PSYCH Schizophrenia Spectrum and other psychotic disorders; sleep wake disorders

Psychosis is not a dx but rather

a sx/general term that can occur with several psychiatric illnesses such as:

- Schizophrenia

- Mania

- Delirium

- Depression

- Major neurocognitive d/o

Can also be substance or medication induced

Psychosis describes a

distorted perception of reality

Poor reality testing may be with

Delusions

Perceptual disturbances (illusions or hallucinations)

Disorganized thinking/behavior

Describe a blunted affect

- Refers to minimal expression and intensity of emotion.

- The individual’s facial expression varies little.

- There are few physical gestures of emotion -> eye contact is either minimal or the patient seems to stare at the interviewer, and the patient speaks in a monotonous tone with little vocal inflection.

Describe flat affect

A more severe form of blunted affect with essentially no affective expression. The interviewer may feel as if they are conversing with an inanimate object

Grandeur delusions

belief that one has special powers or is someone important (Jesus, President)

Paranoid delusions

belief that one is being persecuted

Reference delusions

belief that some events are uniquely related to the patient (ex. a news anchor is sending messages directly to the pt)

Religious delusions

Conventional beliefs exaggerated (ex. God wants me to be the Messiah)

Somatic delusions

False belief concerning body image, certain illness or health condition (ex. pregnancy despite negative tests including ultrasound)

Delusions of controls (2)

Though broadcasting

- Belief that one’s thoughts can be heard by others

Thought insertion

- Belief that thoughts are not one’s own, but have been placed there by some person, group, or force from the outside

Tangentiality thought disorder

Can follow conversation but point never reached

or quesiton never answered

Loosening of associations thought disorderq

no logical connection from one thought to another

Flight of ideas thought disorder

thoughts change abrubtly from one idea to another, often based on understandable associations or distracting stimuli

Usually accompanied by rapid, pressured speech

Neologisms (thought disorder)

made up words

"Word salad" (thought disorder)

incoherent collection of words

Clang associations (thought disorder)

Word connections due to phonetics rather than actual meaning. Can be rhyming or puns.

Thought blocking - Thought Disorder

Abrupt cessation of communication before the idea is finished

Delusion of reference

A delusion of reference is a type of false belief where an individual is convinced that otherwise unrelated occurrences in the external world have a special or personal significance specifically for them.

Delusional d/o more often occurs in ___ age

middle

Inc risk for delusional d/o in what populations (3)

Immigrants

Hearing impaired

FHx of schizophrenia

Dx criteria for delusional disorder

A.The presence of one (or more) delusions with a duration of 1 month or longer.

A.Criterion A for schizophrenia has never been met.

C.Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd.

Delusional d/o: usually ___ delusions

nonbizzare

Delusional d/o: ____ are NOT prominent

Hallucinations

Delusional d/o: Daily ___ are not significantly impaired

functioning

Delusional d/o: patient usually lacks ___

insight

Tx for delusional d/o

Difficult to tx

Meds: Antipsychotic

Supportive therapy

brief psychotic d/o RF

High rates of __

Do they recover?

Significant stressors, peripartum period

High rates of relapse

Almost all completely recover

Brief psychotic d/o dx criteria:

A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3):

1. Delusions

2. Hallucinations

3. Disorganized speech (e.g., frequent derailment or incoherence).

4. Grossly disorganized or catatonic behavior.

Brief psychotic d/o dx criteria

B: Duration of an episode of the disturbance is at least ___ but less than ___, with eventual full return to premorbid level of functioning.

1 day

1 month

Tx of brief psychotic d/o

Brief hospitalization typically required

- workup for medical issues

- safety

- stabilization

Meds:

- antipsychotics for psychosis

- benzodiazepines for agitation

Supportive therapy

Schizophreniform dsm:

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions.

