Overview of PSYCHOTIC DISORDERS

Zimri Yaseen, MDWith thanks to Hyacinth C. Manood, MD,

DPBP

References: Kaplan & Sadock -Synopsis of Psychiatry Schatzberg - Manual of Clinical Psychopharmacology,Stahl - Essential Psychopharmacology

What is psychosis?

-Grossly impaired reality testing:-(contrast with neurotic disorders; reality testing intact)

-What is reality/How do we test it?-Accurate sensory perception (I see it when its there)-Coherence across modalities (It walks like a duck, talks like a duck, smells like a duck…)-Coherence with context (“Is that a duck on your head or am I psychotic?”)

-Falsifiability (That big rock you threw at the duck didn’t injure it at all: “Must be one of those foam rocks” vs. “OMG, its Super Duck!”)

Big Implication: Psychosis involves perceptual and cognitive disruption

The Prototypical Psychotic D/O:

Schizophrenia (what we will talk about most).

Typically involves more than just psychosis: Disorganization/cognitive deficits often prominent (leaving the patient vulnerable to psychosis)

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Associative Process (where disorganization/impoverishment happens):

Stimulus

Response:“monkey see monkey do”

Schizophrenia -Historical development

1st historical concept: dementia precox Benedict Morel (1809-1873)

deteriorated patients whose illness began in adolescence

Emil Kraepelin (1856-1926) the change in cognition (dementia) and early onset

(precox) of the disorder. long-term deteriorating course and the clinical

symptoms of hallucinations and delusions paranoia - persistent persecutory delusions; lacked

the deteriorating course of dementia precox and the intermittent symptoms of manic-depressive psychosis.

Distinct from manic-depressive psychosis -distinct episodes of illness alternating with periods of normal functioning, not deteriorating

Eugene Bleuler (1857-1939) coined the term schizophrenia, expressing

presence of schisms (splits) between thought, emotion, and behavior in affected patients. Not necessarily deteriorating four As:

Associations (loose), affect (abnormal), autism (lack of ability to/interest in relating to others), and ambivalence.

accessory (secondary) symptoms - hallucinations and delusions

Kurt Schneider (1887-1967):

Criteria for Schizophrenia First-rank symptoms

Audible thoughts Voices arguing or

discussing or both Voices commenting Somatic passivity

experiences Thought withdrawal and

other experiences of influenced thought

Thought broadcasting Delusional perceptions All other experiences

involving volition made affects, and made impulses

Second-rank symptoms Other disorders of

perception Sudden delusional ideas Perplexity (ambivalence) Depressive and euphoric

mood changes (affect disordered)

Feelings of emotional impoverishment (affect disordered/autism)

(Schneiderian Sx - distorted perceptions of internal processes/ego boundaries in red)

DSM-IV-TR Diagnostic Criteria for

Schizophrenia A. Characteristic symptoms: Two (or more) of the

following, each present for a significant portion of time during a 1-month period (or less if successfully treated):

delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., affective flattening, alogia, or

avolition Note: Only one Criterion A symptom is required if delusions

are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

B. Social/occupational dysfunction: deteriorated function or expected development arrested in 1 or more major areas

C Duration: > 6 months

The fine print:D. Schizoaffective and mood disorder exclusion:

Schizoaffective disorder and mood disorder with psychotic features have been ruled out because either (1) no major depressive, manic, or mixed episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

E. Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

F. Relationship to a pervasive developmental disorder: Prominent delusions or hallucinations must be present for at least 1 month (or less if successfully Tx-ed)

SUBTYPES:

Paranoid typeA type of schizophrenia in which the following criteria are met:

A. Preoccupation with one or more delusions or frequent auditory hallucinations.

B. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Disorganized typeA type of schizophrenia in which the following criteria are met:

A. All of the following are prominent: disorganized speech disorganized behavior flat or inappropriate affect

B. The criteria are not met for catatonic type

Catatonic typeA type of schizophrenia in which the clinical picture is dominated by at least two of the following:

motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor

excessive motor activity (that is apparently purposeless and not influenced by external stimuli)

extreme negativism (an apparently motiveless resistance to all instructions or maintenance of a rigid posture against attempts to be moved) or mutism

peculiarities of voluntary movement as evidenced by posturing (voluntary assumption of inappropriate or bizarre postures), stereotyped movements, prominent mannerisms, or prominent grimacing

echolalia or echopraxia

Undifferentiated typeA type of schizophrenia in which symptoms that meet Criterion A are present, but the criteria are not met for the paranoid, disorganized, or catatonic type.

