NRNP 6635 Final Exam - Walden University Psychopathology and Diagnostic Reasoning

Schizophrenia-symptoms are variable and include changes in perception, emotion, cognition, thinking, & behavior. The effects of these manifestations vary by person and can change over time, but the illness is always severe and is usually long-lasting. Onset is typically before age 25. Affects people of all socioeconomic backgrounds. Patients and families tend to suffer poor care due to lack of knowledge of schizophrenia. It is one of the most common of the serious mental disorders but its essential nature remains unclear. Sometimes it is referred to as a syndrome, the schizophrenias or the schizophrenia spectrum. There is no lab testing for schizophrenia. History-Symptoms of schizophrenia have been documented throughout history. Early Greek physicians noted patients with delusions of grandeur, paranoia, and deterioration in cognitive function and personality. It wasn’t until the 19th Century that schizophrenia became a medical condition worthy of being studied. Benedict Morel ()-coined the term demence precoce- to identify deterioration in patients who illness began in adolescence Emil Kraepelin ()-Identified dementia precox (from demece precoce)-a condition that identified an early onset change in cognition identified with hallucinations and delusions. He also distinguished manic and depressive episodes as well as paranoia Eugene Bleuler coined the term schizophrenia (replacing dementia precox). He chose the term for the schisms in the thoughts, behaviors, and emotions of the patients. He chose phrenia because he did not believe the disorder was associated with dementia. Schizophrenia is often misconstrued by lay people as multiple personality disorder, which is a separate disorder (schism-can mean split or division, but it can also mean differences in which he was describing the differences). 4As: Associations, Affect, Autism, Ambivalences. Secondary (Accessory): hallucinations, delusions Ernst Kretschmer ()- compiled data to support the idea that people with schizophrenia were more slender, athletic, and dysplastic body types rather than those with short, stocky physiques. Kurt Schneider ()- contributed a description of first-rank symptoms, which he stressed should not be rigidly applied. He stated that diagnoses should not be based solely on first-rank symptoms but if a patient presented with no first-rank symptoms, second-rank symptoms and clinical appearance should be observed. Karl Jaspers ()-psychiatrist and philosopher played a major role in developing existential psychoanalysis. His work paved the way to understand the psychological meaning of schizophrenic signs and symptoms of delusions and hallucinations. Adolf Meyer ()- founder of psychobiology saw schizophrenia as a reaction to life stresses. It was a maladaptation that was understandable in terms of the patient’s life experiences. Meyer’s view was represented in the nomenclature of 1950s, which was referred to the schizophrenic reaction. In later editions of DSM the term reaction was dropped. Epidemiology-The presence of Schizophrenia in the US is 1/100 or 1%. NIH reports the US lifetime percent is 0.6-1.9%. Total population lifetime percent is 0.5% in a single year. Only about half of those with schizophrenia will obtain treatment, despite the severity. lOMoARcPSD| Gender and Age-Schizophrenia affects men and women equally. However, onset usually occurs earlier in men. Peak ages are 10-25 for men and 25-35 for women. Nearly 1/3 of all female schizophrenia patients are first diagnosed with hospitalizations. 3-10% of women onset after age 40. 90% of patients onset between 10-55 years of age. It is very rare to present before age 10 or after age 60, regardless of gender. In general, females typically have a better outcome than males. Reproductive Factors-first-degree relatives have a 10x greater risk of developing schizophrenia than the general population. Medical Illness- people will schizophrenia have a higher mortality rate from accidents and natural causes than the general population. Studies show that up to 80% of schizophrenia patients have concurrent medical illnesses and up to 50% of these conditions may be undiagnosed. Infection and Birth Season- People who develop schizophrenia are more likely to be born during the winter or early spring and less likely to be born during late spring or summer. Northern Hemisphere people with schizophrenia are more likely to be born January to April. Southern Hemisphere people with schizophrenia are more likely to be born July-September. Season-specific changes, such as infections, influenza, viral infections, epidemics, diet changes, maternal starvation during pregnancy, rhesus factor incompatibility, and genetic predisposition. Substance Abuse- Substance abuse occurs commonly in schizophrenia. Tobacco use occurs in greater than 50%, alcohol abuse in 40%, cannabis over 50%. Nicotine dependency occurs in up to 90% of schizophrenic patients. Population Density- The incidence of schizophrenia in children with 1-2 parents with schizophrenia is twice as high in cities as it is in rural areas. This suggests the social stressors in urban settings may influence the development of schizophrenia in at-risk persons. Socioeconomic & Cultural Factors- Schizophrenia is a life-long illness. Patients with schizophrenia account for 15%-45% of the homeless population in America. Development of effective antipsychotic medication, treatment, and better rights for persons with mental illness since the mid 1950s has improved the view of mental illness. Patients with schizophrenia occupy 50% of mental health hospital beds and 16% of psychiatric patients receiving treatment. Etiology- genetic contribution accounts for some, if not all, of cases. Some studies suggest the age of the father correlates with development of schizophrenia citing those born to fathers over age 60 were at a greater risk for developing schizophrenia. Biochemical Factors Dopamine Hypothesis- hypothesizes that schizophrenia results from too much dopaminergic energy. Excessive dopamine in patients with schizophrenia has been linked to more severe psychotic symptoms. There have been reports of increased dopamine in the amygdala, decreased density of dopamine transporter, and increased numbers of dopamine type 4 receptors in the entorhinal cortex. lOMoARcPSD| Serotonin-current hypothesis suggest excess serotonin causes positive and negative schizophrenia symptoms. Clozapine and other 2nd gen antipsychotics coupled with the effectiveness of clozapine to decrease positive sx in chronically ill patients, contributing to the validity of this proposition. Norepinephrine-anhedonia (the inability to feel emotion or pleasure) is a noted feature of schizophrenia. A neuronal degeneration of norepinephrine has been linked to this. Pharmacological & biochemical data to support this theory is inconclusive. GABA- has been implicated. GABA in the hippocampus leads to hyperactivity of dopaminergic neurons. Neuropeptides- (substance P & neurotensin) in the catecholamine & indolamine neurotransmitters influence the actions of these neurotransmitters. Glutamate- implicated bc ingestion of phencyclidine, a glutamate antagonist, produces an acute syndrome similar to schizophrenia. The hypotheses proposed include those of hyperactivity, hypoactivity, & glutamate-induced neurotoxicity. Acetylcholine and Nicotine- postmortem studies indicate decreased muscarinic and nicotinic receptors in the caudate-putamen, hippocampus, and selected regions of the prefrontal cortex. These receptors play a role in regulation of neurotransmitter systems involved in cognition, which is impaired in