Schizophrenia Spectrum and

Other Psychotic Disorders

Britta Ostermeyer, MD, MBA Professor and Chairman

Department of Psychiatry and Behavioral Sciences

University of Oklahoma

Learning

Objectives

At the end of this class, the audience will be able to:

1) Explain symptoms of psychosis

2) Name the DSM-5 psychotic disorders and the symptoms

3) Identify the differences between the DSM-5 psychotic disorders

4) Name first and second generation antipsychotics and

know their main side-effects

Psychosis

Positive Symptoms: Excess/Distortion of Normal Function

• Thought content: delusions

• Perception: hallucinations

• Language/thought process:

disorganized speech

• Behavior:

disorganized/catatonic behavior

Negative Symptoms: Poverty/Restrictions

• Emotional expression: flat affect

• Thought and speech: alogia

• Initiation of behavior: avolition

Bizarre Delusions: Implausible

• Thought withdrawal

• Thought insertion

• Delusions of control

Command Hallucinations

Suicide 52%

Unspecified 17%

Non-violent acts 14%

Injury to self or others 12%

Homicide 5%

Compliance with Commands

• Hallucinated-related delusion

• Familiar voice

• Less dangerous commands

• History of compliance

Patient’s Mother God by Michelangelo

Differential Diagnosis

Differential Diagnosis

• Substance abuse

• Medical causes

• Severe depression with psych features

• Cluster A Personality Disorders

- Paranoid Personality Disorder

- Schizoid Personality Disorder

- Schizotypal Personality Disorder

Psychotic

Disorders

Schizophrenia Spectrum and Other

Psychotic Disorders-1

• Schizotypal (Personality) Disorder

• Delusional Disorder

• Brief Psychotic Disorder

• Schizophreniform Disorder

• Schizophrenia

Schizophrenia Spectrum and Other

Psychotic Disorders-2

• Schizoaffective Disorder

• Substance/Medication-Induced Psychotic Disorder

• Psychotic Disorder Due to Another Medical Condition

• Catatonia

Case: Mr. Lucas

Mr. Lucas is a 19 yo college sophomore who “does not fit in” as

per his mother who is taking him to see you at your new primary

care clinic. Mom says he is odd and preoccupied with “laboratory

worriers.” He spends hours drawing weird looking soldiers with

“three eyes.” Mom explains that he is different, always suspicious

of others, and does not seem to like people. Mr. Lucas lives by

himself in an off-campus apartment. Mom says that he has been

shy, quiet, and reserved since childhood. He has no close friends,

never dated anybody, and “is fascinated by ghosts and telepathy.”

Schizotypal Personality Disorder-1

A. Social and interpersonal deficits marked by discomfort and

reduced capacity for close relationships; cognitive and

perceptional distortions, eccentricities of behavior, beginning in

early childhood, 5 or more:

1. Ideas of references

2. Odd beliefs, magical thinking influencing behavior,

inconsistent with norms (telepathy)

3. Unusual perceptional experiences, bodily illusions

4. Odd thinking and speech

Schizotypal Personality Disorder-2

5. Suspiciousness or paranoid thinking

6. Inappropriate or constricted affect

7. Odd, eccentric behavior or appearances

8. Lack of close friends/confidants

9. Excessive social anxiety associated with paranoid

fears rather than negative self judgment

Case: Mr. Thompson

Your first patient this morning is Mr. Thompson, who is a 51 yo school bus

driver, coming in for “bugs in my bowels.” You open his EMR chart and realize

that your colleagues have been seeing the patient for several months related

to a CC of “bugs in my bowels.” He was worked up but all tests are normal,

including blood work, stool samples as well as an abdominal U/S and CT. Last

year, he even had a colonoscopy, which was normal as well. As you walk into

the exam room, Mr. Thompson greets you with an old glass full with feces

stating “they are all in here, I know it.” He has no hx of voices, visions, PI, or

mood sx. As per his chart, he is in good standing with his employer.

Delusional Disorder

• 1 or more delusions

• 1 month or longer

• Schizophrenia criterion A never met

• Functioning not markedly impaired

Case: Mr. Smith

Mr. Smith is a 26 yo OU mechanical engineer student who was

brought to your ER by campus police who found him at 12:35am

sitting outside his classroom building crying and shouting “leave me

alone.” Upon arrival, he is scanning the room stating, “I have voices

and visions that scare me.” One week ago, he started to hear the

voice of an unknown male telling him that he is “dirty.” He is also

seeing “grey shadows or ghosts that fly around the room.” O/E, he

looks disheveled, there is a smell of body odor, and he is unshaven.

His Utox is negative, he has no known medical illnesses.

