Transcript Psychotic Disorders

LECTURE TITLE :
PSYCHOTIC DISORDERS
Level : 4th year Medical Students
Course : 462 Psych.
Lecturer :
Prof. Mohammed Alsughayir
Consultant Psychiatrist
‫أد محمد بن عـبدهللا‬
‫الصغـيّر‬
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LECTURE OBJECTIVES
Knowledge
SUBSTANCE-INDUCED
AttitudePSYCHOSIS.
Skills
PERSONALITY
DISORDERS RELATED TO PSYCHOSIS.
What “Psychosis”
mean.
Positive attitude toward How to detect
Psychopathology of Psychosis.
Various Types of Psychotic Disorders.
1. Patients with psychotic
illnesses.
psychotic
features.
Focus on :
* Schizophrenia.
2. Antipsychotic Rx.
*Substance-Induced Psychosis.
*Personality Disorders related to
psychosis.
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CASE SCENARIO;
Ahmed is a 28-year-old single man was brought by his father to
Emergency Department with 7 months progressive history of :
1. Talking to himself with giggling and grimacing.
2.Staring at the roof of his room.
3.Over-suspiciousness ( e.g. his family may poison his food).
4.Agitation.
Past history:
Several psychiatric hospitalizations because of
disturbed behavior and perception(hearing non-existent
distressing voices commenting on his action).
Personal history :
Delayed development compared to his siblings.
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Psychotic Disorders
What is madness?
Mental illnesses characterized by :
gross impairment in reality testing and personal functioning.
Mental Function
Examples of Defects
Behavior
Abnormal movements/posture/smile/laughter…
Perception
Hallucinations
Thinking
Delusions /concrete thinking/loose association
Insight
Denial of mental illness
Judgment
Reckless/dangerous decisions
Not all mental functions are defected in all patients.
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PSYCHOPATHOLOGY




Delusions:
= False Fixed Beliefs.
Not arrived at through logic thinking.
Not amenable to reasoning.
? Cultural background.
Common Delusions;
Delusion Of
Reference
some events refer to oneself in particular (TV, newspapers).
( idea of reference >>>>>>>>>>> delusion of reference)
Paranoid D.
being persecuted (mistreated, followed for harm etc.).
Grandiose D.
exaggerated self-importance, power or identity.
Delusion of Influence Action , feeling ,Thinking :
(of control )*
withdrawal/broadcasting/insertion/reading.
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HOW TO DETECT DELUSIONS
Clinical Skills
Ask the patient; Do you think that :
- some events or others' behavior refer to you in particular?
- someone is persecuting you/following you for harm?
- you have a special power, ability, or identity?
- your actions, emotions, or thoughts are being forced on you by someone
else? -If yes, tell me more about that?
- someone is putting thoughts into your head or taking them away?
- your thoughts can be transmitted to others in some way?
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PSYCHOPATHOLOGY
Concrete Thinking:
Impaired ability to deal with concepts and
to make appropriate inferences.
It can be tested by:
1.Similarities & difference:
Tell me the similarity between "car and
train". Tell me the difference between
" book and notebook".
2. Proverbs: ask patient to interpret one
or two proverbs.
Formal Thought Disorders:
(Abnormal Thought Link )
1.Loosening of Associations:
Lack of logic connection between
**
thoughts seen inSkills
chronic
schizophrenia.
2.Flight of Ideas:
Successive rapidly shifting
incomplete ideas but with an
understandable link, seen in
mania and stimulant intoxication.
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PSYCHOPATHOLOGY
Judgment:
Capability for making appropriate
decisions.
Insight:
The degree of awareness and understanding
patient has that he or she is mentally ill.

It can be tested by:
What would you do if you smelled
smoke in a crowded place?
or
What would you do if you found a
stamped addressed envelope
on the street?
Do you believe that you have abnormal
experiences?

Do you believe that your abnormal
experiences are symptoms of illness?

Do you believe that the illness is psychiatric?

Do you believe that psychiatric treatment
might benefit you?
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PSYCHOPATHOLOGY

