1. Psychiatry Review Session #1
Greg Raczkowski, MS-IV
John DiMeglio, MS-IV
Jacobs School of Medicine & Biomedical Sciences
1/31/2020
MSE (GREG)
Psychotic Disorders (GREG)
Antipsychotics (GREG)
Schizophrenia (JOHN)
Drugs (JOHN)
Opiates (JOHN)

2. Our Goals Review sessions should guide your studying
Brief overview of material from this week
Highlight relevant exam/board material
Answer lingering questions
Topics: MSE, Psychotic Disorders, Antipsychotics, Drugs
Review sessions should guide your studying

3. Mental Status Exam
Appearance, Attitude, Activity (Behavior) - anything about appearance or what the patient does during the interview
Mood - exactly what the patient says their mood is
Affect - outward expression of emotional state along with how it changes. E.g. anxious, irritable, dysphoric, incongruent to stated mood, labile, blunted, flat
Speech - rate, rhythm, volume, spontaneity, articulation
Thought Form (process) - Organization of thought. Organized -> word salad
Thought Content - Substance of what the patient talks about. Delusions, but also normal content. HI/SI.
Perception - Changes in sensory perception. Hallucinations (auditory, visual, olfactory, tactile), illusions, deja vu, jamais vu, depersonalization/derealization
Insight - Patient’s own understanding of their illness and behaviors
Judgment - Ability to make appropriate decisions

4. Affect -Emotional expression: dysphoric, anxious, irritable
-Congruence to stated mood: is it congruent to internal emotional state. “Congruent to stated mood”
-Intensity: Blunted, flat
-Range of expression: Full, restricted
-Mobility: labile, mobile, fixed

5. Thought Organization
Organized -> Circumstantial -> Tangential -> Flight of Ideas -> Loosening of Associations -> Word Salad
Circumstantial - makes a point
Tangential - does not make point
Flight - does not make point, less connection between ideas
Loosening of Associations - lost connection between ideas

6. Thought Content
-Delusions: fixed, false beliefs not shared by majority of a culture. Bizarre vs. Non-bizarre
-Overvalued ideas: Like delusions, but not held as strongly and can be reasoned with
-Suicidal/Homicidal ideation
-Obsessions: persistent, intrusive, ego-dystonic (distressing)
-Perseveration
-Magical thinking: “superstitions”
-Ideas of reference: attributing meaning to neutral events or other stimuli
-Poverty of speech

7. Psychosis
-Loss of ability to correctly perceive reality, as evidenced by:
-Hallucinations
-Delusions
-Disorganized speech/thought
-Disorganized behavior

8. Differential Diagnosis of Psychosis
-Brief Psychotic Disorder
-Schizophreniform Disorder
-Schizophrenia
-Delusional Disorder
-Schizotypal/Paranoid/Schizoid/Borderline Personality Disorder
-MDD or Bipolar I with psychotic features,
-Schizoaffective
-PTSD, substance/medication-induced, due to medical condition, neurocognitive

9. Brief/Schizophreniform/Schizophrenia
-SAME symptoms, difference is in the duration of symptoms
-Brief psychotic disorder: <1 month
-Schizophreniform: >1 month to <6 months
-Schizophrenia: >6 months
-may have acute presentation of positive symptoms leading to hospitalization, but may have long prodrome of negative symptoms, which counts towards the duration of symptoms

10. Brief Psychotic Disorder
-Treatment: brief-hospitalization, antipsychotics can be helpful with agitation/distress
-self-limited
-supportive psychotherapy follow-up
-Usual stem: Develops psychosis as a result of a major stressor and then resolves quickly w/ or w/o treatment
-Postpartum psychosis can fall under this

11. Schizophreniform Disorder
-similar symptoms to schizophrenia, but duration between 1 and 6 months
-treat with antipsychotics, hospitalization
-most go on to develop schizophrenia, schizoaffective disorder, or mood disorder
Schizophrenia
-symptom duration >6 months
-Treatment: antipsychotics, hospitalization, ECT, outpatient therapy (specific CBT for psychosis), multi-faceted approach with family therapy most effective

12. Delusional Disorder -delusions for over 1 month
-functioning not impaired
-usually ONLY delusions, no other evidence of psychosis
-difficult to treat, can use antipsychotics, psychotherapy
-SSRIs may be beneficial, especially with associated distress
-Usual stem: Older adult (40-50+), good functioning (has job, married), no prior psychiatric disease, develops delusional thinking. Eg. “wife comes in and says they have a good relationship but her 56 yo husband has developed an obsession that Meryl Streep is in love with him.”