Residual typeA type of schizophrenia in which the following criteria are met:

A. Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior.

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms or two or more symptoms listed in Criterion A for schizophrenia, present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Clinical Features

no clinical sign or symptom is pathognomonic for schizophrenia

patient's symptoms change with time.

clinicians must take into account the patient's educational level, intellectual ability, and cultural and subcultural membership

Making the diagnosis

Premorbid Signs and Symptoms: patients had schizoid or schizotypal

personalities characterized as quiet, passive, and introverted; as children, they had few friends; sudden onset of obsessive-compulsive behavior as part of the prodromal picture. The signs may have started with complaints about somatic symptoms, such as headache, back and muscle pain, weakness, and digestive problems; develop an interest in abstract ideas, philosophy, and the occult or religious questions.

Mental Status Examination Orientation: usually oriented to person,

time, and place Appearance: a patient with schizophrenia

can range from that of a completely disheveled, screaming, agitated person to an obsessively groomed, completely silent, and immobile person

Relatedness: often impaired e.g. Precox Feeling - an intuitive experience of their inability to establish an emotional rapport with a patient

Mood/Affect: reduced emotional responsiveness, sometimes severe enough to warrant the label of anhedonia, and overly active or inappropriate emotions such as extremes of rage, happiness, and anxiety.

flat or blunted affect can be a symptom of the illness itself, of the parkinsonian adverse effects of antipsychotic medications, or of depression

Cognition: relatively subtle basic cognitive deficiencies (eg. mild visual processing or working memory impairments, Folstein mini-mental within normal limits)

Perception: most common hallucinations are auditory, with voices that are often threatening, obscene, accusatory, or insulting;

Cenesthetic hallucinations - are unfounded sensations of altered states in bodily organs; also fairly common

(Blending into) Thought content: may believe/experience that an outside entity controls their thoughts or behavior or, conversely, that they control outside events in an extraordinary fashion

loss of ego boundaries describes the lack of a clear sense of where the patient's own body, mind, and influence end and where those of other animate and inanimate objects begin: eg. ideas of reference, cosmic identity

Thought process/speech: looseness of associations: circumstantiality,

tangentiality, derailment, incoherence, abnormal speech: neologisms, verbigeration, word

salad, echolalia, and mutism Abnormal prosody (e.g. mechanical, monotonous,

weird)

Risk, course/prognosis Violence - Delusions of a persecutory

nature, previous episodes of violence, substance abuse, and neurological deficits are risk factors for violent or impulsive behavior

Suicide is the single leading cause of premature death among people with schizophrenia. (~25% make lifetime attempts, ~10% of Schizophrenia deaths)

cognitive impairment is a better predictor of level of function than is the severity of psychotic symptoms;

poor insight - poor compliance with treatment

Nonlocalizing signs ( soft signs) include dysdiadochokinesia, astereognosis, primitive reflexes, and diminished dexterity

The classic course of schizophrenia is one of exacerbations and remissions

Further deterioration in the patient's baseline functioning generally follows each relapse of the psychosis

Sometimes, a clinically observable postpsychotic depression follows a psychotic episode

vulnerability to stress is usually lifelong

10 to 20 % - good outcome; >50 % - poor outcome

EPIDEMIOLOGY

lifetime prevalence of schizophrenia is about 1 percent

equally prevalent in men and women; Typical onset is earlier in men than in women ( M = 15 – 25; F= 25 – 35)

Onset of schizophrenia before age 10 or after age 60 is extremely rare; When onset occurs after age 45, the disorder is characterized as late-onset schizophrenia.

