BH E2- Schizophrenia & Psychotic disorders

What is a major mental condition characterized by gross impairment in perception of reality and ability to communicate/interact with others?

Psychosis

What are symptoms of psychosis?

Delusions, hallucinations, disorganized speech, bizarre behavior, negative & positive sx

Positive or negative symptoms?

• delusions, hallucinations, disorganized though & speech, disorganized or abnormal motor behavior

Positive

Positive or negative symptoms?

• diminished emotional expresión, avolition, alogia, social withdrawal, anhedonia

Negative

What are things that a person sees, hears, smells, or feels that no one else can see, hear, smell or feel?

Hallucination

What is a fixed, persistent, false belief with no basis in reality in which a person has complete certainty and conviction in their belief and resists arguments & evidence that they are wrong?

Delusion

What are common types of hallucinations?

Auditory (MC), visual, smell & taste, tactile, deep sensation

What is the treatment for psychosis?

Hospitalization, 1st & 2nd gen antipsychotics, & psychotherapy

The following criteria is for what condition?

• criterion A: atleast 2 of 5 (must have atleast 1 of the first 3) for 6 mos:

  • hallucinations (MC auditory)

  • delusions

  • disorganized speech

  • grossly disorganized or catatonic behavior

  • negative sx

• sx have been present for 6 months & ≥ 2 must be persistent for atleast 1 month

Schizophrenia

When does schizophrenia onset?

17-24 y/o, rare before 15 or after age 55; M=W

What are the subtypes of schizophrenia?

Paranoid, disorganized, catatonic, undifferentiated

What is the etiology of schizophrenia?

Inc levels of DA, inc genetic risk w/ hx, gestational and birth complications

The following PE presentation can be seen in what kind of patient?

• disheveled appearance, loss of hygeine

• flat affect, disorganized thoughts

• auditory hallucinations & delusions (paranoid MC)

• abnormal behavior

• lack of insight into their disease

Schizophrenic

What social hx might you see in schizophrenic patients?

Sleep disturbances, lack of social support, PMH or FMH of mental disorders, unemployment, homelessness

What are common comorbidities seen in schizophrenic patients?

Smoking & substance abuse (MC), depression, suicide, obesity, DM, HCV, HIV

What cognitive sx are seen in schizophrenia?

Impairments in attention, executive function & working memory, may cause poor work & school performance

Which symptoms response to antipsychotics?

Positive

Which symptoms are often treatment resistant and contribute to the social isolation of schizophrenic patients?

Negative

What is disorganized thinking?

Abnormal speech patterns

What is tangential speech?

Individual gets increasingly further off topic w/o answering a question

What is circumstantial speech?

Individual eventually answers the question, but in markedly roundabout manner

What is it called when during a conversation, a patient suddenly switches topic without any logic?

Derailment

What is the creation of new meaningless words?

Neologisms

What is it called when words are thrown together without any sensible meaning?

Word salad

What is it called when a patient repeats words or phrases?

Echolalia

What are the 3 ways symptoms in schizophrenia often present?

Prodomal phase, acute/active phase, residual phase

What phase of schizophrenia?

• Behavior changes gradually

• begins to withdraw from social interaction & display less emotion

• less attention to personal hygiene & dressing

• peculiar behavior begins & motor deficiencies may develop

• lasts weeks - up to 5 years

Prodromal phase

What phase of schizophrenia?

• Positive sx begin

• hallucinations, delusions, thought process disorders, disorganized speaking

• disorganized behavior requiring medical intervention

• lasts weeks-months; indefinite w/o treatment

Acute / Psychotic phase

What phase of schizophrenia?

• positive sx subside & negative sx develop

• extreme apathetic emotions, withdraws socially & lacks initiative and drive

• less dramatic than positive sx but can be disabling

Residual phase

What lab findings might be seen in schizophrenia?

Elevated metabolites of DA, dec LH & FHS, and epileptiform activity on EEG

Are the following factors associated with a better or poor prognosis in schizophrenia?

• older age of onset & acute onset

• good premorbid functioning

• positive sx, mood sx

• female gender

• good social support

• few relapses

Better prognosis

Are the following factors associated with a better or poor prognosis in schizophrenia?

• younger age of onset & gradual onset

• negative sx

• males

• poor social support

• FMH, hx of relapses

• comorbid substance abuse

Poor prognosis

What are the treatment goals for schizophrenia?

Eliminate/reduce sx, prevent/minimize SEs of antipsychotic drugs, prevent relapse, & promote social and occupational rehabilitation

What should be obtained in the pretreatment assessment of schizophrenia?

BMI, HR, BP, & check for EPS

CBC, CMP, FBS, lipid profile, liver, renal, TFTs, & EKG

What psychotherapy is used in treatment of schizophrenia?

Individual & family/group therapy (requires long term support)

Describe the activity of the 4 major pathways in the dopaminergic system in schizophrenic patients?

