Transcript OHSU Presentation Template

Detecting Psychosis
in the Primary Care Setting
Presented by: Jonathan Betlinski, MD
Date: 03/05/2015
Disclosures and Learning Objectives
Learning Objectives:
• Know the prevalence of psychotic symptoms in
primary care
• Know the 6 common symptom clusters for
schizophrenia
• Be able to list at least 5 reasons why an
individual might be psychotic
Disclosures: Dr. Jonathan Betlinski has nothing to disclose.
Psychosis in Primary Care
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Review the epidemiology of psychosis
Review common causes of psychosis
Review diagnostic criteria for psychosis
Discuss screening questions for psychosis
Review the basic first steps of managing
psychosis
• Reveal next week’s topic
Psychosis: Epidemiology
• 3.7% of primary care patients report at least one
psychotic symptom
• Most common symptom is believing that others
are spying on or following the individual
http://www.researchgate.net/publication/14290258_Psychotic_symptoms_in_primary_care
• 50-90% of those with a serious mental illness
(SMI) have at least one chronic medical illness
• Individuals with SMI die 25 years earlier
http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-care-providersam-j-m-2012.pdf
• Up to 30% of individuals with psychotic
symptoms rely solely on primary care
https://books.google.com/books?id=Jxfm86wOR8UC&pg=PA237&lpg=PA237&dq=psychosis+in+the+primary+care+setti
Psychosis – Epidemiology for schizophrenia
• 0.7% lifetime risk for schizophrenia
• Mortality rate is 2-3x higher
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3.4x Infectious disease
3.2x Respiratory disease
2.7x Endocrine
2.5x Gastrointestinal
2.3x Cardiovascular (50-60% of premature death)
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Smoking, obesity, DM, HTN, Hyperlipidemia and
Metabolic Syndrome are all 1.5-5x more present
• 5% lifetime risk of suicide (13x greater)
http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-careproviders-am-j-m-2012.pdf
Psychosis
Psychosis is characterized by a loss of
contact with reality
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Delusions (fixed false beliefs)
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Hallucinations (false sensory perceptions)
Disorganized speech
Disorganized behavior
These problems cause lead to social or
occupational dysfunction
http://www.nmji.in/archives/Volume_19_6_Nov_Dec_2006/Everyday_Practice_new/every_day_practice_19_6.htm
Psychosis – Psychological Causes
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Schizophrenia
Schizoaffective Disorder
Brief Psychotic Disorder
Major Depressive Disorder
Bipolar I Disorder
Psychotic Disorder, NOS
Delusional Disorder
Personality Disorders
Narcolepsy
http://www.nhs.uk/Conditions/Psychosis/Pages/Causes.aspx; http://pro.psychcentral.com/dsm-5-changes-
Psychosis – Substance-induced Causes
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Alcohol
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Cannabis
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Cocaine
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Amphetamine
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Methamphetamine
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Mephedrone (MCAT)
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MDMA (ecstasy)
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LSD (acid)
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Psilocybins
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Ketamine
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Jimson Weed
http://www.nhs.uk/Conditions/Psychosis/Pages/Causes.a
spx
http://www.psychiatrictimes.com/sites/def
ault/files/pt/00846.png
Psychosis – Medical Causes
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Epilepsy
Head injury
Brain tumors
Infections
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Malaria
Syphilis
Lyme Disease
HIV and AIDS
Autoimmune Disorders
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Lupus
Multiple sclerosis
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Endocrine Disorders
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Dementias
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Thyroid disorders
Hypoglycemia
Cushing’s Disease
Alzheimer’s Disease
Parkinson's disease
Lewy Body Dementia
Metabolic Disorders
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Acute Intermittent
Porphyria
http://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptomsmedical-%E2%80%9Cmimics%E2%80%9D
Schizophrenia – Diagnostic Criteria A
Two (or more) of the following for 1 month (over 6m),
one of which must be from the first 3
•Delusions
•Hallucinations
•Disorganized speech
•Grossly disorganized or catatonic behavior
•Negative Symptoms (i.e. Affective flattening, Alogia,
Avolition, etc)
http://dnalc.org/view/899-DSM-IV-Criteria-for-Schizophrenia.html
http://pro.psychcentral.com/dsm-5-changes-schizophrenia-psychotic-disorders/004336.html
Schizophrenia – Diagnostic Criteria BCDEF
B. Social/Occupational Dysfunction
C. Duration
-Continuous signs for 6 months
-Active symptoms for 1 month
-Prodromal or residual periods may have only negative
symptoms or 2+ attenuated positive symptoms
D.It’s not SAD or a mood disorder
E.It’s not due to a substance or medical condition
F.If AD or PDD exists, delusions or hallucinations
must be prominent for at least 1 month
http://dnalc.org/view/899-DSM-IV-Criteria-for-Schizophrenia.html
Schizophrenia: DSM 5 Diagnostic Criteria
Symptoms must be present for 6 months,
active for 1 month, and cause dysfunction
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Negative symptoms: amotivation, decreased emotional expression,
limited social interaction and poor speech
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Cognitive dysfunction: may affect memory, processing speed and
executive function
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Disorganization of speech
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Delusions and hallucinations
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Motor system abnormalities: tremor, bradykinesia, catatonia,
akathisia, abnormal involuntary movements
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Affective symptoms: demoralization, major depression, manic
behaviors (energy, excitement, irritability, disinhibition)
http://www.jpshealthnet.org/sites/default/files/schizophrenia_e-resource_-_february_2014.pdf
Screening for Psychosis
Normalize the experience
• Sometimes when people are [under stress or
feeling anxious/depressed], they can have
strange experiences such as trouble with thinking
or seeing or hearing things that others don’t.
