Psychotic Disorders

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Schizophrenia 

Things you should know

• Patient exhibits abnormal behavior and is unable to differentiate real from imaginary.
• Chronic and debilitating
• Disruption of the usual balance of emotions and thinking
• M>F

Signs and Symptoms

• Positive symptoms – Extra feelings or behaviors which are usually not present
  • Delusions and paranoia
  • Hallucinations
  • Irrational, bizarre or odd statements or beliefs
  • Hostility
  • Disorganized speech
  • Inappropriate laughter
  • Hyperactivity
• Negative symptoms –  A lack of behaviors or feelings which are usually present
  • Social isolation and withdrawal
  • Becoming more emotionless
  • Lack of motivation
  • Deterioration in their personal appearance and hygiene
  • Catatonic behavior

Diagnosis

• Thorough Medical and Psychiatric History
• Diagnostic Criteria
  • DSM-5 – Two diagnostic criteria must be met over most of a month with significant changes in social functioning over the past 6 months.

• Delusions – False beliefs held in spite of contradictory evidence.

• Thought broadcasting
• Paranoid delusions
• Somatic Delusions
• Delusions of grandeur
• Hallucinations – A false perception in any sensory modality
  • Auditory – most common
  • Visual
  • Tactile
  • Olfactory
• Disorganized speech – incoherence, tangential responses etc. creating difficulty with communication
• Extremely disorganized behavior
• Catatonic behavior, which can ranges from a coma-like daze to bizarre, hyperactive behavior
• Negative symptoms, which relate to reduced ability or lack of ability to function normally
• Subtypes (No longer in DSM – 5)
  • Paranoid Schizophrenia – Most common.  Auditory hallucinations or delusions of grandiose persecution.  Patient does not have poor thought order or disorganized behavior.
  • Disorganized Schizophrenia – Flattened affect and thought disorder
  • Catatonic Schizophrenia – Either immobile and mute with waxy flexibility or agitated purposeless movements and echolalia (mimicking sound)
  • Undifferentiated schizophrenia – patient has psychotic symptoms but does not fit into the other categories.
  • Residual Type –  Where positive symptoms are present at a low intensity only
• Two additional subtypes from ICD-10
  • Post-schizophrenic depression: A depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present.
  • Simple schizophrenia: Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes.

Treatment

• Psychosocial Interventions
  • Individual therapy
  • Social skills training
  • Family therapy
  • Vocational rehabilitation and supported employment
• Medications
  • Atypical Antipsychotics (Second generation)
    • Aripiprazole (Abilify)
    • Clozapine (Clozaril)
    • Iloperidone (Fanapt)
    • Lurasidone (Latuda)
    • Olanzapine (Zyprexa)
    • Quetiapine (Seroquel)
    • Risperidone (Risperdal)
  • Typical Antipsychotics (first generation)
    • Treatment goals for first generation medicines
      • Psychomotor slowing
      • Emotional quieting
      • Affective indifference
    • Side effects include extrapyramidal symptoms (EPS)
      • Tardive dyskinesia – irregular jerky motion
      • Dystonia – Continuous muscle spasms
      • Parkinsonian movement – tremor, bradykinesia, rigidity
    • Chlorpromazine
    • Fluphenazine
    • Haloperidol
    • Perphenazine

Delusional Disorder

Things you should know

• Delusions which are logically constructed and internally consistent
• May not generally seem odd or bizarre
• Chronic but treatable
• Types of Delusional Disorder
  • Erotomanic: delusions that another person, usually of higher status, is in love with the individual. The person might attempt to contact the object of the delusion, and stalking behavior is common.
  • Grandiose: delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person
  • Jealous: believes that his or her spouse or sexual partner is unfaithful.
  • Persecutory: believes that they, or someone close to them, are being mistreated, or that someone is spying on them or planning to harm them. Common for people with this type of delusional disorder to make repeated complaints to legal authorities.
  • Somatic: believes that he or she has a physical defect or medical problem.

I came in to see my physician assistant today because of…

• An irritable, angry, or low mood
• Hallucinations related to the delusion
• Expresses an idea or belief with unusual persistence or force.
• Secretive and suspicious
• Humorless and oversensitive
• Emotionally over-invested in the idea and it overwhelms other elements of his psyche

Diagnosis

• Psychological assessment
  • Specific Diagnostic Criteria (DSM IV – TR)
    • Delusions lasting for at least 1 month’s duration.
    • Patient does not meet criteria for schizophrenia
    • Apart from the impact of the delusions, functioning is not markedly impaired and behavior is not obviously odd or bizarre.
    • The disturbance is not due to the direct physiological effects of a substance, like drug abuse, a medication, or a general medical condition.

Treatment

• Psychotherapy
  • Individual psychotherapy
    • helps the person recognize and correct the underlying thinking that has become distorted.
  • Cognitive-behavioral therapy (CBT)
    • helps the person learn to recognize and change thought patterns and behaviors that lead to troublesome feelings.
  • Family therapy

• Medications
  • Conventional antipsychotics:
    • Thorazine
    • Loxapine
    • Prolixin
    • Haldol
  • Atypical antipsychotics
    • Risperdal
    • Clozaril
    • Seroquel
    • Zyprexa
  • Tranquilizers – used if the person has a very high level of anxiety or problems sleeping
  • Antidepressants – used to treat depression, which often occurs in people with delusional disorder

Somatoform Disorder

Things you should know

• Physical symptoms with no discernible cause
• Symptoms are sometimes similar to those of other illnesses, usually begin appearing during adolescence, and patients are diagnosed before the age of 30 years
• Not the result of conscious malingering or factitious disorders.  Symptoms are real.
• Types of Somatoform Disorders

• Hypochondriasis
  • Preoccupied with concern they have a serious disease and believes that minor complaints are signs of very serious medical problems
• Body dysmorphic disorder
  • Obsessed with, or may exaggerate, a physical flaw.
• Conversion disorder
  • Neurological symptoms that can’t be traced back to a medical cause.  – Patient may be indifferent to the symptoms
• Pain disorder
  • People with this disorder typically experience pain that started with a psychological stress or trauma

Treatment

• Goal of treatment: help learn to control the symptom
• Having a supportive relationship with a health care provider is the most important part of treatment.
  • Only one primary care provider
  • Schedule regular appointments to review the symptoms
• Psychotherapy
• Cognitive Behavioral Therapy
• Medications
  • Antidepressant medications for those with depression or anxiety symptoms

Study Tips

Active vs passive studying. 

Key Terms and Ideas

• Name three atypical antipsychotics medications
  • Aripiprazole (Abilify)
  • Clozapine (Clozaril)
  • Iloperidone (Fanapt)
  • Lurasidone (Latuda)
  • Olanzapine (Zyprexa)
  • Quetiapine (Seroquel)
  • Risperidone (Risperdal)
• How long must systems be present in order for you to diagnose schizophrenia?
  • 6 months
• A patient has seen several plastic surgeons and no less than three dermatologists in the past 6 months.  Which somatoform disorder might she be suffering from?
  • Body dysmorphic disorder.