What are the differential diagnoses of psychosis?
- primary psychotic disorders: schizophrenia, schizophreniform, brief psychotic, schizoaffective, delusional disorder
- mood disorders: depression with psychotic features, bipolar disorder (manic or depressive episode with psychotic features)
- personality disorders: schizotypal, schizoid, borderline, paranoid, obsessive-compulsive
- general medical conditions: tumor, head trauma, dementia, delirium, metabolic, infection, stroke, temporal lobe epilepsy
- substance-induced psychosis: intoxication or withdrawal, prescribed medications, toxins
What is the DSM-5 diagnostic criteria for schizophrenia?
A. 2 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):
- Delusions
- Hallucinations
- Disorganised speech (e.g. frequent derailment or incoherence)
- Grossly disorganised or catatonic behaviour
- Negative symptoms (i.e. diminished emotional expression or avolition)
B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas is markedly below the level achieved prior to the onset
C. Continuous signs of disturbance for ≥6 months, including ≥1 month of active phase symptoms; may include prodromal or residual phases
D. Schizoaffective and mood disorders excluded
E. The disturbance is not due to the direct physiological effects of a substance or a medical condition
F. If history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucination, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month
What are the signs and symptoms of schizophrenia?
- Positive symptoms - Psychotic symptoms, such as hallucinations, which are usually auditory; delusions; and disorganized speech and behavior
- Negative symptoms - A decrease in emotional range, poverty of speech, and loss of interests and drive; the person with schizophrenia has tremendous inertia
- Cognitive symptoms - Neurocognitive deficits (eg, deficits in working memory and attention and in executive functions, such as the ability to organize and abstract); patients also find it difficult to understand nuances and subtleties of interpersonal cues and relationships
- Mood symptoms - Patients often seem cheerful or sad in a way that is difficult to understand; they often are depressed
Describe the epidemiology of schizophrenia?
- prevalence: 0.3-0.7%, M:F = 1:1
- mean age of onset: females late-20s; males early- to mid-20s
- suicide risk: 5-6% die by suicide, 20% attempt suicide
Describe the aetiology of schizophrenia?
- multifactorial: disorder is a result of interaction between both biological and environmental factors
- genetic: 40% concordance in monozygotic (MZ) twins; 46% if both parents have schizophrenia; 10% of dizygotic (DZ) twins, siblings, children affected
- neurochemistry (“dopamine hypothesis”): excess activity in the mesolimbic dopamine pathway may mediate the positive symptoms of psychosis while decreased dopamine in the prefrontal cortex may mediate negative and cognitive symptoms. GABA, glutamate, and ACh dysfunction are also thought to be involved
- neuroanatomy: decreased frontal lobe function; asymmetric temporal/limbic function; decreased basal ganglia function; subtle changes in thalamus, cortex, corpus callosum, and ventricles; cytoarchitectural abnormalities
- neuroendocrinology: abnormal growth hormone, prolactin, cortisol, and ACTH
- neuropsychology: global defects seen in attention, language, and memory suggest lack of connectivity of neural networks
- environmental: indirect evidence of cannabis use, geographical variance, winter season of birth, obstetrical complications, and prenatal viral exposure
Describe the outcomes for schizophrenia?
- the majority of individuals display some type of prodromal phase
- course is variable: some individuals have exacerbations and remissions and others remain chronically ill; accurate prediction of the long-term outcome is not possible
- negative symptoms may be prominent early in the illness and may become more prominent and more disabling later on; positive symptoms appear and typically diminish with treatment
- over time: 1/3 improve, 1/3 remain the same, 1/3 worsen
What are good prognostic factors for schizophrenia?
- Acute onset
- Shorter duration of prodrome
- Female gender
- Good cognitive functioning
- Good premorbid functioning
- No family history
- Presence of affective symptoms
- Absence of structural brain abnormalities
- Good response to drugs
- Good support system
Describe what might be seen on a MSE for a patient with schizophrenia?
- The patient may be unduly suspicious of the examiner or be socially awkward
- The patient may express a variety of odd beliefs or delusions
- The patient often has a flat affect (ie, little range of expressed emotion)
- The patient may admit to hallucinations or respond to auditory or visual stimuli that are not apparent to the examiner
- The patient may show thought blocking, in which long pauses occur before he or she answers a question
- The patient’s speech may be difficult to follow because of the looseness of his or her associations; the sequence of thoughts follows a logic that is clear to the patient but not to the interviewer
- The patient has difficulty with abstract thinking, demonstrated by inability to understand common proverbs or idiosyncratic interpretation of them
- The speech may be circumstantial (ie, the patient takes a long time and uses many words in answering a question) or tangential (ie, the patient speaks at length but never actually answers the question)
- The patient’s thoughts may be disorganized, stereotyped, or perseverative
- The patient may make odd movements (which may elated to neuroleptic medication)
- The patient may have little insight into his or her problems (ie, anosognosia)
- Orientation is usually intact (ie, patients know who and where they are and what time it is)
Describe the management of schizophrenia?