Hallucinations:
Imagined perception of nonexistent things.
(in the absence of real external stimuli).
You are
…
Visual
2nd Person
Somatic
Auditory
3rd Person
Tactile
He is….
Olfactory
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HOW TO DETECT AUDITORY HALLUCINATIONS
Clinical Skills
Ask the patient;
1-While fully awake, do you hear voices of someone when actually
nobody is speaking around you? How many voices you are hearing?
2- How do the voices refer to you (e.g., as “you” or “him/her”)?
3- Are they commenting on what you are doing? Or discussing you
between themselves?
4- Tell me about your reaction to the voices.
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PSYCHOTIC DISORDERS
1. Organic Psychosis
Medications (e.g. steroids , bromocriptine , L-dopa) /
Autoimmune D. (e.g. SLE)/brain pathology(e.g.
delirium,dementia,TLE)/ Substances of abuse (see later)
2. Brief Psychotic Disorder Psychosis for < 1 month (more in pts with Personality Dis.).
Can be reactive to certain stressors or postpartum. √
3. Schizophreniform
Psychosis for 1 - 6 month. √
4. Schizophrenia
Psychosis for > 6 month (see later).
1 month
2.Brief Psychotic Disorder
> 1 ----------------------- 6 months
3.Schizophreniform
> 6 months
4.Schizophrenia
5 . Affective Psychosis
Psychotic features with mania or severe depression. √
6. Schizoaffective
Schizophrenia features + affective disturbance. √
7.Delusional Disorders
≥ 1 month prominent delusion (nonbizarre – systematized)
Functioning is much less affected. √
Many types (paranoid- grandiose ….. ).
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Diagnostic Criteria for SCHIZOPHRENIA
A-Minimum duration of 6 months disturbance
(including the prodromal and residual phases).
B-At least 1 month period of psychotic features, during which
2 out of 5:
1.Delusions.
2. Hallucinations. 3.Disorganized speech (e.g.
incoherence). 4-Catatonic features or disorganized behavior.
5.Negative features (e.g. flat affect).
C- Significant functional impairment (social, academic. etc.)
D-Exclusion of other psychotic disorders (see the ddx).
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SCHIZOPHRENIA
Acute
Presence of active/positive features :
Prominent Hallucinations:
Chronic
Presence of negative features :
Social withdrawal.
Poor self-care and hygiene.
(3rd or 2nd but with derogatory content)
Lack of initiative and ambition.
Disorganized thinking and speech.
Poverty of thought and speech.
Prominent Delusions (paranoid - bizarre).
Disturbed behavior +/- aggression.
Restricted or apathetic affect.
Cognitive deficit .
Less prominent delusions/hallucinations.
Incongruity between affect ,thinking ,and
behavior.
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EPIDEMIOLOGY OF SCHIZOPHRENIA
Prevalence : worldwide life time prevalence is about 1 %.
Incidence :
-About 20 per 100,000 per year.
-Worldwide, 2 million new cases appear each year.
-The lifetime risk of developing schizophrenia is about 1%.
Age:
-Most common between age 15 - 35 years.
-Paranoid type: later onset than other types.
Sex:
- Sex ratio is 1 : 1
- Median age at onset: Males = 28 years, Females = 32 years.
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ATTITUDE ISSUES
Ahmed’s mother said to the attendant physician :
” I believe that Ahmed’s mental illness is due to either black magic or devil
possession - faith healer opinion- , please don’t give him psychotropic
medications”
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ETIOLOGY OF SCHIZOPHRENIA

