MEDI3004 MENTAL HEALTH ROTATION -YEAR 3 MBBS. Topic 1 - Psychotic Disorders and Schizophrenia.docx

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Associate Professor Jane Turner

1. PSYCHOTIC DISORDERS  Psychosis, in its broadest definition, refers to any major derangement in mental function in which the individual’s ability to perceive and interact with the environment is impaired  Psychosis has o Impaired insight o Impaired reality testing o Inability to meet some ordinary demands of life CLASSIFICATION BY DSM-IV  Schizophrenia  Delusional disorder  Major depression with psychotic features  Bipolar disorder with psychotic features  Brief psychotic disorder  Schizophreniform disorder  Schizoaffective disorder  Psychotic disorder due to general medical condition/ substance induce psychotic disorder DDX Criterion A Other primary psychotic disorder  Delusions  Hallucinations  Schizophrenia  Schizophreniform  Disorganized speech (frequent derailment or  Brief Psychotic disorder incoherence)  Schizoaffective  Grossly disorganized or catatonic behavior  Delusional disorder  Negative Sx (affective flattening, alogia, avolition) Disorder Psychotic Symptoms Duration Mood Sx Brief Psychotic Disorder > 1 Sx of criterion A <1month 2’ or none Schizophreniform Criterion A 1-6months disorder Schizophrenia Criterion A >6 months Schizoaffective disorder >2wks (with no mood >1 month Present symptoms) Delusional disorder Non-bizarre delusions, >1 month 2’ or none hallucinations 2’ to substance Criterion A during intoxication or <1 Variable intoxication/withdrawal month after withdrawal 2’ to mood disorder Mood congruent Delusions/ unspecified 1’ hallucinations Mood disorders General medical conditions  Depression with psychotic features  Tumour  Bipolar disorder – manic episode with  Head trauma psychotic features  Dementia  Delirium Personality disorder  Metabolic  Schizotypal  Schizoid Substance-induced psychosis  Borderline  Intoxication  Paranoid  Withdrawal  Obsessive-compulsive SCHIZOPHRENIA  Involves cognition, emotion, perception and other aspects of behaviour EPIDIMIOLOGY  Life-time prevalence is 1% in the US  Prevalence is equal in Males and Females, but modal age on set: Men 18-25, Women 25-35 (with second peak in middle age)  Persists throughout life CAUSES Supportive evidence for dopamine 1. Environment: hypothesis 1. DA agonists exacerbate  Stress inducing environment  increases in cortisol 2. Antipsychotic drugs block post- levels? synaptic DA receptors  Geographical variance 3. Potency of drugs correlates with  Winter season of birth D2 blockade of port-synaptic  Prenatal viral exposure receptors 2. Genetics: 4. Antipsychotic drugs are  first degree biological relatives of persons with associated with an increase in schizophrenia have a 10x risk. number of D2 and D4 post-  50% concordance in identical twins synaptic receptors 3. Brain chemistry and structure:  excess activity of dopamine in mesolimbic pathway results in positive Sx.  Decreased frontal lobe function, etc  Abnormal GH, prolactin, cortisol and adrenocorticotropic hormone 4. Drug Use  Don’t directly causes, but increase risk of developing it  Cannabis, LSD, methamphetamine CLINICAL FEATURES Positive Symptoms  Delusions (persecutory, bizarre, grandiose)  Hallucinations  Disorganised Speech  Grossly disorganized or catatonic behavior  Impaired insight Negative Symptoms  Affect flattening/blunted  Alogia (poverty of speech)  Avolition (unable to perform goal-direct activities)  Social withdrawal and poor self care Other Symptoms  Defective cognitive function, attention memory  Anxiety and depression F. if history of a pervasive developmental disorder, additional diagnosis of schizophrenia is made only  Suicidal ideation if prominent delusions or hallucinations are also  Defects in Selective Attention – inability present for at last 1 month to discriminate between significant and insignificant stimuli Delusion: abnormal belief held with strong conviction despite superior evidence to the contrary. May be persecutory, religious, grandiose, delusion of references Hallucinations: sensory experiences that are not associated with corresponding sensory input. Can occur in all 5 sensory modalities Thought disorders: Abnormal thought process that impairs the understandability of