schizophrenia. Neuropathology-In the 19th century, neuropathologists failed to identify a neuropathological cause for schizophrenia, so they classified it as a functional disorder. By the end of the 20th century, researchers had made significant strides in revealing a neuropathological causepredominantly in the limbic system & basal ganglia (in the cerebral cortex, thalamus, and brainstem). Loss of brain volume appears to result from reduce density of the axons, dendrites, and synapses that mediate associative functions of the brain. Synaptic density is highest at 1 year and then pares down to adult values in early adolescence. Cerebral Ventricles- CT scans consistently show lateral and 3rd ventricular enlargement and some reduction in cortical volume. Reduced volume of cortical gray matter has been indicated in the early stages of the disease. Some studies indicate that lesions present on CT are present at the onset of the illness and do not progress throughout the disease process. Reduced Symmetry- Reduced symmetry has been noted in several areas of the brain with schizophrenia: temporal, frontal, and occipital lobes. This is believed to have originated during fetal life. Limbic system- because of the role of the limbic system in emotional control, the limbic system is indicated in the development of schizophrenia. Post-mortem studies show decrease in the size of the region (including amygdala, hippocampus, and parahippocampal gyrus). MRI indicates the hippocampus is also functionally abnormal with glutamate distribution disturbances noted. Disorganized neurons are also noted in the hippocampus. lOMoARcPSD| Prefrontal Cortex- considerable evidence from postmortem studies on the brain indicate anatomical abnormalities in the prefrontal cortex. Functional deficits mimic those who have had prefrontal lobotomies or prefrontal lobe syndromes. Thalamus- some evidence points to thalamus shrinkage or neuronal reduction by 30-40%. This appears to be due to effects of antipsychotic medication AEB those with schizophrenia chronically treated with medication have similar sized thalamus to those with neuroleptic-naïve subjects. Basal Ganglia and Cerebellum- bc people with schizophrenia can have awkward movements, facial grimacing, and odd gaits, the basal ganglia and cerebellum are implicated. They control movement. Studies have shown increased D2 receptors in the caudate, putamen, & nucleus accumbens. The question is, is the increased D2 receptors due to antipsychotic medication? Neural Circuits- Rather than look at schizophrenia as a disorder affecting specific areas of the brain, this perspective views it as a disorder involving neuronal circuits of the brain. Early developmental lesions of the dopaminergic tracts to the prefrontal cortex results in disturbances of the prefrontal and limbic system function resulting in positive and negative symptoms associated with schizophrenia. The observation of the disturbance between the prefrontal and limbic system demonstrates a relationship with hippocampal morphological abnormalities & disturbances in prefrontal cortex metabolism. Data suggests that this circuit involvement is responsible for the hallucinations associated with schizophrenia. Brain Metabolism- lower levels of phomonoester and inorganic phosphate and higher levels of phosphodiester noted with schizophrenia. Lower levels of N-acetyl aspartate in the hippocampus and frontal lobes as well. Applied Electrophysiology- schizophrenia patients have more sensitivity to activation procedures (spike in activity after sleep deprivation), decreased alpha activity, increased theta and delta activity, likely more epileptiform activity, and more left-sided abnormalities. These patients may not have the ability to filter out background noise, which may contribute to auditory hallucinations. Complex partial epilepsy-schizophrenia-like psychoses have been reported more frequently in patients with complex partial seizures. Associated factors include left-sided seizure focus, medial temporal location of the lesion, and early onset of seizures. Evoked potentials- the P300 has been identified as a large, positive evoked-potential wave that occurs about 300 milliseconds after a sensory stimulus is detected. The P300 wave is located in the limbic system structures of the medical temporal lobes. In patients with schizophrenia, the P300 has been noted to be significantly smaller. It is also noted to be significantly smaller in children who, bc they have affected parents, are at higher risk for schizophrenia. Other evoked potentials for schizophrenia are N100 and contingent negative variation. Eye movement dysfunction- inability to follow a moving visual target accurate is seen in 50- 85% of patients with schizophrenia, 25% of patients with other psychiatric illnesses, and less than 10% of nonpsychiatrically ill individuals lOMoARcPSD| Psychoneuroimmunology-decreased T cells interleukin-2 production, reduced number and response of peripheral lymphocytes, abnormal cellular and humoral reactivity to neurons, and presence of brain-directed (antibrain) antibodies. The possibility of autoimmune brain antibodies has some data to support it. Psychoneuroendocrinology- persistent nonsuppression of dexamethasone-suppression test in schizophrenia is correlated with poor long-term outcomes. Some data also suggests decreased concentrations of luteinizing hormones or follicle-stimulating hormone (could be correlated with age of onset and length of illness). Two additional abnormalities: blunted release of prolactin & growth hormone on gonadotropin-releasing hormone or thyrotropin-releasing hormone stimulation & blunted release of growth hormone on apomorphine stimulation. Psychosocial & Psychoanalytic Theories- clinicians should consider psychosocial and biological factors affecting schizophrenia. It is a disease of the brain and should be paralleled to other diseases affecting other organs. Psychoanalytic Theories-all propose psychotic symptoms have meaning. Sigmund Freud postulated schizophrenia results from developmental fixations early in life. Margaret Mahler postulates insecure identity from infancy. The child is never able to separate from mother. Paul Federn postulates a defect in ego functions and that intense hostility and aggression distort infant-mother relationship which leads to personality disorganization and vulnerability to stress. This comes evident in adolescence when the teens need a strong ego to function independently. Harry Stack Sullivan postulated various symptoms have significant meaning for the patient ie hallucinations may stem from inability to deal with objective reality. Learning Theories- children learn irrational reactions and ways of thinking by imitating parents with significant emotional problems. Family Dynamics- a study of British 4 year olds had a 6-fold increase of developing schizophrenia when the child had a poor mother-child relationship. Offspring of schizophrenic parents were more inclined to develop schizo when raised in adverse circumstances as compared to those raised in loving homes with stable parents and relationships. Double-blind-formulated by Gregory Bateson & Donald Jackson. Children withdraw to escape the confusion of double-blind ie parent encourages child to share cookies with friends during playdate, then chastises for eating/sharing too many cookies. Schisms & Skewed Families- Theodore Lids described family schisms as one parent who is abnormally close to one child of the opposite gender. A skewed family describes a power struggle between parents that results in one parent being the dominant power. These dynamics stress the tenuous adaptive capacity of the patient with