PSYCHOSES PSYCHOSES Symptoms Delusions Hallucinations

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PSYCHOSES
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PSYCHOSES
Jon Lehrmann MDAssistant Professor of
PsychiatryMedical College of WIVAMC Milwaukee,
WI
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Symptoms

• Delusions
• Hallucinations- Auditory, Visual, Olfactory, and
  Tactile
• Losing Sense of Reality
• Disorganization of Thought
• Thought Blocking

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• Bob! Wake up! Bob! A ship! I think I see a
  shipWhere are your glasses?

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Causes of Psychosis

• Functional vs Organic?
• Primary vs Secondary?
• Secondary/ Organic psychoses secondary to
  medical conditions, substance intox or w/d, or
  focal brain lesions
• Functional/Primary psychoses originating from
  psychiatric illness (Schizophrenia, Major
  Depression, Bipolar Dis or Schizoaffective
  Disorder)

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Neurochemistry of Psychosis- the Dopamine
Hypothesis

• Excess of Dopamine activity in Mesolimbic region
  of the brain
• This is supported by 2 major findings- first
  neuroleptics block D2 receptors and improve sxs
  of psychosis, and second, amphetamines which
  increase DA transmission can provoke psychotic
  states.

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A Psychosis is a Psychosis

• You cannot clearly make a diagnosis of the
  underlying causative illness based upon the
  psychotic sxs alone- but there are clues.
• Look at the course of the illness.
• Look for Family Hx.

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Primary Psychoses

• Schizophrenia
  
  
  
• Major Depression
• Bipolar Disorder
• Schizoaffective disorder

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Schizophrenia

• Occurs in 1 of population
• Onset usually in Teens and 20s
• Runs strongly in families
• Positive Sxs- depending on type of
  Schizophrenia- Thought disorg, AHs , Paranoia,
  Complicated and fixed delusions
• Negative Sxs

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Major Depression w/ Psychosis

• Lifetime Prevalence 15
• 2X more common for women
• Family Hx?
• Mean age is 40, but can occur at any age
• Depressive sxs
• Mood congruent psychotic sxs

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Bipolar Disorder

• Manic sxs
• Course of illness
• Family hx
• Rare after age of 50 for onset of illness

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Schizoaffective Disorder

• Evidence of mood disorder and
• Evidence of psychotic episodes at times without
  the mood component.

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Biological Treatment of Primary Psychoses

• Schizophrenia antipsychotic
• Bipolar- manic psychosis antipsychotic, mood
  stabilizer, benzodiazepine
• Major Depression w/ psychosis antidepressant
  and antipsychotic
• Schizoaffective disorder Antipsychotic, Mood
  stabilizer, ? Antidepressant.

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Secondary Psychoses

• Delirium
• Brief Reactive Psychosis
• Dementias
• Others...

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Axis II Disorders associated w/ Psychosis

• Stress Predisposition
• Borderline
• Schizotypal
• Treatment includes antipsychotic and psychotherapy

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Delirium-

• 15-25 of patients on general medical wards
  experience delirium, S/P surgery- even higher
  percentages.
• Advanced age and underlying dementia are risk
  factors.
• 1 yr mortality rate for those w/ episode of
  delirium up to 50!
• Recognizing and Treating Delirium is a medical
  urgency.

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Etiologies

• Intracranial Causes
  
  Seizures and Postictal states,
  Brain Trauma
  Neoplasms
  Infections
  
  Vascular Disorders (Vasculitis, CVAs
  etc.)

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Etiologies contd

• Extracranial causes
  Drugs/Medications- toxicity,
  intoxication, and w/d.
  Poisons (Carbon
  Monoxide, Heavy metals) Endocrine dysfunction
  Liver dz, Kidney
  failure, Cardiac failure, Arrhythmias,
  Hypotension, Hypoxia Deficiency dzs

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Etiologies contd

• Systemic Infections
• Electrolyte abnormalities
• Postoperative states
• Trauma

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Treatment of Delirium

• High Potency Antipsychotic
• Supportive Care
• Find and Resolve Causative Factor(s)

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Antipsychotics

• Atypical vs Typical
• High vs Low Potency

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Wait a minute Mr Crumbly. This may not be kidney
stones after all!
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Secondary Psychoses

