PSYCHOSES Jon Lehrmann MD Assistant Professor of Psychiatry Medical College of WI VAMC Milwaukee,...
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PSYCHOSES
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PSYCHOSES
Jon Lehrmann MDAssistant Professor of PsychiatryMedical College of WIVAMC Milwaukee, WI
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Symptoms
• Delusions
• Hallucinations- Auditory, Visual, Olfactory, and Tactile
• Losing Sense of Reality
• Disorganization of Thought
• Thought Blocking
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Bob! Wake up! Bob! A ship! I think I see a ship…Where are your glasses?
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Causes of Psychosis
• Functional vs Organic?
• Primary vs Secondary?
• Secondary/ Organic= psychoses secondary to medical conditions, substance intox or w/d, or focal brain lesions
• Functional/Primary= psychoses originating from psychiatric illness (Schizophrenia, Major Depression, Bipolar Dis or Schizoaffective Disorder)
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Neurochemistry of Psychosis- the Dopamine Hypothesis:
• Excess of Dopamine activity in Mesolimbic region of the brain
• This is supported by 2 major findings- first neuroleptics block D2 receptors and improve sx’s of psychosis, and second, amphetamines which increase DA transmission can provoke psychotic states.
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A Psychosis is a Psychosis
• You cannot clearly make a diagnosis of the underlying causative illness based upon the psychotic sx’s alone- but there are clues.
• Look at the course of the illness.
• Look for Family Hx.
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Primary Psychoses:
• Schizophrenia
• Major Depression
• Bipolar Disorder
• Schizoaffective disorder
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Schizophrenia
• Occurs in 1% of population
• Onset usually in Teens and 20’s
• Runs strongly in families
• Positive Sx’s- depending on type of Schizophrenia- Thought disorg, AH’s , Paranoia, Complicated and fixed delusions
• Negative Sx’s
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Major Depression w/ Psychosis
• Lifetime Prevalence 15%
• 2X more common for women
• Family Hx?
• Mean age is 40, but can occur at any age
• Depressive sx’s
• Mood congruent psychotic sx’s
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Bipolar Disorder
• Manic sx’s
• Course of illness
• Family hx
• Rare after age of 50 for onset of illness
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Schizoaffective Disorder
• Evidence of mood disorder and
• Evidence of psychotic episodes at times without the mood component.
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Biological Treatment of Primary Psychoses
• Schizophrenia: antipsychotic
• Bipolar- manic psychosis: antipsychotic, mood stabilizer, benzodiazepine
• Major Depression w/ psychosis: antidepressant and antipsychotic
• Schizoaffective disorder: Antipsychotic, Mood stabilizer, ? Antidepressant.
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Secondary Psychoses:
• Delirium
• Brief Reactive Psychosis
• Dementias
• Others...
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Axis II Disorders associated w/ Psychosis
• Stress + Predisposition
• Borderline
• Schizotypal
• Treatment includes antipsychotic and psychotherapy
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Delirium-
• 15-25% of patients on general medical wards experience delirium, S/P surgery- even higher percentages.
• Advanced age and underlying dementia are risk factors.
• 1 yr mortality rate for those w/ episode of delirium= up to 50%!
• Recognizing and Treating Delirium is a medical urgency.
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Etiologies:
• Intracranial Causes: Seizures and Postictal states, Brain Trauma Neoplasms Infections Vascular Disorders (Vasculitis, CVA’s etc.)
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Etiologies cont’d
• Extracranial causes: Drugs/Medications- toxicity, intoxication, and w/d. Poisons (Carbon Monoxide, Heavy metals) Endocrine dysfunction Liver dz, Kidney failure, Cardiac failure, Arrhythmias, Hypotension, Hypoxia Deficiency dz’s
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Etiologies cont’d
• Systemic Infections
• Electrolyte abnormalities
• Postoperative states
• Trauma
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Treatment of Delirium
• High Potency Antipsychotic
• Supportive Care
• Find and Resolve Causative Factor(s)
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Antipsychotics
• Atypical vs Typical
• High vs Low Potency
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Wait a minute Mr Crumbly…. This may not be kidney stones after all!
