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

9 Pages
104 Views
Unlock Document

Department
Medicine
Course
MEDI2022
Professor
Associate Professor Jane Turner
Semester
Spring

Description
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
More Less

Related notes for MEDI2022

Log In


OR

Join OneClass

Access over 10 million pages of study
documents for 1.3 million courses.

Sign up

Join to view


OR

By registering, I agree to the Terms and Privacy Policies
Already have an account?
Just a few more details

So we can recommend you notes for your school.

Reset Password

Please enter below the email address you registered with and we will send you a link to reset your password.

Add your courses

Get notes from the top students in your class.


Submit