Psychotic disorders

Psychotic Disorders

Al-Momtan

1

Definitions

• Psychotic behavior – Cluster of disorders characterized by hallucinations and/or loss of contact with reality.

Psychotic Symptoms- Presence of Delusions and Hallucinations- Severely disorganized behavior, speech and thought- Also occurs in Mood Disorders- May be associated with substance use- May be due to medication side effects- May be due to Delirium, GMC

DSM-IV

2

Schizophrenia

• Schizophrenia vs. Psychosis– Psychosis – Broad term (e.g.,

hallucinations, delusions) – Schizophrenia – A type of psychosis – Psychosis and Schizophrenia are

heterogeneous– Disturbed thought, emotion, behavior

3

Schizophrenia

• Neurological disease that affects a person’s perception, thinking, language, emotion, and social behavior.

4

Facts and How common?

• Onset and Prevalence of Schizophrenia worldwide

– About 1% of the population

– Usually develops in early adulthood, but can emerge at any time

• Schizophrenia Is Generally Chronic

– Most suffer with moderate-to-severe impairment throughout their lives

– Life expectancy in persons with schizophrenia is slightly less than average

• Schizophrenia Affects Males and Females About Equally

– Females tend to have a better long-term prognosis

– Onset of schizophrenia differs between males (earlier) and females (later)

• Schizophrenia Appears to Have a Strong Genetic Component5

DSM-IV-TR Criteria for Schizophrenia

Characteristic symptoms – • Two or more of the following, one month, less

if treated: 1. Delusions.2. Hallucinations.3. Disorganized Speech.4. Disorganized or Catatonic Behavior.5. Negative symptoms.(flat affect)

6

Assessment of Symptoms

• Symptoms may be classified as– Positive – “attention getter” symptoms i.e.

hallucinations, delusions, bizarre behavior, disorganized speech

– Negative – “crippling” symptoms i.e. apathy, lack of motivation, anhedonia

– Cognitive - i.e. difficulty with attention, memory, and problem solving

– Disorganized – i.e. disorganized speech, inappropriate affect

7

Alterations in Thinking

• Delusions• Ideas of Reference• Persecution• Grandiosity• Bodily Functions• Jealousy• Control

8

Also observed!

– Thought broadcasting– Thought insertion– Thought withdrawal– Being controlled– Loose Association– Neologisms– Concrete Thinking– Echolalia– Clang Association– Word Salad

9

Alterations in Perception

• Hallucinations- auditory, visual, olfactory, gustatory, and tactile– 90% of schizophrenics experience

hallucinations - auditory most common– Difference between Illusions and Hallucinations– Depersonalization and Derealization (loss of

ego boundaries)

• Bizarre Behavior

10

Negative Symptoms

• Develop over time• May not be detected (masked by positive symptoms

Negative symptoms include: poverty of speech content, thought blocking, anergia, anhedonia, affective blunting, and lack of avolition.

11

Associated symptoms

• Depression and Suicide• Water Intoxication• Substance Abuse• Violent Behavior

12

Management

• Phases of presentation:- Acute.- Maintenance.- Stable.• Psychopharmacology:- Typical (Traditional) Antipsychotics – target the positive

symptoms• Older drugs – Watch for signs of EPS

- Atypical (Novel) Antipsychotics – diminish the positive and negative symptoms 13

Pharmacology Typical ones!!

– Thorazine (chlorpromazine)

– Mellaril (thioredazine)– Stelazine (Trifluoperazine)– Trilafon (perphenazine)– Serentil (Mesoridazine)– Prolixin (Fluphenazine)– Navane (Thiothixene)– Haldol (Haloperidol and

Haloperidol deconate)– Loxapine – Moban (molindon)

14

Atypicals !!

- Clozapine (Clozaril) agranulocytosis and seizures

LOWER SIDE EFFECTS:-Risperidone (Risperdal).-Olanzapine (Zyprexa).-Quetiapine (Seroquel)-Ziprasidone (Geodon)

Side Effects of antipsychotics

15

•Anticholinergic Symptoms

•Extrapyramidal Symptoms (EPS):

1. Pseudoparkinsonism.2. Acute dystonic reactions

Opisthotonos Oculogyric Crisis.

3. Akathisia.4. Tardive Dyskinesia

Adjuncts to Antipsychotic Therapy

• Antidepressants• Antimanic Agents• Benzodiazepines• ECT

16

Sub-types of Schizophrenia

• Paranoid Type• Disorganized Type• Catatonic Type

17

Paranoid type

• Any intense and strongly defended irrational suspicion

• Most common symptoms - hallucination and delusions

• Defense Mechanism - Projection

18

Disorganised type

• Most regressed and socially impaired• Symptoms - loose association,

inappropriate affect, bizarre mannerisms, incoherent speech and withdrawn

• Onset?• Prognosis

19

Catatonia type

• Abnormal motor behavior

• Be familiar with other symptoms

• Prognosis?

• Physical Needs are a Priority

20

Help and Support

• Educate patient and family about illness• Assist patient in improving his or her ability to solve

problems related to environmental stress• Teach the patient coping strategies • Assist family and patient to identify sources for

ongoing support

21

Better Prognosis

• Acute onset• Marked confusion while psychotic• Good premorbid functioning• No affective blunting or flattening• No family history of psychosis• Clear precipitant/stressor• Later onset.• Insight preserved• Female• Minimal residual symptoms• Normal neurological functioning• Family history of a mood disorder• Early treatment and good compliance

22

To be familiar with!!

• Loose association.• Neolgism• Echolalia• Clang association• Word salad• Concrete thinking• Thought broadcasting.• Thought insertion, withdrawal.• Delusion of being controlled!

23

Gross and Imaging changes!

– Increased size of lateral ventricles– Decreased brain volume– Smaller Prefrontal Cortex?– Loss of asymmetry between left and

right brain.

24

Schizophreniform Disorder vs Breif psychotic disorder

• Same criteria as Schizophrenia except for duration: – Lasts at least 1 month but less than 6

months

• Diagnosis is “Provisional” if made without waiting for recovery (ie. Before 6 months)

25

Schizoaffective disorder

• Mixture of Schizophrenic and Affective symptoms– I.e. alterations in mood as well as disturbances in

thought• Thought by some to be a severe form of Bipolar

(Varcarolis, 1998)• Treatment: Lithium used with antipsychotic

therapy for treatment of manic symptoms

26

Other Disorders with Psychotic Features (cont.)

• Delusional Disorder– Delusions that are contrary to reality– Lack other positive and negative symptoms– Types of delusions include

• Erotomanic• Grandiose• Jealous• Persecutory• Somatic

– Extremely rare– Better prognosis than schizophrenia

Psychosis due to GMC

- R/O them 1st.- PD?, tumours?, strokes? Aura of migraine?- DLB, MS, alzehimer? Sarcoidosis?- Vitamins dif.?, endocrinopathies?- RF?, Liver failure?- Infxns: syphilis, AIDS, Leprosy? Malaria?- Electrolyte disturbance?

28

Substance induced Psychosis

- toxins?- Drugs?- hormons- Withdrawal of sedatives/hypnotics.- Hormons? Bromocriptine?- Cannabis?

29

Associated mental disorders

• MR• OCD• Autism• Post-traumatic stress disorders.

30

Thank you!

Best of Wishes,,

31