Psychotic DisordersA Patient-Centered, Evidence-Based Diagnostic and Treatment Process for Schizophrenia1,2,3

Kendall L. Stewart, MD, MBA, DLFAPAMarch 21, 2014

1My aim is to offer practical clinical insights that you can use right away in caring for patients.2Please let me know whether I have succeeded on your evaluation forms.3These are complicated and exasperating patients; your gut instincts will not serve you well.

Why is this important?

• About 1 in 100 people will develop this devastating disorder in their lifetime.1,2

• Schizophrenia is found in every society and in every country.

• It is best thought of a group of disorders with– Unknown cause,– Similar presentation,– Bizarre behavior,– Hallucinations,– Delusions, and– Deterioration in overall

functioning• You can view a brief

documentary here.

• After listening to this presentation, you will be able to answer the following questions:– Why is this important?– How do these patients present?– What are the diagnostic criteria?– What is the differential diagnosis?– What is the treatment?– What are some of the treatment

challenges?

1This is the cancer of mental illness.2The families are the experts; you are at best a caring and knowledgeable consultant.

What diagnoses are included in the Schizophrenia Spectrum and Other Psychotic Disorders category?

• Schizotypal (Personality) Disorder• Delusional Disorder• Brief Psychotic Disorder• Schizophreniform Disorder• Schizophrenia• Schizoaffective Disorder• Substance/Medication-Induced Psychotic Disorder• Psychotic Disorder Due to Another Medical Condition• Catatonia Associated With Another Mental Disorder• Catatonic Disorder Due to Another Medical Condition• Unspecified Catatonia• Other Specified Schizophrenia Spectrum and Other Psychotic

Disorder• Unspecified Schizophrenia Spectrum and Other Psychotic

Disorder

How do patients with schizophrenia typically present?• The patient is 22 years old.• He is withdrawn and hesitant to

talk.• He was brought in for

evaluation “against my will.”• The history is obtained

primarily from his parents.1,2

• “During his senior year of college he became more and more convinced that his roommates were making fun of him.”

• “He observed that they would cough, sneeze or look away when he came into the room.”

• “When his girlfriend broke it off with him, he decided that she had been replaced with a look-alike.”

• “He called the police to report her kidnapping.”

• “He stopped going to class because he believed that the professors were taking thoughts out of his mind.”

• “He stopping showering and shaving.”

• “He thought someone was putting something in his food and he lost weight.”

• “We just can’t reason with him.”

1When families are involved, I obtain the patient’s consent and view myself as their consultant.2One of my patient’s elderly mother comes in with her son every time.

What are the diagnostic criteria for Schizophrenia?

• Two of more of the following:– Delusions– Hallucinations– Disorganized speech– Grossly disorganized or

catatonic behavior– Negative symptoms such as

affective flattening, alogia1,2 or absence of volition

• Social or occupational dysfunction

• Continuous symptoms for 6 months

1This is a common symptom in hospitals—and now—prisons.2A mute patient suddenly told me about Rapid City, SD.

• Schizoaffective and Mood Disorder have been ruled out

• Substance Disorder or an underlying General Medical Disorder has been ruled out.

• If there is a history of autism or communication disorder, prominent delusions or hallucinations are present.

What are some of the associated features?

• Inappropriate affect (smiling, giggling or weird facial expressions)

• Loss of interest or pleasure• Dysphoric mood• Sleep disturbances• Abnormal psychomotor

behavior• Diminished concentration,

memory and attention• 80-90% of these patients smoke• Comorbid mental disorders

1Eminent violence is very hard to predict in these patients.2A patient nearly killed a patient who had attacked a fellow psychiatrist.

• Poor insight• Noncompliance • Somatic concerns• Motor abnormalities• Decreased life expectancy• Increased risk for suicide• Higher incidence of assault and

violence among males, younger age, people with prior history of violence and noncompliant patients1,2

What are some of the differential diagnoses?1,2

• Psychosis due to a General Medical Condition

• Delirium• Dementia• Schizotypal, Schizoid and

Paranoid Personality Disorders

• Substance-Induced Psychotic Disorder

• Substance-Induced Delirium• Substance-Induced Dementia

1At a moment in time, this can be a very difficult diagnosis to make.2The diagnosis becomes increasingly clear over time.

• Substance-Related Disorders• Mood Disorder with

Psychotic Features• Schizoaffective Disorder• Depressive Disorder Not

Otherwise Specified (NOS)• Bipolar Disorder NOS• Delusional Disorder• Neurodevelopmental

Disorders

What interventions should be included in the treatment plan?

• Combination treatment– Biological– Psychological– Social

• Biological– Typical antipsychotics

• Phenothiazines• Haloperidol

1These are now usually the psychiatrist’s initial choices.