speech. E.g. Derailments, Tangential, Neologisms, Illogicality Catatonia: Involuntary psychomotor abnormalities not associated with motor system disease. E.g. bizarre posturing, mannerisms, stereotypes, negativism SUBTYPES 1. Paranoid  Typically persecutory or grandiose and systemized delusions  precoccupation with one or more delusion/s or frequent auditory hallunications  Rleative preservation of cognitive functioning and affect  Onset tends to be later in life  Best prognosis 2. Catatonic  Two or more of: o Lack of movement/motor immobility: catalepsy or stupor o Excess movement: purposeless, not influenced by external stimuli o Extreme negatism: resistant to instructions or attempts to be moved o Mutism o Peculiar voluntary movements: posturing, stereotyped movements, prominent mannerisms o Echolalia: repeat words or phrases from another’s speech o Echopraxia: repeat movements imitating another’s movements, gestures or postures 3. Disorganised:  Disorganized thoughts, speech and behaviours  Flat or inappropriate affect  Poor premorbid personality  Early and insidious onset  Continuous course without significant remissions 4. Undifferentiated:  mix type  Symptoms of criterion A met but does not fall into previous 3 categories 5. Residual:  Absence of prominent delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior  Presence of negative symptoms or two or more positive symptoms attenuated (weakened) PRESENTATION Course 1. Pre-clinical 2. Prodromal  Attenuated positive symptom syndrome: Abnormal/unusual thought content, suspiciousness, grandiosity, perceptual abnormalities, and/or organization of communication; onset or worsening in past year  Brief intermittent psychotic syndrome: Frankly psychotic, unusual thought content, suspiciousness, grandiosity, perceptual abnormalities, and/or organization of communication; onset in past three months  Genetic risk plus functional deterioration: First-degree relative with history of any psychotic disorder or schizotypal personality disorder in patient; substantial functional decline in past year 1. Psychotic symptoms 2. First admission 3. Diagnosis MANAGEMENT Issues with Management  Treatments work better at the first Principles of Treatment 1. Therapeutic relationship episode  resistance increases with  Effect of disorder on insight, motivation each relapse  50% of patients with schizophrenia have and cognition little or no illness insight  Need for long-term treatment  involuntary treatment orders  Listen attentively and response effectively  noncompliant to meds 2. Early identification and intervention  Risk of harm to self and others   period during which a person suffers from disease improves outcome 3. Diagnosis  Take full psychiatric history, MSE and physical examination (neuro assessment)  Investigations:: FBC, electrolytes, calcium, creatinine, ura, LFTs, BGL, lipids, thyroid FTs, prolactin concentration, urine toxicology, CT/MRI of brain  If indicated: immunological screen, EEG, ECG 4. Liaise with GP  Can monitor treatment and clinical progress, discuss relapse prevention strategies, refer to toher agencies and services, provide counseling and family support  Maintain good physical health, identify physical illness early and provide treatment 5. Assess Risk  Suicide  Self harm  Danger to others  Cormid abuse of alcohol, nicotine and drugs  Hospitalisation? ITO? 6. Psychosocial interventions  Family support: assistance from mental health services, carer support groups and GPs  Follow up for 3-5 yers from onset of first psychotic episode 7. Pharmacological Mx  Antipsychotics o Diminish positive symptoms of hallucinations, delusions and thought disorders and symptoms of excitement e.g. hostility o Limited impact on cognitive impairment, negative symptoms and mood disturbance o Generally an oral second generation (atypical) antipsychotic is commenced on first episode of psychosis. Started on a low dose then rising the an initial target does. If no response with dose is increased o If unacceptable partial response after 6-12 weeks of treatment as adequate doses with good treatment concordance and absence of complicating factors, witch to an antipsychotic with different properties from the first drug used  E.g. an alternative atypical antipsychotic
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