2. Hallucinations

3. Disorganized speech (e.g., frequent derailment or incoherence).

4. Grossly disorganized or catatonic behavior.

5. Negative symptoms (i.e., diminished emotional expression or avolition).

Schizophreniform dsm:

B: An episode of the disorder lasts at least ____ but less than ___. When the diagnosis must be made without waiting for recovery, it should be qualified as ___

1 month

6 months

"provisional."

Schizophreniform: with good prognostic fts vs without

With good prognostic fts: Requires the presence of at least two of the following features: onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity; good premorbid social and occupational functioning; and absence of blunted or flat affect.

Without good prognostic fts:

This specifier is applied if two or more of the above features have not been present.

Tx for schizophreniform d/o

Hospitalization if necessary

Medications: 6-month course of antipsychotics

Supportive psychotherapy

Do men or women have better outcome in schizophrenia?

When does it present in both genders?

Men: present in early to mid-20’s, more negative symptoms and poorer outcome

Women: present in late 20s, less negative symptoms and better outcome than men

Better prognostic factors for schizophrenia

Later onset

Good social support

Positive symptoms

Mood symptoms

Acute onset

Female gender

Few relapses

Good premorbid functioning

Prodrome of schizophrenia course

Decline in function, precedes first psychotic episode

Social w/d, irritable

May have physical complaints, declining in school/work performance, and/or newfound interest in religion or occult

Psychotic course of schizophrenia

Perceptual disturbances, delusions, disordered thought process/thought content

Residual course of schizophrenia

Follows episode of active psychosis, mild hallucinations or delusions, social withdrawal, negative symptoms

Positive sxs of schizophrenia

Hallucinations

Delusions

Thought d/o

Movement d/o

Depersonalization

Bizarre behavior

Disorg speech

Neg sxs of schizophrenia

Flat or blunted affect

Alogia - poverty of speech

Anhedonia - inability to experience joy or pleasure

Avolition - a significant dec in initiation, motivation, and goal directed behavior

Social w/d

Cognitive sxs of schizophrenia

Disorg thinking

Poor concentration

Poor memory

Difficulty expressing ideas

Difficulty integrating thoughts and feelings

Poor attention

Schizophrenia dsm:

A.Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1. Delusions.

2. Hallucinations.

3. Disorganized speech (e.g., frequent derailment or incoherence).

4. Grossly disorganized or catatonic behavior.

5. Negative symptoms (i.e., diminished emotional expression or avolition).

Schizophrenia dsm:

B. For a significant portion of the time since the onset of the disturbance, level of functioning in _______, is markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, there is failure to achieve expected level of interpersonal, academic, or occupational functioning).

one or more major areas, such as work, interpersonal relations, or self-care

Schizophrenia dsm:

C. Continuous signs of the disturbance persist for at least ___ months.

6 months

Schizophrenia tx

Multimodal approach—tailored to the specific patient

Team approach to care—ACT (Assertive Community Treatment) 24/7 services provided

Case Management

Behavioral therapy-improve ability to function in society, social skills, become self-sufficient, minimize disruptive behaviors

Group therapy

Family therapy

Medications: antipsychotics including long-acting injectable antipsychotics due to high risk of nonadherence to Tx regimen

List the disorders based on their timeline:

< 1 month

1-6 months

>6 months

< 1 month: Brief psychotic d/o

1-6 months: Schizophreniform disorder

>6 months: Schizophrenia

delusions: delusional d/o vs schizophrenia

Delusional: nonbizarre delusions

Schiz: bizarre or nonbizzare delusions

daily functioning delusional d/o vs schizophrenia

Delusional: daily functioning not significantly impaired

Schiz: Daily functioning significantly impaired

Which FGA can cause blue gray skin discoloration, as well as corneal and lens deposits; photosensitivity

Chlorpromazine

List some FGAs

Chlorpromazine

Fluphenazine

Haloperidol

___ and ___ more likely to cause QTc prolongation and need EKG

Haloperidol and Ziprasidone

FGA Anti- HAM effects

Antihistaminic

- Sedation, weight gain

Anti-alpha 1 adrenergic

- Orthostatic hypotension, cardiac abnormalities, sexual dysfunction

Antimuscarinic

- Anticholinergic effects—dry mouth, tachycardia, urinary retention, blurry vision, constipation, and precipitation of narrow-angle glaucoma

Anti dopaminergic SE FGAs

Check serum ___

Tx?