Brief Psychotic Disorder

• Presence of 1 or more, at least 1 must be 1., 2., or 3.:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

• 1 day - 1 month

Case: Mr. Lee

Mr. Lee is a 22 yo college freshman who was taken to your ER by his

GF and mother. He states that he came bc of “migraines and spiritual

feelings” for the past 3 months. He reports his headache is really bad

when he hears “voices that make me feel guilty.” For the past 3

months, he has been hearing strangers commenting “on my past

sins.” He states no mood changes, no anxiety, and no substance

abuse. His GF reports that Mr. Lee has become socially “very isolated

and quiet” after having previously been “fun and outgoing. “

Schizophreniform Disorder

• 2 (or more) for 1 month, one must be 1.,2.,or 3.:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

• 1 month - 6 months

• Schizoaffective Disorder, bipolar ruled out

Case: Mr. Jones

Mr. Jones is a 28 yo WM who is brought into your ER by his family

with a CC of “They are after me, you are one of them.” He has had

paranoid ideations since about age 21. At home, he pushed his

mother against the wall shouting at her over and over that she is to

quit her job as a spy for the Cuban government. He also has been

pacing in the garden while loudly arguing with himself. In the EC,

he reports that he is seeing Cuban soldiers who want to kill him. As

you inquire further, Mr. Jones tells you, “They are after me bc I am a

white man. And I am refusing to belong to their army of the devil.”

Schizophrenia

• 2 (or more) for 1 month, one must be 1.,2.,or 3.:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic behavior

5. Negative symptoms

• Functional impairment

• 6 months or longer

• Schizoaffective Disorder, bipolar ruled out

• Not due substance or medical condition

Movie: “A Beautiful Mind”

Professor Nash’s Mental Illness

Video Clip

Russell Weston,

Capitol Shooting, 1998

Schizophrenia

Good Prognostic Factors

Female

Good premorbid functioning

Acute onset

Late onset

Obvious predisposing factors/stressors

Positive sx

Mood sx

Fhx of mood ds

Good support

Married

Schizophrenia

Poor Prognostic Factors

Male

Poor premorbid functioning

Insidious onset

Early onset, < age 20

No obvious predisposing factors/stressors

Negative sx

Soft neuro signs

No mood sx

No Fhx of mood ds

Poor support

Single

Schizophrenia

Lifetime prevalence: 1%

Most common hallucination: Auditory

Case: Ms. Dee

Ms. Dee is a 32 yo homemaker who was taken to your ER via police after she

attacked her HB at home. She hit him with a frying pan. She is agitated and

states that her HB is “in cahoots with the CIA.” She says, “He is arranging for

them to come and get me!” Her HB tells you that for the past one week, the

patient is enormously irritable, not sleeping at night, is talking fast on the

phone for hours, and is shouting or hitting him. As you obtain some past hx

from her HB, he tells you that she has had times in the past during which she

was hearing voices, believing that she is talking to the CIA but otherwise had a

normal mood and was calm during those times. These psychotic episodes

with normal mood lasted about 3 weeks. She has no medical problems.

Schizoaffective Disorder-1

• Major mood episode (major depressive or manic) concurrent

with psychotic symptoms of schizophrenia

and

• Psychotic symptoms of delusions or hallucinations for 2 weeks

or more in the absence of major mood symptoms

Schizoaffective Disorder-2

Specify If:

Bipolar type

Depressive type

Schizoaffective Disorder

Lifetime prevalence: 0.3%

Case: Ms. Watson

Ms. Watson is a 41 yo court reporter who is brought to your ER by her

sister for voices and agitation. The sister tells you that Ms. Watson lost

her job 4 weeks ago. Since then “is partying with different guys and

never home.” The sister says that Ms. Watson has “totally changed for

the worse over the past 4 weeks and believes that she is taking “some

drugs or so.” She stated that she saw a “pipe in her room.” As a savvy

ER doc, you had already ordered a utox prior to talking to the sister as

the patient is very agitated, covering her ears with her hands, and

yelling “I want them to shut up!” Her utox comes back positive for

cocaine and cannabis.

Substance/Medication- Induced

Psychotic Disorder

• Delusions and/or hallucinations

• Evidence from hx, PE, or lab findings of both:

1. Sx developed during or soon after substance

intoxication, w/d, or after exposure to a medication

2. Substance is capable of producing the sx

Case: Ms. Wu

While you are on your psych CL rotation at Presbyterian Hospital,

you are being asked to consult on Ms. Wu for paranoid behavior by

neurology. You are told by the neuro intern that she is refusing all of

her meds and appears paranoid and distrustful towards nursing staff.

Ms. Wu was admitted for the first time for tx of progressive MS with IV

solumetrol. When you arrive at her bedside, you find a suspicious

and paranoid patient who is guarded and not talking to you. You talk

to her brother and father who tell you that the patient has been

hearing some voices.

Psychotic Disorder Due

to Another Medical Condition

• Hallucinations or delusions

• Evidence from hx, PE, or lab findings that sx is direct

pathophysiological consequence of another medical

condition

• Not better explained by another mental disorder

Case: Ms. Max

Ms. Max is a 39 yo WF coming into your EC via ambulance. She has a hx of

bipolar 1 disorder with multiple hospitalizations due to manic episodes,

including psychotic features of religious delusions and auditory and visual

hallucinations. She is living in an assisted living facility, where the medication

is offered to the residents. Presently, she is on Risperidone 1 mg po qhs and

Risperdal Consta 37.5 mg IM q 2 weeks, the latter since March 2014. You are

told by EMS that she progressively declined at her assisted living home

showing less mimicry, staring, negativism, mutism, and immobility. When she

was found stuporous on the floor of her room, staff called 911. O/E, you find a

stuporous woman on the stretcher. There were no signs of autonomic

dysregulation; her VS are normal, and she is afebrile.