HINT: psychosocial
- biological
- acute treatment and maintenance with antipsychotics ± anticonvulsants ± anxiolytics
- Antipsychotics: olanzapine, quetiapine, risperidone, haliperidol
- Anxiolytics: diazepam
- Anticonvulsants:
- Treatment resistant patients: Clozapine
- acute treatment and maintenance with antipsychotics ± anticonvulsants ± anxiolytics
- psychosocial
- psychotherapy (individual, family, group): supportive, CBT
- ACT: mobile mental health teams that provide individualized treatment in the community and help patients with medication adherence, basic living skills, social support, job placements, and community resources
- social skills training, employment programs, disability benefits
housing (group home, boarding home, transitional home)
Describe how to assess a patient with suspected schizophrenia?
- Psychiatirc Hx
- MSE
- physical exam: particular attention to neurological assessment
- Ix
- Bloods: FBC, UEC, Ca, LFTs, fasting glucose, TFT, prolactin conc., urine tocicology
- Imaging: CT/MRI brain
- EEG and ECG
Describe in detail the pharmacological management of schizophrenia?
- Typical antipsychotics (First generation antipsychotics)
- E.g. Chlorpromazine, Haloperidol, Trifluoperazine, Thioridazine, Acuphase, Depots (except Risperdal Consta and Olanzapine Relprevv)
- Blocks dopamine 2 (D2) receptors with little effect on serotonin
- Work mainly on positive symptoms, no benefit on negative symptoms and worsen cognitive problems, but cheap
- Side effects – antihistaminergic, anticholinergic, extra-pyramidal, prolactin
- Atypical antipsychotics (Second generation antipsychotics)
- First line for acute episodes and maintenance therapy
- Affects dopamine and 5HT, increases dopamine and reduces the effect of dopamine blockade
- Effective for positive symptoms, as well as benefit in negative symptoms, cognitive symptoms, mood and aggression
- Side effects – weight gain, glucose intolerance/diabetes, sedation, EPS/akathisia, hyperprolactinaemia, anticholinergic effects
- Clozapine
- Consider early for management of treatment-resistant schizophrenia
- Monitor WCC (not dispensed by pharmacy unless done)
- Side effects – neutropenia, cardiac effects, tachycardia/hypotension, sedation, weight gain, diabetes/cholesterol/TG, seizures/myoclonus, hypersalivation, reflux and constipation
What are the main adverse outcomes of medication management of schizophrenia?
- Akathisia
- “Lack of ability to sit still”; onset acute, delayed (tardive) or withdrawal
- Symptoms – tension, anxiety, dysphoria, irritability, restlessness, inner sense of dysphoria and distress, drive to move to ease the discomfort, disappears in sleep
- Signs – fidgeting, rocking, pacing, tapping
- Increased risk with increase in dose, frequency or potency of meds; less likely with atypical
- Treatment – reduce dose, change agent, anticholinergics, propranolol, benzodiazepines short term
- Tardive dyskinesia
- Involuntary movements that increase when the patient is aroused, decrease when relaxed, disappear in sleep
- Caused by anti-dopaminergic drugs; may worsen if treatment continued, reduced or ceased
- Prevention – keep antipsychotic dose lowest to manage illness and keep anticholinergics to a minimum (due to cognitive effects, tardive dyskinesia)
- Neuroleptic malignant syndrome
- Rare but under-reported consequence of neuroleptic treatment
- Symptoms – fever, rigidity, confusion, delirium, autonomic dysfunction
- Tests – increased WCC, CPK and LFT
- Treatment – symptomatic, stop neuroleptic, Dantrolene, Benzodiazepines, ECT
What is the DSM-5 criteria for schizophreniform disorder?
A. Two (or more) of the following, each present for a significant portion of time during a 1-month period.
At least one of these must be (1), (2) or (3):
- Delusions
- Hallucinations
- Disorganised speech (e.g. frequent derailment or incoherence)
- Grossly disorganised or catatonic behaviour
- Negative symptoms (i.e. diminished emotional expression or avolition)
B. An episode lasts at least 1 month but less than 6 months
C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out
D. The disturbance is not attributable to a substance or another medical condition
What is the DSM-5 criteria for schizoaffective disorder?
