Transcript Epidemiology of Psychoses

Psychosis and Schizophrenia:
Differential Diagnosis
William R. Yates, M.D.
Professor of Research
OU College of Medicine, Tulsa
Laureate Research Center
Brain Cortex in Schizophrenia
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Psychotic Disorders-Overview
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Common signs & symptoms
Case vignettes
Differential Diagnosis
Medications and psychotic symptoms
Management principles
Psychopharmacologic overview
Objectives
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Describe the common symptoms of psychosis
List the key differential diagnoses for
psychotic symptoms
Describe the criteria for schizophrenia
Outline a treatment plan for management of
acute and chronic psychotic disorders
Psychiatric exam-simplified
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Cognitive impairment?
Psychotic symptoms/disorder?
Mood disorder?
Anxiety disorder?
Substance use disorder?
Differential Diagnosis: Psychosis
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Psychosis due to medical disorder?
Psychosis due to medication?
Psychosis due to drug/alcohol
intoxication or withdrawal?
Psychotic depression or mania?
Psychosis of schizophrenia?
Delusional disorder?
Case Vignette #1
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BT was recently admitted for fever, bloody diarrhea
and following colonoscopy diagnosed with
inflammatory bowel disease. He was admitted,
placed on IV antibiotics and high dose
corticosteroids. His medical condition improved and
he was discharged. However, soon after returning
home, his wife calls in the middle of the night. She
found her husband up wandering around. He
appears confused, agitated and reports he hears the
voice of God telling him to prepare to become the
next Messiah. His wife asks what she should do.
Case Vignette #2
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BF is a 72 year old women who lives
alone. Her daughter brings her in for
evaluation after she is noted to be more
disorganized and agitated. She has told
her daughter that her purse and money
have been stolen. She also reports
seeing small miniature men sneaking
into her apartment and taking her things
during the evening.
Case Vignette #3
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You are asked to evaluate a 40 year old man
admitted to the hospital for fever and abdominal pain.
He resides in a nursing home and has had several
weeks of LLQ pain and a 20 pound weight loss. He
has required residential care since age 22 due to a
mental disorder. He refuses to have any blood drawn
or other other diagnostic procedures. He states he
feels his doctors are conspiring to kill him and inject
him with the AIDS virus. A surgeon recommends
surgical exploration for his clinical presentation and
asks you to proceed with what is necessary to
accomplish this.
Common signs & symptoms
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Disturbances of perception & cognition
– hallucinations: auditory, visual, tactile,
olfactory, gustatory
– delusions: paranoid, somatic, grandiose,
religious, nihilisitic
– First rank delusions: thought broadcasting,
withdrawal, thought insertion, passivity
– thought disorder: derailment, blocking,
tangentiality, perseveration
Common signs & symptoms II
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Disturbances of behavior and motor fx
– psychomotor agitation or retardation
– aggressive verbal or motor behavior
– catatonia: immobility, mutism, waxy
flexibility, posturing, sterotypy
– bizarre behavior/social deterioration
– avolition: lack of goal directed activity
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Disturbances of affect: flat/ anhedonia
National Comorbidity Survey
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One or more psychosis screening
questions endorsed by 28.4% (CIDI)
Lifetime prevalence rates for narrowly
defined psychotic illness 1.3%
Lifetime prevalence rates for more
broadly defined psychotic illness 2.2%
National Comorbidity Survey
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Clinicians then reviewed the positive
screened cases using CIDI interview
and interviewed patients/reviewed
records
Lifetime prevalence rates for narrowly
defined schizophrenia 0.2%
Lifetime prevalence for more broadly
defined schizophrenia was 0.7%
Workup for new-onset psychosis
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History and physical
Psychiatric evaluation
General medical evaluation: chemistry
panel, ABGs, CBC, thyroid function,
HIV, Lumbar puncture, EEG
Urine drug screen
Brain imaging: CT/ MRI
Medical Causes for Psychosis
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Delirium with psychotic features:
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I nfectious
W ithdrawal
A cute metabolic
T rauma
C NS pathology
H ypoxia
D eficiencies
E ndocrinopathy
A cute Vascular
T oxins