Catatonia

3 (or more) symptoms:

1. Stupor

2. Catalepsy (passive induction of a posture held against gravity)

3. Waxy flexibility (slight, even resistance to positioning by examiner)

4. Mutism

5. Negativism (opposition or no response)

6. Posturing (spontaneous, active maintenance of a posture against

gravity)

7. Mannerism (odd, circumstantial caricature of normal actions)

8. Stereotypy (repetitive, abnormal frequent, non-goal directed

movements

9. Agitation, not influenced by external stimuli

10. Grimacing

11. Echolalia (mimicking another’s speech)

12. Echopraxia (mimicking another's movements)

Treatment of Psychotic

Disorders

• Therapy

• Medications

Therapy

• Supportive Individual Psychotherapy

• Social Skills Training

• Family-Oriented Therapy

• Case Management

First Generation:

Typical Antipsychotics

Low Potency

• Chlorpromazine (Thorazine)

• Chlorprothixene (Taractan, Truxal)

• Levomepromazine (Levoprome)

• Mesoridazine (Serentil)

• Thioridazine (Mellaril)

Medium Potency

• Loxapine (Loxitane)

• Molindone (Moban)

• Perphenazine (Trilafon)

• Thiothixene (Navane)

High Potency

• Droperidol (Dehydrobenzperidol)

• Fluphenazine (Prolixin)

• Haloperidol (Haldol)

• Pimozide (Orap)

• Prochlorperazine (Compro)

• Trifluoperazine (Stelazine)

IV Haldol

• Not IV push, very slowly

• Increased risk of torsade de pointes

Extrapyramidal Symptoms (EPS)

1. Dystonia (acute, early)

• Involuntary contractions

• Tongue, throat, eyes, neck, back

• Benadryl 50 IM

2. Akathisia

• Restlessness, often mistaken for agitation

• Decrease dose, switch to atypical

• Ativan, B-blocker

3. Parkinsonian Symptoms

• Cogentin, switch to Seroquel

Extrapyramidal Symptoms (EPS)

4. Tardive Dyskinesia

Facial

• Perioral movements, tics, eye blinking

Extremities

• Wormlike movements

• Toe bending or jerking

Trunk

• Torticollis

• Trunk or pelvic thrusting, rocking

Tardive Dyskinesia

Tardive Dystonia: Torticollis

AIMS Evaluation

(Abnormal Involuntary Movement Scale)

Twice yearly to monitor for Tardive Dyskinesia:

1. Facial Muscles

2. Lips/Perioral Area

3. Jaws

4. Tongue

5. Upper Extremities

6. Lower Extremities

7. Neck/Shoulders/Hips

Antipsychotics + Added Benzo

Ativan or Klonopin

• Much faster control of psychosis

• Keeps dose of antipsychotics down

• Treats potential antipsychotic SEs, e.g. akathisia, acute dystonia

• Add Ativan to IM Haldol

• Ativan: treatment for catatonia

Treatment of Tardive Dyskinesia

• Taper antipsychotic

• Caution b/c of withdrawal dyskinesias

• Switch to Seroquel

• Clozaril

Second Generation:

Atypical Antipsychotics

• Aripiprazole (Abilify)

• Asenapine (Saphris)

• Clozapine (Clozaril)

• Iloperidone (Fanapt)

• Lurasidone (Latuda)

• Olanzapine (Zyprexa)

• Paliperidone (Invega)

• Quetiapine (Seroquel)

• Risperidone (Risperdal)

• Ziprasidone (Geodon)

Metabolic Syndrome

• Abdominal obesity

• Elevated triglycerides

• Low HDL

• Elevated blood pressure

• Elevated fasting glucose

Long Acting Therapy

Typical Depot Injections:

• Haloperidal Decanoate (Haldol), monthly

• Fluphenazine Decanoate (Prolixen), every 3 weeks

Atypical Depot Injections:

• Aripiprazole (Abilify Maintena), monthly

• Olanzapine (Relprevv), every 2 to 4 weeks

• Paliperidone Palmitate (Invega Sustenna), monthly

• Paliperidone Palmitate (Invega Trinza), every 3 months

• Risperidone Consta (Risperdal Consta), every 2 weeks

Professor Nash Accepting The Nobel

Prize in Stockholm

Learning

Objectives

At the end of this class, the audience will be able to:

1) Explain symptoms of psychosis

2) Name the DSM-5 psychotic disorders and the symptoms

3) Identify the differences between the DSM-5 psychotic disorders

4) Name first and second generation antipsychotics and

know their main side-effects

Thank you!