schizophrenia. Pseudomutual and Pseudohostile Families- Lyman Wynne says some families surpress emotional expression with pseudomutual or pseudohostile verbal communication. When the child leaves the home, he has problems communicating and relating to others. Expressed Emotion- Families with high emotional expression have high levels of relapse for schizophrenia patients. Diagnosis: Diagnosis is based on the DSM-5 with several options with specifiers for clinicians to detail symptoms. Subtypes: lOMoARcPSD| Paranoid-characterized by preoccupation with one or more delusions or frequent auditory hallucinations as well as delusions of persecution or grandeur. Usually occurs at a later age than catatonic schizophrenia or disorganized. Disorganized-Marked regression to primitive disinhibition, and unorganized behavior, and lack of symptoms to meet catatonic type. Onset usually before age 25. Disorganized, aimless, nonproductive. Appear disheveled. Social and emotional responses are inappropriate. Catatonic- previously common several decades ago is now rare in Europe & North America. Marked disturbance in motor function (stupor, negativism, rigidity, excitement, or posturing). Mutism is common. May show rapid alterations in extremes of excitement and stupor. Need careful supervision bc of malnutrition, hyperpyrexia, exhaustion, and self-inflected injury. Undifferentiated-when the patient does not easily fit into another category, he is categorized as undifferentiated type. Residual-continuing evidence of the schizophrenic disturbance in the absence of a complete set of active symptoms or sufficient symptoms to meet the diagnosis of another type. Emotional blunting, social withdrawal, eccentric behavior, illogical thinking, and mild loosening of associations are common among residual type. When delusions or hallucinations occur, they are neither prominent nor accompanied by strong affect. Other Subtypes Bouffée Délirante (acute delusional psychosis)-French diagnosis differs based on symptom duration of less than 3 months. Similar to DSM-5 dx schizophreniform disorder. French clinicians report approximately 40% of their Bouffée Délirante patients will eventually be classified as having schizophrenia. Latent-developed during a time when theorists conceived the disorder in broad diagnostic terms. Only patients who were severely ill with schizophrenia symptoms would be diagnosed with schizophrenia. Patients who presented with more mild symptoms (peculiar behaviors or thought disorders without psychotic symptoms) were given the diagnosis of Latent schizophrenia. These patients are who would now be diagnosed as borderline, schizoid, and schizotypal personality. In the past, the syndrome was also called borderline schizophrenia. Oneiroid- refers to a dream-like state in which patients may be deeply perplexed and may not be fully oriented to time & place. Has been used to describe patients who are engaged in their hallucinatory experiences to escape involvement in the real world. Paraphrenia-sometimes used synonymously with paranoid schizophrenia or for either a progressively deteriorating course of illness or the presence of a well-systemized delusional system. The multiple meanings make it ineffective for accurately communicating information. Psuedoneurotic Schizophrenia-characterized by patients who initially have anxiety, phobias, obsessions, and compulsions and later reveal thought disorders and psychosis. These patients are characterized by pananxiety, panphobia, panambivilance, and sometimes chaotic sexuality. Pseudoneurotic patients have free-floating anxiety that rarely subsides. They seldom become overtly and severely psychotic. This condition is currently dx as borderline personality disorder. Simple Deteriorative Disorder (Simple Schizophrenia)-gradual, insidious loss of drive and ambition. Typically patients are not overly psychotic and do not experience persistent hallucinations or delusions. Primary symptom is withdraw from work or social situations. Must be differentiated from depression, a phobia, dementia, or an exacerbation of a personality trait. Postpsychotic Depressive Disorder of Schizophrenia-after an acute schizophrenia episode, some patients become depressed. These symptoms can resemble residual schizophrenia as well lOMoARcPSD| as medication side effects to treat the acute episode. Careful consideration and assessment must be done. This occurs in nearly 25% of patients with schizophrenia and are associated with increased risk for suicide. Early-Onset Schizophrenia- a small minority of people develop symptoms of schizophrenia in childhood. Symptoms used to diagnose childhood schizophrenia are the same as adult. The prognosis is mostly unfavorable for those diagnosed in childhood. Late-Onset Schizophrenia-diagnosed after 45 years of age. Trends more in females than males. Typically characterized by paranoid symptoms. Prognosis is favorable and they tend to do well on antipsychotic medication. Deficit Schizophrenia- in the 1980s patients who presented with idiopathic negative schizophrenia symptoms were identified as deficit schizophrenia patients. Those who presented with positive symptoms were said to have nondeficit schizophrenia. Deficit patients have a more severe course of illness with a higher prevalence of abnormal involuntary movements and poorer social functioning before onset of psychotic symptoms. Six features (restricted affect, diminished emotional range, poverty of speech, curbing of interests, diminished sense of purpose, diminished social drive). Less long-term recovery of function & less likely to marry. Decreased risk of depression and suicide. Associated with summer births, greater familial risk, and higher prevalence in men. Their cognitive impairment, lack of motivation, lack of distress, and asocial nature affects their ability to adhere to medication regimen and achieve remission of symptoms. Psychological Testing: typically perform poorly on neuropsychological tests. Vigilance, memory, and concept formation are most affected & are consistent with pathological involvement in the frontotemporal cortex. Intelligence Tests: Patients who have schizophrenia typically perform lower on intelligence tests. Lower intelligence is typically presented at onset and continues to deteriorate throughout the progression of the disorder. Projective and personality tests: Projective tests such as Rorschach and the Thematic Apperception may indicate bizarre ideation. Personality inventories, like Minnesota Multiphasic Personality Inventory often gives abnormal results in persons with schizophrenia but the contribution to diagnosis and treatment plan is minimal. Clinical Features- (3 key issues) 1. No clinical sign or symptom is pathognomonic for schizophrenia-every sign or symptoms occurs in other psychiatric and neurologic disorders. Patient’s history is essential for diagnosis. 