Psychotic+Disorders

=**Psychotic Disorders**=


 * 1. Define psychosis.**

Psychosis is the presence of impaired reality evidenced by impaired reality testing or evaluation and judgment of the world outside of the self.


 * 2. State the prevalence of schizophrenia; indicate the effect of age and gender on incidence.**

Schizophrenia has a lifetime prevalence of 1-1.5% in the US and 0.85% in the world. It has a 1% prevalence across societies and occurs in males in females with equal prevalence. However, it tends to have an earlier onset and worse prognosis in men. It is predominately a disease of young adulthood, with the age of onset between 15-25 for men and 25-35 for women.


 * 3. Describe the epidemiology of schizophrenia, in terms of genetic disposition, environmental influence, socioeconomic status, and neurobiology.**

There is a strong genetic factor related to schizophrenia and is the second more heritable mental illness behind ADHD.

More schizophrenic persons are born during winter months in both hemispheres; this phenomenon is thought to be related to viral infections in genetically susceptible persons. Schizophrenia also appears to follow extraordinary life stresses, suggesting that certain people are more susceptible to psychotic breaks under stress. Schizophrenics also have an incredibly high rate of substance abuse (e.g. up to 75% smoke cigarettes) which may be related to reducing side effects of anti-psychotic medications or affects on DA receptors in the brain.

Schizophrenia also seems to be identified more often among persons of low SES; however, it is thought that low SES is not causative. Rather schizophrenia is diagnosed among persons of all SES, but, after diagnosis, individuals fall into a downward drift towards lower SES.

Several neurotransmitters including DA, 5HT, NE, and glutamate have been implicated in being related, but not specific, to schizophrenia. That is, schizophrenia exhibits neurotransmitter problems that are probably secondary to an underlying problem. Over activity in the limbic system appears to be related to the positive symptoms of schizophrenia while over activity in the basal ganglia and prefrontal cortex appears to be related to negative symptoms.


 * 4. List the positive and negative symptoms of schizophrenia.**

Primary symptoms are productive symptoms such as: delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior. Negative symptoms are deficit symptoms such as the absence of motivation, loss of direction, flat affect, or emotionless speech.

For diagnosis, patient must have two or more symptoms including the positive symptoms or any negative symptom for at least 1 month resulting in significant dysfunction lasting for at least 6 months. Schizoaffective disorder, mood disorder, substance abuse, and medical condition must be ruled out. Also, if patient has a history of autistic disorder or pervasive developmental disorder, additional diagnosis of schizophrenia is only warranted if very prominent.


 * 5. Discuss the characteristics of the subtypes of schizophrenia.**

__Paranoid__ Paranoid subtype doesn’t mean that the patient has to be paranoid. The predominant symptom of paranoid subtype is preoccupation with one ore more delusions or frequent auditory hallucinations. //None of the following are predominant//: disorganized speech, disorganized or catatonic behavior, or flat/inappropriate affect.

__Disorganized__ Patient presents with predominant disorganized speech, behavior, and flat/inappropriate affect. Criteria must not be met for catatonic subtype.

__Catatonic__ Dominated by two of the following: (1) motor immobility evidenced by catalepsy (including waxy flexibility) or stupor, (2) excessive motoric activity (that is apparently purposeless and not influenced by external stimuli), (3) extreme negativism (motionless resistance to all instructions or maintenance of a rigid posture against all attempts to be moved) or mutism, (4) peculiarities of voluntary movement as evidenced by posturing, stereotyped movements predominant mannerisms or prominent grimacing, and (5) echolalia or echopraxia.

__Undifferentiated__ Criteria for schizophrenia are met but not classifiable under paranoid, disorganized, or catatonic subtypes.


 * 6. Demonstrate the assessment of the psychotic patient with the mental status examination, and indicate the most likely deficits.**

__Appearance__ May seem uniquely odd with personal appearance deteriorating in chronic schizophrenia with negative symptoms. May have bizarre posture and behaviors.

__Speech__ May be stilted, lacking expression and inability to understand or create the usual emotional inflections of speech.

__Mood and Affect__ Mood may be depressed (25% of patients) or indifferent, often with emotional shallowness. Affect is often blunted or flat chronically. May be heightened with first onset with dramatic emotional displays.

__Thought__ Thought forms often have loosening of association, loss of continuity with illogical or even bizarre connections. May exhibit blocking, neologism, and/or echolalia. Content of thoughts may be delusional and exhibit poverty of content.