Parkinsonism

Akathisia

Dystonia

Hyperprolactinemia

Decreased libido, galactorrhea, gynecomastia, impotence, amenorrhea

Check serum prolactin

Tx - d/c offending agent

Monitor for movement d/o at every visit when on antipsychotics with ___ testing q 3-6 months

AIMS

AIMS is used to help clinicians...

detect TD early, monitor its severity over time, and evaluate the effectiveness of treatment.

Sxs and tx of akathisia

Compulsive restless movements

Anxiety and agitation

Reduce dose

Switch meds

BB - Propranolol or Benztropine

Sxs and tx of Acute dystonia

Spasm of the muscles of the tongue, face, neck, and back

Diphenhydramine or Benztropine

Sxs and tx of tardive dyskinesia

Choreoathetoid (writhing, irregular) movements of mouth and tongue or other body parts

Pt has used antipsychotics for > 6 months

TX: discontinuation of current antipsychotic if possibly, change med to one with less potential of TD (clozapine); VMAT inhibitors (-benazine)

TD mc in ___, ___, and ____

face

tongue

head

MOA Vmat inhibitors

Inhibit the Vesicular Monoamine Transporter Type 2 (VMAT2) reducing dopamine storage and release

Decreasing dopamine release—decreases overstimulation of D2 dopamine receptors in the motor striatum that causes TD

List some VMAT inhibitors

Valbenazine

Deutetrabenazine

NMS sxs

FALTERED

Fever (most common presenting symptom)

Autonomic instability (tachycardia, labile HTN, diaphoresis)

Leukocytosis

Tremor

Elevated CPK (creatinine phosphokinase)

Rigidity (lead pipe rigidity—considered universal)

Excessive sweating

Delirium (mental status changes)

NMS tx

DISCONTINUE OFFENDING AGENT

Supportive - hydration and cooling

Sodium Dantroline

Bromocriptine

Amantadine

ECT

SGAs have higher rates of _ than FGAs

SGAs have a lower incidence of __ than FGAs

metabolic syndrome

Lower incidence of EPS and NMS

First line SGA for schizophrenia and Bipolar

Why?

Aripiprazole

Fewer SE other than akathisia

#1 MOST EFFECTIVE for schizophrenia and decreases suicide

What is key about labs for this drug?

Clozapine

Weekly CBC for the 1st 6 months (Neutropenia agranulocytosis), then every other week for weeks 26-52, then every 4 weeks for 1 year and beyond

REMS program

Approved for schizophrenia and bipolar depression

Lurasidone

SGA #1 for weight gain and DM risk

Olanzapine

SGA used for hallucinations of parkinsons dz

Pimavanserin

Weak antipsychotic that is more often used for mood disorders than for schizophrenia

Quetiapine

SGA with several peds indications - including autism associated irritability for ages 5+

Risperidone

SGA monitoring

Baseline:

Screen for drug abuse and Physical Examination

General Chemistry (CMP)

Fasting glucose/HbA1c

Serum lipids

Weight/BMI

Blood pressure

Metabolic Tests every 6 to 12 months:

Weight/BMI

Fasting glucose/HbA1c

Serum lipids

Blood pressure

Schizoaffective D/O DSM

A. It is an ___ period of illness which there is a major mood episode (major depressive or manic)

B. Delusions or hallucinations for___ weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness.

C. Symptoms that meet criteria for a major mood episode are present for the ___ of the total duration of the active and residual portions of the illness.

A. Uninterrupted

B. 2 or more

C. majority

Bipolar type of schizoaffective d/o

This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur.

