Psychosis and Schizophrenia: Differential Diagnosis

1
Psychosis and Schizophrenia Differential
Diagnosis

• William R. Yates, M.D.
• Professor of Research
• OU College of Medicine, Tulsa
• Laureate Research Center

2
Brain Cortex in Schizophrenia
3
Psychotic Disorders-Overview

• Common signs symptoms
• Case vignettes
• Differential Diagnosis
• Medications and psychotic symptoms
• Management principles
• Psychopharmacologic overview

4
Objectives

• Describe the common symptoms of psychosis
• List the key differential diagnoses for psychotic
  symptoms
• Describe the criteria for schizophrenia
• Outline a treatment plan for management of acute
  and chronic psychotic disorders

5
Psychiatric exam-simplified

• Cognitive impairment?
• Psychotic symptoms/disorder?
• Mood disorder?
• Anxiety disorder?
• Substance use disorder?

6
Differential Diagnosis Psychosis

• Psychosis due to medical disorder?
• Psychosis due to medication?
• Psychosis due to drug/alcohol intoxication or
  withdrawal?
• Psychotic depression or mania?
• Psychosis of schizophrenia?
• Delusional disorder?

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Case Vignette 1

• BT was recently admitted for fever, bloody
  diarrhea and following colonoscopy diagnosed with
  inflammatory bowel disease. He was admitted,
  placed on IV antibiotics and high dose
  corticosteroids. His medical condition improved
  and he was discharged. However, soon after
  returning home, his wife calls in the middle of
  the night. She found her husband up wandering
  around. He appears confused, agitated and
  reports he hears the voice of God telling him to
  prepare to become the next Messiah. His wife
  asks what she should do.

8
Case Vignette 2

• BF is a 72 year old women who lives alone. Her
  daughter brings her in for evaluation after she
  is noted to be more disorganized and agitated.
  She has told her daughter that her purse and
  money have been stolen. She also reports seeing
  small miniature men sneaking into her apartment
  and taking her things during the evening.

9
Case Vignette 3

• You are asked to evaluate a 40 year old man
  admitted to the hospital for fever and abdominal
  pain. He resides in a nursing home and has had
  several weeks of LLQ pain and a 20 pound weight
  loss. He has required residential care since age
  22 due to a mental disorder. He refuses to have
  any blood drawn or other other diagnostic
  procedures. He states he feels his doctors are
  conspiring to kill him and inject him with the
  AIDS virus. A surgeon recommends surgical
  exploration for his clinical presentation and
  asks you to proceed with what is necessary to
  accomplish this.

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Common signs symptoms

• Disturbances of perception cognition
• hallucinations auditory, visual, tactile,
  olfactory, gustatory
• delusions paranoid, somatic, grandiose,
  religious, nihilisitic
• First rank delusions thought broadcasting,
  withdrawal, thought insertion, passivity
• thought disorder derailment, blocking,
  tangentiality, perseveration

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Common signs symptoms II

• Disturbances of behavior and motor fx
• psychomotor agitation or retardation
• aggressive verbal or motor behavior
• catatonia immobility, mutism, waxy flexibility,
  posturing, sterotypy
• bizarre behavior/social deterioration
• avolition lack of goal directed activity
• Disturbances of affect flat/ anhedonia

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National Comorbidity Survey

• One or more psychosis screening questions
  endorsed by 28.4 (CIDI)
• Lifetime prevalence rates for narrowly defined
  psychotic illness 1.3
• Lifetime prevalence rates for more broadly
  defined psychotic illness 2.2

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National Comorbidity Survey

• Clinicians then reviewed the positive screened
  cases using CIDI interview and interviewed
  patients/reviewed records
• Lifetime prevalence rates for narrowly defined
  schizophrenia 0.2
• Lifetime prevalence for more broadly defined
  schizophrenia was 0.7

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Workup for new-onset psychosis

• History and physical
• Psychiatric evaluation
• General medical evaluation chemistry panel,
  ABGs, CBC, thyroid function, HIV, Lumbar
  puncture, EEG
• Urine drug screen
• Brain imaging CT/ MRI

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Medical Causes for Psychosis