A. An uninterrupted period of illness during which there is a major mood episode (depressive or manic) concurrent with Criterion A of schizophrenia
B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode during the lifetime duration of the illness
C. Symptoms that meet 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 or another medical condition
What is the DSM-5 criteria for a brief psychotic disorder?
A. Presence of one (or more) of the following symptoms, at least one must be (1), (2) or (3):
- Delusions
- Hallucinations
- Disorganised speech (e.g. frequent derailment or incoherence)
- Grossly disorganised or catatonic behaviour
B. Duration of an episode is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning
C. 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 or another medical condition
What is the DSM-5 criteria for a delusional disorder?
A. The presence of one (or more) delusions with a duration of 1 month or longer
B. Criteria A for schizophrenia has never been met (hallucinations, if present, are not prominent and are related to the delusional theme)
C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behaviour 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 a substance or other medical condition, and is not better explained by another mental disorder
What are some subtypes of delusions?
- Erotomanic – another person is in love with the individual
- Grandiose – having some great (but unrecognised) talent or insight or having made some important discovery
- Jealous – his or her spouse or lover is unfaithful
- Persecutory – 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 – involves bodily functions or sensations
- Mixed
- Unspecified
What are the DDx of anxiety?
- Cardiovascular – post-MI, arrhythmia, CHF, PE, mitral valve prolapse
- Respiratory – asthma, COPD, pneumonia, hyperventilation
- Endocrine – hyperthyroidism, phaeochromocytoma, hypoglycaemia, hyperadrenalism, hyperparathyroidism
- Metabolic – vitamin B12 deficiency, porphyria
- Neurologic – neoplasm, vestibular dysfunction, encephalitis
- Substance-induced – intoxication (caffeine, amphetamines, cocaine, thyroid preparations, OTC for cold/decongestants), withdrawal (benzodiazepines, alcohol)
- Other psychiatric disorders – psychotic disorders, mood disorders, personality disorders (OCPD), somatoform disorders
What is the DSM-5 criteria for social phobia?
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. will be humiliating or embarrassing)
C. The social situations almost always provoke fear or anxiety
D. The social situations are avoided or endured with intense fear or anxiety
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
H. The fear, anxiety or avoidance is not attributable to the physiological effects of a substance or another medical condition
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder
J. If another medical condition (e.g. Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive
What is the treatment for social phobia?
- Psychological – CBT, more efficacious than medication
- Biological - ß-blockers or benzodiazepines in acute situations (e.g. public speaking)
What is the DSM-5 criteria for specific phobia?
A. Marked fear or anxiety about a specific object or situation
B. The phobic object or situation almost always provoked immediate fear or anxiety
C. The phobic object or situation is actively avoided or endured with intense fear or anxiety
D. The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context
E. The fear, anxiety or avoidance is persistent, typically lasting for 6 months or more
F. The fear, anxiety or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning
G. The disturbance is not better explained by the symptoms of another mental disorder
What is the DSM-5 criteria for panic disorder?
A. Recurrent unexpected panic attacks. A panic attack is an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which ≥4 of the following symptoms occur:
a. Palpitations, pounding heart, or accelerated heart rate
b. Sweating
c. Trembling or shaking
d. Sensations of shortness of breath or smothering
e. Feelings of choking
f. Chest pain or discomfort
g. Nausea or abdominal distress
h. Feeling dizzy, unstead, light-headed or faint
i. Chills or heat sensations
j. Paraesthesias (numbness or tingling sensations)
k. Derealisations (feelings of unreality) or depersonalisation (being detached from oneself)
l. Fear or losing control or “going crazy”
m. Fear of dying
B. At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
a. Persistent concern or worry about additional panic attacks or their consequences (e.g. losing control, having a heart attack, “going crazy”)
b. A significant maladaptive change in behaviour related to the attacks (e.g. behaviours designed to avoid having panic attacks, such as avoidance of exercise or unfamiliar situations)
C. The disturbance is not attributable to a substance or another medical condition
D. The disturbance is not better explained by another mental disorder
Psychotherapy: duration, typical patient, focus?
Cognitive behavioural therapy (CBT)
- Duration: Time limited
- Typical patient:
- Maladaptive thoughts
- Avoidance behaviour
- Ability to participate in homework
- Focus:
- Combines cognitive and behavioural techniques
- Challanges maladaptive thoughts that underlie emotional reactions
- Targets avoidance with behavioural techniques (relaxation, exposure, behaviour modification)
Psychotherapy: duration, typical patient, focus?
Interpersonal psychotherapy.
- Duration: time limited
- Typical patient: depressed with relationship conflicts
- Focus: Links current relationship conflicts o depressive symptoms
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