Answers for Psychotic Disorder Cases Neuroscience and Behavior Block 1/29/16 1) Psychosis is a loss of reality testing, in which the patient is unable to distinguish between his or her own thoughts and those that he or she obtains by observing the outside world. It is characterized by delusions and/or hallucinations. This particular patient displays both delusions (false, fixed beliefs that are not in line with the subject s cultural background) and hallucinations (abnormal sensory perceptions in the absence of a stimulus). His delusions are based around thoughts that people are able to both read his mind and withdrawal his thoughts via imaginary metal that has been implanted in his mouth. His hallucinations include hearing voices comment on his thoughts/behavior and a taste of metal of his mouth despite none being present. Differential Diagnosis: - Brief psychotic disorder-duration between I day and I month - Schizophreniform disorder-schizophrenia criteria met, but for less than six months - Schizophrenia (see criteria in next question) - Psychotic disorder due to a general medical condition, delirium, or dementia - Substance-induced psychotic disorder (amphetamines, cocaine, PCP, anticholinergics, hallucinogens, etc.) - Schizoaffective disorder-mood symptoms that meet criteria for a mood episode are present for a substantial portion of the acute and residual phases of illness - Mood disorder w/psychotic features-psychotic features occur only during mood disturbance - Delusional disorder-non-bizarre delusions, functioning is not impaired - Schizotypal, paranoid, schizoid, or borderline personality disorder-may display brief, mild Psychotic features of patter or behavior 2) DSM-5 Diagnostic Criteria for Schizophrenia A. Two or more of the following symptoms present for one month 1. Delusions 2. Hallucination 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (One must be 1, 2, or 3) B. Decline in social and/or occupational functioning since onset of illness C. Continuous signs of illness for at least six months with at least one month of active symptoms D. Schizoaffective disorder and mood disorder excluded E. If history of autistic disorder/pdd,prominent delusions or hallucinations have been present for one month
- Positive Sxs are distortions of normal function and are the ones usually noticed by others-delusions, hallucinations, disorganized speech and behavior - Negative symptoms are diminished/absent normal functions and include alogia, anhedonia, affective flatteninig, attentional deficits, and avolition - "Schneiderian"Sx- hallucinations of one's thoughts being spoken aloud, voices in the form of running commentary, and voices conversing about a patient and/or delusions of thought broadcasting, insertion or withdrawal to be the first rank symptoms of schizophrenia 3) Epidemiology and course: - Incidence of 1% - Point prevalence 0.5%, Lifetime prevalence 1% - Males and females are equally affected, but the mean age of onset is approximately six years later in females (first psychotic break at age 21 yrs. In males vs. 27 yrs. for females) - Higher prevalence in lower SES groups, probably due to Downward Drift resulting from impaired social and occupational functioning - Lifespan of schizophrenics is approximately 10 yrs. less then general population, 10% will commit suicide The Course may involve a single continuous episode of Sx, be episodic, or evolve from episodic to continuous. About 25% experience an insidious onset, continuous course, and eventual severe impairment. Up to 2/3 may experience social recovery with adequate treatment, but not necessarily complete remission of symptoms Genetics: - Rate of schizophrenia among first degree relatives of persons with the disease of increased 10X - 40-50% concordance for monozygotic twins, 10% for dizygotic twins - Risk if both parents are schizophrenic is about 40% - Defects in smooth pursuit eye movements have been associated with some familial patterns of transmission - Likely a polygenic transmission of vulnerability to the disease 4) Positive prognostic factors: female sex, acute onset, short duration, mood symptoms present, no assultiveness, good premorbid functioning, married, no structural brain abnormalities, high social class, negative family history Poor prognostic factors are essentially the opposite of above 5) Schizophrenia Case One, Part 2 A) V.C. is having an acute dystonic reaction, which are sustained muscle contractions usually affecting the neck (torticollis), eyes (oculogyric crisis), tongue and jaw. This reaction usually occurs within 3-5 days following initiation of a neuroleptic. It is most commonly seen in young males. If laryngeal muscles become involved it can lead to dangerous airway obstruction. Tx: Benztropine, Diphenhydramine if laryngeal spasm Other EPS: - Drug-induces parkinsonism-pt. presents with cogwheel rigidity, mask-like facies, bradykinesia, and shuffling gate. Onset usually after 2 weeks with older patients being at higher risk. Tx: lowering neuroleptic dose, benztropine, trihexyphenidyl, amantadine - Akathisia-characterized by strong feelings of inner restlessness. Pt. may present with pacing/ excessive walking. This unpleasant experience may result in medication non-compliance or even suicidality. Tx: beta-blocker (propanolol), bezodiazepines
