med has been discontinued. Still, some pts have had dramatic weight loss on ziprasidone and aripiprazole after being switched from olanzapine.

95

Action of typicals

Q. What is action site of typical antipsychotics?

96

Action of typicals

• Ans. D2 antagonist

97

Atypicals & dopamine pathways

• Q. Which dopamine pathway do most atypicals block?

98

Atypicals & dopamine pathways

• Ans. Mesolimbic.

• [exception: aripiprazole]

99

QTc interval

• Q. What is the QTc interval?

100

QTc interval

• Ans. Time from beginning of ventricular depolarization through repolarization.

• c = correction for heart rate

101

Torsades de Pointes

• Q. What is torsades de pointes?

102

Torsades de pointes

Ans. Prolonged QTc leading to malignant ventricular arrhythmia. Sometimes fatal.

103

QTc black box

• Q. Which antipsychotics have QTc black box?

104

QTc black box

• Ans. Thioridazine and mesoridazine. [mesoridazine no longer is available]

105

QTc prolongation

• Q. QTc prolongation can result from which receptor being blocked?

106

QTc prolongation

• Ans. Alpha1-adrenergic receptor

107

Action of atypicals

• Q. What is action of atypicals?

108

Action of atypicals

• Ans. D2 and 5-HT2 antagonists.

109

Blocking D2

• Q. What does blocking D2 produce as to side effects? List the two major headings.

110

Blocking D2

• Ans.

• 1. EPS

• 2. Increased prolactin.

111

EPS

• Q. What are the signs of EPS? List three that can occur soon after use of typical antipsychotics.

112

EPS

Ans. Signs include:

• -- Parkinsonism

• -- Akathisia

• -- Dystonia

[TD, of course, would be the answer as to long-term use.]

113

Increased prolactin

• Q. Increased prolactin causes?

114

Increased prolactin

Ans.

• -- decreased sex drive

• -- amenorrhea

• -- increased breast size

115

EPS

• Q. Which antipsychotic med has the highest rate of EPS?

116

EPS

Ans. Haloperidol.

117

TD

Q. Which antipsychotic has the highest rate of TD?

118

TD

Ans. Haloperidol.

119

Prolactin elevation

• Q. Which two antipsychotics have a high level of prolactin elevation?

120

Prolactin elevation

• A. Haloperidol and risperidone.

[There are others, but these two probably reach the answers.]

121

Lipids

• Q. Aripiprazole and ziprasidone’s effect on lipids?

122

Lipids

Ans. All to the good:

• Decrease LDL

• Increase HDL

• Decrease triglycerides

123

Weight gain and dosage

• Q. For the pt who seems to gain weight on an antipsychotic med, what is the relationship to med dosage? Does it make a difference if the pt is on 20 mg of olanzapine rather than 10?

124

Weight gain and dosage

• Ans. Not related.

125

Schizophrenia & diabetes

• Q. In medication-naïve people with schizophrenia, what is rate of diabetes?

126

Schizophrenia and diabetes

• Ans. Even in medication-naïve, people with schizophrenia are more likely to have elevated glucose levels

127

Diabetes risk factors

• Q. What are the five risk factors of a pt with schizophrenia developing diabetes?

128

Diabetes risk factors

Ans. Like all of us:

• 1. Weight gain

• 2. Family hx of diabetes

• 3. co-occurring substance abuse/dependence

• 4. Inactivity

• 5. Lack of access to health care

129

Anticholinergic side effects

• Q. Which antipsychotic has most anticholinergic side effects?

130

Anticholinergic side effects

• Ans. Clozapine

131

AIMS = ?

Q. What does AIMS = ?

132

AIMS = ?

Ans. Abnormal Involuntary Movement Scale.

133

AIMS

Q. In using antipsychotic meds, how often should you do the AIMS? Two answers:

1] If your pt is on typical.

2] If on atypical.

134

AIMS

• Ans.

• Typical, q 6 months

• Atypical, q 12 months

135

AIMS – elderly

Q. How often to do an AIMS in the elderly?

136

AIMS - Elderly

Ans.

Typical: every 3 months

Atypical: every 6 months.

137

Sedation

• Q. Which antipsychotic is most sedating?

138

Sedation

• Ans. Clozapine.

139

Hypotension

• Q. Which atypical antipsychotic has highest incidence of hypotension?

140

Hypotension

• Ans. Clozapine

141

SSRIs

• Q. When using SSRIs with antipsychotics, what do you need to watch for?

142

SSRIs

• Ans. SSRIs [fluoxetine, paroxetine, fluvoxamine] can inhibit P450 enzymes which can, in turn, elevate antipsychotic blood levels.

143

BMI

• Q. If your pt’s BMI > 25, for what do you want to monitor besides the pt’s weight?

144

BMI

• Ans. BP, serum lipids and blood glucose. You can also mentioned waist-hip ratio despite overlap with BMI.