• The next questions are about unusual things, like
seeing visions or hearing voices that some
people may not believe in. In fact these things
may be quite common in certain situations.
http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-care-providersam-j-m-2012.pdf
http://ocfp.on.ca/docs/collaborative-mental-health-care-network/15-minute-psych-assessment-presentation.pdf
Screening for Psychosis
• Have your eyes or ears (or brain) ever played
tricks on you?
• Have there ever been times when you heard or
saw things that other people could not?
• Have you ever heard voices that other people
could not hear? I don't mean having good
hearing, but rather…voices coming from inside
your head talking to you or about you, or voices
coming out of the air when there was no one
around. Did you ever hear voices in this way?
http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-careproviders-am-j-m-2012.pdf
http://ocfp.on.ca/docs/collaborative-mental-health-care-network/15-minute-psych-assessment-presentation.pdf
Screening for Psychosis
• Have you had any strange or odd experiences
lately that are difficult to explain or that others
would find hard to believe?
• Have you felt people are watching or following
you?
• Does anyone in particular seem intent on
harassing or hurting you?
• Have you felt like others can hear your thoughts
or that you can hear another person’s thoughts?
http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-care-providersam-j-m-2012.pdf
http://ocfp.on.ca/docs/collaborative-mental-health-care-network/15-minute-psych-assessment-presentation.pdf
Screening for Psychosis
• Have you ever felt that some mysterious force was
inserting thoughts—that were that were definitely not
your own thoughts—directly into your head?
• Have you ever felt that your thoughts were being read by
other people or were being stolen out of your mind?
• Did you ever have a time when you felt that that your
mind was being taken over by others?
• Have you ever felt that someone or something was
trying to communicate directly with you by sending
special signs or signals?
http://ocfp.on.ca/docs/collaborative-mental-health-care-network/15-minute-psych-assessment-presentation.pdf
http://www.hcp.med.harvard.edu/wmhcidi/about.php
Screening for Psychosis
• Has a doctor ever told you that you have
schizophrenia?
• Who in your family has had problems with
psychosis or schizophrenia?
• Do you have any special powers that
most people lack?
http://ocfp.on.ca/docs/collaborative-mental-health-care-network/15-minute-psych-assessment-presentation.pdf
http://www.hcp.med.harvard.edu/wmhcidi/about.php
Psychosis – Initial Workup
• Medical and family
history
• Physical exam
• Focused Neuro
exam
• Labs
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CBC, CMP, Thyroid
Vit B12, HIV,UDS
RPR vs. FTAAT?
If Clinically Indicated
• Head Imaging
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MRI preferred
Low Yield
EEG
Ceruloplasmin
CXR
Lumbar Puncture
http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primarycare-providers-am-j-m-2012.pdf
Psychosis – Initial Management
• Evaluate for safety
• Refer for psychiatric evaluation
• EASA referral for first psychosis
• If no safety concerns exist and there is no
timely referral available, consider starting
an antipsychotic
• Go with what’s worked best in the past
• Risperidone or Perphenazine if no prior
http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-careproviders-am-j-m-2012.pdf
Psychosis – Initial PCP Treatment (NICE)
• Do not start AP for 1st psychosis without
consultation
• Collect the following baseline information
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Weight, girth
BP, pulse
Fasting glucose, HbA1c, Lipid profile, prolactin
assessment of any movement disorders
assessment of nutritional status, diet and
level of physical activity
http://www.guidelines.co.uk/central_nervous_system_nice_psychosis_schizophrenia_feb14#.VPedV-85CW8
Psychosis – Treatment Considerations
APA Treatment Guidelines
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia-watch.pdf
http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia-guide.pdf
NICE Treatment Guidelines
http://www.guidelines.co.uk/central_nervous_system_nice_psychosis_schizophrenia_feb14#.VPedV-85CW8
http://www.nice.org.uk/guidance/cg120/chapter/guidance
National Medical Journal of India
http://www.nmji.in/archives/Volume_19_6_Nov_Dec_2006/Everyday_Practice_new/every_day_practice_19_6.htm
Australian Guidelines
http://www.ycentral.com.au/wp-content/uploads/2014/11/Aust-Clinical-Guidelines-for-Early-Psychosis.pdf
https://www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/APY535-pdf.aspx
http://www.guideline.gov/content.aspx?id=43862
Summary
• Nearly 4% of primary care patients have
psychotic symptoms
• Less than 1% will have schizophrenia
• Psychosis can arise for psychological, medical
and substance-induced reasons
• Those with psychotic symptoms tend to have
worse medical outcomes
• Treatment of psychosis includes medical
assessment, routine monitoring and targeted
interventions
The End!
Pharmacologic
Interventions
for Psychosis
03/12/15
http://earthobservatory.nasa.gov/IOTD/view.php?id=84560