Mesolimbic overactive (positive sx), mesocortical underactive, nigrostriatal DA blockade (parkinsonism), & tuberoinfundibular/anterior pituitary DA blockade (inc prolactin)

What is in a B52 injection used for acute psychosis to calm/sedate the patient?

Benadryl 50mg, Haldol 5mg, Lorazepam 2mg

Major tranquilizers - 1st or 2nd gen antipsychotics?

• Blocks D2

• More EPS

• Haldol or thorazine

• Do not start outpatient

First generation antipsychotics

1st or 2nd gen antipsychotics?

• blocks D2/5HT2A

• more metabolic SEs

• clozapine most effective but lots of SEs, REMS program

Second generation antipsychotics

With which SGA should you get a baseline EKG due to QT prolongation?

Ziprasidone (Geodon)

What SGAs are partial DA agonists that are often less potent & have less SEs but more akathisia, and may not be as effective as full D2 antagonists?

Aripiprazole (Abilify), brexpiprazole (rexulti), cariprazine (vraylar)

What should be monitored while on SGAs?

BMI, FG/A1C, LDL, CBC, CMP, LFTs, EKG, assess for EPS/TD at each visit & document AIMS

What condition is a side effect of seen with antipsychotics (MC FGAs) due to D2 blockade that causes involuntary painless movements of the face & upper limbs?

Tardive dyskinesia (TD)

If a newer SGA such as caplyta does not block D2, can it cause TD?

No

What drugs are used to treat TD?

VMAT2 inhibitors - Valbenazine (Ingrezza) & Deutetrabenazine (Austedo)

What is used to treat or prevent EPS w/ antipsychotics, NOT used to treat or prevent TD?

Congentin (anticholinergic)

What are examples of 1st gen antipsychotics used to treat schizophrenia?

Thioridazine, chlorpramazine haloperidol, perphenazine, pimozide

What atypical SGAs are used to treat schizophrenia?

Clozapine, risperidone, olanzapine, quetiapine, aripiprazole

What might be required for the acute treatment of schizophrenia, psychosis & agitation?

Hospitalization for rapid sx control & initiation of effective dose of antipsychotics

What drugs are used in the hospitalization of acute treatment for schizophrenia, psychosis, agitation?

Antipsychotics ± benzos or benztropine:

1st line- IM haloperidol (most immediately effective)

Other- risperidone, olanzapine, or aripiprazole (PO/ODT)

What is a common combo of meds used in the acute treatment of psychosis and agitation in a hospitalized schizophrenic patient?

5 mg haloperidol, 2 mg lorazepam, 1 mg benztropine

What is only used for treatment resistant schizophrenia?

Clozapine

What is 1st line for treatment of a first episode of psychosis?

SGAs (avoid clozapine & olanzapine)

*high risk EPS → start low, go slow

What is the dose of risperidone (resperdal) to treat a first episode of psychosis in schizophrenia?

1-3 mg daily

What is the dose of aripiprazole (abilify) to treat a first episode of psychosis in schizophrenia?

10 mg daily

Which SGA is associated with life threatening agranulocytosis?

Clozapine

Which SGA is associated with weight gain, DM, & increased lipids?

Olanzapine

What is seen when monitoring the treatment of a first episode of psychosis?

1-2 days → improved sleep & agitaiton

1st week → improved positive & cognitive sx

1-4 weeks → increase dose if lack of improvement

6-8 weeks → max effect, if no improvement change to diff SGA

How long should antipsychotics be taken for schizophrenia?

Indefinitely, even after remission

What should you consider for schizophrenia treatment in a patient with a high risk of relapse and non adherence?

Injectable FGA → Fluphenazine 6.25-50 mg IM every 2 weeks

*monitor for EPS

What SEs are seen with low potency 1st gen antipsychotics?

Sedation, anticholinergic SEs (dry mouth, blurred vision, constipation)

What SEs are seen with high potency 1st gen antipsychotics?

Sedation, neuro effects- parkinsonian syndrome, dystonia, akathisia, tardive dyskinesia

What SEs are seen with SGAs?

Sedation, weight gain, DM, inc prolactin levels, agranulocytosis (clozapine)

What is the treatment for akathisia?

1st line: BBs (propranolol)

2nd line: Benztropine, benzos

What is the treatment for parkinsonian syndrome?

1st line: Benztropine

2nd line: Amantadine

What is the treatment for dystonia?

IM or IV benztropine or benadryl

What is the treatment for TD?

D/C or switch to SGA, valbenazine (ingrezza)

What is the treatment for metabolic syndrome caused by schizophrenia treatment?

Change antipsychotics, diet & exercise, treat w/ statins, hypertensives, metformin

What is the treatment for prolactin elevation caused by schizophrenia treatment?

Switch to different antipsychotic

What is the MC type of schizophrenia that usually has an older age of onset?

Paranoid schizophrenia

The following key features are with what subtype of schizophrenia?

• frequent delusions of persecution

• frequent auditory hallucinations

• pt may be anxious, guarded, angry, argumentative, violent

• difficult to treat (noncompliant)

Paranoid schizophrenia

The following key features are with what subtype of schizophrenia?