13. Schizoaffective Disorder
-both mood symptoms (i.e. major depressive episode or mania) and psychosis
-must have at least 2 weeks of psychosis IN ABSENCE of mood symptoms
-may have mania or a major depressive episode during an episode of psychosis or without (mood disorder w/ psychotic features - psychosis only with mood symptoms)
-Treatment: antipsychotics, mood stabilizers or antidepressants as adjuvants, ECT

14. Antipsychotics
-no one antipsychotic has better therapeutic effect than another, except clozapine
-easiest to remember the differences between medications via their side effect profile
-all decrease seizure threshold
-all atypicals cause weight gain/metabolic syndrome, varying levels of anticholinergic, sedation, orthostasis

15. Antipsychotics: Dopamine Pathways
Mesolimbic: Increased dopamine causes positive symptoms
Mesocortical: Decreased dopamine causes negative symptoms
Nigrostriatal: Decreased dopamine causes Parkinsonism
Tuberoinfundibular: Decreased dopamine causes prolactinemia

16. Typical/First Generation Antipsychotics
-Exerts therapeutic effect through blockage of D2 receptors
-Adverse effects via:
-muscarinic (M1) blockade: anticholinergic effects
-histamine (H1) blockade: sedation
-alpha blockade: orthostatic hypotension
-dopamine blockade: EPS, prolactinemia

17. Typical/First Generation Antipsychotics
-potency refers to dopamine binding, which tells you their side effect profile
-Low potency: chlorpromazine
-anticholinergic, alpha blocking, antihistaminergic side effects predominate
-anticholinergic = bad in elderly
-High potency: haloperidol, fluphenazine, trifluoperazine
-EPS predominate, hyperprolactinemia
-Overall: improve positive sx, may worsen negative sx, cause EPS, anticholinergic, antihistaminergic, alpha blockade

18. Extrapyramidal Symptoms
-Akathisia: feeling of restlessness, can lead to decrease sleep and increased anxiety. Stem may say patient “can’t sit still”, “walking around the room” but is otherwise cooperative and organized. Tx with propranolol (1st line), benztropine
-Parkinsonism: bradykinesia, “mask-like” facies, cogwheeling, pill-rolling tremor. Tx with anticholinergics (benztropine, trihexyphenidyl, diphenhydramine)
-Dystonia: painful, involuntary muscle contraction. Develops soon after starting antipsychotic. Tx with anticholinergics (diphenhydramine, benztropine)
-Tardive Dyskinesia: involuntary movements, usually of face, mouth, neck, extremities. Eg. lip smacking, chewing, tongue movements. Develops after long-term antipsychotic use. Tx: can switch to clozapine

19. Neuroleptic Malignant Syndrome
-muscle rigidity, fever, autonomic instability, increased CPK
-Tx: STOP ANTIPSYCHOTIC (if this answer is there, it’s that one)
-Tx: supportive, dantrolene, dopamine agonists (bromocriptine)
-similar to malignant hyperthermia and serotonin syndrome, but stem will have recent use of antipsychotic (malignant hyperthermia - anesthetic, serotonin syndrome - hyperreflexia)
-can occur at any time when taking an antipsychotic, but more common when starting the medication

20. Atypical/Second Generation Antipsychotics
Mechanism: D2 blockade and Serotonin (5HT2A) Blockade
-Serotonin inhibits Dopamine, so blocking serotonin will increase dopamine activity
-Low 5HT2A receptors in mesolimbic, higher in mesocortical, nigrostriatal, and tuberoinfundibular pathways
-Theoretically, the increased dopamine helps to reduce negative symptoms and improve side effect profile while still alleviating (decreasing dopamine) positive symptoms

21. Atypical/Second Generation Antipsychotics
-Olanzapine: “O” for overweight. Weight gain/metabolic syndrome.
-Quetiapine: Sedation (brand name Seroquel - “S” for sedation)
-Aripiprazole: “A” for akathisia. Activating - akathisia, lower weight gain, better for negative sx
-Risperidone: Hyperprolactinemia! Higher risk of EPS amongst atypicals. Lower risk for weight gain/metabolic syndrome.
-Ziprasidone: most weight neutral, QTc

22. Clozapine -Agranulocytosis!
-Usual stem: starts new antipsychotic, becomes sick (usually with uncommon bug)
-Also weight gain/metabolic syndrome - clozapine and olanzapine are the most likely to cause this
-because of side effects, used to treat resistant disease - usually trial of two different antipsychotics, then use clozapine
-decreases suicide risk
-only one with increased efficacy
-can be used to treat tardive dyskinesia

23. Drugs

24. Intoxication & Withdrawal
Substance Use Disorder
Problematic pattern of substance use leading to significant impairment or distress.
Includes 2+ of the following over a 12 month period
The Puzzling Unidimensionality of DSM-5 Substance Use Disorder Diagnoses - Scientific Figure on ResearchGate. Available from: [accessed 30 Jan, 2020]