In general, the outcome for female schizophrenia patients is better than that for male schizophrenia patients

higher mortality rate from accidents and

natural causes than the general population

more likely to have been born in the winter and early spring - Season-specific risk factors, such as a virus or a seasonal change in diet, may be operative .

gestational and birth complications, exposure to influenza epidemics, or maternal starvation during pregnancy, Rhesus factor incompatibility, and an excess of winter births. - neurodevelopmental pathological process

Etiology I. Genetic Factors:Prevalence of Schizophrenia in Specific

Populations

Population Prevalence (%)

General population 1 Non-twin sibling of a schizophrenia patient 8Child with one parent with Schizophrenia 12Dizygotic twin of a schizophrenia patient 12Child of two parents with schizophrenia 40Monozygotic twin of a schizophrenia patient 47

II. Biochemical Factors:

1. Dopamine Hypothesis - schizophrenia results from too much dopaminergic activity (now clearly out of date).

1. Revision: Dopaminergic activity too high in mesolimbic pathway, too low in mesocortical pathway

2. Serotonin - excess as a cause of both positive and negative symptoms in schizophrenia. 5HT-2A receptors on dopaminergic neurons inhibit dopamine release (strong mesocortical and weak mesolimbic effect)

3. Norepinephrine - selective neuronal degeneration within the norepinephrine reward neural system could account for the impaired capacity for emotional gratification and the decreased ability to experience pleasure.

4. GABA - GABA has a regulatory effect on dopamine activity, and the loss of inhibitory GABAergic neurons could lead to the hyperactivity of dopaminergic neurons.

5. Neuropeptides -substance P and neurotensin, are localized with the catecholamine and indolamine neurotransmitters and influence the action of these neurotransmitters.

6. Glutamate - ingestion of phencyclidine, a glutamate antagonist, produces an acute syndrome similar to schizophrenia. The hypotheses proposed about glutamate include those of hyperactivity, hypoactivity, and glutamate-induced neuro- toxicity.

7. Acetylcholine and Nicotine - decreased muscarinic and nicotinic receptors ; dysregulation of neurotransmitter systems involved in cognition

Neuropathology :1. lateral and third ventricular enlargement

and some reduction in cortical volume;

2. reduced symmetry in several brain areas in schizophrenia, including the temporal, frontal, and occipital lobes ;

3. decrease in the size of the region including the amygdala, the hippocampus, and the parahippocampal gyrus;

4. several symptoms of schizophrenia mimic those found in persons with prefrontal lobotomies or frontal lobe syndromes

5. The medial dorsal nucleus of the thalamus, which has reciprocal connections with the prefrontal cortex, has been reported to contain a reduced number of neurons

6. cell loss or the reduction of volume of the globus pallidus and the substantia nigra.

III. Psychosocial and Psychoanalytic Theories

Sigmund Freud - postulated that schizophrenia resulted from developmental fixations that occurred earlier than those culminating in the development of neuroses.

Margaret Mahler - there are distortions in the reciprocal relationship between the infant and the mother .

Paul Federn - the defect in ego functions permits intense hostility and aggression to distort the mother-infant relationship, which leads to eventual personality

disorganization and vulnerability to stress.

Harry Stack Sullivan - schizophrenia is an adaptive method used to avoid panic, terror, and disintegration of the sense of self .

Karl Jaspers - existential psychoanalysis trying to understand the psychological meaning of

schizophrenic signs and symptoms such as delusions and hallucinations.

Adolf Meyer - founder of psychobiology reaction to life stresses ; schizophrenic reaction

The useful idea in all of this: All psychodynamic approaches are founded

on the premise that psychotic symptoms have meaning in schizophrenia

Learning theory - the poor interpersonal relationships of persons with schizophrenia develop because of poor models for learning during childhood.