145

Monitoring for diabetes

• Q. How often to monitor for diabetes of people with schizophrenia who are on an atypical? What to monitor?

146

Diabetes - monitor

• Ans. Monitor 1] fasting blood sugar* or hemoglobin A1c q 4 months for a year [i.e., three times the first year], then annually.

*In 2007, some began championing 2 hour post-prandial blood sugar as more meaningful.

147

Renal failure

• Q. If renal failure is a concern, for what to test?

148

Renal failure

• Ans. Microalbuminuria in urine.

149

Acute phase - environmental

• Q. During acute phase, environmental interventions are aimed at?

150

Acute phase – environmental

Ans. Reducing over-stimulation and reducing stress.

151

Stabilization phase

• Q. Your pt has completed acute phase. What is the strategy to medicating the stable phase?

152

Stabilization phase - meds

• Ans. Continue with what worked in acute phase for at least 6 months, except for changes needed to address any side effects.

153

Antipsychotics - general

• Q. In general, antipsychotics meds work relatively well for what symptoms and poorly if at all for what symptoms? Answer as to the major breakdown of symptomotology in schizophrenia.

154

Antipsychotics - general

• Ans. Work well for psychotic* signs, poorly for deficit** and poorly for cognitive signs.

*Psychotic = “positive”

**Deficit = “negative”

155

Clozapine use

• Q. When is clozapine indicated? List three major situations.

156

Clozapine use

• A. Useful for:

• -- Suboptimal response with at least two antipsychotic meds [at least one of which is an atypical]

• Or

• -- persistently suicidal

• OR

• -- has TD

157

Prolactin elevation

Q. Pt has hx of untoward sensitivity to prolactin elevation with typical antipsychotics. Atypical antipsychotic choices for such a pt ?

158

Prolactin elevation

Ans. Any atypical except risperidone.

159

Weight gain

• Q. Among antipsychotics, which two have greatest weight gain?

160

Weight gain

• Ans. Clozapine and olanzapine.

161

Glucose abnormalities

• Q. Which two antipsychotics have the greatest tendency to have glucose abnormalities?

162

Glucose abnormalities

• Ans. Clozapine and olanzapine.

163

Lipid abnormalities

• Q. Which two antipsychotics have the highest incidence of lipid abnormalities?

164

Lipid abnormalities

• Ans. Clozapine and olanzapine.

165

QTc prolongation

• Q. Which antipsychotics, still on the market, have QTc prolongation. List three in order of severity.

166

QTc prolongation

Ans.

Thioridazine

MORE than

ziprasidone

MORE than

risperidone

167

Time to clarify status

• Q. When using an antipsychotic, about how long does it take to clarify its clinical usefulness, how many weeks before deciding that it is not efficacious?

168

Time to clarify status

• Ans. 2 – 4 weeks.

169

Not responding

• Q. If a pt is not responding, in addition to the possibility that you selected a medication with no efficaciousness for that pt, what are some other possibilities?

170

Not responding

• Ans. Three:

• -- non-adherence [most likely possibility]

• -- rapid medication metabolism

• -- poor gastrointestinal absorption

171

Stable phase - psychosocial

• Q. List 5 psychosocial treatments that have demonstrated effectiveness in stable phase.

172

Stable phase - psychosocial

• Ans.

• 1. family interventions: stress-free and stable setting

• 2. assertive community treatment

• 3. skills training

• 4. supportive employment

• 5. CBT

173

CBT

• Q. CBT focuses on?

174

CBT

• Ans. Residual psychotic signs, i.e., delusions and hallucinations that remain.

175

Supported employment

• Q. Supportive employment includes? List 5 characteristics of successful supportive employment programs for people with schizophrenia.

176

Supportive employment

Ans.

• -- focus on competitive employment

• -- pt’s choice

• -- rapid job search

• -- integration of rehabilitation and mental health programs

• -- unlimited time of job support, i.e., indefinite.

177

Social skills training

• Q. Social skills training consists of? List four characteristics of successful social skills programs?

178

Social skills training

Ans.

• -- behavioral based instruction

• -- modeling

• -- corrective feedback

• -- contingent social reinforcement

179

Half-life -- short

• Q. Among antipsychotics, which has shortest half-life?

180

Half-life -- short

Ans.

Shortest, loxapine, 4 hours.

181

Half-life -- long

Q. Which antipsychotic has the longest half-life?

182

Half-life -- long

Ans. Aripiprazole, 75 hours.

183

Informed consent

• Q. Usually, of what does informed consent consist relative to your choice of an antipsychotic in a pt hospitalized for the first time?

184

Informed consent

• Ans. • -- nausea• -- orthostatic hypotension• -- dizziness• -- dystonic reactions• -- insomnia• -- sedation• [usually leave longer-term effects, like diabetes

and TD, until later as the important immediate goal is to prepare for the immediate untoward events.]