H eavy metals
encephalitis
alcohol
acidosis, hepatic failure
head trauma
stroke, vasculitis
pulmonary embolus
vitamin
hypoglycemia
hypertensive encephalopathy
medications, pesticides, solvents
lead, mercury
Psychosis in Dementia
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Psychotic symptoms common in
Alzheimers and other dementias
May involve perceptual disturbances
and interact with memory impairment
Often accompanied by agitation,
wandering, aggression
Can significant contribute to functional
deterioration
Substance-induced psychosis
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Stimulants: Cocaine/Amphetamines
– Often with paranoid delusions
– Can also include auditory and tactile
hallucinations
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Hallucinogens: LSD/PCP/Psilocybin
Alcohol Withdrawl
– Often includes visual hallucinations
Medication-induced psychosis
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Paranoid and other delusions:
– acyclovir, cephalosporins, cimetidine,
corticosteroids, dopamine agonists
(levodopa), theophylline
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Hallucinations
– anticholinergics, calcium channel blockers,
cimetidine, dopamine agonists,
indomethacin, phenytoin
Psychosis due to mood disorder
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Depression
– may include
hallucinations and
delusions
– delusions tend to
match the mood
state: I.e having
committed terrible
sin, being worthless
and doomed to hell
or death
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Mania
– may include
hallucinations and
delusions
– delusions tend to be
grandiose, religious,
and bizarre: I.e.
becoming a famous
person or religious
person
Primary psychotic disorders
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Schizophrenia: chronic hallucinations or
delusions lasting 6 months, lifetime
prevalence of about 1%, variable course
but often progressive and disabling
Schizophreniform disorder: like
schizophrenia but less than 6 months
Schizoaffective disorder: major mood
disorder plus psychosis during periods
of remission from mood symptoms
Non-affective Psychoses:
Definitions
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Schizophrenia
Schizophreniform disorder
Delusional disorder
Atypical Psychosis
Diagnosis: Schizophrenia
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A. Two or more of following x 1 month
– delusions
hallucination
– disorganized speech
negative sx
– disorganized or catatonic behavior
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B. Social/Occupational Dysfunction
C. Duration of A/B at least 6 months
D. R/O schizoaffective, psychotic mood,
substance abuse, gen medical cond.
Prevalence Rates-Schizophrenia
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Article
Criteria
– Eaton
pre-DSM
– Eaton (2) pre-DSM
– Levav
SAD/RDC 6 mo
– Kessler
– 1. (NCS)
SCID/DSM-IIIR
– non-affective psychoses rate
Rate/100
2.7
3.7
0.7
0.1
0.7
Prevalence Rates-Schizophrenia
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Environmental Catchment Area Study
– Diagnostic Interview Schedule(DIS)
– Lay interviewer measure
– Only 20% agreement with psychiatric
evaluation
– ECA not a suitable source of information to
estimate the prevalence of schizophrenia
Prevalence Rates Schizophrenia
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Assuming most accurate survey in the
NCS the in Tulsa SMA (750,000)
Estimates of number of patients with
schizophrenia would range from 750 to
5000
Community centers where services
provided tend to increase prevalence
rates
Risk Factors-Schizophrenia
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Social Class
Gender and Age
Marital Status
Season of Birth
Pregnancy & Birth Complications
Substance Abuse
Genetic Factors
Social Class
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Low social class increases risk
Hypotheses
– Environmental factors associated with low
SES cause schizophrenia
– Selection-drift hypothesis-failure to attain
social rank or downward drift
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Several studies support selection-drift
hypothesis
Social Class-ECA
9
8
7
6
5
High
2
3
Low
4
3
2
1
0
Odds Ratio
Education-NCS
2.5
2
0-11
12
13-15
16 or greater
1.5
1
0.5
0
Odds Ratio
Gender and Age
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Very similar gender rates
Some evidence male predominance
– males may have higher severity
– seek admission and treatment earlier
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Some support for higher rates of men in
younger populations (under 35 years)
and higher rates for women in older
populations
Marital Status
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Risk ratio for nonmarried vs married
individuals ranges from 2.6 to 7.2
Women are more likely to be married
than men (30 % vs 10%)
Some of this may be due to later onset
or milder forms of the illness in women
compared to men
