Psychotic Disorders

describe in general terms, theories of etiology of schizophrenia and other psychotic disorders (genetics, prenatal risk factors, environmental triggers)

1) genetics:

- identical twins: 1 in 2 chance of developing if twin also has schizophrenia

- non identical twins: 1 in 7 chance

- non-related individuals: 1 in 100 chance

2) prenatal risk factors:

- certain maternal viral infections during pregnancy

- nutritional deficits during first 6 months of pregnancy

3) potential environmental triggers:

- psychoactive drugs (eg. LSD, methamphetamines)

- marijuana

- typically thought of as increasing risk in those already susceptible

describe the neuroanatomical changes seen in patients w schizophrenia

1) overall decreased brain volume

2) enlarged lateral and third ventricles

3) smaller medial temporal lobes

4) decreased cortical gray matter

describe what is meant by positive symptoms of schizophrenia

positive symptoms include hallucinations, delusions, disorganized thinking/speech

what are examples of hallucinations (positive symptoms)

most common: auditory and visual

possible: other sense, too (eg. tactile, olfactory, gustatory)

what are examples of delusions (positive symptoms; what are the 5 different types)

1) grandiose: you are extremely important, influential, knowledgeable

2) referential/reference: ordinary events have hidden meanings to only you

3) paranoid: others are out to harm or sabotage you

4) control: others are able to control you

5) erotomanic: others (usually famous) are madly in love with you

what are examples of disorganized thinking/speech (positive symptoms)

1) derailment/loose association

2) tangentality

3) "word salad"

describe what is meant by negative symptoms of schizophrenia

negative symptoms include:

- diminished emotional expression

- avolition

- alogia

- anhedonia

- asociality

what are examples of diminished emotional expression (negative symptoms)

1) facial expression

2) eye contact

3) intonation of speech

4) movements of hands, head, and face

what is avolition (negative symptoms)

decrease in motivated, self-initiated, purposeful activities

what is alogia (negative symptoms)

diminished speech output

what is anhedonia (negative symptoms)

decreased pleasure in activities

what is asociality (negative symptoms)

lack of interest in social interactions

what is the diagnostic criteria of brief psychotic disorder

1) presence of one or more of the following symptoms; at least one must be A, B, or C:

A: delusions

B: hallucinations

C: disorganized speech

D: grossly disorganized or catatonic behavior

2) duration is at least one day, but less than one month

3) disturbance is not better explained by MDD, bipolar disorder, or another psychotic disorder

what is the diagnostic criteria of schizophrenia

1) 2 or more of the following, each present for a significant amount of time during a 1-month period (or less if successfully treated); at least one must be A, B, or C

A: delusions

B: hallucinations

C: disorganized speech

D: grossly disorganized or catatonic behavior

E: negative symptoms

2) level of functioning is markedly below what is "normal" for the person

3) disturbance must persist for at least 6 months

4) not attributable to physiological effects of a substance

5) rule out schizoaffective disorder, major depressive disorder, or bipolar disorder

schizophrenia is not?? (4)

1) it is NOT "multiple personalities" or "split personalities" - this is dissociative identity disorder (very rare)

2) it is NOT a condition that makes people violent - in fact, people w schizophrenia are more likely to be victims of violent crime

3) it is NOT something that involves only delusions and hallucinations - often involves blunting of affect, disorganized speech, low motivation

4) it is NOT untreatable - it cannot be cured, but it can be treated

what are 2 forms of pharmacologic treatments for psychotic disorders

1) first generation (typical) antipsychotics (FGAs)

2) second generation (atypical) antipsychotics (SGAs)

what is the MOA of first-generation antipsychotics?

1) also referred to as "neuroleptics"

2) block D2 (dopamine) receptors, particularly in the basal ganglia

3) extrapyramidal side effects are common (eg. tardive dyskinesia)

4) examples: chlorpromazine (thorazine), haloperidol (haldol)

what is the MOA of SGAs

1) block 5HT2 (serotonin) receptors with more potency than FGAs

2) block D2 (dopamine) receptors less than FGAs

3) fewer extrapyramidal side-effects than FGAs (eg. tardive dyskinesia)

4) linked to more weight gain and type II diabetes

5) ex: aripiprazole (abilify), olanzapine (zyprexa), quetiapine (seroquel)

what are some psychotherapy treatment modalities used for psychotic disorders

1) stress reduction

2) family support therapy

3) minimize use of drugs and alcohol

describe dental considerations that a dentist should be aware of when treating patients with psychotic disorders

1) consider talking with a patient's PCP or psychiatrist to establish ability to consent for dental treatment

2) good if family member or caregiver can be present for familiarity and to reinforce dentist's recommendations

3) model oral hygiene (eg. dentist/hygienist flosses own teeth) rather than just explaining

4) treatment: pharmacology

- frequent recalls (eg every 3 months)

- sedation may be used in consultation with treating physician (may interact with antipsychotics and increase CNS depression)

- use epinephrine sparingly to avoid hypotension