__ Perception__ May present with hallucinations of any of the five special senses with auditory being most common, followed by visual. Tactile, olfactory, and gustatory hallucinations are rare and may indicate another medical condition. May also present with cenesthetic hallucinations which are sensations of altered states in bodily organs (e.g. “my body is on fire” or “needles in my veins”).

__Sensorium and Cognition__ Patients are usually oriented unless contaminated by delusional thinking. Usually alert but attention may be faulty. However, cognition is usually intact (i.e., can talk about current events, add, subtract, etc.).

__Judgment and Insight__ Judgment and insight usually exhibit deficits. Patients with insights of hallucinations are usually associated with better prognosis.

__Violence__ Patients are usually more violent than the general population but violence is usually poorly focused, especially in more disorganized patients, and, therefore, less dangerous. When patients’ exhibit directed violence, it is well-planned and usually follows delusions of paranoid schizophrenia. Nonetheless, homicides are rare though difficult to predict.


 * 7. Define the following terms relevant to psychotic illness: blocking, neologism, flight of ideas, loose associations, clang associations, word salad, hallucinations, illusion, and delusion. Highlight the difference between illusion, delusion, and hallucination.**

__Blocking__ Abrupt interruption in train of thinking before a thought or an idea is finished.

__Neologism__ Creation of new word by patient.

__Flight of Ideas__ Rapid continuous verbalizations or plays on words that produce constant shifting from one idea to another.

__Loose Associations__ Flow of thought in which ideas shift from one subject to another in complete unrelated ways.

__Clang Associations__ Association of words similar in sound but not in meaning, such as rhyming or puns.

__Word Salad__ Incoherent mixture of words or phrases.

__Hallucination__ False sensory perception that is not assoicated with external reality.

__Illusion__ Misperception or misinterpretation of real external sensory stimuli.

__Delusion__ False belief based on incorrect inference about external reality that cannot be corrected by reasoning. It is not consistent with patient's intelligence and cultural background.


 * 8. Differentiate among the psychotic disorders.**

See Objective 12.


 * 9. Explain the impact of psychotic illness on the person, the family and society.**

Schizophrenics have higher mortality rate from accidents and natural causes than the general population, with the leading cause of mortality being suicide. 15% are successful in committing suicide with 50% having at least 1 suicide attempt.

Schizophrenics also have a high incidence of substance abuse, with up to 50% abusing alcohol, up to 25% abusing marijuana, 10% abusing cocaine, and 75% smoking cigarettes.

Currently, $50 billion annually is spent on schizophrenics. At one time, most hospital beds were dedicated to schizophrenic treatment, but the policy of deinstitutionalization has brought that number down with the advent of better out patient facilities and medications. However, deinstitutionalization also means that 75% of schizophrenics are unemployed and account for 55% of the homeless population.

Diagnosis of psychotic illness is devastating to individuals, families, and society. Schizophrenics are frequently diagnosed during the young adulthood years, resulting in significant impact on an individual’s life. As a result, treatment is directed to reduce the patient’s suffering from symptoms and offer the best change of rehabilitation as well as help those close to the patient.


 * 10. Discuss factors involved in pharmacological treatment of psychotic illness.**

Antipsychotic medications are not specific for schizophrenia treatment but also psychosis of other etiologies. Typical antipsychotic medications have been around from the 1950s-1990s and block DA receptors (especially D2); the include phenothiazines and butyrophenones. Typical antipsychotics are effective in treating positive symptoms with 25% of patients regaining normal mental function; however, typical antipsychotics have prominent neurological side effects due to indiscriminant DA blockage, leading to Parkinson’s-like symptoms. Additonally, typical antipsychotics take time to work.

Atypical antipsychotic medications are recently developed medications that have strong antagonistic actions on DA and 5HT receptors. They are more effective at treating negative symptoms and have fewer neurological symptoms because they block DA receptors more discriminately (i.e., avoid blocking D2). However, they have significant metabolic side effects, often placing the patient at risk for ketoacidosis, diabetes, hyperlipidema, and weight gain. These drugs include risperidone, clozaril, olanzapine, quetiapine, ziprasidone, and aripiprazole.

Other adjunctive medications treat coexisting conditions and include anticonvulsants such as carbamazepine and valproate, benzodiazepines for sedation, and antidepressants.


 * 11. Explain the evolution of non-pharmacological treatments of psychotic illness.**

Non-pharmacological treatments include behavior therapy, social skills training, supportive therapy, family-oriented therapy, group therapy, illness management and recovery (IMR), and case management.

Assertive community treatment (ACT) is a type of case management therapy where the physician makes house calls and sees the patient rather than having the patient see the doctor. This technique helps prevent psychotics from slipping through the cracks in the system.