25. Illicit Drugs
Stimulants: Cocaine, Amphetamines, Crystal Meth, MDMA, Bath Salts
Sedatives: Alcohol, Benzos, Barbiturates, Opioids
Hallucinogens: LSD, Psilocybin, Mescaline
Dissociative Anesthetics: PCP, Ketamine
Cannabinoids: Marijuana, K2

26. Stimulants
Cocaine – ↓ reuptake of Dopamine (DA), Norepinephrine (NE), Serotonin (5HT)
smoking and injection, highest/most rapid increase in blood levels
blocks nerve impulses causing a local anesthetic effect
Amphetamines – ↓ reuptake, ↑ release, ↓ degradation of NE and DA
Ecstasy – amphetamines + ↑release of 5HT
Crystal Meth – ↑ fat solubility therefore ↑ BBB penetration. More addictive.
Bath Salts – More intense amphetamine effect. No tox screen.

27. Stimulants
Intoxication: Think of the sympathomimetic effects; increased HR, BP, and RR. Euphoria, mydriasis, n/v, perspiration, chills, confusion, psychomotor agitation.
Ecstasy: euphoria, feelings of openness, jaw clenching*
Cocaine, overdose: formications, delirium, seizure, stroke, MI
Withdrawal: Malaise, fatigue, depression, suicidal ideation, hypersomnolence, miosis.
Symptomatic treatment.
Long term use of MDMA can deplete 5HT, leading to depression

28. Dissociative Anesthetics
Phencyclidine (PCP) Mechanism: antagonist of NMDA glutamate receptors, activation of DA receptors
Intoxication: hallucinations, vertical nystagmus*, violence, anesthesia In overdose: fever, rhabdo, kidney failure, seizures, resp. depression, death.
Treatment: *DO NOT USE ANTIPSYCHOTICS, can the worsen psychosis* Use benzos for agitation, isolate the patient, restrain as needed, urine acidification can increase PCP clearance.
Ketamine: Hallucinations, dissociation, resp. depression

29. Hallucinogens LSD, Psilocybin, Mescaline:
Mechanism of Action - 5HT agonist
Intoxication: visual distortions, mydriasis, intense emotions, tachycardia, alterations in perception of time/space
Flashbacks can occur in times of fatigue, stress or use of other drugs
“Bad Trip” (hallucinogen persisting perception) - acute anxiety reaction. Can include depression, anxiety, confusion, fear of insanity.

30. Hallucinogens ...continued
Duration:
LSD, mescaline: 6-10 hours
Psilocybin: 2-4 hours
Treatment: *REASSURANCE + WAIT* You can use benzos; antipsychotics are a last resort.

31. Marijuana
Cannabis:
Mechanism of Action - THC binds endogenous cannabinoid receptors
Intoxication: Euphoria, relaxation, conjunctival injection, paranoia, increased appetite
Withdrawal: Irritability, restlessness, anxiety, depressed mood, abdominal pain
K2 (Spice):
Synthetic cannabinoids, have a much greater affinity for receptors than THC. Symptoms are more severe as well including hallucinations, thought disorganization and aggression

32. Sedatives Alcohol, Benzodiazepines, Barbiturates
Mechanism: potentiates the effect of GABA Intoxication- incoordination, slurred speech, nystagmus, coma
Benzo overdose? Can use flumazenil (more correct board questions than real life)
ONLY LIFE THREATENING WITHDRAWAL.
Autonomic hyperactivity, tremore, seizures, delirium tremens (DTs)
Treatment: check vitals frequently, slow benzodiazepine taper. In severe withdrawal, carbamazepine can decrease seizure risk.

33. Opioids - Heroin, Methadone, Buprenorphine, Naltrexone
Mechanism: Bind opioid receptors (full and partial agonists, antagonists), mu receptors most important
Intoxication: Euphoria, analgesia, resp. depression, miosis, constipation. Constipation persists regardless of tolerance Overdose can be fatal. Treat with naloxone (Narcan) which is an antagonist
Withdrawal: dysphoria, n/v, diarrhea, lacrimation, runny nose, yawning*, mydriasis, piloerection*
Treatment for Dependence: Methadone, Suboxone - detox AND maintenance Naltrexone - maintenance only

34. Schizophrenia

35. Schizophrenia
Schizophrenia is a chronic or recurrent disorder characterized by: sustained periods of psychosis and long-term deterioration in the ability to function

36. Schizophrenia
A. 2+ of the following symptoms (must include at least one of the first three):
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms
B. Social/Occupational Dysfunction
C. Overall duration of at least 6 months
D. Not attributable to schizoaffective or mood disorder, substance use, general medical condition, pervasive developmental disorder

37. Risk Factors for Schizophrenia
• Family hx
• Obstetric complications
• Infection
• Winter Birth
• Immune factors
• Nutritional Deficiencies
• Cannabis/drug use
• Immigration
• Advanced paternal age

38. Schizophrenia Incidence 1.5 per 10,000 people. Prevalence is .3 -.7%.
Men more likely to develop than women. (1.4:1)
Men have a 15-year lower average life expectancy and women are 12-years lower compared to the general population.