• Delirium with psychotic features
• I nfectious encephalitis
• W ithdrawal alcohol
• A cute metabolic acidosis, hepatic failure
• T rauma head trauma
• C NS pathology stroke, vasculitis
• H ypoxia pulmonary embolus
• D eficiencies vitamin
• E ndocrinopathy hypoglycemia
• A cute Vascular hypertensive encephalopathy
• T oxins medications, pesticides, solvents
• H eavy metals lead, mercury

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Psychosis in Dementia

• Psychotic symptoms common in Alzheimers and other
  dementias
• May involve perceptual disturbances and interact
  with memory impairment
• Often accompanied by agitation, wandering,
  aggression
• Can significant contribute to functional
  deterioration

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Substance-induced psychosis

• Stimulants Cocaine/Amphetamines
• Often with paranoid delusions
• Can also include auditory and tactile
  hallucinations
• Hallucinogens LSD/PCP/Psilocybin
• Alcohol Withdrawl
• Often includes visual hallucinations

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Medication-induced psychosis

• Paranoid and other delusions
• acyclovir, cephalosporins, cimetidine,
  corticosteroids, dopamine agonists (levodopa),
  theophylline
• Hallucinations
• anticholinergics, calcium channel blockers,
  cimetidine, dopamine agonists, indomethacin,
  phenytoin

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Psychosis due to mood disorder

• Depression
• may include hallucinations and delusions
• delusions tend to match the mood state I.e
  having committed terrible sin, being worthless
  and doomed to hell or death

• Mania
• may include hallucinations and delusions
• delusions tend to be grandiose, religious, and
  bizarre I.e. becoming a famous person or
  religious person

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Primary psychotic disorders

• Schizophrenia chronic hallucinations or
  delusions lasting 6 months, lifetime prevalence
  of about 1, variable course but often
  progressive and disabling
• Schizophreniform disorder like schizophrenia but
  less than 6 months
• Schizoaffective disorder major mood disorder
  plus psychosis during periods of remission from
  mood symptoms

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Non-affective Psychoses Definitions

• Schizophrenia
• Schizophreniform disorder
• Delusional disorder
• Atypical Psychosis

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Diagnosis Schizophrenia

• A. Two or more of following x 1 month
• delusions hallucination
• disorganized speech negative sx
• disorganized or catatonic behavior
• B. Social/Occupational Dysfunction
• C. Duration of A/B at least 6 months
• D. R/O schizoaffective, psychotic mood, substance
  abuse, gen medical cond.

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Prevalence Rates-Schizophrenia

• Article Criteria Rate/100
• Eaton pre-DSM 2.7
• Eaton (2) pre-DSM 3.7
• Levav SAD/RDC 6 mo 0.7
• Kessler
• 1. (NCS) SCID/DSM-IIIR 0.1
• non-affective psychoses rate 0.7

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Prevalence Rates-Schizophrenia

• Environmental Catchment Area Study
• Diagnostic Interview Schedule(DIS)
• Lay interviewer measure
• Only 20 agreement with psychiatric evaluation
• ECA not a suitable source of information to
  estimate the prevalence of schizophrenia

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Prevalence Rates Schizophrenia

• Assuming most accurate survey in the NCS the in
  Tulsa SMA (750,000)
• Estimates of number of patients with
  schizophrenia would range from 750 to 5000
• Community centers where services provided tend to
  increase prevalence rates

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Risk Factors-Schizophrenia

• Social Class
• Gender and Age
• Marital Status
• Season of Birth
• Pregnancy Birth Complications
• Substance Abuse
• Genetic Factors

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Social Class

• Low social class increases risk
• Hypotheses
• Environmental factors associated with low SES
  cause schizophrenia
• Selection-drift hypothesis-failure to attain
  social rank or downward drift
• Several studies support selection-drift hypothesis

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Social Class-ECA
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Education-NCS
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Gender and Age

• Very similar gender rates
• Some evidence male predominance
• males may have higher severity
• seek admission and treatment earlier
• Some support for higher rates of men in younger
  populations (under 35 years) and higher rates for
  women in older populations

31
Marital Status

• Risk ratio for nonmarried vs married individuals
  ranges from 2.6 to 7.2
• Women are more likely to be married than men (30
  vs 10)
• Some of this may be due to later onset or milder
  forms of the illness in women compared to men

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ECA-Marital Status
33
Risk Factors Season of Birth

