Schizophrenia and Other Psychotic Disorders

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Schizophrenia and Other Psychotic Disorders

• Anita S. Kablinger MD
• Associate Professor
• Departments of Psychiatry of Pharmacology
• LSUHSC-Shreveport

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What is Psychosis?

• Generic term
• Break with Reality
• Symptom, not an illness
• Caused by a variety of conditions that affect the
  functioning of the brain.
• Includes hallucinations, delusions and thought
  disorder

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Differential Diagnosis

• Medical/surgical/ substance-induced
• Psychotic d/o due to GMC
• Dementias
• Delirium
• Medications
• Substance induced
• Amphetamines
• Cocaine
• Withdrawal states
• Hallucinogens
• Alcohol

• Mood disorders
• Bipolar disorder
• Major depression with psychotic features

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PSYCHOSIS
Mood disorders
Substance induced
organic mental disorders
Functional disorders
Delirium Dementia Amnestic d/o
Schizophrenia spectrum disorders
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Differential Diagnoses (Cont)

• Personality disorders
• Schizoid
• Schizotypal
• Paranoid
• Borderline
• Antisocial

• Miscellaneous
• PTSD
• Dissociative disorders
• Malingering
• Culturally specific phenomena
• Religious experiences
• Meditative states
• Belief in UFOs, etc

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Workup of New-Onset PsychosisRound up the
usual suspects

• Good clinical history
• Physical exam, ROS
• Labs/Diagnostic tests

Metabolic panel CBC with diff B12, Folate RPR,
VDRL Serum Alcohol Urinalysis Thyroid profile
URINE DRUG SCREEN!!!
CSF/LP HIV serology
CT or MRI EEG
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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.

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Talking Points

• 1 prevalence
• Early onset, MgtF
• Early, aggressive treatment decreases long-term
  problems
• Multiple subtypes- catatonic, disorganized,
  paranoid, undifferentiated, residual

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Schizophrenia

• Diagnostic features

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DSM-IV Diagnosis of Schizophrenia

• Psychotic symptoms (2 or more) for at least one
  month
• Hallucinations
• Delusions
• Disorganized speech
• Disorganized or catatonic behavior
• Negative symptoms

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Diagnosis (cont.)

• Impairment in social or occupational functioning
• Duration of illness at least 6 mo.
• Symptoms not due to mood disorder or
  schizoaffective disorder
• Symptoms not due to medical, neurological, or
  substance-induced disorder

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Clinical featuresFormal Thought Disorders

• Neologisms
• Tangentiality
• Derailment
• Loosening of associations (word salad)
• Private word usage
• Perseveration
• Nonsequitors

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Clinical featuresDelusions

• Paranoid/persecutory
• Ideas of reference
• External locus of control
• Thought broadcasting
• Thought insertion, withdrawal
• Jealousy
• Guilt
• Grandiosity

• Religious delusions
• Somatic delusions

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Clinical featuresHallucinations

• Auditory
• Visual
• Olfactory
• Somatic/tactile
• Gustatory

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Clinical featuresBehavior

• Bizarre dress, appearance
• Catatonia
• Poor impulse control
• Anger, agitation
• Stereotypies

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Clinical featuresMood and Affect

• Inappropriate affect
• Blunting of affect/mood
• Flat affect
• Isolation or dissociation of affect
• Incongruent affect

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Positive vs. negative symptoms

• Positive symptoms
• Delusions
• Hallucinations
• Behavioral dyscontrol
• Thought disorder

• Negative symptoms
• (Remember Andreasens As)
• Affective flattening
• Alogia
• Avolition
• Anhedonia
• Attentional impairment

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Psychotic Disorders
Onset
Symptoms
Course
Duration
Schizo-phrenia Usually insidious Many Chronic gt6 months
Delusional disorder Varies (usually insidious) Delusions only Chronic gt1 mo.
Brief psychotic disorder Sudden Varies Limited lt1 mo.
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Psychosocial Factors

• Expressed emotion
• Stressful life events
• Low socioeconomic class
• Limited social network

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Some factors rejected as causal

• Schizophrenogenic Mother
• Skewed family structure

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Genetic factors(The evidence mounts)

• Monozygotic twins (31-78) vs dizygotic twins
• 4-9 risk in first degree relatives of
  schizophrenics
• Adoption studies
• Linkage, molecular studies

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Genetics of SchizophreniaThe take-home message

• Vulnerability to schizophrenia is likely
  inherited
• Heritability is probably 60-90
• Schizophrenia probably involves dysfunction of
  many genes

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Anatomical abnormalities

• Enlargement of lateral ventricles
• Smaller than normal total brain volume
• Cortical atrophy
• Widening of third ventricle
• Smaller hippocampus

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Physiologic studiesPET and SPECT

• Generally normal global cerebral flow
• Hypofrontality
• Failure to activate dorsolateral prefrontal
  cortex (problem-solving, adaptation, coping with
  changes)

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Biochemical factorsThe dopamine hypothesis

• All typical antipsychotics block D2 with varying
  affinities
• Dopamine agonists can precipitate a psychosis
• Amphetamines
• Cocaine
• L-dopa

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Dopamine systems
Clinical implications
Functions
Cell bodies
Projections
Nigro-striatal Substantia Nigra Caudate and putamen Move-ment Extrapyramidal symptoms, dystonias, Tardive dyskinesia
Meso-limbic Ventral tegmental area, subst. nigra Accumbens amygdala Olfactory tubercle Emotions, affect, memory Positive symptoms
Meso-cortical Ventral tegmental area Prefrontal Cortex Thought, volition, memory Blockade here can worsen negative symptoms.
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Typical Neuroleptics

• Low potency
• Chlorpromazine
• Thioridazine
• Mesoridazine

• High potency
• Haloperidol
• Fluphenazine
• Thiothixene
• Loxapine (mid)

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Neuroleptic (typicals)side effects

• Acute dystonia
• Parkinsonian side effects (EPS)
• Akathisia
• Tardive dyskinesia
• Sedation, orthostasis, QTC prolongation,
  anticholinergic, lower seizure threshold,
  increased prolactin

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Atypical Antipsychotics

• Risperidone
• Olanzapine
• Quetiapine
• Clozapine
• Ziprasidone
• Aripiprazole (new-partial DA agonist)

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Atypical antipsychotics

• Broader spectrum of receptor activity (Serotonin,
  dopamine, GABA)
• May be better at alleviating negative symptoms
  and cognitive dysfunction
• Clozaril (clozapine) associated with
  agranulocytosis, seizures

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Atypical Antipsychotics Side Effects

• Sedation
• Hyperglycemia, new-onset diabetes
• Anticholinergic effects
• Less prolactin elevation
• QTC prolongation
• Some EPS
• Increased lipids

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Psychosocial Treatment

• Education, compliance 1
• Hospitalize for acute loss of functioning
• Outpatient treatment is rehabilitative
• Psychoanalysis, exploratory therapies have
  limited value
• Families should be involved