2. A patient’s symptoms change with time. 3. Clinicians must take into account the patient’s educational level, intellectual ability, and cultural and subcultural membership. Premorbid Signs and Symptoms-Appear before the prodromal phase of the illness (meaning they appear before the disease process presents itself). These may be few friends during childhood, or avulsion to social activities, or somatic complaints (headache, back or muscle pain, weakness, digestive problems). Initial diagnosis may be chronic fatigue syndrome, malingering, or somatization disorder. Family & friends may notice the person no longer functions well in social, occupational, and personal activity settings. During this time, he may develop an interest lOMoARcPSD| in abstract ideas, philosophy, and the occult. SX include peculiar behavior, abnormal affect, unusual speech, bizarre ideas, and strange perceptual experiences. Mental Status Examination- Appearance can range from disheveled and ungroomed, agitated, screaming, to obsessively groomed and completely silent or anywhere in between. Patients with schizophrenia are often poorly groomed, unbathed, and dressed overly warm for the temperatures (dressed in layers). Other odd behaviors include tics, stereotypies, mannerisms, and occasionally echopraxia (imitating the posture or behavior of the examiner). Precox Feeling-some experienced clinicians report a precox feeling, an intuitive experience of their inability to establish an emotional rapport with a patient. The feeling is common but there is no reliable date linking it to schizophrenia Mood, Feelings, & Affect- 2 common affective symptoms 1. Reduced emotional responsiveness (anhedonia if severe enough) 2. Overly active and inappropriate emotions (rage, happiness, anxiety) Other feeling tones include perplexity, sense of isolation, overwhelming ambivalence, depression, blunted affect. Perceptual Disturbances: Hallucinations-Any of the 5 sense can be affected by hallucinations. The most common hallucination is auditory-hearing threatening, obscene, accusatory, or insulting voices. 2 or more voices may talk among themselves and even comment on the patient’s life choices or behaviors. Visual hallucinations are also common. Tactile, olfactory, and gustatory hallucinations are uncommon and the clinician should look for an underlying medical or neurological cause. Cenesthetic Hallucinations- unfounded sensations of altered states in bodily organs ie burning sensation in the brain or bodily distortions. Illusions-are distortions of real images. Whereas hallucinations are not based on real sensations. Thought- thought disorders are the most difficult symptoms for many clinicians & students to understand but they are the core of schizophrenia. Dividing thought content, form of thought, and thought process helps to clarify them. Thought Content-reflects the persons ideas, beliefs, and interpretations of stimuli. Delusions are the most obvious example of a disorder of thought content. Some experience persecutory, grandiose, religious, or somatic forms. Loss of ego boundaries. They can believe they control the sun, or aliens are controlling them, the television/radio, is referring to them, etc. Form of Thought- objectively observable in patents spoken and written language. Loose association, derailment, incoherence, tangentiality, circumstantiality, neologisms, echolalia, verbigeration, work salad, and mutism. This can be evident with preoccupation with religion and religious views, mixed with philosophy. Thought Process- concerns the way ideas and language are formulated. Examiner infers a disorder based on how the patient speaks, writes, or draws. Examiner can also examine thought process based on behavior, especially with discrete tasks (OT). Disorders of thought include flight of ideas, thought blocking, impaired attention, poverty of thought content, poor abstraction abilities, perseveration, idiosyncratic associations (identical predicates, clang associations), overinclusion, and circumstantiality. Patients think others can read their minds, or ther thoughts are broadcast on television or radio. lOMoARcPSD| Impulsiveness, Violence, Suicide, & Homicide- patients with schizophrenia may be agitated and have little self-control when ill. Some can exhibit impulsive behaviors like smoking cigarette butts from a can to physical violence. Violence- violent behavior is common among untreated schizophrenia. Delusions of persecutory nature, previous episodes of violence, and neurological deficits are precursors for violent or impulsive behaviors. If a clinician feels fearful of a patient, it could be a precursor of a patient on the verge of a violent outburst. In such cases, terminate the interview or have an attendant present. Suicide- Single-leading cause of premature death among people with schizophrenia. Suicide attempts are made by 25-50% of patients with long-term rates of suicide estimated to be 10-13%. According to the DSM-5 suicide rate of patients with schizophrenia is 5-6%. 2/3 or more of schizophrenia patients who commit suicide have seen an apparently unsuspecting clinician within 72 hours of death. Up to 80% of patients with schizophrenia will experience a depressive episode. Those at greatest risk are young males who had high expectations, declined from a higher level of functioning, realizes that his dreams are not likely to come true, and has lost faith in the effectiveness of treatment. Clozaril may be particularly effective in reducing suicidal ideation in schizophrenia patients. Homicide-when a patient with schizophrenia does commit murder, it may be for bizarre reasons based on hallucinations or delusions. Possible predictors of homicide include history of previous violence, dangerous behavior while hospitalized, and hallucinations or delusions involving such violence. Sensory & Cognition: Orientation-Typically oriented to person, place, and time. Lack of such orientation should prompt further medical and neurological investigation. Some patients with schizophrenia may give bizarre answers, ie, “I am Jesus Christ, this is Heaven, AD 35” Memory- Memory is usually intact with some minor cognitive deficiencies. It may not be possible to get the patient to focus enough to test the memory adequately. Cognitive Impairment- Cognitive impairment is one of the classic traits of schizophrenia. Patients with schizophrenia tend to exhibit subtle cognitive dysfunction in the domains of attention, executive function, working memory, and episodic memory. By the time the first episode is experienced, cognitive impairment is present. Although a substantial number of patients with schizophrenia show an average IQ, it is possible that they have cognitive impairment compared to what they could have accomplished/level of functioning without schizophrenia. Cognitive impairments have become the focus of pharmacological and psychosocial treatments. Judgment & Insight-classically described as having poor judgment and insight into the nature and severity of their disorder. This creates poor compliance with treatment. When interviewing, define various aspects of insight such as relationships and getting along with people, awareness of symptoms, reasons for these problems. Reliability- a patient with schizophrenia is no less reliable than other patients, however, the important data given should be verified through additional sources. Somatic Comorbidity: Neurological Findings- localized and nonlocalized findings have been reportedly more common in people with schizophrenia than other psychiatric disorders. Nonlocalized signs include lOMoARcPSD| dysdiadochokinesia, astereognosis, primitive reflexes, and diminished dexterity. The presence of symptoms correlates with increased severity of illness and poorer prognosis. Other abnormal neurological signs include tics, stereotypies, grimacing, impaired fine motor skills, abnormal motor tone, and abnormal movements. Only about 25% of patients are aware of their own abnormal involuntary movements. Lack of awareness is correlated with lack of insight about primary psychiatric disorder and duration of illness. Eye Examination- in addition to the disorder of the smooth ocular pursuit (saccadic movement), patients with schizo have an increased blink rate. It is believed to reflect hyperdopaminergic activity. Speech- although speech disorders in schizo are thought to be reflective of thought disorders, they may also indicate a forme fruste of aphasia, perhaps implicating the dominant parietal lobe. Inability