ch 8 exam review

Chapter 8: Psychotic Disorders and Antipsychotics

DSM-5: Psychotic Disorders

• Psychotic Disorders Overview

  • Characterized by significant impairment in thought processes, perception, and emotional regulation.

  • Major Types:

    • Schizotypal Personality Disorder

      • Discomfort in close relationships.

      • Cognitive or perceptual distortions, including magical thinking (e.g. telepathy).

      • Ideas of reference and odd thinking/speaking.

    • Delusional Disorder

      • More than one month of delusions.

      • Key characteristics: falsity of beliefs, resistant to change.

      • Can feature bizarre delusions such as thought insertion or broadcasting.

    • Brief Psychotic Disorder

      • Episode lasts less than one month with at least one symptom of schizophrenia.

      • Resembles an emotional breakdown.

    • Schizophreniform Disorder

      • Symptoms meet schizophrenia criteria but last less than six months.

    • Schizophrenia

      • Required criteria: Two or more symptoms present for over six months, including delusions, hallucinations, and disorganized behavior.

    • Schizoaffective Disorder

      • Meets criteria for both schizophrenia and mood disorders (either MDD or BPD).

Delusional Disorder Details

• Delusions

  • Definition: a false belief that remains unchanged despite contradictory evidence.

  • Types of delusions:

    • Bizarre delusions (implausible).

    • Examples:

      • Thought insertion: Others are inserting thoughts.

      • Thought broadcasting: Belief that thoughts are accessible to others.

      • External control: Belief that thoughts are controlled externally.

• Cultural Considerations:

  • Culturally held beliefs, even if bizarre, do not qualify as a disorder if generally accepted within that culture (e.g., Koro, Wendigo).

• Diagnosis Criteria

  • No requirements of functional impairments other than delusions.

  • Delusions can be tactile/olfactory if related to the delusion.

  • Must specify type: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified.

Schizophrenia Overview

• Diagnostic Criteria

  • Two or more symptoms prolonged for at least six months, including:

    • Delusions.

    • Hallucinations.

    • Disorganized speech.

    • Grossly abnormal behavior (catatonia).

    • Negative symptoms.

• Symptom Types:

  • Positive Symptoms: Hyperactivity of the mesolimbic system.

    • Includes delusions, hallucinations (predominantly auditory), and disorganized speech.

  • Negative Symptoms: Hypoactivity in the mesocortical system.

    • Affective flattening, alogia, avolition, apathy, anhedonia, attentional impairment.

• Symptom Impact on Functioning:

  • Negative symptoms correlate more with real-world functioning than positive symptoms.

Hallucinations in Schizophrenia

• Prevalence: 70-83% of individuals experience hallucinations, predominantly auditory.

• Types of Hallucinations:

  • Visual (30-57%).

  • Tactile, olfactory, gustatory (14-27%).

• Symptom Presentation:

  • Paranoid, disorganized, or depressive presentations with varying symptoms and attitudes.

Differentiation from Other Disorders

• Psychotic symptoms can occur in various psychiatric disorders including bipolar disorder, major depression, schizoaffective disorder, and dementias like Alzheimer's and Lewy body dementia.

Prevalence and Heritability

• Delusional Disorder:

  • Rarity: 0.05-0.1%.

  • Heritability: 31-39%.

• Schizophrenia:

  • Prevalence: Approximately 0.5%, equal gender distribution.

  • Heritability significant: 80% (high concordance in MZ twins compared to DZ twins).

Neurobiology of Schizophrenia

• Focus on Dopamine Pathways:

  • Mesolimbic Pathway: Involved in positive symptoms; D2 receptor blockade can reduce symptoms but may reduce motivation.

  • Mesocortical Pathway: Involved in negative symptoms; dysfunction can cause cognitive issues.

  • Nigrostriatal and Tuberoinfundibular Pathways: Related to motor side effects and prolactin secretion, respectively.

  • Serotonin's Role:

    • Influences dopamine release; modulation may help with treatment efficacy.

Antipsychotics Overview

• Types of Antipsychotics:

  • First-Generation (Typical): Primarily D2 blockers.

  • Second-Generation (Atypical): Block both DA and 5-HT2A, can be more effective for negative symptoms.

• Key Antipsychotics Introduced:

  • Chlorpromazine (1950), Haloperidol (1958), Clozapine (1990), and others.

Side Effects of Antipsychotics

• Elderly Patients with Dementia:

  • Increased risk of death, particularly from cardiac and cerebrovascular incidents.

  • Box warning for all antipsychotics when used in geriatric patients.

Considerations in Choosing Antipsychotics

• Evaluation of patient history and existing conditions to ensure correct diagnosis and treatment options.

• Addressing possible non-compliance and understanding the therapeutic range and the time required for medication to take effect.