Lecture 8: Psychotic Disorders

mental health notes 8ectfre :2 1/&1 Psychotic Disorders Psychosis N Schizophrenia bharacteristics Psychosis DeFning ueatfres oC Schizophrenia Schizophrenia Epidemiology/Etiology Organic Psychosis Positive Symptoms 1pidemiology Many medical causes of psychosis ex. Syphilis, HIV/AIDS, hepatic/renal dz, traumatic brain injury, brain tumor, hypoglycemia, multiple sclerosis, lupus, Alzheimers, Parkinson's Substance-induced psychosis 25-50% of people with marijuana-induced psychosis go on to develop schizophrenia May uncover latent schizophrenia Delusions Hallucinations (eneral population prevalence of schizophrenia is )% worldwide Disorganized thinking: Inferred from speaking Males: 1arlier onset F)5-253 (rossly disorganized/abnormal motor behavior Nemales: Later onset F25-T53 Jegative Symptoms Most common in schizophrenia Gognitive Impairment 1tiology Biological factors: (enetics Neurobiological: Dopamine theory Avoid cannabis if family history or S/S Stimulants: Methamphetamine, cocaine Hallucinogens: MDMA, LSD, psilocybin Dissociative agents: Ketamine Psychiatric Diagnoses Schizophrenia Delusional disorder Brief psychotic disorder Schizophreniform disorder Other neurochemical hypotheses bomorvidities Substance abuse disorders Jicotine dependence: Antipsych interaction Anxiety Perionality disorders Brain structure abnormalities: Decreased brain volume, enlarged ventricles Prenatal stressors Immune system overactivation Psychological and environmental stressors Depression Physical illness SchizoaUective disorder CnspeciEed schizophrenia spectrum and other psychotic disorder Gatatonia associated with another disorder Psychosis as a feature of another mental illness bofrse N Symptoms bofrse oC Schizophrenia PositiLe Symptoms bognitiLe Symptoms Premorbid phase Alterations in reality-testing and thinking Prodromal: ) month-year or more prior to onset Delusions: Nalse, Exed beliefs Attention, memory Isolation Persecution/paranoia Information processing Irritability Ideas of reference Gognitive in_exibility Suspiciousness and vague thought issues (randeur Psychomotor functions Misinterpretation of stimuli Ffacial expressions and social cues3 Gontrol Onset of full psychosis: Almost always between ages )5-T5 Prognosis: Lifetime illness with episodic/recurrent nature Rhe cancer of psychiatry Intervening early may help to reduce symptoms in biologically vulnerable individuals Somatic delusions 1rotomanic MIectiLe Symptoms Wealousy Mood ;eligiosity Depressed Magical thinking 1lated, euphoric Goncrete thinking Cnstable, erratic, hostile Gircumstantial Incongruent Rangential AegatiLe Symptoms Alterations in aUect Nlat, blunted, constricted Inappropriate, bizarre Alogia: Poverty of thought Poverty of speech or content Avolition: Loss of motivation Anhedonia: Inability to experience pleasure/joy Apathy: IndiUerence and disinterest Asociality: Disinterest in socializationZ solitude Anergia: Lack of energy DiQculties Assessment for Depression Perseveration GrucialZ further impairment of functioning Rhought broadcasting May herald impending relapse Alterations in Speech Loose associations Increased substance misuse Increased suicide risk Glang associations &ord salad Jeologisms Alterations in Perception Depersonalization Derealization Hallucinations Auditory Fcommand3 Visual Ractile Mggression N Mnosognosia Aggression Pts with schizophrenia are more likely to be victims of violence SCD and violence are much better predictors of violence than schizophrenia Anosognosia Medication nonadherence Olfactory, gustatory bonCronting SeLere (ental )llnesses TS()Ghallenge establishing a meaningful life Gomorbid Gonditions Physical disorders Depression and suicide Substance abuse Social Issues Stigma Isolation and loneliness Victimization Alterations in