Case 1: Binh Hau - Psychosis + Schizophrenia

Psychotic Disorders: Description

Disease/condition causing psychosis

Psychotic Disorders: Types

Primary: From psychiatric disorders

Secondary:

• Toxin/substance-induced

• From medical conditions

Primary Psychotic Disorders

Schizophrenia

Schizoaffective disorder

Schizophreniform disorder

Delusional disorder

Bipolar disorder with psychotic symptoms

Major depressive disorder with psychotic symptoms

Postpartum

Primary Psychotic Disorder: Schizoaffective Disorder

Mood symptoms + psychotic symptoms (in ≥ 2 weeks without mood symptoms)

Primary Psychotic Disorder: Schizophreniform Disorder

Psychotic symptoms for 1-6 months

Primary Psychotic Disorder: Delusional Disorder

Non-bizarre delusions for ≥ 1 month

NO schizophrenia symptoms

Primary Psychotic Disorder: Bipolar Disorder with Psychotic Symptoms

Psychotic symptoms during manic/mixed episodes

Primary Psychotic Disorder: Major Depressive Disorder with Psychotic Symptoms

Psychotic symptoms during depressive episodes

Primary Psychotic Disorder: Postpartum

≤ 6 weeks after delivery

Decreasing estrogen + progesterone

Secondary Psychotic Disorder: Toxin/Substance-Induced

Substances

• Intoxication or withdrawal

Toxins

• Anticholinesterases

• Organophosphates

• CO

Iatrogenic: Side effect from medications

• Anticholinergics

• Glucocorticoids

• Anticonvulsants

• Antibiotics

Secondary Psychotic Disorder: Medical Conditions

Neurologic

Endocrine

Metabolic

Autoimmune

• SLE

Psychosis: Description

Impaired perception of reality from…

• Hallucinations

• Delusions

• Disorganized thinking/behaviour

Schizophrenia: Description

Chronic psychiatric disorder with psychotic symptoms (negative + positive)

Psychosis + Schizophrenia: Epidemioloy/Etiology

Risk factors…

• Genetics: Relatives with schizophrenia = Increase risk

• Environmental

  • Stress + psychosocial

    • Low SES

    • Refugee

    • Urban localization

  • Adolescent cannabis use

    • Unmask/trigger psychotic disorders

    • Exacerbate symptoms

  • Older parental age at conception

Adolescent Cannabis Use + Psychosis

1. THC activate CB1 receptors = Disrupt endocannabinoid system in prefrontal cortex + striatum during neurodevelopment window (adolescence)

2. Abnormal synaptic pruning (neuron connections) + dopamine circuit development

Schizophrenia: Pathophysiology

2 hypotheses

• NT dysregulation

• Structural brain changes

Schizophrenia Pathophysiology: NT Dysregulation

Dopamine:

• Decreased in prefrontal cortical pathway = Negative symptoms

• Increased in mesolimbic pathway = Positive symptoms

Serotonin: Increased

Glutamate: Decreased

GABA: Decreased GABA = Increased dopamine

Schizophrenia Pathophysiology: Structural Brain Changes

Decreased dendritic branching

Large ventricles

Decreased volume in…

• Limbic system

• Prefrontal cortex

• Thalamus

• Hippocampus

• Amygdala

Psychosis: Clinical Presentation

Hallucinations

Delusions

Disorganized thinking + speech

Psychosis: Hallucinations

Perception without stimuli

Types:

• Auditory: More common in psychiatric

• Visual: More common in organic/medical (intoxication, delirium)

• Gustory

• Olfactory

• Tactile

• Somatic

Hallucinations Vs Illusions

Illusions: Misperception of real stimuli

Psychosis: Delusions

Fixed false beliefs despite contradicting reality/facts

Types:

• Bizarre: Cannot be true

• Nonbizarre: Could be true or consistent with social/cultural norms

• Mood Congruent: Consistent with pt mood

• Mood Incongruent: Inconsistent with pt mood

Grandiosity: Thinking they have powers/are of great importance

Persecutory: Thinking they are being conspired against/harassed

Delusions of Reference: Believing normal events are special to them

Psychosis: Disorganized Thinking + Speech

Loose Associations: Incoherent thought = Switching between topics quickly

Word Salad: Speaking words with no connection

Tangential Speech: Speech gradually deviates from focused topic

Flight of Ideas: Rapid shifting between loosely connected topics

Derailment: Unrelated ideas in speech

Schizophrenia: Clinical Presentation

Negative symptoms

Positive symptoms

Other symptoms

• Inattention

• Impaired memory

• Depression + anxiety

• Sleep disturbances

Schizophrenia: Negative Symptoms

Before positive symptoms

Emotional withdrawal

• Flat affect: Decreased emotional expression

• Anhedonia: Decreased pleasure from positive activities

• Apathy

Social withdrawal

Schizophrenia: Positive Symptoms

After negative symptoms

Psychosis

Disorganized behaviours

• Catatonia: Decreased/increased motor activity + decreased reactivity to environment

• Inappropriate emotional responses

Psychosis: Investigations

Physical exam

Cognitive assessment

• Mental status exam (MSE)

• Montreal cognitive assessment (MoCA)

Schizophrenia: Diagnostic Criteria

DSM-5

≥ 2 + ≥ 1 from first 3:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Disorganized behaviour + catatonia

5. Negative symptoms

Continuous disturbance for ≥ 6 months

Schizophrenia: Investigations

Lab tests + EEG

• CBC

• TFTs

• Lytes

• Vit B12

R/O:

• Schizoaffective disorder

• Mood disorders

• Drug/toxin-induced disorders

Schizophrenia: Patient Insight

Insight: Aware they are experiencing illness → Better treatment outcomes

No Insight: Unaware they are experiencing illness → Worse treatment outcomes

Schizophrenia: Treatment/Management

Nonpharmacological

Pharmacological

Schizophrenia Management: Nonpharmacological

CBT

Cognitive remediation therapy: Improve cognitive function

Social skills training

Educate family + patient

Schizophrenia Management: Pharmacological

Antipsychotics:

• First-generation (typical)

• Second-generation (atypical)

• Third-generation

Continue indefinitely

• DO NOT STOP FOR PREGNANCY

First-Generation Antipsychotics

High-potency

Low-potency

First-Generation Antipsychotics: High-Potency

Ex: Haloperidol + cogentin (prevent EPS), fluphenazine, trifluoperazine

MOA: D2 receptor antagonist

Indications:

• Acute agitation + psychosis

• Schizophrenia (positive symptoms)

Adverse Effects:

• Extrapyramidal symptoms (EPS)

  • Bradykinesia

  • Rigidity

  • Chorea

  • Tremors

• Long QT

• Neuroleptic malignant syndrome (NMS)

  • High fever

  • Altered mental status

  • Muscle rigidity

  • Autonomic instability

• Hyperprolactinemia

First-Generation Antipsychotics: Low-Potency

Ex: Chlorpromazine, thioridazine

MOA: Inhibit dopamine, cholinergic, and histamine receptors (sedation)

Indications: Acute agitation

Adverse Effects:

• Sedation

• Anticholinergic symptoms

  • Dry skin

  • Tachycardia

Second-Generation Antipsychotics

Ex: Clozapine, risperidone, olanzapine

MOA:

• D2 receptor antagonist

• 5-HT2A (serotonin) receptor antagonist

Indications:

• Schizophrenia (positive + negative symptoms)

• Psychosis

• Clozapine: Treatment-resistance

Adverse Effects:

• Metabolic

  • Weight gain

  • Hyperglycemia

  • DM

  • Dyslipidemia

• Hyperprolactinemia

• Long QT

• NMS

• Clozapine: Agranulocytosis

Third-Generation Antipsychotics

Ex: Apipiprazole, brexipiprazole, cariprazine

MOA: Partial D2/3 receptor agonists (dopamine stabilizers)

Indications: All schizophrenia phases

Adverse Effects:

• Impulse control disorders

  • Akathisia: Restlessness

• Weight gain

Psychosis + Schizophrenia: Complications

Increased risk of…

• Alcohol use disorder

• Depression

• Violence

• Suicide