Psychotic DisordersPsychotic Disorders

ArchetypeArchetype

SchizophreniaSchizophrenia

PhenomenologyPhenomenology

The mental status examThe mental status exam AppearanceAppearance MoodMood ThoughtThought CognitionCognition Judgment and InsightJudgment and Insight

AppearanceAppearance

Motor disturbancesMotor disturbancesCatatoniaCatatonia

StereotypyStereotypy

MannerismsMannerisms Behavioral problemsBehavioral problems

HygieneHygiene

Social functioningSocial functioning ““Soft signs”Soft signs”

Mood and AffectMood and Affect

Affective flatteningAffective flattening AnhedoniaAnhedonia Inappropriate AffectInappropriate Affect

ThoughtThought

Thought ProcessThought Process ContentContent

Thought ProcessThought Process

Associative disordersAssociative disorders Circumstantial Circumstantial

ThinkingThinking Tangential thinkingTangential thinking

Other associative problemsOther associative problems

PerseverationPerseveration

DistractibilityDistractibility

ClangingClanging

NeologismsNeologisms

Thought ContentThought Content

PhenomenologyPhenomenology

Thought contentThought content

HallucinationsHallucinations

DelusionsDelusions

CognitionsCognitions

Subtle impairmentsSubtle impairments Frontal lobe functionFrontal lobe function

Associative thinkingAssociative thinking

Positive versus Negative SxsPositive versus Negative Sxs

PositivePositive HallucinationsHallucinations DelusionsDelusions Bizarre behaviorBizarre behavior Associative disordersAssociative disorders

Negative SymptomsNegative Symptoms

AlogiaAlogia

Affective flatteningAffective flattening

AnhedoniaAnhedonia

Avolition/apathyAvolition/apathy

EpidemiologyEpidemiology

EpidemiologyEpidemiology

~1% prevalence~1% prevalence

GendersGenders Age of onsetAge of onset

SocioeconomicSocioeconomic

PathologyPathology

AnatomicAnatomic

Widened ventriclesWidened ventricles

Decreased size Decreased size certain regionscertain regions

HistologyHistology

Abnormalities of Abnormalities of cytoarchitecturecytoarchitecture AlignmentAlignment AmountAmount

PathologyPathology

NeurophysiologyNeurophysiology HypofrontalityHypofrontality

More NeurophysiologyMore Neurophysiology

Other neurological changesOther neurological changes Eye movementsEye movements Blink rateBlink rate Sleep disordersSleep disorders

EtiologyEtiology

DopamineDopamine

Dopamine HypothesisDopamine Hypothesis

MetabolitesMetabolites

Dopamine receptor agonistsDopamine receptor agonists

Action of antipsychoticsAction of antipsychotics

Other TransmittersOther Transmitters

GlutamateGlutamate Primary excitatory transmitterPrimary excitatory transmitter May relate to glutaminergic toneMay relate to glutaminergic tone NMDA receptor antagonistsNMDA receptor antagonists

PCP PCP

Neurodegenerative theoriesNeurodegenerative theories

Evidence for cell lossEvidence for cell loss Reduced neuronal Reduced neuronal

densitiesdensities EtiologyEtiology

Neurodevelopmental TheoriesNeurodevelopmental Theories

Abnormalities of Abnormalities of cytoarchitecturecytoarchitecture

Absence of gliosisAbsence of gliosis

GeneticsGenetics

Genetic TheoriesGenetic Theories

Family studiesFamily studies 11oo relatives = 5% relatives = 5% Dizygotic twins = 10%Dizygotic twins = 10% Monozygotic twins = 50%Monozygotic twins = 50%

Adoption studiesAdoption studies Greater riskGreater risk

Possible Environmental CulpritsPossible Environmental Culprits

Bad parentingBad parenting

Social/economicSocial/economic

ViralViral

Allergic/AntibodiesAllergic/Antibodies

EtiologyEtiology

DiagnosisDiagnosis

DiagnosisDiagnosis

Schizophrenia: DSM-IVSchizophrenia: DSM-IV

““A” CriteriaA” Criteria = Psychosis= Psychosis

DurationDuration 6 months6 months

Global CriteriaGlobal Criteria

DiagnosisDiagnosis

““A Criteria”A Criteria” Two or more:Two or more:

DelusionsDelusions

HallucinationsHallucinations

Disorganized speechDisorganized speech

Disorganized behaviorDisorganized behavior

Negative symptomsNegative symptoms

Schizophrenia SubtypesSchizophrenia Subtypes

CatatonicCatatonic MovementMovement

DisorganizedDisorganized ProcessProcess

ParanoidParanoid ContentContent

UndifferentiatedUndifferentiated

ResidualResidual

DifferentialDifferential

DeliriumDelirium

DementiaDementia

Medication-inducedMedication-induced

Other Psychiatric IllnessesOther Psychiatric Illnesses

ComorbidityComorbidity

DepressionDepression

Substance AbuseSubstance Abuse

Course and PrognosisCourse and Prognosis

Course of SchizophreniaCourse of Schizophrenia

PrognosisPrognosis

Usually deterioratesUsually deteriorates

~ exacerbations w/ incomplete recovery~ exacerbations w/ incomplete recovery

Symptoms change over timeSymptoms change over time

OutcomeOutcome

Good Bad Intermediate

Positive PredictorsPositive Predictors

Acute onsetAcute onsetShort durationShort durationGood premorbid functioningGood premorbid functioningAffective symptomsAffective symptomsGood social functioningGood social functioningHigh social classHigh social classNeg fam hx psychoticNeg fam hx psychoticNo structuralNo structural

Poor PredictorsPoor Predictors

Insidious onsetInsidious onsetLong durationLong durationFamily hx of psych illnessFamily hx of psych illnessObsessions/CompulsionsObsessions/CompulsionsAssaultive BehaviorAssaultive BehaviorPoor premorbid functioningPoor premorbid functioningNeurological/anatomic abn.Neurological/anatomic abn.Low social classLow social class

TreatmentTreatment

Antipsychotic MedicationsAntipsychotic Medications

PhenothiazinesPhenothiazines ChlorpromazineChlorpromazine

ButyrophenonesButyrophenones HaloperidolHaloperidol

AtypicalsAtypicals ClozapineClozapine

AntipsychoticsAntipsychotics

Mechanism of actionsMechanism of actions Dopamine blockadeDopamine blockade D-2 and analoguesD-2 and analogues

Antipsychotics: IndicationsAntipsychotics: Indications

Acute psychosisAcute psychosis

Prevention of relapsePrevention of relapse

Also used in other disordersAlso used in other disorders Acute maniaAcute mania Anxiety/insomniaAnxiety/insomnia Aggressive disordersAggressive disorders

Antipsychotics: Side EffectsAntipsychotics: Side Effects

AnticholinergicAnticholinergic

Extrapyramidal (Parkinson’s-like)Extrapyramidal (Parkinson’s-like)

Other effectsOther effects

DopaminergicDopaminergic Tardive dyskinesiaTardive dyskinesia NMSNMS

IdiopathicIdiopathic HematologicHematologic

ClozapineClozapine Rashes, skin pigmentary, temperature Rashes, skin pigmentary, temperature

dysregulationdysregulation

AntipsychoticsAntipsychotics

ApproachApproach Lower doses usually adequateLower doses usually adequate Adjust to side effectsAdjust to side effects Evaluate for TDEvaluate for TD

How long?How long? 11stst episode episode Maintenance Maintenance

Other TreatmentsOther Treatments

ElectroshockElectroshock

Other tranquilizersOther tranquilizers

Psychosocial TreatmentsPsychosocial Treatments

SupportiveSupportive

Social/educativeSocial/educative

FamilyFamily

Other DiagnosisOther Diagnosis

SchizophreniformSchizophreniform

SchizoaffectiveSchizoaffective

Brief PsychoticBrief Psychotic

Delusional DisordersDelusional Disorders

Shared PsychosesShared Psychoses

Psychosis due to somethin’ elsePsychosis due to somethin’ else