1. Psychotic Disorders A Patient-Centered, Evidence-Based Diagnostic and Treatment Process for Schizophrenia 1,2,3 Kendall L. Stewart, MD, MBA, DLFAPA March 21, 2014 1 My aim is to offer practical clinical insights that you can use right away in caring for patients. 2 Please let me know whether I have succeeded on your evaluation forms. 3 These are complicated and exasperating patients; your gut instincts will not serve you well.

2. 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. Schizophrenia It is best thought of a group of disorders with – Unknown cause, – Similar presentation, – Bizarre behavior, – Hallucinations, Hallucinations – Delusions, and Delusions – Deterioration in overall functioning You can view a brief documentary here.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? 1 This is the cancer of mental illness. 2 The families are the experts; you are at best a caring and knowledgeable consultant.

3. 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 Catatonia Catatonic Disorder Due to Another Medical Condition Unspecified Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

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 He is withdrawn and hesitant to talk.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

5. 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, alogia 1,2 or absence of volition Social or occupational dysfunction Continuous symptoms for 6 months 1 This is a common symptom in hospitals—and now—prisons. 2 A 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.

6. 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 1 Eminent violence is very hard to predict in these patients. 2 A 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 patients 1,2

7. What are some of the differential diagnoses? 1,2 Psychosis due to a General Medical Condition Delirium Dementia Schizotypal, Schizoid and Paranoid Personality Disorders SchizotypalSchizoid Paranoid Personality Disorders Substance-Induced Psychotic Disorder Substance-Induced Delirium Substance-Induced Dementia 1 At a moment in time, this can be a very difficult diagnosis to make. 2 The 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

8. What interventions should be included in the treatment plan? Combination treatment – Biological – Psychological – Social Biological – Typical antipsychotics Phenothiazines Haloperidol 1 These are now usually the psychiatrist’s initial choices. – Atypical antipsychotics 1 Clozapine Risperidone Olanzapine Quetiapine Psychological – Prevent harm – Minimize stress – Minimize risk of relapse Social – Social support – Good alliance with patient and the family

9. What prescription guidelines 1 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 ECT 1 Chiles, et. Al., “The Texas Medication Algorithm Project: Development and Implementation of the Schizophrenia Algorithm,” Psychiatric Services, January 1999, Vol. 40 No. 1

10. 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. 1 One of my patients brought one card from his collection to each visit as a gift to my sons.

11. How should you behave 1,2 while treating these patients? Adopt a quiet, calm demeanor. Isolate your own emotional arousal.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. 1 Begin with the result you want—this patient to receive the best possible care—then focus on those behaviors necessary. 2 The only behaviors you can really control are your own!

12. 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. 1 Lieberman, 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)

13. The Psychiatric Interview A 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 AIDET 1.AIDET 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. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

14. How can you access the OU-HCOM psychiatry flash cards online? Go to Quizlet.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.link 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.

15. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of Neurology, 2011The Massachusetts General Hospital Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Third Edition, 2011First Aid© for the Psychiatry Clerkship, Third Edition Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition, 2012Psychiatry PreTest Self-Assessment and Review, Thirteenth Edition Blitzstein, Sean, Lange Q&A Psychiatry, 2011Lange Q&A Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, 2010Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School

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

17. How can you contact me? Kendall L. Stewart, MD, MBA, DLFAPA VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. Clinical Professor of Psychiatry Ohio University Heritage College of Osteopathic Medicine 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com

18. Are there other questions? 1,2  Safety  Quality  Service  Relationships  Performance  1 Learn more about Southern Ohio Medical Center.Southern Ohio Medical Center 2 Learn more about our Family Medicine and Emergency Medicine Residencies.Family Medicine and Emergency Medicine Residencies Justin Greenlee, DO Director Family Medicine Residency Thomas Carter, DO Director Emergency Medicine Residency