• NOT PSYCHIATRIC
• ORGANICALLY BASED
• VARIANTS
• PEDUNCULAR HALLUCINOSIS
• CLASSIC CHARLES BONNET SYNDROME
• RELEASE HALLUCINATIONS
• Kathleen Patterson, Ph.D.
• VAMC

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PEDUNCULAR HALLUCINOSIS LHERMITTES SYNDROME
(1922)

• VIVID VISUAL, CHROMATIC, DETAILED, OFTEN MOVING
  (LILLIPUTIAN) FIGURES AND/OR OBJECTS IN THE WHOLE
  VISUAL FIELD
• INTACT VISUAL ACUITY AND VISUAL FIELDS
• DREAMLIKE STATES WITH LUCID MENTATION
• LESIONS IN THE THALAMUS, BRAINSTEM (TUMORS
  COMPRESSING THE BRAINSTEM), AND SUBSTANTIA NIGRA
  PARS RETICULATA
• AURA OF BASILAR MIGRAINE LOCALIZABLE TO THE
  BRAINSTEM AFTER VETEBRAL ANGIOGRAPHY
  MANIFESTATION OF VERTEBROBASILAR INSUFFICIENCY
  D/T SEVERE HYPOPLASIA OF A VETEBRAL ARTERY

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CLASSIC CHARLES BONNET SYNDROME

• FORMED PLEASANT OR NEUTRAL, NONTHREATENING VISUAL
  HALLUCINATIONS IN OLDER PERSONS WITH NORMAL
  COGNITION AND INSIGHT 1769
• ? NO MRI OR COMPLEX COGNITIVE TESTING TO R/O
  SUBTLE COGNITIVE DECLINE
• IMPAIRED VISUAL ACUITY
• MORE RECENTLY ALSO DIAGNOSED IN PATIENTS WITH MS,
  FRONTAL AND OCCIPITAL LOBE CHANGES, TEMPORAL
  ARTERITIS, AND PITUITARY TUMORS
• WHY? BRAIN COMPENSATES FOR SENSORY DEPRIVATION

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RELEASE HALLUCINATIONS

• ANY MODALITY BUT VISUAL MOST COMMON DEPENDS ON
  END ORGAN AFFECTED
• NONTHREATENING RECOGNITION THAT THEY ARE NOT
  REAL MAY PROGRESS FROM SIMPLE TO COMPLEX
• ABNORMAL FUNCTIONING OF A LARGE SCALE NEURONAL
  NETWORK
• THESE ARE MUCH MORE COMMON THAN THOUGHT AND
  UNDERREPORTED BECAUSE PEOPLE DO NOT WANT TO BE
  CONSIDERED CRAZY.

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VISUAL RELEASE HALLUCINATIONS

• VISUAL IMPAIRMENT GLAUCOMA, CATARACTS, MACULAR
  DEGENERATION
• LESIONS ANYWHERE FROM THE EYE TO THE OCCIPITAL
  CORTEX
• USUALLY REPETITIOUS AND NONTHREATENING BUT
  IRRITATING
• AWARENESS THAT THEY ARE NOT REAL
• MODIFIED BY CHANGING VISUAL INPUT

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TREATMENT OPTIONS

• ORGANICALLY BASED HALLUCINATIONS ARE USUALLY
  SELF-LIMITING. With either end organ or central
  nervous system changes, they disappear after a
  few days, months, or years. THE FIRST STEP IS TO
  REASSURE THE PATIENT.
• INTERVENTIONS
• CHANGE PATIENTS ENVIRONMENT.
• HASTEN END ORGAN CHANGE, E.G., CATARACT REMOVAL.
• GOOD MEDICAL MANAGEMENT OF CNS RISK FACTORS,
  E.G., HTN, DM, ET AL.
• MEDICATIONS DO NOT ROUTINELY USE CLASSIC
  NEUROLEPTICS.
• PEDUNCULAR HALLUCINOSIS CLOZAPINE
• RELEASE HALLUCINATIONS CARBAMAZEPINE,
  GABAPENTIN, MELPERONE, VALPROATE, CISAPRIDE

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