to perceive the prosody of speech or inflect their own speech can be seen as a neurological symptom stemming from the nondominant parietal lobe. Other parietal lobe-like symptoms can include inability to carry out tasks (apraxia), right-left disorientation, and lack of concern regarding the disorder. Other Comorbidity: Obesity-Patients with schizophrenia tend to be more obese with higher BMIs than their gendermatched cohorts. This is believed to be due to antipsychotic medication, poor nutritional balance, and decreased motor activity. Obesity tends to increase risk of cardiovascular morbidity and mortality as well as diabetes and other obesity-related conditions. Diabetes Mellitis-associated with increased risk of DM r/t obesity and partly due to antipsychotic medication Cardiovascular Disease- antipsychotic medications have direct effect on cardiac electrophysiology. In addition to obesity, increased rates of smoking, DM, hyperlipidemia, and sedentary lifestyle all contribute. HIV- Increased risk of HIV (1.5-2x of the general population) due to behaviors such as unprotected sex, multiple partners, and drug use. COPD- increased compared to the general population r/t increased prevalence of smoking. Rheumatoid Arthritis- 1/3 risk of RA that is found in general population. This inverse association has been replicated several times and the significance is unknown. Differential Diagnosis: Secondary Psychotic Disorders-A wide range of psychiatric and nonpsychiatric disorders can cause symptoms of psychosis and catatonia. 1. clinician should explore an undiagnosed nonpsychiatric diagnosed medical condition for an abrupt change in the patient’s condition or for any rare or unusual symptoms. 2. obtain a complete family history including medical, neurological, and psychiatric disorders 3. clinicians should consider nonpsychiatric causes even with patients previously diagnosed with schizophrenia because a patient with schizophrenia has the same odds of developing a brain tumor as someone without schizophrenia Other Psychotic Disorders-psychotic symptoms of schizophrenia can be identical to other psychotic disorder. The differentiating factor could be the length of time the patient is affected by the psychosis or trauma preceding the psychosis. lOMoARcPSD| Mood Disorders- Patients with depression can present with delusions and hallucinations. Delusions seen with mood disorders, like depression are typically mood congruent and involve themes like guilt, deserved punishment, self-depreciation, and incurable illness. In mood disorders, psychotic symptoms resolve with resolution of depression. A depressive episode can be severe enough that the patient withdraws and socially isolates, has loss in functioning, and decline in self-care, but these are all directly related to the depression. A full-blown manic episode often presents with delusions and sometimes hallucinations. Delusions in mania are most-often mood-congruent & typically involve grandiose themes. Special attention during examination of a patient with flight of ideas is required to note whether the associative links between topics are conserved, although the conversation is difficult for the observer to follow r/t patient’s accelerated rate of thinking. Personality Disorders- various personality disorders may have some features of schizophrenia (borderline personality disorder, schizoid, schizotypal). Severe OCD may mask an underlying schizophrenic process. Unlike schizophrenia, personality disorders have mild symptoms, historically occur throughout a patient’s life, and lack an identifiable date of onset. Malingering and Factitious Disorders- A patient who imitates the symptoms of schizophrenia but does not have the disorder, is malingering or factitious. Malingering individuals will present with schizophrenia-like symptoms which can be controlled. They typically have a financial or legal motivation behind their actions. Factitious patients don’t have as much control over their false symptoms. Course & Prognosis: Course- premorbid pattern of symptoms may be the first evidence of illness (although it is usually only recognized retrospectively). Symptoms usually begin in adolescence and are followed by the development of prodromal symptoms in days to a few months. Social or environmental changes (going away to college, death of relative) may precipitate the disturbing symptoms and the prodromal syndrome may last a year or more before onset of overt psychotic symptoms. Classic course entails exacerbations and remissions. Over time functionality gradually declines and the patient fails to return to their baseline functioning. Positive symptoms tend to become less severe with time but socially debilitating negative symptoms or deficit symptoms may increase in severity. 1/3 of all schizophrenia patients have some marginal or integrated social existence, most live in and out of hospitals, inactive, homeless, and in urban settings. Prognosis- studies show that over a 5-10 year period after first psychiatric hospitalization for schizophrenia, about 10-20% can be described as having a good outcome. More than 50% are described as having poor outcome with repeated hospitalizations, exacerbation of symptoms, major mood disorders, and suicide attempts. Schizophrenia does not always run a glum, deteriorating course. Several factors contribute to a positive prognosis. Reasonable readmission rates are 10-60% with estimation of 20-30% living somewhat normal lives. About 20-30% continue to experience moderate symptoms and 40-60% remain significantly impaired by their disorder for their entire lives. 20-25% of mood disorder patients are also severely disturbed at long-term follow-up. Treatment-antipsychotic medications are mainstay treatment. Psychosocial interventions, like psychotherapy can augment clinical improvement Hospitalization-indicated for diagnostic purposes; for stabilization of medications; for patients’ safety r/t suicidal or homicidal ideation; and for grossly disorganized or inappropriate behavior, lOMoARcPSD| including ability to take care of basic needs like food, clothing, and shelter. 4-6 week stays can be just as effective as long-term hospitalizations. Hospitals with active behavioral approaches have better outcomes than custodial institutions. Pharmacotherapy- introduction of chlorpromazine (Thorazine) in 1952 may be the single-most important contribution to the treatment of a psychiatric illness. Henri Laborit, a surgeon in Paris noted a reduction in presurgical anxiety with chlorpromazine. Chlorpromazine was shown to reduce hallucinations and delusions as well as excitement. It was also noted to cause Parkinsonlike side effects. Antipsychotics diminish psychotic symptom expression and reduce relapse rates. Approximately 70% of patients treated with antipsychotics achieve remission. Older antipsychotics drugs are called first-generation antipsychotics and newer are called secondgeneration antipsychotics (Serotonin dopamine antagonist, or SDA). Clozapine (Clozaril) discovered in 1958. Studied in 60s. 1976 substantial risk of agranulocytosis. 