185

droperidol

• Q. Droperidol has a black box for?

186

droperidol

• Ans. QTc interval.

187

Blood levels

• Q. For which antipsychotics can blood levels be of clinical use?

188

Blood levels

• Ans. clozapine and haloperidol

189

Akathisia

Q. Treatment for akathisia? Practice Guideline lists 6.

190

Akathisia

Ans.

• -- benztropine

• -- trihexyphenidyl

• -- diphenhydramine

• -- amantadine

• -- propranolol

• -- lorazepam

191

Dystonia

• Q. Treat dystonia with? Practice Guideline lists 3.

192

Dystonia

Ans.

• -- benztropine

• -- trihexyphenidyl

• -- diphenhydramine

193

Parkinsonism

Q. Treat parkinsonism reaction to an antipsychotic with? Practice Guideline list 4.

194

Parkinsonism

• Ans.

• -- benztropine

• -- trihexyphenidyl

• -- amantadine

• -- diphenhydramine

195

Targeted intermittent medicating

• Q. Targeted intermittent medicating means slowly tapering the antipsychotic and awaiting signs of illness before re-medicating. Is this a recommended approach to people with schizophrenia?

196

Targeted intermittent treatment

Ans. Not recommended because results 1] in more relapses and 2] more TD.

197

Discontinuing meds

• Q. If you do decide to discontinue the antipsychotic medication, what is the recommended dosing rate of discontinuing the meds?

198

Discontinue meds

• Ans. Decrease 10% a month.

199

depression

• Q. What is the management of signs of depression in pts with schizophrenia?

200

depression

• Ans. Depressive signs are common is all three phases. Antipsychotics themselves may improve the depressive signs. If the pt fully meets the DSM-IV criteria for “depressive event,” then you should prescribe an antidepressant.

201

Obsessive-compulsive signs• Q. What about medicating for obsessive-

compulsive signs?

202

Obsessive-compulsive signs

Ans. Consider an antidepressant if obsessions and compulsions are still present after antipsychotics have failed to improve these signs.

203

Insomnia

• Q. What meds for insomnia?

204

Insomnia

• Ans. If antipsychotic is not reaching the insomnia, trazodone, mirtazapine or a benzodiazepine. But first review the dosing schedule of meds already prescribed as there may one about which the pt takes in the AM and is complaining of sedation – or pt takes in the PM and is complaining of being too active. Quetiapine is common HS choice in addition to the three meds listed above.

205

Agitation

• Q. You are called to the ward to prescribe something for a very agitated pt. What to consider? Practice Guideline lists four.

206

Agitation

• Ans. Practice Guideline list four – haloperidol, ziprasidone, olanzapine and lorazepam. There are probably others that are acceptable. Ziprasidone has a specific FDA approval for agitation in schizophrenia.

207

Delusional disorders - criteria

Q. Key aspects to DSM-IV criteria for delusional disorder?

208

Delusional disorders – criteria

Ans.

1. Nonbizarre delusions.

2. Not part of another disorder, especially doesn’t meet criteria for schizophrenia.

3. Distressing to the pt or has led to pt’s becoming socially, educationally or occupationally dysfunctional.

209

Subtypes

Q. Which is most common subtype of delusional disorder?

210

Subtypes

Ans. Persecutory.

211

Onset

Q. Mean age of onset of delusional disorders?

212

Onset

Ans. About 40 y/o

Ref: Kaplan & Sadock Synopsis

213

Delusional disorders - gender

Q. Which gender is more common?

214

Delusional disorders - gender

Ans. Females.

[First & Tasman, p 716]

215

Delusional disorder - confrontation

Q. Place of confrontation to the delusion within the physician-patient relationship?

216

Delusional disorder - confrontation

Ans. Is not helpful at best and destroys physician-pt relationship at worst.

[First & Tasman, 717]

217

Delusional disorder - meds

Q. Name meds for this disorder.

218

Delusional disorder - meds

Ans. While antipsychotics and antidepressants have anecdotal support, exam question may be looking for pimozide.

[First and Tasman, p 717]

219

Shared psychotic disorder – criteria

Q. Basic criteria for shared psychotic disorder?

220

Shared psychotic disordercriteria

Ans. Delusion develops in an individual who has a close relationship with another person who already had that delusion – and not part of another disorder. Commonly, parent and child.

221

Shared psychotic disordertreatment

Q. What is the treatment plan for this disorder?

222

Shared psychotic disordertreatment

Ans. 1. Separate the two people.2. If the second person is still delusional after a week of separation, begin an antipsychotic.3. Supportive psychotherapy4. Steps to avoid social isolation may help prevent reemergence. Treating the first person is obviously a need and family therapy may be important if within a family.

[First & Tasman, p 719]

223

Name

Q. Another name for Shared Psychotic Disorder?

224

Name

Ans. Folie a Deux.