Psychotic Disorders

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Psychotic Disorders
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Archetype

• Schizophrenia

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Phenomenology

• The mental status exam
• Appearance
• Mood
• Thought
• Cognition
• Judgment and Insight

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Appearance

• Motor disturbances
• Catatonia
• Stereotypy
• Mannerisms
• Behavioral problems
• Hygiene
• Social functioning
• Soft signs

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Mood and Affect

• Affective flattening
• Anhedonia
• Inappropriate Affect

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Thought

• Thought Process
• Content

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Thought Process

• Associative disorders
• Circumstantial Thinking
• Tangential thinking

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Other associative problems

• Perseveration
• Distractibility
• Clanging
• Neologisms

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Thought Content

• Phenomenology
• Thought content
• Hallucinations
• Delusions

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Cognitions

• Subtle impairments
• Frontal lobe function
• Associative thinking

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Positive versus Negative Sxs

• Positive
• Hallucinations
• Delusions
• Bizarre behavior
• Associative disorders

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Negative Symptoms

• Alogia
• Affective flattening
• Anhedonia
• Avolition/apathy

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Epidemiology
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Epidemiology

• 1 prevalence
• Genders
• Age of onset
• Socioeconomic

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Pathology
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Anatomic

• Widened ventricles
• Decreased size certain regions

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Histology

• Abnormalities of cytoarchitecture
• Alignment
• Amount

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Pathology

• Neurophysiology
• Hypofrontality

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More Neurophysiology

• Other neurological changes
• Eye movements
• Blink rate
• Sleep disorders

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Etiology

• Dopamine

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Dopamine Hypothesis

• Metabolites
• Dopamine receptor agonists
• Action of antipsychotics

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Other Transmitters

• Glutamate
• Primary excitatory transmitter
• May relate to glutaminergic tone
• NMDA receptor antagonists
• PCP

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Neurodegenerative theories

• Evidence for cell loss
• Reduced neuronal densities
• Etiology

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Neurodevelopmental Theories

• Abnormalities of cytoarchitecture
• Absence of gliosis

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Genetics

• Genetic Theories
• Family studies
• 1o relatives 5
• Dizygotic twins 10
• Monozygotic twins 50
• Adoption studies
• Greater risk

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Possible Environmental Culprits

• Bad parenting
• Social/economic
• Viral
• Allergic/Antibodies

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Etiology
Function
Neurodevelopment
Genetics
Environment
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Diagnosis
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Diagnosis

• Schizophrenia DSM-IV
• A Criteria
• Psychosis
• Duration
• 6 months
• Global Criteria

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Diagnosis

• A Criteria
• Two or more
• Delusions
• Hallucinations
• Disorganized speech
• Disorganized behavior
• Negative symptoms

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Schizophrenia Subtypes

• Catatonic
• Movement
• Disorganized
• Process
• Paranoid
• Content
• Undifferentiated
• Residual

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Differential

• Delirium
• Dementia
• Medication-induced
• Other Psychiatric Illnesses

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Comorbidity

• Depression
• Substance Abuse

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Course and Prognosis
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Course of Schizophrenia
Premorbid
Prodr.
Acute
Stable/Residual
10
20
30
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Prognosis

• Usually deteriorates
• exacerbations w/ incomplete recovery
• Symptoms change over time

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Outcome
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Positive Predictors

• Acute onset
• Short duration
• Good premorbid functioning
• Affective symptoms
• Good social functioning
• High social class
• Neg fam hx psychotic
• No structural

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Poor Predictors

• Insidious onset
• Long duration
• Family hx of psych illness
• Obsessions/Compulsions
• Assaultive Behavior
• Poor premorbid functioning
• Neurological/anatomic abn.
• Low social class

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Treatment
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Antipsychotic Medications

• Phenothiazines
• Chlorpromazine
• Butyrophenones
• Haloperidol
• Atypicals
• Clozapine

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Antipsychotics

• Mechanism of actions
• Dopamine blockade
• D-2 and analogues

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Antipsychotics Indications

• Acute psychosis
• Prevention of relapse
• Also used in other disorders
• Acute mania
• Anxiety/insomnia
• Aggressive disorders

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Antipsychotics Side Effects

• Anticholinergic
• Extrapyramidal (Parkinsons-like)

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Other effects

• Dopaminergic
• Tardive dyskinesia
• NMS
• Idiopathic
• Hematologic
• Clozapine
• Rashes, skin pigmentary, temperature dysregulation

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Antipsychotics

• Approach
• Lower doses usually adequate
• Adjust to side effects
• Evaluate for TD
• How long?
• 1st episode
• Maintenance

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Other Treatments

• Electroshock
• Other tranquilizers

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Psychosocial Treatments

• Supportive
• Social/educative
• Family

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Other Diagnosis

• Schizophreniform
• Schizoaffective
• Brief Psychotic
• Delusional Disorders
• Shared Psychoses
• Psychosis due to somethin else