Psychotic Disorders

Salina Chan 2013

Julius Elefante & Brynn Fredricksen 2014

Psychosis: Definition

• Mental disorder that affects• Thoughts

• Affective response

• Ability to recognize reality

• Ability to communicate and relate to others

• Sufficiently impaired to interfere with the capacity to deal with reality

• Classic characteristics: impaired reality testing, hallucination, delusions, illusions

Exercise # 1:Let’s work out an approach

• Pen and paper

• iPad or tablet plus stylus

• At the top write “psychosis” then draw two branching points: psychiatric, non-psychiatric

• After this exercise, the next slides will focus on the psychiatric conditions

Schizophrenia

• > 2 of following, present for a sig portion of time during a 1-month period (less if successfully treated)1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic speech

5. Negative symptoms

• Level of function in > 1 major area markedly below level achieved prior to onset

• Continuous signs of disturbance last > 6 months

• r/o SczA and Bipolar, secondary to substances/GMC

Schizophrenia

• Prodromal symptoms often precede active phase

• Residual symptoms may follow active phase• Mild or subthreshold forms of

hallucinations/delusions

Q: What are the Subtypes of Schizophrenia?

Schizophrenia Subtypes

• Paranoid

• Catatonic

• Disorganized

• Undifferentiated

• Residual

Q: Which one has the best prognosis?

Schizophrenia Subtypes

The subtypes have been dropped in DSM5

Diagnostic stability is poorQuestionable internal validity

The previous slide will still probably show up in your written exams, in psychiatric parlance… the same way some people will still talk about Homann’s sign for DVT.

Schizophrenia

• Males early-mid 20s; females late 20s• Younger = worse prognosis

• Few will recover completely, ~20% get better, rest chronically ill

• Psychotic symptoms tend to diminish over life course

• Negative symptoms more closely related to prognosis

Schizophrenia & Violence

• Hostility and aggression can be associated but vast majority not aggressive

• But spont or random assaults uncommon

• Aggression more frequent for younger males, &, ind with past history of violence, non-adherence with txn, substance abuse & impulsivity

Exercise # 2: Let’s have a kiki

• A kiki is a party for calming all your nerves

Exercise # 2:

• We will watch a video

• Take note of the MSE

Schizophrenia Videos

• Thought d/o: http://www.youtube.com/watch?v=v1XO6o-9mqQ (40-240s)

• Catatonia: http://www.youtube.com/watch?feature=player_embedded&v=zAEJ-Jvndms

• Inappropriate affect: http://www.youtube.com/watch?v=0LB2tISgoBw&list=PLBF726B10625C8E42

Quizlet

• Does catatonia = psychiatric condition?

Schizophrenia

• Males early-mid 20s; females late 20s• Younger = worse prognosis

• Few will recover completely, ~20% get better, rest chronically ill

• Psychotic symptoms tend to diminish over life course

• Negative symptoms more closely related to prognosis

Schizophrenia & Violence

• Hostility and aggression can be associated but vast majority not aggressive

• But spontaneous or random assaults uncommon

• Aggression more frequent for• younger males

• past history of violence

• non-adherence with tx

• substance abuse & impulsivity

Schizophrenia MSE

• Appearance

• Disheveled/unkempt

• Internally preoccupied

• Poor eye contact/intense stare

• Stiff/agitated/slowed

• Speech

• Mumbled

• Decreased content

• Decreased spontaneity

• Mood

• Depressed

• Angry

• Anxious

• Affect

• Flattened

• Inappropriate

• Perplexed, anxious

• Thought form and content

• Disorganized, Vague

• Tangential -> word salad

• Focused/preoccupied, poverty, bizarre delusions

• Perceptions

• +AH/VH

• Appears to be responding to stimuli

• Cognitive

• Deficits common

Schizophrenia Videos

• Thought d/o: http://www.youtube.com/watch?v=v1XO6o-9mqQ (40-240s)

• Catatonia: http://www.youtube.com/watch?feature=player_embedded&v=zAEJ-Jvndms

• Inappropriate affect: http://www.youtube.com/watch?v=0LB2tISgoBw&list=PLBF726B10625C8E42

Other Psychotic Disorders

Brief Psychotic Disorder

• > 1 of the following symptoms (must include one from 1-3)1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic speech

• 1 day to <1 month duration

• Returns to premorbid level of functioning

Schizophreniform Disorder

• > 2 of the following, each present for a sig portion of the time during 1 month period (or less if successfully treated)1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly disorganized or catatonic speech

5. Negative symptoms

• 1 month to < 6 months

• r/o SczA and Bipolar, secondary to substances/GMC

Schizoaffective Disorder

• MDE (w/ depressed mood) or manic episode with psychosis

AND

• 1st criteria for Scz

• Delusions or hallucinations for 2 or more weeks in absence of major mood episode

• Mood episode present for the majority of the total duration of the active and residual portions of the illness

Delusional Disorder

• One or more delusions, > 1 month, not schizophrenia

• Hallucinations allowed if related to delusional theme & not a prominent symptom

• Aside from delusion, function and behaviour not markedly impaired/bizarre/odd

• Manic or depressive episodes brief relative to delusional period

• Erotomanic

• Grandiose

• Jealous

• Persecutory

• Somatic

• Mixed

• Unspecific

Other Psychotic Disorders

• Shared Psychotic Disorder (Folie a Deux)

• One person develops a similar delusion to another

• Separation from the originally psychotic person resolves delusion

Hallucinations

• Perception-like experiences that occur w/o an external stimulus

• Vivid and clear, with full force and impact of normal perceptions

• Not voluntary

• AH most common in Scz• While waking up/falling asleep = normal

• Tactile most likely Substances!

