psychotic disorders kheradmand ali m.d. assistant professor of shahid beheshti medical university
TRANSCRIPT
Psychotic Disorders
Kheradmand Ali M.D.Assistant Professor of Shahid Beheshti Medical University
PSYCHOSIS
Mood disorders
Schizophrenia “spectrum”
disorders
“organic” mental disorders
Substanceinduced
DeliriumDementia
Amnestic d/o
“Functional”disorders
Differential Diagnosis• Medical/surgical/
substance-inducedPsychotic d/o due to GMCDementiasDelirium MedicationsSubstance induced
AmphetaminesCocaineWithdrawal statesHallucinogensAlcohol
• Mood disordersBipolar disorderMajor depression with psychotic
features
Differential Diagnoses: (Cont)
• Personality disordersSchizoidSchizotypalParanoidBorderlineAntisocial
• Miscellaneous PTSDDissociative disordersMalingeringCulturally specific phenomena:
Religious experiencesMeditative statesBelief in UFO’s, etc
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.
Clinical features:Formal Thought Disorders
• Neologisms• Tangentiality• Derailment• Loosening of associations (word salad)• Private word usage• Perseveration• Non sequiturs
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 , mannerism
Clinical features:Mood and Affect
• Inappropriate affect• Blunting of affect/mood• Flat affect• Incongruent affect
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
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)
Copyright © 2004 Allyn and Bacon
Copyright 2009 John Wiley & Sons, NY
26
Etiology of Schizophrenia: Brain Structure and
Function
Congenital Factors» Damage during gestation or birth
– Obstetrical complications rates high in patients with schizophrenia
Reduced supply of oxygen during delivery may result in loss of cortical matter
» Viral damage to fetal brain– In Finnish study, schizophrenia rates higher
when mother had flu in second trimester of pregnancy (Mednick et al., 1988)
– Maternal exposure to parasite associated with higher rates of schizophrenia in their offspring
Copyright 2009 John Wiley & Sons, NY
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Etiology of Schizophrenia: Brain Structure and
Function
Developmental Factors» Prefrontal cortex matures in adolescence or
early adulthood» Dopamine activity also peaks in
adolescence» Stress activates HPA system which triggers
cortisol secretion– Cortisol increases dopamine activity
May explain why symptoms appear in late adolescence but brain damage occurs early in life
Copyright 2009 John Wiley & Sons, NY
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Etiology of Schizophrenia: Psychological Stress
Reaction to stress» Individuals with schizophrenia and their first-
degree relatives more reactive to stress– Greater decreases in positive mood and increases in
negative mood
Socioeconomic status» Highest rates of schizophrenia among urban
poor. – Sociogenic hypothesis
Stress of poverty causes disorder– Social selection theory
Downward drift in socioeconomic status
» Research supports social selection
Copyright 2009 John Wiley & Sons, NY
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Etiology of Schizophrenia: Family Factors
Schizophrenogenic mother » Cold, domineering, conflict inducing» No support for this theory
Communication deviance (CD)» Hostility and poor communication
– Family CD predicted onset in one longitudinal study (Norton, 1982)
– CD not specific to families of schizophrenic patients
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Paranoid Type Disorganized Type Catatonic Type Undifferentiated Type Residual Type
Disorganized Speech Disorganized Behavior Flat or Inappropriate Affect Hallucinations and Delusions
– Fragmented or Lacking a Theme Often Chronic
Disorganized Speech Disorganized Behavior Flat or Inappropriate Affect Hallucinations and Delusions
– Fragmented or Lacking a Theme Often Chronic
Disorganized Speech Disorganized Behavior
Waxy flexibility, rigidity, odd mannerisms, mimicry
Flat or Inappropriate Affect Hallucinations and Delusions
– Fragmented or Lacking a Theme Often Chronic
Disorganized Speech Disorganized Behavior
Waxy flexibility, rigidity, odd mannerisms, mimicry
Flat or Inappropriate Affect Hallucinations and Delusions
– Fragmented or Lacking a Theme Often Chronic
Beginnings of Breakdown Major Sx of Schizophrenia DO NOT Meet Other Criteria “Wastebasket” Category
Beginnings of Breakdown Major Sx of Schizophrenia DO NOT Meet Other Criteria “Wastebasket” Category
Have Had One Episode Now Mostly Symptom Free
Have Had One Episode Now Mostly Symptom Free
Once a Schizophrenic ,Always a Schizophrenic?
Once a Schizophrenic ,Always a Schizophrenic?