Behavior Motor retardation Motor agitation Stereotyped behaviors &axy _exibility Phases oC Schizophrenia Phase I: Acute Phase II: Stabilization Phase III: Maintenance 1chopraxia Jegativism Impaired impulse ctontrol (esturing or posturing Boundary impairment 1conomic Ghallenges Cnemployment, poverty Housing instability Garegiver burden Rreatment Issues Jonadherence, anosognosia Medication side eUects ;esidual symptoms ;elapse, chronicity, and loss Pharmacological )nterLentions DopamineR1 eceptor Mntagonists2 Bypical Rypical FNirst-(eneration3 Antipsychotics )nterLentions N Breatment )nterLentions Acute Phase S()2 ELidenceR ased Breatment Assertive community treatment FAGR3 Psychiatric, medical, and neuro evaluation Gognitive behavioral therapy FGBR3 Psychopharmacological treatment Gognitive enhancement therapy FG1R3 Support, psychoeducation, and guidance Namily support and partnership Supervision and limit-setting in the millieu Social skills training Meet basic needs FMaslow's hierarchy3 Supportive psychotherapy Involve family as appropriate Vocational 444 and related services Stabilization q Maintenance Phases ;educe likelihood of relapse Haloperidol FHaldol3 ;elationships with trusted ones Nluphenazine FProlixin3 Medication administration, promote adherence Rhithixene FJavane3 Psychological treatments Rri_uoperazine FStelazine3 1ducation and support Perphenazine FRrilafon3 Gommunity-based therapeutic services Ghlorpromazine FRhorazine3 ;ecovery model of care Rhioridazine FMellaril3 (oal of Rherapy Rarget positive symptoms of schizophrenia Pharmacological )nterLentions Advantages Less expensive than second generation Less risk for metabolic side eUects Disadvantages 1xtrapyramidal side eUects F1PS3 Anticholinergic side eUects Rardive dyskinesia &eight gain, sexual dysfunction, endocrine disturbances DMR1 eceptor Mntagonists2 Mtypical MntiREPS (edications Atypical F2nd/Trd (eneration3 Antipsychotics Anticholinergics ;isperidone F;isperidol3 Olanzapine F9yprexa3 Lurasidone FLatuda3 7uetiapine FSero>uel3 Benztropine FGogentin3: )-8 mg Antihistamines Diphenhydramine HG FBenadryl3: 25-200 mg Dopaminergic Agonists Clozapine (Clozaril) Amantadine FSymmetrel3: )00 mg Aripiprazole FAbilify3 Bromocriptine FParlodel3: )0-T0 mg 1xtrapyramidal side eUects F1PS3: Involves neurons traveling through extrapyramidal motor pathways Brexpiprazole F;exulti3 Levodopa FDopar3: 500-)000 mg Akathisia: Restlessness Paliperidone FInvega3 Acute dystonia: Involuntary muscle contractions Asenapine FSaphris3 Dangerofs esponses to Mntipsychotics 9iprasadone F(eodon3 Anticholinergic Syndrome Adverse 1Uects Abnormal movements and postures Tardive dyskinesia: Ghronic, involuntary movement Parkinsonism: Motor S/S found in Parkinson's Rremor, bradykinesia Fslowed movements3, rigidity, and postural instability Illoperidone FNanapt3 Gariprazine FVraylar3 Advantages Never Nlushed skin Newer 1PS and generally well-tolerated Mydriasis Rarget both negative and positive symptoms Dry mouth, dry eyes, and decreased sweating Often chosen as Erst-line treatment Delirium Disadvantages Metabolic symptoms: Increased risk associated with dosing &eight gain Insulin resistance and R2DM Hyperglycemia, obesity, HLD, HRJ Potentially sedation Crinary retention Jeuroleptic Syndrome FJMS3 Only occurs after exposure to a neuroleptic medication Fantipsychotics3 <0% of cases occur within )0 days after drug tx initiation, but possible after many years Csually evolves >uickly F28-^2 hours3 Gardinal features: Severe muscular rigidity Hyperthermia F T G3 Autonomic instability Ghanges in LOG Agranulocytosis Primarily a concern with clozapine )% of patients Almost always within T months of tx start Jo speciEc S/S other than infection Blood monitoring is necessary Medication should be stopped if &BG drops below T.0 x )0