Multifactorial / Biopsychosocial
Genetic: Mono-dizygotic twin concordance rate (50 % , 15 % respectively).
Neurobiological : several hypotheses (DA - 5HT – GABA - Glutamate).
Neuropathology and Neuroimaging: Abnormal structure and metabolism in
frontal, parietal and temporal lobes.
Psychosocial and Environmental:
Life stressors - High Expressed Emotions (EE) of the family.
** Culture Attitude & Practice related to etiology :
Social Stigma .
Supernatural causes > exorcism /physical abuse.
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Source: Schizophrenia.com
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Source: Laboratory of Neuro Imaging, UCLA
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SUBTYPES OF SCHIZOPHRENIA
1. Paranoid Schizophrenia.
2. Catatonic Schizophrenia.
3. Disorganized Schizophrenia.
4. Undifferentiated Schizophrenia (1+3).
5. Residual Schizophrenia.
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MANAGEMENT OF SCHIZOPHRENIA
Bio-psycho-social approach / Multidisciplinary team.
Hospitalization
Indications:
-Clarify diagnosis .
- Control the disturbed
behavior.
- Protect patient/others
Medications
Psychosocial
First Generation Antipsychotics
e.g. haloperidol,clopixol, sulpride:
-Social skill training (e.g.
for positive psychotic features (delusions,
self-care).
hallucinations, agitation), but >> EPSE.
Second generation Antipsychotics
e.g. olanzapine,risperidone,clozapine:
(risk of dangerousness or
for both positive and negative symptoms of
suicide)
psychosis and can help some resistant cases but
-Give ECT* for resistant
>> metabolic syndrome .
cases ,catatonic type, and
Depot Injections :
those with concomitant
in poor compliance
e.g. clopixol depot , risperdal consta.
depression.
-Illness-management
skills (e.g. when to take
medication)
- Vocational rehabilitation
(for more stable cases).
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TYPICAL ( FGA)
ATYPICAL ( SGA)
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Atypical ( SGA)
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Source: Schizophrenia.com
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ANTIPSYCHOTICS ; MECHANISM OF ACTION:
A- Therapeutic effects:
B – Adverse effects:
1. In mesolimbic tract;
1. In nigrostriatal tract; EPSE
postsynaptic blockade of D2 reduces
positive psychotic features.
2. In mesocortical tract;
Atypical antipsychotics act on dopamine
DA
Ach
2. In tuberoinfundibular tract;
HT
DA
dopamine inhibits prolactin
and serotonin receptors to improve
Release from the anterior
negative symptoms (which arise due to
pituitary. Antidopaminergics
either low DA or high 5HT that inhibits DA)
induce excessive prolactin
secretion.
APit
Prolactin
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Extra-Pyramidal Side Effects (EPSE)
oculogyric crisis
1- Acute dystonia:
appears within days after
Rx. Severe painful spasm of neck muscles
(torticollis), ocular muscles (oculogyric crisis)
muscles of the back (opisthotonus) and tongue
protrusion. Treated with anticholinergic drugs
(e.g. procyclidine 5 – 10 mg IM or P.O.).
2- Parkinsonism:
Torticollis
Tongue
protrusion
appears within weeks after
treatment, its features: stooped posture,
akinesia, muscle rigidity, masked face, and
coarse tremor. Treated with anticholinergic
drugs (e.g. procyclidine)
Opisthotonus
‫شد وألم شديد في‬
‫عضالتي من المسؤول‬
DA / Ach?
.‫عالجوني بسرعة‬
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Extra-Pyramidal Side Effects (EPSE)
3- Akathisia :
Inability to keep still + unpleasant feelings of inner tension.
Appears within days – weeks.
Generally disappears if the dose is reduced.
Benzodiazepine or beta-blockers may help
in the treatment, whereas anticholinergics
have no therapeutic effect.
4- Rabbit Syndrome:
Rapid perioral tremor.
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5- Tardive Dyskinesia:
It occurs in about 10 – 20 % of patients
on long-term antipsychotics for several
years. Features: chewing, sucking or
choreo-athetoid movements of the facial
neck and hand muscles.
Super-sensitivity of dopamine receptors.
No specific treatment, the only agreed
treatment is to discontinue the
antipsychotic drug when the patient’s
state allows this.
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ANTIADRENERGIC
Postural hypotension.
ANTICHOLINERGIC
Blurred vision
Precipitation of closed – angle glaucoma.
Dry mouth.
Constipation .
Urinary retention.
Inhibition of ejaculation.
Poor erection.
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Metabolic syndrome
( with atypical Rx)
Others:
Hyperprolactinemia.
The syndrome is diagnosed when a patient
has three or more of the following five risk
factors:
(1) abdominal obesity,
(2) high triglyceride level,
(3) low HDL cholesterol level,
(4) hypertension.
Galactorrhea.
Amenorrhea.
Low libido.
Sedation
(antihistamine effect).
Weight gain.
(5) an elevated fasting blood glucose level.
Toxic Effect:
It increases risk of cardiovascular disease
Neuroleptic Malignant Syndrome (NMS)
and type II diabetes.
see Psychiatric Emergencies.
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Clozapine
It is indicated for :
1-Resistant psychosis not responding to traditional antipsychotics.
2-Schizophrenia with negative features.
3-In patients who cannot tolerate the adverse effects associated with those
drugs.
It has serious side effects (neutropenia and agranulocytosis) therefore, regular
blood tests are required. These are not dose dependent. Risk is about 2%.
Others side effects : seizure , sedation, weight gain, sialorrhea, hypotension,
constipation and tachycardia (all are dose dependent)
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COURSE OF SCHIZOPHRENIA

Patient may recover from the active psychotic phase but
complete return to normal level of functioning is very unusual.

The common course is one of acute exacerbations with
increasing residual impairment between episodes.

