Psychotic Disorders

Archetype Schizophrenia

Phenomenology The mental status exam The mental status exam Appearance Appearance Mood Mood Thought Thought Cognition Cognition Judgment and Insight Judgment and Insight

Appearance Motor disturbances Motor disturbancesCatatoniaStereotypyMannerisms Behavioral problems Behavioral problemsHygiene Social functioning “Soft signs” “Soft signs”

Mood and Affect Affective flattening Affective flattening Anhedonia Anhedonia Inappropriate Affect Inappropriate Affect

Thought Thought Process Thought Process Content Content

Thought Process Associative disorders Associative disorders Circumstantial Thinking Circumstantial Thinking Tangential thinking Tangential thinking

Other associative problems PerseverationDistractibilityClangingNeologisms

Thought Content Phenomenology Thought content HallucinationsDelusions

Cognitions Subtle impairments Frontal lobe function Frontal lobe function Associative thinking

Positive versus Negative Sxs Positive Hallucinations Hallucinations Delusions Delusions Bizarre behavior Bizarre behavior Associative disorders Associative disorders

Negative Symptoms Alogia Affective flattening AnhedoniaAvolition/apathy

Epidemiology

Epidemiology ~1% prevalence Genders Age of onset Age of onsetSocioeconomic

Pathology

Anatomic Widened ventricles Decreased size certain regions

Histology Abnormalities of cytoarchitecture Alignment Alignment Amount Amount

Pathology Neurophysiology Hypofrontality Hypofrontality

More Neurophysiology Other neurological changes Other neurological changes Eye movements Eye movements Blink rate Blink rate Sleep disorders Sleep disorders

Etiology Dopamine

Dopamine Hypothesis Metabolites Dopamine receptor agonists Action of antipsychotics

Other Transmitters Glutamate Primary excitatory transmitter Primary excitatory transmitter May relate to glutaminergic tone May relate to glutaminergic tone NMDA receptor antagonists NMDA receptor antagonistsPCP

Neurodegenerative theories Evidence for cell loss Evidence for cell loss Reduced neuronal densities Reduced neuronal densities Etiology Etiology

Neurodevelopmental Theories Abnormalities of cytoarchitecture Absence of gliosis

Genetics Genetic Theories Family studies 1 o relatives = 5% 1 o relatives = 5% Dizygotic twins = 10% Dizygotic twins = 10% Monozygotic twins = 50% Monozygotic twins = 50% Adoption studies Greater risk Greater risk

Possible Environmental Culprits Bad parenting Social/economicViralAllergic/Antibodies

Etiology

Diagnosis

Diagnosis Schizophrenia: DSM-IV “A” Criteria = Psychosis = PsychosisDuration 6 months 6 months Global Criteria

Diagnosis “A Criteria” Two or more: Two or more:DelusionsHallucinations Disorganized speech Disorganized behavior Negative symptoms

Schizophrenia Subtypes Catatonic Movement MovementDisorganized Process ProcessParanoid Content ContentUndifferentiatedResidual

Differential DeliriumDementiaMedication-induced Other Psychiatric Illnesses

Comorbidity Depression Substance Abuse

Course and Prognosis

Course of Schizophrenia

Prognosis Usually deteriorates ~ exacerbations w/ incomplete recovery Symptoms change over time

Outcome

Positive Predictors Acute onset Short duration Good premorbid functioning Affective symptoms Good social functioning High social class Neg fam hx psychotic No structural

Poor Predictors Insidious onset Long duration Family hx of psych illness Obsessions/Compulsions Assaultive Behavior Poor premorbid functioning Neurological/anatomic abn. Low social class

Treatment

Antipsychotic Medications Phenothiazines Chlorpromazine ChlorpromazineButyrophenones Haloperidol HaloperidolAtypicals Clozapine Clozapine

Antipsychotics Mechanism of actions Dopamine blockade Dopamine blockade D-2 and analogues D-2 and analogues

Antipsychotics: Indications Acute psychosis Prevention of relapse Also used in other disorders Acute mania Acute mania Anxiety/insomnia Anxiety/insomnia Aggressive disorders Aggressive disorders

Antipsychotics: Side Effects Anticholinergic Extrapyramidal (Parkinson’s-like)

Other effects Dopaminergic Tardive dyskinesia Tardive dyskinesia NMS NMSIdiopathic Hematologic HematologicClozapine Rashes, skin pigmentary, temperature dysregulation Rashes, skin pigmentary, temperature dysregulation

Antipsychotics Approach Lower doses usually adequate Lower doses usually adequate Adjust to side effects Adjust to side effects Evaluate for TD Evaluate for TD How long? 1 st episode 1 st episode Maintenance Maintenance

Other Treatments Electroshock Other tranquilizers

Psychosocial Treatments SupportiveSocial/educativeFamily

Other Diagnosis SchizophreniformSchizoaffective Brief Psychotic Delusional Disorders Shared Psychoses Psychosis due to somethin’ else