1990 finally became available in the USA for those who responded poorly to other agents. Phases of Treatment in Schizophrenia Treatment of Acute Psychosis- Requires immediate attention. Focus is on relieving severe psychosis. Usually lasts 4-8 weeks. Sx may include severe agitation, frightening delusions, hallucinations, suspiciousness, or can be from other causes such as stimulant abuse. Patients with akathisia can appear agitate when they experience a subjective feeling of motor restlessness. Differentiating akathisia from psychotic agitation can be difficult. If patients are receiving an agent associated with EPSE, usually a 1st generation antipsychotic, a trial with an anticholinergic anti-parkinson medication, benzodiapine, or propranolol may be helpful to distinguish. To treat agitation, benzodiazepines and antipsychotics work relatively quickly to calm the patient. IM medication may be necessary for extremely agitated patients. The advantages of IM antipsychotic medication (Haldol, fluphenazine, olanzapine, or ziprasidone) is it can result in calming without the excessive sedation or postural hypotension. IM ziprasidone & olanzapine are similar to the oral administration in that they do not cause EPSE. Olanzapine also offers a rapid-dissolving oral tablet (Zydis) as an alternative to IM injections. Benzos are effective to treat agitation during acute psychosis. Lorazepam has the advantage of reliable absorption when administered PO or IM. Use of benzos can reduce the amount of antipsychotic medication necessary to control the psychotic patient. Treatment During Stabilization & Maintenance Phase- this stage the illness is in relative remission. The goal is to prevent psychotic relapse and improve level of functioning. Stable patients who remain on antipsychotics have a lower rate of relapse than those whose medication is discontinued. 16-23% of patients receiving medication will relapse in 1 year. That number increases to 53-72% without the use of medication to stabilize psychosis. Stopping medication increases risks of relapse 5 fold. It is recommended that multi-episode patients receive maintenance treatment for at least 5 years. Noncompliance- noncompliance with antipsychotic medication is very high. Estimated 40-50% of patients become noncompliant within 1-2 years. Compliance increases with use of long-acting meds over oral meds. Some oral medication supplementation may be required when beginning long-acting treatment. Long-acting medication also offer better long-term control without the highs and lows noted with oral medication use. Strategies for Poor Responders-Approximately 60% of acute schizophrenia patients achieve complete remission or only experience mild symptoms with antipsychotic medication. The remaining 40% will improve but still have varying levels of positive symptoms which are lOMoARcPSD| resistant to medication. A reasonable trial is 4-6 weeks. Patients can continue to show steady improvement for 3-6 months though. Make sure therapeutic blood levels of the drug with bloodwork. Some people are rapid metabolizers and require stronger or more frequent doses. Some patients have such severe symptoms that don’t respond to treatment that they will remain institutionalized. If a patient doesn’t respond well to one SDA, switching to another is not likely to help. Clozapine has been shown to be effective to treat those who are traditionally poor responders. Managing Side Effects-low-potency drugs side effects can be sedation, postural hypotension, and anticholinergic effects; high-potency drugs are likely to cause extrapyramidal side effects. Extrapyramidal Side Effects (EPSEs)- Treatment options can be reducing the potency of the medication causing the EPSEs (most commonly a DRA), adding an anti-parkinson (which is often only partially effective) & changing the patient to an SDA (anti-parkinson medication can cause dry mouth, blurred vision, constipation, and memory loss), or adding a centrally-acting beta blocker, like propranolol (30-90mg/day most commonly used). If conventional antipsychotics are being used and the patient is likely to experience EPSEs ie patient has a history of EPSEs, clinician may consider prescribing an antiparkinson agent prophylactically. Prophylactic antiparkinson meds are also often considered for young males who are prescribed high-potency medications and are increasingly vulnerable to developing dystonia. If the patient is highly sensitive to the EPSE at the dose necessary to control psychosis and it is worse for them than the actual psychosis, those patients should be treated with an SDA because they are less likely to have EPSE side effects. Tardive Dyskinesia (TD)-20-30% of patients on long-term DRA treatment will experience TD. 3-5% of young patients receiving DRA develop TD every year. The risk in elderly is much higher. Seriously disabling dyskinesia is uncommon but TD can affect breathing, walking, eating, and talking. People wo are sensitive to EPSE are typically sensitive to TD as well. Patient with comorbid mood or cognitive disorders are also more vulnerable to TD. Onset of TD is either during treatment, within 4 weeks of stopping oral medication, or within 8 weeks of stopping depot antipsychotic. Risk of TD is slightly lower with new antipsychotic drugs. Recommendations to preventing TD: 1. Use lowest dose possible to treat, 2. Use cautiously in children, elderly, and patients with mood disorders, 3. Examine patients regularly, 4. Consider alternatives to antipsychotics, 5. Consider other options if TD worsens. Clozaril has been effective in reducing TD symptoms. Other Side Effects- low-potency DRAs (like perphenazine)- sedation & postural hypotension most severe with initial dosing. With clozapine (may require weeks to obtain therapeutic dose) pts develop a tolerance to sedation and postural hypotension. Sedation may continue to be a problem as daytime sleeping can affect community life. All DRAs as well as SRAs elevate prolactin levels, which can result in galactorrhea and irregular menses. Long-term elevations in prolactin levels can lead to suppression of gonadotropin releasing hormone which can suppress gonadal hormones decreasing libido and sexual function. Elevated prolactin levels may also decrease bone density leading to osteoporosis. There is also some concern with elevated prolactin levels leading to tumors. Health Monitoring in Patients Received Antipsychotics-Because of SDAs effects on metabolic metabolism, BMI, fasting glucose, and lipid profiles should be monitored. Pt’s should be weighed with BMI checked for 6 months after initiating therapy. Side Effects of Clozapine-serious risk of agranulocytosis can be potentially fatal & occurs in 0.3% of patients treated with clozapine in the 1st year. Patients who are administered clozapine in lOMoARcPSD| the US are required to be in a program with weekly blood monitoring for the first 6 months, then biweekly for the next 6 months. After 1 year of treatment with no hematologic problems, monitoring can be moved to monthly. Clozapine is also associated with higher risk of seizures than other antipsychotics. Nearly 5% of people who are on doses higher than 600mg. IF seizures develop, decrease the dose and add and antiepileptic agent, like Depakote. Myocarditis occurs in 5/100,000 patients/year. Other side effects include hypersalivation sedation, tachycardia, weight gain, DM, fever, and postural hypotension. Other Biological Therapies- Electroconvulsive Therapy (ECT) has been studied in acute and chronic schizophrenia. Some studies indicate ECT is as effective as antipsychotic medication. Other studies suggest supplementing ECT with antipsychotic medication. *Pearl of Wisdom* Monitor for choking and falls when patients return from ECT Psychosocial Therapies- includes a variety of skills to increase social abilities, self-sufficiency, practical skills, and interpersonal communication in schizophrenia patients. These treatments can be done at home, hospitals, outpatient clinics, mental health centers, etc. Social Skills Training- AKA behavioral skills therapy along with medication therapy, can be directly supportive and useful. In addition to psychiatric symptoms, patients can have difficulty communicating and relating to others: poor eye contact, unusual delays in response, odd