39. Historical Highlights
Emil Kraeplin - referred to it as dementia praecox (destruction of personality); paraphrenia is persistent psychosis w/o loss of personality
Paul Eugen Bleuler - coined “schizophrenia.” Four As (Autism, loose Associations, Affective disturbance, Ambivalence)
Kurt Schneider - “1st Rank Symptoms” Thought insertion, broadcasting. Made feelings, impulses

40. Symptom Domains
Positive Symptoms: Delusions, Hallucinations, Thought Disorganization, Catatonia
Negative Symptoms: Blunted affected, Anhedonia, Asociality, Alogia, Inattention, Avolition, Apathy
Cognitive Symptoms: Memory, language, attention, executive function
Mood Symptoms: Depression, dysphoria, suicidality (20-50% of people with schizophrenia attempt suicide, and 5-6% complete it).

41. Prognostic Factors Concordance Rate
Positive Prognostic Factors
Acute and/or late onset
Positive symptoms
Family Hx of affective disorder
Supportive family
Good premorbid functioning
Negative Prognostic Factors
Insidious and/or early onset
Negative symptoms
Family Hx of schizophrenia
Concordance Rate
• Twins/both parents: 50% • Siblings/one parent: ~10%

42. Etiology 1. Dopamine Hypothesis
Positive symptoms due to over activity of dopamine in mesolimbic tract; psychotic symptoms can be induced by dopamine agonists
2. Neurodevelopmental Hypothesis
Genetic + Environmental risk
3. Neurodegenerative Hypothesis
Functional and structural brain abnormalities
Cognitive disturbances
Progressive nature of disease

43. A few practice questions...

44. A 77-year-old woman is brought to the emergency department after being found in a park in a lethargic state. The patient has been having trouble sleeping and admits to recently taking a sedative originally prescribed for her husband who is being treated for alcoholism. She says the medication has helped with her sleep disturbance, allowing her to sleep throughout the night. However, she says that she is having a hard time getting out of bed in the morning and feels sluggish and tired throughout the day. The patient’s speech is slurred and difficult to understand. Her pulse is 70/min, respirations are 14/min, and blood pressure is 135/90 mm Hg. When asked to walk across the room, the patient stumbles and appears uncoordinated.
At this time, the patient is at increased risk for developing which of the following?
Agranulocytosis
Insomnia
Orthostatic Hypotension
Parkinsonism
Respiratory Depression
Seizures

45. A 39-year-old man was evaluated by a psychiatrist 1 month ago after reports that he was locking himself in his apartment because the devil was trying to put thoughts into his head. He initially responded well to pharmacologic treatment and was able to resume normal daily activities. However, 3 weeks after initiation of treatment, he presents to the hospital with muscular rigidity and mental status changes. His temperature is 39.7°C (103.5°F), blood pressure is 173/91 mm Hg, pulse is 116/min, and respiratory rate is 22/min.
Which of the following best describes the mechanism of action of the drug used to treat this patient's acute medical condition?
Blocks gamma-aminobutyric acid receptor
Blocks dopamine D2 receptor
Competitively inhibits alcohol dehydrogenase
Inhibits calcium release from the sarcoplasmic reticulum of skeletal muscle
Potentiates gamma-aminobutyric acid effects by increasing the duration of Cl- channel opening

46. Brief Psychotic Disorder Delusional Disorder Schizoaffective Disorder
A 19-year-old boy is brought to the emergency department by his parents after he attempted to jump off the balcony of their 23rd story condominium. Three months ago, he began to hear voices telling him “use your superpowers to save the world.” Additionally, he is paranoid that the Russian government is trying to “hack his brain for intel.” He used to be a full- time student at the local community college; however, after he failed all of his classes, his parents demanded he that take a semester off. On physical examination, he appears disheveled and disinterested. When the physician attempts question him directly, the patient ignores the questions entirely and jumps to unrelated topics that are difficult to follow. A consulting psychiatrist admits the patient to the psychiatry ward and low-dose olanzapine is initiated immediately.
Which of the following is the most likely diagnosis?
Brief Psychotic Disorder
Delusional Disorder
Schizoaffective Disorder
Schizoid Personality Disorder
Schizophrenia
Schizophreniform Disorder
Schizotypal Personality Disorder