Family Dynamics (stressors that may reveal vulnerability to or exacerbate psychosis)

Double Bind - children receive conflicting parental messages about their behavior, attitudes, and feelings. In Bateson's hypothesis, children withdraw into a psychotic state to escape the unsolvable confusion of the double bind.

Schisms and Skewed Families - In one family type, with a prominent schism between the parents, one parent is overly close to a child of the opposite gender. In the other family type, a skewed relationship between a child and one parent involves a power struggle between the parents and the resulting dominance of one parent.

Pseudomutual and Pseudohostile Families -suppress emotional expression by consistently using pseudomutual or pseudohostile verbal communication.

Expressed Emotion - families with high levels of expressed emotion (hostile critical and controlling), the relapse rate for schizophrenia exacerbation is high

Treatment Antipsychotics (=weight gain/metabolic syndrome,

=depot injection available, green=weak or no association with weight gain)

1st generation

(D2 +/- Ach/H)

2nd generation

(D2 & 5HT-2a +/- ACh/H)

Haldol (haloperidol) Prolixin (fluphenazine)

Risperdal (risperidone) Geodon (ziprasidone)

Trilafon (perphenazine) Abilify(aripiprazole D2 partial agonist) Zyprexa (olanzapine)

Compazine (prochlorperazine)

Seroquel (quetiapine) +/-

Mellaril (thioridazine) Thorazine(chlorpromazine)

Clozaril (clozapine)

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Other Pharmacologics

Anxiolytics (benzodiazepines): can help reduce positive symptoms

Antidepressants: can help treat comorbid depression, anxiety, obsessive/compulsive Sx

Antiepileptics (VPA, Lamotrigine) Lithium: can be used as mood stabilizers to treat manic symptoms. Lamotrigine may be useful as an anxiolytic

Medications to treat adverse effects Tremor/Akathesia

Benztropine Propranolol Benzodiazepines Amantadine

Dystonia Diphenhydramine

NMS Stop Antipsychotic Dantrolene Bromocriptine

Weight Gain Topiramate Metformin

Sedation Stimulants (eg provigil)

Non-Pharmacological treatments Individual supportive therapy Cognitive behavioral therapy Art therapy Group therapy Family therapy (Experimental Treatment: Transcranial

Magnetic Stimulation) ECT - controversial

Other psychotic disorders

<1mo Brief Psychotic d/o

<6mo Schizophreniform d/o

Duration: >6mo schizophrenia

With cognitive symptoms Without major cognitive symptoms

Delusional Disorders

With significant mood symptoms

Schizoaffective d/o

SCHIZOPHRENIFORM DISORDER

acute psychotic disorder that has a rapid onset and lacks a long prodromal phase

similar to schizophrenia, except that its symptoms last at least 1 month but less than 6 months.

return to their baseline level of functioning once the disorder has resolved.

lifetime prevalence rate = 0.2 percent

1-year prevalence rate of 0.1 percent

have more affective symptoms (especially mania) and a better outcome

increased occurrence of mood disorders in the relatives

progression to schizophrenia range between 60 and 80 percent

DSM-IV-TR Diagnostic Criteria for Schizophreniform Disorder

A. Criteria A, D, and E of schizophrenia are met.

B. An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as provisional)

Specify if: Without good prognostic features

   With good prognostic features: as evidenced by two (or more) of the following:

onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning

confusion or perplexity at the height of the psychotic episode

good premorbid social and occupational functioning

absence of blunted or flat affect

Brief Psychotic Disorder sudden onset of psychotic symptoms, which lasts

1 day or more but less than 1 month

Remission is full, and the individual returns to the premorbid level of functioning

occurs more often among younger patients (20s and 30s)

with personality disorders (most commonly, histrionic, narcissistic, paranoid, schizotypal, and borderline personality disorders).

precipitating stressors - major life events

Schizoaffective Disorder symptoms of both schizophrenia and

mood disorders onset of symptoms was sudden and often

occurred in adolescence. good premorbid level of functioning, and

often a specific stressor preceded the onset of symptoms.