– Atypical antipsychotics1

• Clozapine• Risperidone• Olanzapine• Quetiapine

• Psychological– Prevent harm– Minimize stress– Minimize risk of relapse

• Social– Social support– Good alliance with patient and

the family

What prescription guidelines1 should you consider?

• Stage 1 - Olanzapine, quetiapine or resperidone• Stage 2 - Switch to another atypical agent; for

noncompliant patients use decanoate preparations• Stage 3 - Switch to a third atypical antipsychotic• Stage 4 - Switch to a typical antipsychotic• Stage 5 - Use clozapine• Stage 5a - Augment clozapine• Stage 6 - Augment with additional drugs and or

ECT1Chiles, et. Al., “The Texas Medication Algorithm Project: Development and Implementation of the Schizophrenia Algorithm,”Psychiatric Services, January 1999, Vol. 40 No. 1

What treatment challenges can you expect?

• These patients have a hard time building and sustaining a therapeutic relationship.

• Families often burn out and opt out.

• Noncompliance is a constant challenge.

• Maintaining hope is not always easy.

• Setting realistic expectations is difficult.

• These patients are often desperately poor.1

• The medications often seem to cause more harm than benefit.

1One of my patients brought one card from his collection to each visit as a gift to my sons.

How should you behave1,2 while treating these patients?• Adopt a quiet, calm demeanor.• Isolate your own emotional arousal.• Avoid perceived intrusion.• Observe carefully.• Listen intently.• Know the diagnostic criteria.• Ask brief clarifying questions.• Avoid painful exploration.• Review available records.• Engage the patient’s family and

social support network.• Consider the differential diagnoses.

• Convey understanding, confidence and intent to help.

• Recommend the most appropriate medications.

• Explain most common side effects briefly.

• Explain treatment plan briefly.• Invite questions.• Begin educating the family about

what to expect.• Arrange for social support.• Communicate with stakeholders.• Arrange for follow up.

1Begin with the result you want—this patient to receive the best possible care—then focus on those behaviors necessary.2The only behaviors you can really control are your own!

What have you learned?

• The first descriptions of schizophrenia date back to 1400 BC.• Schizophrenia is currently viewed as a devastating group of disorders

that involve– Deterioration from a previous level of functioning,– Characteristic symptoms involving multiple mental processes,– Typical psychotic symptoms during the active phases of the illness, and– A demoralizing, chronic course.

• Onset usually is in the patient’s teens and 20s.• The treatment challenges are daunting.• Antipsychotic medications are helpful but not dramatically so, and side

effects are real problems in themselves.• Only clozapine stands out;1 the rest differ only in expense and side effects.• Multi-modal intervention is the key to maximizing recovery and

preventing relapse.

1Lieberman, et. al., “Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia,” The New England Journal of Medicine, September 22, 2005, Volume 353;1209-1223 (CATIE)

The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Treatment Process

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment

plan while making sure that I understand.• Repeatedly invite my clarifying questions.• Be patient with me.• Provide me with the appropriate

educational resources.• Invite me to call you with any additional

questions I may have.• Make a follow up appointment.• Communicate with my other physicians.

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some

routine demographic questions.• Ask me to list all of my problems and

concerns.• Using my problem list as a guide, ask me

clarifying questions about my current illness(es).

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status

examination.

1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

How can you access the OU-HCOM psychiatry flash cards online?

• Go to Quizlet.• Create a free account.• When you receive a confirmatory email, click on the link

to activate your new account.• With your activated account open in another browser

window, click on this link to join the class.• You can download the free Quizlet app to your iPhone or

import these learning sets to the more robust Flashcards Deluxe app.

• Enjoy. I hope you find these cards helpful.• Please post your feedback or suggestions on the Quizlet

site.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008

• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.

• Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of Neurology, 2011

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Third Edition, 2011

• Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition, 2012

• Blitzstein, Sean, Lange Q&A Psychiatry, 2011• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,

2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, 2010

Where can you find evidence-based information about mental disorders?

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.

• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.

How can you contact me?

Kendall L. Stewart, MD, MBA, DLFAPA

VPMA and Chief Medical OfficerSouthern Ohio Medical Center

Chairman & CEOThe SOMC Medical Care Foundation, Inc.

Clinical Professor of PsychiatryOhio University Heritage College of Osteopathic Medicine

1805 27th StreetWaller Building

Suite B01Portsmouth, Ohio 45662

740.356.8153StewartK@somc.org

KendallLStewartMD@yahoo.comwww.somc.org

www.KendallLStewartMD.com

Are there other questions?1,2

Safety Quality Service Relationships Performance

1Learn more about Southern Ohio Medical Center.2Learn more about our Family Medicine and Emergency Medicine Residencies.

Justin Greenlee, DODirectorFamily Medicine Residency

Thomas Carter, DODirectorEmergency Medicine Residency