 * 12. Describe other psychotic disorders, including schizoaffective disorder, delusional disorder, brief psychotic disorder, schizophreniform disorder.**

__Schizoaffective Disorder__ Schizoaffective disorder is a combination of schizophrenia and a mood disorder. There must be an uninterrupted period of illness during which at some time there is either a major depressive episode, a manic episode, or a mixed episode with symptoms that meet criteria A for schizophrenia. During the same period if illness, there must be delusions or hallucinations for at least 2 weeks in absence of prominent mood symptoms.

Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of illness. Symptoms must not be due to the effects of a substance or a general medical condition.

Schizoaffective disorder has a prevalence of less than 1% and is more prevalent in women. Its etiology and genetic links with schizophrenia and mood disorders is unknown but is probably a heterogeneous group. Prognosis is better than schizophrenia but worse than mood disorders. Good prognosis is associated with good premorbid history, rapid onset, prominent mood symptoms compared to psychotic symptoms, and late onset response to treatment.

Treatment is primarily aimed at control of mood disorder with treatment of mania/depression with mood stabilizers. Antipsychotics are used for control of psychotic symptoms.

__Delusional Disorder__ Delusional disorder is characterized by non-bizarre delusions of at lease 1 month in duration (i.e., “I think my wife is cheating on me” is possible and non-bizarre; “somebody is controlling my thoughts” is just crazy). Criterion A for schizophrenia must have never been met. Apart from the impact of delusion, functioning is not markedly impaired and behavior is not obviously odd or bizarre.

If mood episodes are occurring concurrently with delusions, their total duration should be brief relative to the duration of delusional periods. Disturbance is not due to substance abuse or a general medical condition.

There are several subtypes of delusional disorder. //Erotomanic// type has delusions that another person, usually of higher social status, is in love with the individual. //Grandiose// type has delusions of inflated worth, power, knowledge, identity, or special relationship with a deity or famous person (e.g. David Koresh). //Jealous// type, or Othello syndrome, is characterized by delusions that the individual’s sexual partner is unfaithful. //Persecutory// type is characterized by delusions that the person (orsomeone whom the person is close) is being malevolently treated in some way; it is important to assess potential for violence in persecutory type. //Somatic type// suffers from delusions that the patient has some defect or general medical condition such as an infestations, dysmorphophobia, or foul odors; somatic type symptoms are different than hypochondriasis because of the bizarre level of delusion. Delusional disorders can also be of //mixed// or //unspecified// types.

Prevalence of delusional disorders is rare (0.03%) with a mean age of 40 years and greater prevalence in women than men. Appearance, behavior, mood, and affect of delusional disorder patients are congruent with non-bizarre delusions. Patients have no prominent or sustained hallucinations but may have hallucinations congruent with delusions. Patients are characterized with disorganized thought processes and systematized non-bizarre delusions. Insight and judgment is usually influenced with delusion.

Patients with delusional disorders are usually not self-referred and have stressors present at onset. Nonetheless, patients have good prognosis with 50% long-term recovery, 20% improvement, and 30% with no change in symptoms. Treatment is usually on an outpatient basis. Physicians should assess for violence and try to build a trusting relationship. Low dose antipsychotic medications and psychotherapy are used.

__Brief Psychotic Disorder__ Brief psychotic disorder has one or more symptoms of hallucination, delusion, disorganized speech (derailment/incoherence), and grossly disorganized or catatonic behavior. There should be //no negative symptoms//. Duration of disturbance episode is at least 1 day but less than 1 month with eveutnal return to premorbid functioning.

The disturbance must not be better accounted for by mood disorder with psychotic features, schizoaffective disorder or schizophrenia and not due to substance abuse or general medical conditions.

Prevalence of brief psychotic episodes is unknown but is characterized by abrupt onset, often due to clear precipitating stressors. Brief psychotic disorder is characterized by emotional liability, outlandish behavior, screaming or muteness, and impaired memory. Patients have good prognosis with 50-80% having no further psychiatric problems.

Treatment of brief psychotic disorder is usually through hospitalization, medication (antipsychotics, benzodiazepine for short duration), and psychotherapy.

__Schizophreniform Disorder__ Schizophreniform disorder matches criteria A, D and E of schizophrenia but has not met the 6 months of disturbance criteria. Each episode of criteria lasts at least one month but less than 6 months. Patients generally have better prognosis than schizophrenics and return to baseline mental functioning with in 6 months. Some patients go on to get diagnosed with schizophrenia when disturbance continues beyond 6 months.