ECA-Marital Status
3
2.5
2
Married
Single
Divorced
Widowed
1.5
1
0.5
0
Odds ratio
Risk Factors: Season of Birth
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A number of studies have reported that
the proportion of patients with
schizophrenia born during winter is 5 to
15 % greater than expected
Higher proportion in those without a
family history of schizophrnenia
Has not been linked to specific viral
infections
Pregnancy & Birth Complication
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Studies inconsistent looking at a variety
of PBCs (I.e. bleeding, low APGARs)
PBCs are associated with abnormal
brain structure by MRI
PBCs may be potentiator of risk in those
with genetic predispositon to schiz
PBCs may be indicator of fetal viral inf
PBCs occur more commonly in low SES
ECA Substance Abuse
Comorbidity
35
30
25
Alcohol Dep
Alc Abuse/Dep
Drug Dep
Drug Abuse/Dep
20
15
10
5
0
Rate %
Substance Abuse
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Large Swedish study showed cannabis
use (more than 15 x) increased risk of
schizophrenia 6 x
Cannabis associated psychosis
associated with FH schizophrenia
Also some interest in LSD and other
hallucinogens role in initiation
Definition: Delusional Disorder
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A. Nonbizarre delusions of 1 month
B. Criterion A for schizophrenia not met
C. Function not markedly impaired
D. No prominent mood disorder
E. Not due to substance or GMC
Subtypes: erotomanic, grandiose,
jealous, persecutory, somatic, mixed
Course & Prognosis
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Community sample groups often have
better prognosis than those collected in
hospital samples
Still overall high rates of chronicity
Worse than affective psychoses
Poor Prognosis
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Male
Unmarried
Family history of schizophrenia
Long duration of symptoms before RX
Few positive sx/Many negative sx
Noncompliance
Substance abuse comorbidity
Case Vignette #1
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BT was recently admitted for fever, bloody diarrhea and
following colonoscopy diagnosed with inflammatory bowel
disease. He was admitted, placed on IV antibiotics and high
dose corticosteroids. His medical condition improved and he
was discharged. However, soon after returning home, his wife
calls in the middle of the night. She found her husband up
wandering around. He appears confused, agitated and reports
he hears the voice of God telling him to prepare to become the
next Messiah. His wife asks what she should do.
Case Vignette #2

BF is a 72 year old women who lives
alone. Her daughter brings her in for
evaluation after she is noted to be more
disorganized and agitated. She has told
her daughter that her purse and money
have been stolen. She also reports
seeing small miniature men sneaking
into her apartment and taking her things
during the evening.
Case Vignette #3

You are asked to evaluate a 40 year old man
admitted to the hospital for fever and abdominal pain.
He resides in a nursing home and has had several
weeks of LLQ pain and a 20 pound weight loss. He
has required residential care since age 22 due to a
mental disorder. He refuses to have any blood drawn
or other other diagnostic procedures. He states he
feels his doctors are conspiring to kill him and inject
him with the AIDS virus. A surgeon recommends
surgical exploration for his clinical presentation and
asks you to proceed with what is necessary to
accomplish this.
Typical Antipsychotics
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Phenothiazines (aliphatic)
– chlorpromazine (Thorazine)
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Phenothiazines (piperidine)
– thioridizine (Mellaril)
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Phenothiazines (piperazine)
– fluphenazine (Prolixin)
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Butyrophenone-haloperidol (Haldol)
Thioxanthene-thiothixene (Navane)
Atypical Antipsychotics
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Clozapine (Clozaril)
Olanzapine (Zyprexa)
Risperidone (Risperdal)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega)
Psychosis: Acute Management
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Haloperidol 2 to 5 mg IM q 30 minutes
until agitation/psychosis is controlled
Can alternate with lorazepam 1 to 2 mg
IM or IV for a synergistic sedative effect
Haloperidol has been administered IV
for rapid control, however this is not
approved by FDA and probably best
done with cardiac monitoring
Psychosis: Chronic management
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Typical antipsychotics: chlorpromazine,
fluphenazine, haloperidol--all have significant
rates of dystonic reactions, Parkinsonian
symptoms & tardive dyskinesia
Haloperidol/Prolixin decanoate forms
Atypical agents: Clozapine, olanzapine,
risperidone, quetiapine & ziprasidone,
palliperidone