0.5 to 0.8 percent lifetime prevalence

depressive type of schizoaffective disorder may be more common in older persons; bipolar type may be more common in young adults;

age of onset for women is later than that for men

better prognosis than patients with schizophrenia and a worse prognosis than patients with mood disorders

DSM-IV-TR Diagnostic Criteria for Schizoaffective Disorder

A. An uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode, or a mixed episode concurrent with symptoms that meet Criterion A for schizophrenia.Note: The major depressive episode must include Criterion A1: depressed mood.

B. During the same period of illness, there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms.

C. Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness.

D. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify type:      Bipolar type: if the disturbance includes a manic or a

mixed episode (or a manic or a mixed episode and major depressive episodes)Depressive type: if the disturbance only includes major depressive episodes

Delusional Disorder and Shared Psychotic Disorder

nonbizarre delusions of at least 1 month's duration that cannot be attributed to other psychiatric disorders

.025 to 0.03 percent

mean age of onset is about 40 years

slight preponderance of female

Men are more likely to develop paranoid delusions

women are more likely to develop delusions of erotomania.

defense mechanisms of reaction formation, denial, and projection

Mental Status may seem eccentric, odd, suspicious, or hostile.

quite normal except for a markedly abnormal delusional system

moods are consistent with the content of their delusions

do not have prominent or sustained hallucinations

delusions are usually systematized and are characterized as being possible

no insight into their condition and are almost always brought to the hospital by the police, family members, or employers. Judgment can best be assessed by evaluating the patient's past, present, and planned behavior.

Men are more likely to develop paranoid delusions

Types :

Persecutory Type

Jealous Type

Erotomanic Type

Somatic Type

Grandiose Type

DSM-IV-TR Diagnostic Criteria for Delusional Disorder

A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration.

B. Criterion A for schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme.

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

D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods.

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Shared Psychotic Disorder - shared paranoid disorder, induced psychotic disorder, folie a deux, folie impose, and double insanity)

characterized by the transfer of delusions from one person to another.

DSM-IV-TR Diagnostic Criteria for Shared Psychotic Disorder

A. A delusion develops in an individual in the context of a close relationship with another person(s), who has an already-established delusion.

B. The delusion is similar in content to that of the person who already has the established delusion.

C. The disturbance is not better accounted for by another psychotic disorder (e.g., schizophrenia) or a mood disorder with psychotic features and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

DSM-IV-TR Diagnostic Criteria for Brief Psychotic Disorder

A. Presence of one (or more) of the following symptoms: 1.delusions 2.hallucinations 3.disorganized speech (e.g., frequent derailment or incoherence) 4.grossly disorganized or catatonic behavior

Note: Do not include a symptom if it is a culturally sanctioned response pattern.

B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning.

C. The disturbance is not better accounted for by a mood disorder with psychotic features, schizoaffective disorder, or schizophrenia and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

•Specify if:•With marked stressor(s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture

• Without marked stressor(s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person's culture

•   With postpartum onset: if onset within 4 weeks postpartum

DSM-IV-TR Diagnostic Criteria for Psychotic Disorder Not Otherwise Specified

This category includes psychotic symptomatology (i.e., delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate information to make a specific diagnosis or about which there is contradictory information, or disorders with psychotic symptoms that do not meet the criteria for any specific psychotic disorder.

Examples include 1.Postpartum psychosis that does not meet criteria for mood disorder with psychotic features, brief psychotic disorder, psychotic disorder due to a general medical condition, or substance-induced psychotic disorder 2.Psychotic symptoms that have lasted for less than 1 month but that have not yet remitted, so that the criteria for brief psychotic disorder are not met 3.Persistent auditory hallucinations in the absence of any other features 4.Persistent nonbizarre delusions with periods of overlapping mood episodes that have been present for a substantial portion of the delusional disturbance 5.Situations in which the clinician has concluded that a psychotic disorder is present, but is unable to determine whether it is primary, due to a general medical condition, or substance induced