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Secondary Psychoses
NOT PSYCHIATRIC
ORGANICALLY BASED
VARIANTS
PEDUNCULAR HALLUCINOSIS
CLASSIC CHARLES BONNET SYNDROME
RELEASE HALLUCINATIONS
Kathleen Patterson, Ph.D.
VAMC
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PEDUNCULAR HALLUCINOSIS: LHERMITTE’S SYNDROME (1922)
• VIVID VISUAL, CHROMATIC, DETAILED, OFTEN MOVING (LILLIPUTIAN) FIGURES AND/OR OBJECTS IN THE WHOLE VISUAL FIELD
• INTACT VISUAL ACUITY AND VISUAL FIELDS
• DREAMLIKE STATES WITH LUCID MENTATION
• LESIONS IN THE THALAMUS, BRAINSTEM (TUMORS COMPRESSING THE BRAINSTEM), AND SUBSTANTIA NIGRA PARS RETICULATA
• AURA OF BASILAR MIGRAINE LOCALIZABLE TO THE BRAINSTEM; AFTER VETEBRAL ANGIOGRAPHY; MANIFESTATION OF VERTEBROBASILAR INSUFFICIENCY D/T SEVERE HYPOPLASIA OF A VETEBRAL ARTERY
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CLASSIC CHARLES BONNET SYNDROME
FORMED PLEASANT OR NEUTRAL, NONTHREATENING VISUAL HALLUCINATIONS IN OLDER PERSONS WITH
NORMAL COGNITION AND INSIGHT: 1769
? NO MRI OR COMPLEX COGNITIVE TESTING TO R/O SUBTLE COGNITIVE DECLINE
IMPAIRED VISUAL ACUITY
MORE RECENTLY ALSO DIAGNOSED IN PATIENTS WITH MS, FRONTAL AND OCCIPITAL LOBE CHANGES, TEMPORAL ARTERITIS, AND PITUITARY TUMORS
WHY? BRAIN COMPENSATES FOR SENSORY DEPRIVATION
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RELEASE HALLUCINATIONS
ANY MODALITY BUT VISUAL MOST COMMON: DEPENDS ON END ORGAN AFFECTED
NONTHREATENING: RECOGNITION THAT THEY ARE NOT REAL: MAY PROGRESS FROM SIMPLE TO COMPLEX
ABNORMAL FUNCTIONING OF A LARGE SCALE NEURONAL NETWORK
THESE ARE MUCH MORE COMMON THAN THOUGHT AND UNDERREPORTED BECAUSE PEOPLE DO NOT WANT TO BE
CONSIDERED “CRAZY.”
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VISUAL RELEASE HALLUCINATIONS
VISUAL IMPAIRMENT: GLAUCOMA, CATARACTS, MACULAR DEGENERATION
LESIONS ANYWHERE FROM THE EYE TO THE OCCIPITAL CORTEX
USUALLY REPETITIOUS AND NONTHREATENING BUT IRRITATING
AWARENESS THAT THEY ARE NOT REAL
MODIFIED BY CHANGING VISUAL INPUT
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TREATMENT OPTIONS
• ORGANICALLY BASED HALLUCINATIONS ARE USUALLY SELF-LIMITING. With either end organ or central nervous system changes, they disappear after a few days, months, or years. THE FIRST STEP IS TO REASSURE THE PATIENT.
• INTERVENTIONS:– CHANGE PATIENT’S ENVIRONMENT.
– HASTEN END ORGAN CHANGE, E.G., CATARACT REMOVAL.
– GOOD MEDICAL MANAGEMENT OF CNS RISK FACTORS, E.G., HTN, DM, ET AL.
– MEDICATIONS: DO NOT ROUTINELY USE CLASSIC NEUROLEPTICS.
• PEDUNCULAR HALLUCINOSIS: CLOZAPINE
• RELEASE HALLUCINATIONS: CARBAMAZEPINE, GABAPENTIN, MELPERONE, VALPROATE, CISAPRIDE
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