The longitudinal course is that of downhill nature (disintegration
of personality and deterioration of mental abilities and
psychosocial functioning).
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PROGNOSIS OF SCHIZOPHRENIA
Good Prognostic Factors
Bad Prognostic Factors
Late onset
Young age at onset
Acute onset
Insidious onset
Obvious precipitating factors
No precipitating factors
Good premorbid personality
Poor premorbid Personality / Low IQ
Presence of mood symptoms
Many relapses
(especially depression)
No remission in 3 years
Presence of positive symptoms
Poor compliance
Good support (married, stable family)
Negative symptoms
Poor support system
Family history of schizophrenia
High EE family
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BACK TO AHMED ;
CASE DEVELOPMENT 1
Drug history:
Ahmed had frequently abused both
1. Amphetamine.
2. Cannabis (hash)
He developed brief
paranoid ideas
towards his
brothers.
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STIMULANT-INDUCED PSYCHOTIC DISORDER
(AMPHETAMINE–COCAINE )
Main features
-- Overconfidence > grandiosity.
- Hyperactivity +/- euphoria.
-Suspiciousness .? paranoid delusion.
-Confusion and incoherence,
-Hallucinations (visual > auditory).
Treatment
-Inpatient setting .
-symptomatic use of an antipsychotic
medication e.g. olanzapine 10-20mg. For
4- 6 months )
-Psychotherapeutic methods (individual,
family, and group psychotherapy) are usually
necessary to achieve lasting abstinence.
However , it can be indistinguishable from schizophrenia, and only the resolution of the symptoms
in a few days or a positive finding in a urine drug screen test eventually reveals the diagnosis.
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CANNABIS-INDUCED PSYCHOTIC DISORDER
Main features
-Transient paranoid ideation is more common
than florid sustained psychosis .
-Features may be correlated with a preexisting
personality disorder.
-Impaired memory.
Treatment
- Usually out-patient .
- Short-term symptomatic use of an
antipsychotic medication (e.g.
risperidone 2- 4 mg /day for 4- 6
months )
-Impaired psychomotor performance.
+Reddening of the conjunctiva.
+Respiratory tract irritation.
Chronic use of cannabis can lead to a state of apathy and amotivation (amotivation
syndrome) but this may be more a reflection of patient’s personality structure than an
effect of cannabis.
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WHAT KIND OF PERSON AHMED WAS? CASE DEVELOPMENT 2:
Premorbid History:
As described by his family, Ahmad's prominent characters include:
1.
A chronic sense of insecurity and suspiciousness towards others.
2.
2. Difficulties in initiating and maintaining relationships.
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PERSONALITY DISORDERS
Life long pervasive disturbances in interpersonal relationships
/behavior/emotional reactions/ adaptation to stress/or impulse control.
 Lead to functional impairment /significant distress.
Age : > 18 years (21 years).
Not due to other causes.
Cluster A (Odd thinking)
1-Schizoid .
2-Paranoid .
3- Schizotypal.
Cluster B (Dramatic behavior)
1- Borderline.
2-Antisocial.
3-Narcissistic .
4- Histrionic.
Cluster C ( Fearful )
1-Avoidant .
2.Dependent .
3.Obsessive
Compulsive.
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CLUSTER A ( >> ?! Psychosis))
1-Schizoid
- Social isolation with
-Self-sufficiency
-Indifference to praise,
criticism and feelings of
others.
- Choosing solitary activities
and jobs.
- Poor social skills.
-Defense Mechanism:
Fantasy.
Treatment:
Psychotherapy +
Antipsychotics.
2-Paranoid
3- Schizotypal
-Excessive mistrust
/suspiciousness of others’
motives even friends /
associates without
sufficient basis.
-Exaggerated bearing of
grudges persistently (e.g.
insults, slights, injuries).
Defense Mechanism:
Denial – Projection .
- Odd patterns of thinking,
Treatment:
Psychotherapy +
Antipsychotics .
speech, belief, behavior or
appearance compared to
the social norms.
-Unusual perceptual
experiences (e.g. bodily
illusions).
-Superstitious or claim
powers of clairvoyance.
--Idea of reference.
Defense Mechanism:
Several …
Treatment:
Psychotherapy +
Antipsychotics .
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REVIEW – SUMMARY OF PSYCHOTIC DISORDERS
1. Signs & Symptoms
Thought disorders.
Perception disorders.
2. D Dx.
1.Brief P D (1 m).
Functional Psychosis
2.Schizophreniform (>1 -6 m).
3.Schizophrenia ( > 6 m ):
[ C/F – types- epidemiology-etiology-Rx- Prognosis].
4.Affective Psychosis.
5.Schizoaffective
6.Delusional Disorders
Drug-induce Psychosis
Stimulants – Cannabis.
Personality Disorders
Cluster A ( schizoid – paranoid – schizotypal ).
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ASSESSMENT
A 23 year-old single woman has 9-month history of self-neglect, flat
affect, social isolation and inappropriate smiles. The following is the
most appropriate statement:
a. She has a neurotic illness.
b. An atypical antipsychotic drug is indicated.
c. The most likely diagnosis is brief psychosis.
d. She is likely to be a case of schizophreniform disorder.
e. She has features suggestive of delusional disorder.
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