Depressive type of schizoaffective d/o

This subtype applies if only major depressive episodes are part of the presentation.

___ may predispose to psychogenic polydipsia

TBI and other neurological insults

Psychogenic polydipsia is characterized by

Compulsive, excessive water intake, most commonly seen in pts with chronic psych d/o, especially schizophrenia, but also anxiety and depression

Dx of PDD

Must exclude other causes of polyuria and polydipsia -> syndrome of inappropriate antidiuretic hormone secretion (SIADH)

S/sxs of PDD

Excessive drinking

Low serum Na or osmolarity

Abn diurnal WG

Low urine sp. gravity

Gold standard eval test for PDD

Water deprivation test

- often combined with desmopressin administration, to assess osmolality response

___ is a surrogate marker for AVP that can help distinguish PPD from DI

Copeptin

Tx for PPD

Fluid restriction

Pt ed

Behavioral therapy

Address psychiatric comorbidities

Dyssomnias vs parasomnias

Dyssomnias:

- insufficient, excessive, or altered timing of sleep

Parasomnias

- Unusual sleep-related behaviors

Most prevalent of all sleep d/o

insomnia

Insomnia: <6 hours a night RF for ___ (4)

CV dz

Anziety d/o

MDD

SUD

DSM - insomnia:

A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms: (3)

1. Difficulty initiating sleep. (In children, this may manifest as difficulty initiating sleep without caregiver intervention.)

2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings. (In children, this may manifest as difficulty returning to sleep without caregiver intervention.)

3. Early-morning awakening with inability to return to sleep.

Insomnia DSM - B. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning.

C. The sleep difficulty occurs at ___

D. The sleep difficulty is present for at least ___

E. The sleep difficulty occurs despite ___

C. least 3 nights per week.

D. 3 months.

E. adequate opportunity for sleep.

Episodic or acute insomnia usually a/w

Stress OR

Changes in sleep schedule

Insomnia tx - sleep hygiene measures

Stimulus control

Relaxation techniques

First line tx for insomnia

Other option?

CBT

Other option: Entrain circadian rhythm with chronotherapy (bright light therapy)

Antidepressants used for insomnia tx

Trazodone

Mirtazapine

Amitriptyline

Doxepin (FDA approved for sleep maintenance)

Antidepressant SE of insomnia tx

Residual sedation more common with TCA, dizziness

psychomotor impairment

weight gain with some

Melotonin receptor agonist used for insomnia

MOA?

Ramelteon

Works at MT1 and MT2 receptors which are involved in regulation of circadian rhythm, sleep onset

Non benzo hypnotics insomnia tx SEs

tolerance

dependence

rebound insomnia

elderly-increased fall risk (dose lower in elderly)

GI

Anterograde amnesia

Hallucinations

Parasomnias (sleep walking, sleep eating)

Insomnia tx benzos SE

tolerance, dependence, daytime sleepiness, rebound insomnia, elderly (falls, confusion, dizziness)

Non rapid eye movement sleep arousal usually occurs during the ____ of the major sleep episode

first third

Non rapid eye movement sleep arousal - eyes open or closed

open usually

Non rapid eye movement sleep arousal disorder DSM - A.Recurrent episodes of incomplete awakening from sleep, usually occurring during the first third of the major sleep episode, accompanied by either one of the following: (2)

1. Sleepwalking: Repeated episodes of rising from bed during sleep and walking about. While sleepwalking, the individual has a blank, staring face; is relatively unresponsive to the efforts of others to communicate with him or her; and can be awakened only with great difficulty.

2. Sleep terrors: Recurrent episodes of abrupt terror arousals from sleep, usually beginning with a panicky scream. There is intense fear and signs of autonomic arousal, such as mydriasis, tachycardia, rapid breathing, and sweating, during each episode. There is relative unresponsiveness to efforts of others to comfort the individual during the episodes.