• begins in adolescence/young adulthood

• disorganized speech, thinking, behavior

  • word salad, rambling, incoherent speech

  • odd/senseless behavior → bizarre and inappropriate emotional responses (laughter)

Disorganized schizophrenia

The following key features are with what subtype of schizophrenia?

• extremely rare type

• negativism, mutism

• posturing

• catalepsy

• echolalia, echopraxia

Catatonic schizophrenia

The following criteria is for what condition?

• ≥ 2 sx lasts 30 days to 6 mos

  • delusions

  • hallucinations

  • disorganized speech

  • grossly disorganized or catatonic behavior

  • negative sx

• return to premorbid level of functioning after 6 mos

Schizophreniform disorder

Who is schizophreniform MC IN?

M > F, onset late teens-20s

How is the course of schizophreniform disorder different than schizophrenia?

Does not cause progressive decline in social & occupational functioning

Rapid prodromal phase, positive sx ± negative sx & return to premorbid behavior

What is the treatment for schizophreniform disorder?

Hospitalization, 6 month course antipsychotics, supportive psychotherapy

The following criteria is for what condition?

• atleast 1 sx lasts 1 day but < 1 month

  • delusions,

  • hallucinations,

  • disorganized speech,

  • grossly disorganized or catatonic behavior

• return to premorbid level of functioning

• (often onsets in response to life stressor)

Brief psychotic disorder

Who is brief psychotic disorder MC in?

W > M, younger patients 20s-30s, in response to stressful life event

What disorders has brief psychotic disorder been linked to?

Personality & mood disorders (BPD, histrionic, schizotypical)

The following course is associated with what disorder?

• normal premorbid period → trigger/stressor →

• positive sx & SI

• depressive sx my follow

• return to premorbid functioning

• can progress to schizophrenia or mood disorder

Brief psychotic disorder

What is the treatment for brief psychotic disorder?

Hospitalization, psychotherapy, antipsychotics & benzos for agitation

What antipsychotics are used to treat brief psychotic disorder?

Haloperidol

Risperidone 1-2 mg/day, increased to 2-3 mg/day over a week

What benzodiazepine is used to treat agitation in brief psychotic disorder?

Clonazepam 0.25 mg BID

How should risperidone and clonazepam be started for brief psychotic disorder?

Start risperidone 1mg daily & clonazepam 0.25 mg BID → monitor positive sx/SE for 1-2 weeks → inc dose slowly if sx continue → continue meds for 1-3 mos after remission → taper dose over 1-2 weeks & monitor for relapse

The following criteria is for what condition?

• ≥ 1 delusions for atleast 2 month

  • daily functioning not impaired

  • no obvious bizarre behavior

  • does not meet criteria for schizophrenia

Delusional disorder

What kind of delusion?

• being conspired against or potentially harmed

Persecutory type

What kind of delusion?

• unfaithfulness

Jealous type

What kind of delusion?

• believes that another person is in love with the individual

Erotomanic type

What kind of delusion?

• delusion of having great talent

Grandiose type

What kind of delusion?

• believes that something awful is wrong with their body

Somatic type

Who is delusional disorder MC in?

M = F, mid 30s-40s

What are RF for delusional disorder?

Psychosocial stressor, FMH paranoid personality disorder, sensory impairment (hearing/vision)

Describe the course of delusional disorder

Psychosocial stressor → sudden onset of delusions → delusions become elaborate & consuming → sx may wax and wane over time (50% recover)

What factors are associated with a good prognosis in delusional disorder?

High levels of occupational & social functioning, female, onset before age 30, sudden onset, short duration of illness, presence of triggering event

What is the treatment for delusional disorder?

1st line: SGAs- ariprazole, ziprasidone

Psychotherapy - CBT, supportive

How should aripiprazole be started for delusional disorder treatment?

Start ariprazole 2.5 mg/daily → inc gradually over days-wks & monitor for tolerability → therapeutic dose 10 mg/daily → eval clinical response & observe for 1 wk before adjusting

The following criteria is for what condition?

• uninterrupted period of illness during which there is major mood episode (depressive or manic) concurrent with criterion A of schizophrenia

• delusions or hallucinations for ≥ 2 wks in absence of major mood episode during the lifetime duration of illness

• *dx made in pts who:

  • meet criteria for depressive or manic episode

  • meet criteria for schizophrenia

  • psychotic episode lasts ≥ 2 wks in absence of any mood sx

Schizoaffective disorder

Who is schizoaffective disorder MC in?

M = F for bipolar subtype, W > M for depressive subtype; onset early adulthood

*better prog than schizophrenia, worse than mood disorders

The following course is associated with what condition?

• Hx/current dx of schizophrenia

• hx/dx of MDD or bipolar disorder →

• delusions or hallucinations begin to manifest →

• NO sx of mood disorder during manifestations

Schizoaffective disorder