• A number of studies have reported that the
  proportion of patients with schizophrenia born
  during winter is 5 to 15 greater than expected
• Higher proportion in those without a family
  history of schizophrnenia
• Has not been linked to specific viral infections

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Pregnancy Birth Complication

• Studies inconsistent looking at a variety of PBCs
  (I.e. bleeding, low APGARs)
• PBCs are associated with abnormal brain structure
  by MRI
• PBCs may be potentiator of risk in those with
  genetic predispositon to schiz
• PBCs may be indicator of fetal viral inf
• PBCs occur more commonly in low SES

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ECA Substance Abuse Comorbidity
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Substance Abuse

• Large Swedish study showed cannabis use (more
  than 15 x) increased risk of schizophrenia 6 x
• Cannabis associated psychosis associated with FH
  schizophrenia
• Also some interest in LSD and other hallucinogens
  role in initiation

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Definition Delusional Disorder

• A. Nonbizarre delusions of 1 month
• B. Criterion A for schizophrenia not met
• C. Function not markedly impaired
• D. No prominent mood disorder
• E. Not due to substance or GMC
• Subtypes erotomanic, grandiose, jealous,
  persecutory, somatic, mixed

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Course Prognosis

• Community sample groups often have better
  prognosis than those collected in hospital
  samples
• Still overall high rates of chronicity
• Worse than affective psychoses

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Poor Prognosis

• Male
• Unmarried
• Family history of schizophrenia
• Long duration of symptoms before RX
• Few positive sx/Many negative sx
• Noncompliance
• Substance abuse comorbidity

40
Case Vignette 1

• BT was recently admitted for fever, bloody
  diarrhea and following colonoscopy diagnosed with
  inflammatory bowel disease. He was admitted,
  placed on IV antibiotics and high dose
  corticosteroids. His medical condition improved
  and he was discharged. However, soon after
  returning home, his wife calls in the middle of
  the night. She found her husband up wandering
  around. He appears confused, agitated and
  reports he hears the voice of God telling him to
  prepare to become the next Messiah. His wife
  asks what she should do.

41
Case Vignette 2

• BF is a 72 year old women who lives alone. Her
  daughter brings her in for evaluation after she
  is noted to be more disorganized and agitated.
  She has told her daughter that her purse and
  money have been stolen. She also reports seeing
  small miniature men sneaking into her apartment
  and taking her things during the evening.

42
Case Vignette 3

• You are asked to evaluate a 40 year old man
  admitted to the hospital for fever and abdominal
  pain. He resides in a nursing home and has had
  several weeks of LLQ pain and a 20 pound weight
  loss. He has required residential care since age
  22 due to a mental disorder. He refuses to have
  any blood drawn or other other diagnostic
  procedures. He states he feels his doctors are
  conspiring to kill him and inject him with the
  AIDS virus. A surgeon recommends surgical
  exploration for his clinical presentation and
  asks you to proceed with what is necessary to
  accomplish this.

43
Typical Antipsychotics

• Phenothiazines (aliphatic)
• chlorpromazine (Thorazine)
• Phenothiazines (piperidine)
• thioridizine (Mellaril)
• Phenothiazines (piperazine)
• fluphenazine (Prolixin)
• Butyrophenone-haloperidol (Haldol)
• Thioxanthene-thiothixene (Navane)

44
Atypical Antipsychotics

• Clozapine (Clozaril)
• Olanzapine (Zyprexa)
• Risperidone (Risperdal)
• Quetiapine (Seroquel)
• Ziprasidone (Geodon)
• Aripiprazole (Abilify)
• Paliperidone (Invega)

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Psychosis Acute Management

• Haloperidol 2 to 5 mg IM q 30 minutes until
  agitation/psychosis is controlled
• Can alternate with lorazepam 1 to 2 mg IM or IV
  for a synergistic sedative effect
• Haloperidol has been administered IV for rapid
  control, however this is not approved by FDA and
  probably best done with cardiac monitoring

46
Psychosis Chronic management

• Typical antipsychotics chlorpromazine,
  fluphenazine, haloperidol--all have significant
  rates of dystonic reactions, Parkinsonian
  symptoms tardive dyskinesia
• Haloperidol/Prolixin decanoate forms
• Atypical agents Clozapine, olanzapine,
  risperidone, quetiapine ziprasidone,
  palliperidone