Psychotic Disorders and Their Treatments

Psychotic Disorders Overview

  • Echopraxia:

    • Mimicking the movements of another person.

  • Positive (Hard) Symptoms:

    • Medications can control these symptoms.
    • Mood stabilizers or antidepressants may be added if needed.

  • Schizoaffective Disorder:

    • Client is severely ill and presents a mixture of psychotic and mood symptoms.
    • Symptoms include apathy, which is often diagnosed in late adolescence or early adulthood and rarely manifest in childhood.
    • Examples of symptoms:
    • Hallucinations
    • Delusions: Fixed false beliefs with no basis in reality.
    • Flat affect
    • Bizarre behavior
    • Indifference towards people/events
    • The disorder can present a syndrome or disease process with many varieties and symptoms.

  • Common Symptoms in Schizophrenia:

    • Avolition: Lack of will or drive.
    • Disorganized Speech/Thinking: Difficulty with attention and inattention.
    • Negative (Soft) Symptoms:
    • Medications often do not remedy these symptoms, which include:
      • Asociality: Social withdrawal.
      • Alogia: Poverty of speech.
      • Anhedonia: No joy or pleasure.
      • Flat affect.

Demographics and Clinical Features

  • Schizophrenia Demographics:

    • Women typically affected between ages 25-35 years.
    • Men typically affected between ages 15-25 years.

  • Age of Onset:

    • The onset can be abrupt or insidious (gradual).
    • Early onset is associated with worse outcomes.

  • General Clinical Features:

    • Causes include distorted and bizarre thoughts, perceptions, emotions, movements, and behaviors.
    • Symptoms include difficulty in concentration, inattention, and asociality.

Biological Theories

  • Genetic Factors:

    • Twin studies show a 50% concordance rate for schizophrenia.
    • If one parent has schizophrenia, the risk is increased to 35%, while fraternal twins show a 15% risk.

  • Neurochemical Factors:

    • Dopamine and serotonin play crucial roles in the disorder.

  • Neuroanatomic Factors:

    • Decreased brain tissue and enlarged ventricles observed in brain scans.

  • Immunovirological Factors:

    • Viral exposure or immune response may alter brain physiology.

Specific Disorders

  • Delusional Disorder:

    • Characterized by one or more non-bizarre delusions (content is believable).
    • Psychosocial functioning is not markedly impaired.

  • Brief Psychotic Disorder:

    • One psychotic symptom lasting from 1 day to 1 month.

  • Catatonia:

    • Marked psychomotor disturbance with either excessive motor activity or virtual immobility and motionlessness.

  • Schizotypal Personality Disorder:

    • Presents odd, eccentric behavior and may eventually be diagnosed with schizophrenia.

  • Schizophreniform Disorder:

    • Acute reactive psychosis lasting less than 6 months.

Treatment Approaches

  • Pharmacological Interventions:

    • Antipsychotics do not cure the disorder, but they manage symptoms.
    • Atypical Antipsychotics:
    • First-choice treatment for schizoaffective disorder.
    • Medications include:
      • Risperidone, clozapine, olanzapine.
      • Targets both positive and negative symptoms.

  • Typical Antipsychotics:

    • Haloperidol and chlorpromazine are examples.
    • D2 dopamine antagonists, primarily targeting positive symptoms but have many side effects including Extrapyramidal Symptoms (EPS).

  • Side Effects:

    • Tardive Dyskinesia (TD):
    • Potentially irreversible repetitive movements.
    • Neuroleptic Malignant Syndrome (NMS):
    • Rare, potentially fatal reaction characterized by high fever and muscle rigidity.
    • Cognitive Enhancement Therapy (CET):
    • Combines computer-based cognitive training with group sessions to improve attention and social cognition.

  • Maintenance therapy:

    • Long-acting injections (LAIs) require several weeks of oral therapy to achieve stable dosing.
    • Ongoing screening for side effects like TD every 3-6 months.

Community and Psychosocial Considerations

  • Social Skills Training:

    • Breaks complex behavior into simpler steps.
    • Aims to improve interpersonal interactions.

  • Assessment Areas:

    • Self-Care: Significant deficits in hygiene, grooming, nutrition.
    • Mood and Affect:
    • Flat, blunted, or inappropriate affect (e.g. a masklike appearance).
    • Thought Processes:
    • Disordered thinking leading to hallucinations (e.g. auditory voices).
    • Manifestations like word salad and echolalia.

  • Safety Assessments:

    • Monitoring for risks of violence or suicide, especially during acute phases.
    • Ensuring adequate nutrition and hydration.

  • Community-Based Care:

    • Most clients return to the community but require monitoring for escalating agitation.

Medications Specific Information

  • Chlorpromazine:

    • Pharmacologic class: D2 dopamine receptor antagonist, therapeutic class: antipsychotic.
    • Side effects include dizziness, drowsiness, and orthostatic hypotension.
    • Long-acting forms may show delayed effect.
    • Caution in patients with alcohol withdrawal.

  • Haloperidol:

    • Pharmacologic class: D2 dopamine receptor antagonist.
    • Used for acute and chronic psychotic disorders.
    • Must not be abruptly discontinued to avoid severe reactions.

  • Risperidone:

    • Pharmacologic class: D2 dopamine receptor antagonist, therapeutic class: atypical antipsychotic.
    • Adverse effects include EPS and increased prolactin levels, leading to decreased libido.
    • Effective as a first-line treatment for schizophrenia and acute mania.