Hallucinations Differential

• Psychotic

• MDD w/ psychosis

• Bipolar disorder

• Delirium

• Borderline PD

• Substances

• GMC

• Seizures

• Stroke

• Hyperthyroid

• Hyper Ca, hyper Mg

• Dementia

• Delirium

Anti-Psychotics

• Olanzapine (Zyprexa)

• Risperidone (Risperidal)

• Quetiapine (Seroquel)

• Aripiprazole (Abilify)

• Ziprazidone (Zeldox)

• Paliperidone (Invega)

• Clozapine (Clozaril)

• Chlorpromazine• Flupenthixol• Fluphenazine• Haloperidol• Loxapine• Methotrimeprazine• Pericyazine• Pimozide• Trifluoperazine• zuclopenthixol

Atypical Typical

Antipsychotics - Mechanism of Action

• DA and 5HT antagonist

• But leads to increased DA in some areas

• DA antagonist

Atypicals Typicals

Efficacy vs. effectiveness

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Efficacy vs. effectiveness

• Leucht, Lancet, June 2013: Comparative efficacy and toleralability of 15 antipsychotics in a multiple-treatments meta-analysis

• 22 trials

• 43,049 participants

• Despite the current dogma that all SGAs, are the same, the best, most recent evidence is – they are not!• Food for thought: have you heard of ASE, ARI, ZIP, LURA

being used? Ask why. There could be a good clinical reason.• Food for thought # 2: what are the limitations of meta’s?

• For the interested, get the article or email me: rjelefante@gmail.com

Olanzapine

• Route: po, dissolvable (“Zyprexa, Zydis”), SA inj

• Side-Effects to consider:

• Most metabolic: weight gain, diabetes, hyperlipidemia, Liver

• Moderate sedation

• IM + Ativan = resp failure! **BLACK BOX WARNING**

• Sure, but what is the NNH?

• 1 adverse event per 3,369 IM Olanzapine exposures

• 1 serious event in 6,494• 1 fatality per 18,586• Key point: Respect black box warnings, but

know the evidence behind them. In cases where BBWs limit tx (AD and suicidality in adolescents, AD and QTc), knowing the evidence helps in justifying going against BBW. This is not the case for parenteral OLA + BDZ.

Olanzapine

• Indications:

• Schizophrenia/psychosis

• BP I – acute mania and/or maintenance

• Dose Range:5 to 30 mg

• Up to 40mg/d

Risperidone

• Route: po, dissolvable “M-tab”, liquid or LA inj (Consta)

• Side-Effects to Consider:• Metabolic: as previously mentioned

• Most “typical” of atypicals

• May elevate Prolactin levels

• Sexual

• Indications:• Schizophrenia/psychosis• BP I – acute mania and/or maintenance

• Dose range:• PO 2-8 mg

• 25-50 mg IM q2wks

Quetiapine (Seroquel)

• Route: po (regular and XR)

• Side-Effects to consider: • Metabolic

• Most sedating of the atypicals

• Indications:• Schizophrenia/Psychosis

• BP I – acute mania and/or acute depression

• Depression/anxiety Adjuvant

• Usual dose range:• 300 to 900 (multiple times a day dosing)

• 300 to 900 (once daily dosing for XR form)

• Lower doses of 25-100 if used as prn or augmentation

Aripiprazole (Abilify)

• Route: PO

• Side-effects to consider:• Less metabolic SE

• Less sedation

• Indications:• Schizophrenia/psychosis

• BP I disorder – acute mania

• Depression Adjuvant

• Dose range:• 10 to 30 mg

Paliperidone (Invega)

• Route: PO or LA inj

• Side-Effects to consider:• Less metabolic side-effects

• Less drug-drug interactions

• Indications:• Schizophrenia/psychotic disorders

• Dose range:• 3 to 9 mg

Ziprazidone (Zeldox)

• Route: PO

• Side-Effects to consider:• Less metabolic SE

• Less sedation

• QT prolongation

• Indications:• Schizophrenia/psychosis

• BP I disorder – acute mania

• Dose range:• 40 mg BID to 80 mg BID

Clozapine (Clozaril)

• Route: PO

• Indications:• Schizophrenia/

psychosis• Treatment refractory

only after failed at least 2 other anti-psychotics

• Not a first line treatment

• Dose range:• 100 to 800 mg

(starting dose 25 mg)

• Side-Effects to Consider:• Metabolic

• Sedation

• Increased Sz risk at doses > 500 mg

• Agranulocytosis• Cardiac myotosis

Side-Effects to Consider

• More EPS: parkinsonism, akathisia, dystonia, TD• Benztropine for acute dystonia

• NMS – neuroleptic malignant syndrome• Rare, stop AP

• Da agonist, e.g. bromocriptine, and symptom management

• Increased Prolactin:• Galactorrhea, amenorrhea & sexual

• Prolonged QT• ECG, ECG, ECG!

Other Common IM’s

• Loxapine IM:• PRN for agitation when po not an option

• 5 mg to 20 mg

• Haldol IM:• Prn for agitation when po not an option

• 2.5 mg to 10 mg

sga

Risperidone 0.5 t0 1.0 2 to 6Increase by 0.5 to 3 to 4 days

Risperidone LA 25 IM q 2 weeksPO x 3 weeks

37.5 mg IM q 2wIncrease by 12.5 every 4 to 8 weeks

Olanzapine* 5 to 10 10 to 20Increase by 2.5 to 5 q 3 to 4 days

Quetiapine** 100 600A hundred daily

Clozapine 12.5 to 25 300 to 60012.5 to 25 on the second day, then up to 25 to 50 daily

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Videos

• http://symptommedia.com/

• Catatonia• http://www.psy-world.com/videos.htm

• 5 minute break