facial expressions, lack of spontaneity in social situations, and inaccurate perception or lack of perception emotions in other people. Behavioral skills addresses these behaviors by using videos, role playing, and homework assignments. Social skills training has been shown to reduce relapse rates by decreasing the need for hospitalization. Family-Oriented Therapies- because schizophrenia requires continuous treatment, and often patients who have acute psychosis are discharged home to families. The goal is to empower the family to resolve problems quickly. Often family members will try to help by push patients with schizophrenia to resume regular activities too quickly, in which they are not ready. Therapists can be instrumental in educating families and patients about schizophrenia, including encouraging discussion about psychotic episodes. Later, therapists can direct family therapy to long-term goals of community integration in everyday life, including stress-reduction and coping strategies. Therapists are tasks with controlling the emotional intensity of the family sessions. Excessive emotional expression during sessions can be damaging to the recovery process. Studies have shown that family therapy is effective to reduce relapses. National Alliance on Mental Illness (NAMI)- NAMI and similar groups offer support groups for family and friends of people who are mentally ill. They offer emotional and practical advice on obtaining care. NAMI has also launched a campaign to destigmatize mental illness Case Management- because cases can be complex and include psychiatrists, social workers, occupational therapists, and many others, it is helpful to have a main contact point, or a case manager. The case manager ensures all efforts are coordinated and the patient keeps appointments. Case Managers can make home visits and accompany patients to work. Case managers can often be overwhelmed with cases, making it difficult to manage. Success of programs/case management can depend on education, training, compensation (pay, benefits, work-life balance), and workload. Assertive Community Treatment- Assertive Community Treatment (ACT) Program originally developed by researchers in Madison, Wisconsin in the 1970s for delivery of services for people with chronic mental illness. Patients were assigned to a multidisciplinary team (Case manager, lOMoARcPSD| psychiatrist, nurse, physician, etc) which delivered services as needed 24/7. This was an intensive, mobile unit providing medication, treatment, and support activities. High staff-patient ratio (1:12) and ACT effectively reduced the risk of rehospitalization with schizophrenia but it is an intensive program to deliver. Group Therapy- Focuses on real-life plans, problems, and relationships. Groups can be behavioral oriented, psychodynamically or insight oriented, or supportive. Group therapy is effective in reducing social isolation, increasing sense of cohesiveness, and improving reality testing for patients with schizophrenia. Groups led in a supportive manner appear most helpful to patients. Cognitive Behavioral Therapy- improves cognitive distortions, reduces distractibility, and corrects errors in judgment. Reports of ameliorating delusions and hallucinations in some patients using this therapy. Patients who may benefit from this therapy have some insight into their illness. Individual Psychotherapy- helpful and the effects are additive to those of pharmacological treatment. Developing a rapport is critical. The patient must trust the therapist and feel safe. Psychotherapy should be thought of in terms of decades rather than months or sessions. Patients with schizophrenia who are able to form a good alliance with a therapist are more likely to remain in psychotherapy, remain compliant with medication, and have good outcomes at 2-year folowups. Establishing a relationship can be difficult as these patients are often lonely but may become angry, hostile, or regress when people get close due to paranoia, suspiciousness, or fear. Therapists must respect a patient’s distance & privacy throughout care. Patients can perceive exaggerated warmth as bribery, manipulation, or exploitation. Flexibility is essential as the therapist may go on walks with the patient, sit on the floor, have a meal, play games, or just sit silently. The major aim is to convey the idea that the therapist is trustworthy. Personal Therapy- Flexible type of psychotherapy recently developed to provide individual treatment for schizophrenia. Objective is to enhance personal and social adjustment and forestall relapse. It uses social skills, relaxation exercises, psychoeducation, self-reflection, selfawareness, and exploration of individual vulnerability to stress. Patients receiving personal therapy show improvements in social settings, work performance, leisure, and interpersonal relationships and have a lower relapse rate after 3 years than those not receiving personal therapy. Dialectal Behavioral Therapy- combines cognitive and behavioral theories in both individual and group settings. Has been useful in borderline cases and may be beneficial in schizophrenia. Emphasis on improving interpersonal skills in the presence of an active and emphatic therapist. Vocational Therapy- Variety of methods and settings used to help patients regain old skills or develop new ones. These include sheltered workshops, job clubs, and part time or transitional employment. Enabling others to be gainfully employed is a means toward and a sign of recovery. Many patients with schizophrenia are capable of performing high-quality work. Others may exhibit exceptional skill or even brilliance in a limited field as a result of some idiosyncratic aspect of their disorder. Art Therapy- provides an outlet for constant bombardment of imagery. It helps communicate with others and share their inner, often frightening world with others. Cognitive Training- AKA Cognitive Remediation recently introduced to treat schizophrenia. Utilizing computer-generated exercises, neural networks are influenced in such a way that cognition (working memory included) is improved. This means more effective social functioning. lOMoARcPSD| 7.2 Schizoaffective Disorder- It has features of schizophrenia and mood disorders. Prevalence- 0.5 to 0.8 percent 6 categories Schizophrenia with Mood sx Mood disorder with SZ sx Both mood and Sz Pt with a 3rd psychosis unrelated to Sz and mood disorder Pt whose disorder is on a continuum between Sz and mood disorder Some combination of the above Diagnostic Criteria (See other specification in DSM5 book) A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1 : Depressed mood. B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness. C. Symptoms that meet the criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness. D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Differential diagnosis All possibilities considered for mood disorders and Sz Psychotic disorder- check hx of substance abuse and medical condition. Neurological abnormality warrants an EEG Course and Prognosis Predominant sx were affective- better prognosis; schizophrenic- worst prognosis Treatment Mood stabilizers- carbamazepime superior for Schizoaffective SSRI- Fluoxetine and Sertraline – 1st line TCA- for agitated and insomniac ECT Psychosocial ttt include family therapy, social skills training and CBT. 7.3 Schizophreniform Disorder -Mood and clouding of consciosness that last for 1 month but less than 6 months. Patient return to baseline functioning when disorder is resolved.Prevalence 0.09 -0.11 percent.Limitted LEFT HEMISPHERE , enlarge cerebral ventricles in Brain MRI. Diagnostic Criteria (See other specification in DSM5 book) A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition). lOMoARcPSD| B. An episode of the disorder lasts at least 1 month but less than 6 months. When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional.” ' C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1 ) no major depressive or manic episodes have occurred concurrently with the active-phase symptoms, or 2) if mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. D. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Differential diagnosis Psychotic disorder- check detailed hisotry and PE, lab test, imaging, hx of substance abuse and medical condition. DURATION OF PSYCHOTIC SX- less than 1 month Co morbid with mood and anxiety disorders Course and Prognosis Most estimates progression to SZ range between 60-80 %. Some have 2nd or 3rd episode that progresses to SZ. Few will have only a single episode then return to baseline functioning. Treatment Hopsitalization- 3-6 months antipsychotics Trial of mood stabilizers as prophylaxis if the patient has a recurrent epsiode. Psychotherapy ECT 7.4. Delusional Disorder and Shared Psychotic Disorder- non bizarre delusions for atleast 1 month. Tend to be underreported . Prevalence is 0.2- 0.3 percent. Onset at 40 but some can start at 18-90 y/o. Involves suspisiousness, jealousy, secretiveness. LIMBIC system and BASAL Ganglia is affected. Lack of trust in relationships, uses reaction formation as defence mechanism. Risk factors: Advance age, sensory impairment, family hx, social isolation, personality features, recent immigration. Diagnostic Criteria (See other specification in DSM5 book) A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation). C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder, such as body dysmorphic disorder or obsessive-compulsive disorder. lOMoARcPSD| Erotomanic type: This subtype applies when the central theme of the delusion is that another person is in love with the individual.Patients tend to be solitary, withdrawn, sexually inhibitted. Exhibit paradoxical conduct. High potentila for violence. Grandiose type: Aka MEGALOMANIA. This subtype applies when the central theme of the delusion is the conviction of having some great (but unrecognized) talent or insight or having made some important discovery. Jeaious type: Conjugal paranoia. This subtype applies when the central theme of the individual’s delusion is that his or her spouse or lover is unfaithful. Persecutory type: This subtype applies when the central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals. Somatic type: Aka Monosymptomatic hypochondraical psychosis. This subtype applies when the central theme of the delusion involves bodily functions or sensations. Ex; Delusion of infestation, dysmorphophia, foul body odors or halitosis. Mixed type: This subtype applies when no one delusional theme es to patients with two or more delusional themes. Unspecified type: This subtype applies when the dominant delusional belief cannot be clearly determined or is not described in the specific types (e.g., referential delusions without a prominent persecutory or grandiose component). Example: Capgras syndrome- familiar person replaced to an impostor. With bizarre content: Delusions are deemed bizarre if they are clearly implausible, notunderstandable, and not derived from ordinary life experiences (e.g., an individual’s belief that a stranger has removed his or her internal organs and replaced them with someone else’s organs without leaving any wounds or scars). Shared Psychotic disorder: also known as shared paranoid disorder, induced psychotic disorder, folie impose, double insanity. Transfer of delusion from one person to another for persons who typically live together. Differential Diagnosis Toxic metabollic conditions Huntingtons disease Delerium, Dementia, Substance related disorder Other disorders, like malingering and factitious disorder, OCD, Somatoform disorder, Paranoid personality disorder Course and Prognosis 50 percent recovered, 20 percent has decreased sx, 30 has no change. Patients with persecutory, somatic, erotic delusions better prognosis that grandiose and jelous delusions Treatment Psychotherapy to establish trust. Ability to respond to mistrust . Succesfull treatment shows social adjustment. Hospitalization to determine non-psychiatric medical condition. To control violent impulses. The patient require professional intervention as they can’t function in a family setting. lOMoARcPSD| Pharmacotherapy. Antipsychotics like low dose haldol, risperdal. And trial with mood stabilizer. 7.5 Brief Psychotic Disorder, Other Psychotic Disorder, And Catatonia. Brief Psychotic Disorder-sudden onset that last for 1 day but less than 1 month. The content of the psychosis is related to the nature of traumatic experience. Psychosis seem to serve as an escape of the trauma.This disorder is seen in personality disorder. Patients who experience this disorder ussually has a family history of SZ and/ or Mood conditions in the family. Also hypothesize as defense against prohibited fantasy or stressful psychosocial situation. Diagnostic Criteria (See other specification in DSM5 book) A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. Note: Do not include a symptom if it is a culturally sanctioned response. B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder such as schizophrenia or catatonia, and is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Differential diagnosis Present longer than 1 month: SZ, Schizophreniform, Schizoaffective, mood disorders. Factitious disorder, like malingering Epilepsy Delirium Course and Prognosis Acute and residual sx is commonly few days. 50-80 % of patients have no major psychiatric px. Example: Temporal Meningioma has good prognosis. Treatment Hospitalization- monitor sx and ax patients danger to self and others. Pharmacotherapy-Antipsychoti- haldol. Benzodiazepine. Ziprazidone. Psychotherapy- provide opportunity to discuss stressors and psychotic episode. Family involvement is a must. Psychotic Disorder Not otherwise Specified. 1. Autoscopic Psychosis. Visual hallucination of persons own body. Treatment ussually involve anxiolytics and antipsychotic medications. 2. Motility Psychosis. Variant and brief psychosis. Akinetic example is the catatonic stupos. Hyperkinetic form is fast resolving. This disorder pose danger on the excited phase as mood is extremely labile. lOMoARcPSD| 3. Postpartum psychosis. AKA Puerperal psychosis. Delusion of mom to harm either infant or self. Psychotic Disorder Due to a Medical Condition Diagnostic Criteria (See other specification in DSM5 book) The patient presents psychotic sx due to a brain tumor (Cerebral neoplasm) or phencyclidine (PCP), or meds like cortisol. Seen in patients who abuse alcohol or substances. Clinical featurs include hallucinations and delusions. A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. C. The disturbance is not better explained by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. Differential diagnosis Delerium Dementia Schizophrenia Treatment Hospitalization for safety, Antipsychotic agents like Olanzapine or Haldol, Benzodiazepine to control aggression. Catatonic Disorder. Occurs in severe psychotic and mood disorders. It is a disorder due to the physiologic effects of a general medical condition. Laboratory examination include CBC, electrolytes, brain imaging, electroencephalography. If NMS is suspected, There is an elevated creatinine phosphokinase, WBC, serum transaminase. Catatonia Disorder due to Another Mental Disorder (Catatonia Specifier) Diagnostic Criteria (See other specification in DSM5 book) A. The clinical picture is dominated by three (or more) of the following s