Schizophrenia and Other Psychotic Disorders

Anita S. Kablinger MD

Associate Professor

Departments of Psychiatry of Pharmacology

LSUHSC-Shreveport

What is Psychosis? Generic term “Break with Reality” Symptom, not an illness Caused by a variety of conditions

that affect the functioning of the brain.

Includes hallucinations, delusions and thought disorder

Differential Diagnosis Medical/surgical/

substance-inducedPsychotic d/o due to GMCDementiasDelirium MedicationsSubstance induced

AmphetaminesCocaineWithdrawal statesHallucinogensAlcohol

Mood disordersBipolar disorderMajor depression with

psychotic features

PSYCHOSIS

Mood disorders

Schizophrenia “spectrum” disorders

“organic” mental

disorders

Substance

induced

DeliriumDementia

Amnestic d/o

“Functional”disorders

Differential Diagnoses: (Cont) Personality

disordersSchizoidSchizotypalParanoidBorderlineAntisocial

Miscellaneous PTSDDissociative disordersMalingeringCulturally specific phenomena:

Religious experiencesMeditative statesBelief in UFO’s, etc

Workup of New-Onset Psychosis:“Round up the usual suspects”

Good clinical history Physical exam, ROS Labs/Diagnostic tests:

Metabolic panelCBC with diffB12, FolateRPR, VDRLSerum AlcoholUrinalysisThyroid profile

URINE DRUG SCREEN!!!

CSF/LPHIV serologyCT or MRIEEG

Talking Points Schizophrenia is not an excess of

dopamine. The differentiation between “functional”

and “organic” is artificial. Schizophrenia and other psychiatric

illnesses are syndromes. Schizophrenia is a diagnosis of exclusion.

Talking Points 1% prevalence Early onset, M>F Early, aggressive treatment

decreases long-term problems Multiple subtypes- catatonic,

disorganized, paranoid, undifferentiated, residual

Schizophrenia

Diagnostic features

DSM-IV Diagnosis of Schizophrenia Psychotic symptoms (2 or more) for

at least one month Hallucinations Delusions Disorganized speech Disorganized or catatonic behavior Negative symptoms

Diagnosis (cont.) Impairment in social or occupational

functioning Duration of illness at least 6 mo. Symptoms not due to mood disorder

or schizoaffective disorder Symptoms not due to medical,

neurological, or substance-induced disorder

Clinical features:Formal Thought Disorders Neologisms Tangentiality Derailment Loosening of associations (word

salad) Private word usage Perseveration Nonsequitors

Clinical features:Delusions Paranoid/persecutory Ideas of reference External locus of

control Thought broadcasting Thought insertion,

withdrawal Jealousy Guilt Grandiosity

Religious delusions Somatic delusions

Clinical features:Hallucinations Auditory Visual Olfactory Somatic/tactile Gustatory

Clinical features:Behavior Bizarre dress, appearance Catatonia Poor impulse control Anger, agitation Stereotypies

Clinical features:Mood and Affect Inappropriate affect Blunting of affect/mood Flat affect Isolation or dissociation of affect Incongruent affect

Positive vs. negative symptoms

Positive symptoms

DelusionsHallucinationsBehavioral dyscontrolThought disorder

Negative symptoms(Remember

Andreasen’s “A”s)

Affective flatteningAlogiaAvolitionAnhedoniaAttentional impairment

Psychotic Disorders

Schizo-phrenia

Usually insidious

Many Chronic >6 months

Delusional disorder

Varies (usually insidious)

Delusions only

Chronic >1 mo.

Brief psychotic disorder

Sudden Varies Limited <1 mo.

Onset Symptoms Course Duration

Psychosocial Factors Expressed emotion Stressful life events Low socioeconomic class Limited social network

Some factors rejected as causal

“Schizophrenogenic Mother”

“Skewed” family structure

Genetic factors:(The evidence mounts…) Monozygotic twins (31%-78%) vs

dizygotic twins 4-9% risk in first degree relatives of

schizophrenics Adoption studies Linkage, molecular studies

Genetics of Schizophrenia:The take-home message Vulnerability to schizophrenia is

likely inherited “Heritability” is probably 60-90% Schizophrenia probably involves

dysfunction of many genes

Anatomical abnormalities Enlargement of lateral ventricles Smaller than normal total brain

volume Cortical atrophy Widening of third ventricle Smaller hippocampus

Physiologic studies:PET and SPECT Generally normal global cerebral

flow Hypofrontality Failure to activate dorsolateral

prefrontal cortex (problem-solving, adaptation, coping with changes)

Biochemical factors:The dopamine hypothesis All typical antipsychotics block D2

with varying affinities Dopamine agonists can precipitate a

psychosis Amphetamines

Cocaine

L-dopa

Dopamine systems

Nigro-striatal

SubstantiaNigra

Caudate and putamen

Move-ment

Extrapyramidal symptoms, dystonias, Tardive dyskinesia

Meso-limbic

Ventral tegmental area, subst. nigra

Accumbens amygdalaOlfactory tubercle

Emotions,affect, memory

Positive symptoms

Meso-cortical

Ventral tegmental area

PrefrontalCortex

Thought, volition, memory

Blockade here can worsen negative symptoms.

Cell bodies Projections FunctionsClinical

implications

Typical Neuroleptics Low potency:

Chlorpromazine Thioridazine Mesoridazine

High potency: Haloperidol Fluphenazine Thiothixene Loxapine (mid)

Neuroleptic (typicals):side effects Acute dystonia Parkinsonian side effects (EPS) Akathisia Tardive dyskinesia Sedation, orthostasis, QTC

prolongation, anticholinergic, lower seizure threshold, increased prolactin

Atypical Antipsychotics: Risperidone Olanzapine Quetiapine Clozapine Ziprasidone Aripiprazole (new-partial DA agonist)

Atypical antipsychotics: Broader spectrum of receptor

activity (Serotonin, dopamine, GABA)

May be better at alleviating negative symptoms and cognitive dysfunction

Clozaril (clozapine) associated with agranulocytosis, seizures

Atypical Antipsychotics: Side Effects Sedation Hyperglycemia, new-onset diabetes Anticholinergic effects Less prolactin elevation QTC prolongation Some EPS Increased lipids

Psychosocial Treatment Education, compliance #1 Hospitalize for acute loss of

functioning Outpatient treatment is

rehabilitative Psychoanalysis, exploratory

therapies have limited value Families should be involved