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
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
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
Extrapyramidal Sx. (EPS)
• Acute Dystonias• Antipsychotic-induced Parkinsonism • Akathisia• Tardive Dyskinesia (TD)
• Neuroleptic Malignat Syndrome (NMS)
Acute Dystonias
• Muscle spasm face-neck-trunk-eye-larinx• Early in Tx., young males• Dose Related, Tolerance, incidence 50%• Treatment: Benadryl 50 mg IM (IV 25-50
for laryngospasm), Cogentin 1-4 mg IM • Prevention reduces incidence to 5%
– Low dose, – Benztropine 1 mg / every Haldol 5 mg
Antipsychotic-induced Parkinsonism
• Incidence 50-75% with high pot.• Rigidity• Bradikinesia: mask face-gait problems• Resting Tremor• Flexed Posture• Dif Dx. with flat affect• Tx: Cogentin, Artane 2 mg bid-tid (elder)
– Reduces incidence to 5-10%
Akathisia
• Subjective feeling of restlesness• Unable to sit still, pacing• Incidence 20-30%, lower with low dose• Dif Dx.: psychosis, agitation, anxiety• Tx: Propranolol 30-90 mg/d (not in
asthma or diabetes), Klonopin 1 mg bid• SSRI Antidepressants cause akathisia too
Tardive Dyskinesia (TD)
• Slow choreo-athetotic movements• Oro-facial muscles• Risk 4% per year of exposure
– Risk factors elderly women, mood DO, diab.
• Risk management– document informed consent, AIMS Tests
• Tx?: Vit E 1600 U/d, Clozapine low risk
Neuroleptic Malignant Syndrome (NMS)
• Medical Emerg, mort. 20% (now 4%)• 1. Fever >100.4F / 37.5C• 2. Severe EPS: lead-pipe/cogwheel
rigidity, sialorrhea, oculogyric crisis• 3. Autonomic DysFx: BP fluctuations,
tachycardia, tachypnea, diaphoresis• Also: Alt. conciousness, delirium,
leukocytosis (>15.000 WBC), CPK > 300, seizures, arrithmias, mioglobinuria, ARF
NMS
• Incidence 0.1-1%, (60% of it in 1st 2 wks)• Risk factors: multiple IM injections, high
dose, rapid increase of dose agitation, dehydration, heat, lithium use
• Tx: STOP ALL antipsychotics, also antiemetic Reglan (Metoclopramide), antidepr. Amoxapine
NMS Treatment
• Stop ALL Antipsychotics• Dif. Dx: fever & delirium• Dantrolene (muscle relax) 1-3 mg/kg/day
NTE 10 mg/kg/d• Bromocriptine (DA Agonist) 5 mg tid-qid• Supportive Tx:
– IV fluids, antipyretics, cooling blankets, close cardiac & renal monitoring
Atypical Antipsychotics:• Risperidone• Olanzapine• Quetiapine• Clozapine• Ziprasidone• Aripiprazole (new-partial DA agonist)
Serotonergic Pathways and Innervation
Hypo = hypothalamus SN = substantia nigra
Thal = thalamus
Atypical antipsychotics
MARTA (multi acting receptor targeted agents)• clozapine, olanzapine, quetiapine
SDA (serotonin-dopamine antagonists)• risperidone, ziprasidone, sertindole
Selective D2/D3 antagonists• sulpiride, amisulpiride
Atypical Antipsychotics: Side Effects
• Sedation• Hyperglycemia, new-onset diabetes• Anticholinergic effects• Less prolactin elevation• QTC prolongation• Some EPS• Increased lipids
ESTIMATED MEAN WEIGHT GAIN AT 10 WEEKS
Allison DB , Mentore JL , Heo M, et al: Weight gain associated with conventional and newer antipsychotics :a meta - Analysis. AJP, 1999.
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Zipras
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Halope
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Risper
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Chlorp
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Sertin
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Thiorid
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Olanza
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Clozap
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1
2
3
4
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•A comprehensive literature search identified 78 studies that included data on weight change in patients treated with a specific antipsychotic.
•For each agent a meta-analysis and random effects regression estimated the change in weight at 10 weeks of treatment.
HaloperidolHaloperidol ClozapineClozapine RisperidoneRisperidone OlanzapineOlanzapine
QuetiapineQuetiapine ZiprasidoneZiprasidone
5HT2A D2 D1 Alpha 1 Musc H1 5HT1A (agonist)
Casey 1994Casey 1994
Atypical Antipsychotics In Vivo Binding Affinities
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