Potent typical antipsychotic medications, such as haloperidol and fluphenazine, are most likely to cause EPS. Low potency typicals are more likely to cause anticholinergic side effects (dry mouth, constipation, blurry vision, urinary retention). Atypical antipsychotics tend not to cause EPS. B) The pt. is experiencing Neuroleptic Malignant Syndrome, which is a rare idiosyncratic reaction or antipsychotic medications. It is characterized by muscle rigidity, fever, autonomic instability, and altered level of consciousness. It can be fatal. Laboratory tests often reveal elevated WBC, CPK (from muscle breakdown), and liver transaminases. Tx: immediately discontinue antipsychotic medication, supportive care (respiratory, cardiovascular-often in ICU), and dantrolene (muscle-relaxer) or bromocriptine (dopamine agonist) C) Tardive dyskinesia can be caused by all neuroleptics, except clozapine, although atypicals are much less likely to cause it (that s why the patient was switched to olanzapine) Metabolic Syndrome criteria 3 or more of these factors: - Abdominal obesity-bmi>40 in men, >35 in women - triglycerides 150 mg/dl\ - HDL cholesterol < 40 in men, < in women - BP 130/85 - fasting blood glucose 110 Olanzapine and Clozapine have the most risk for causing the metabolic syndrome, followed by risperidone and quetiapine Important side effects of atypical antipsychotic meds: - Clozapine - agranulocytosis, weight gain, sedation, sialorrhea (drooling) - Olanzapine weight gain - Risperidone - prolactin (causing galactorrhea) - Questiapine sedation - Ziprasidone QT prolongation - Aripiprazole akathisia D) Clozapine is used for the treatment of patients who have not responded to, or cannor tolerate (i.e. severe tardive dyskinesia), other neuroleptic medications. However, it is associated with a 1% incidence of agranulocytosis, which can be fatal. Monitoring for this serious problem involves weekly WBC counts for first six months of TX, with bi-weekly checks following thereafter. Clozapine must be discontinued if ANC drops below 1500/mm³ in the general population. Also, need to monitor for signs of infection. Pt. compliance is extremely important. Clozapine does not cause EPS, tardive dyskinesia, or NMS.
Case Two 1) Differential Dx: See case one differential The patient in this case presents with a non-bizarre (plausible, although unlikely) delusion that is not significantly impairing his social or occupational functioning. He is not having any hallucinations and his thought processes are goal-directed and organized. Though non-bizarre is no longer a criteria for a Delusional Disorder, clinically non-bizarre delusions are the most commonly seen. His delusions can be described as non-bizarre, systematized (delusion fits into a complex, allencompassing scheme that makes logical sense to the patient, i.e. Angelina having many children to please him as signals), and encapsulated (apart from the delusion and its ramifications, the patient generally behaves normally/non-bizarre). 2) Types of Delusional Disorder: Erotomanic delusions that another person, usually of higher status, is in love with the individual (as in case #2) Grandiose delusions of inflated worth, power, knowledge, or special relationship to a deity or famous person -Jealous delusions that sexual partner is unfaithful -Persecutory delusions that individual is being harassed -Somatic delusion of a physical defect or medical condition -Mixed delusions characteristic or more than one of the above -Unspecified Capgras Syndrome patient believes person closely related to him or her has been replaced by a double (Invasion of the Body Snatchers), Fregoli Syndrome person identifies a familiar person in other people he or she encounters. 3) Epidemiology and Course - Prevalence of 24-30/100,000 (rare) - considered a disorder of middle to late adult life - may affect women more than men, but most sources say prevalence is equal in both sexes - patients tend to be married, poorly educated, and from lower SES classes, however, the tend to be selfsupporting and employed (lead a normal life outside of delusion) -course tends to be unremitting and chronic, but unlike patients with schizophrenia pt. remains stable - family studies have shown that having delusional disorder does not increase the risk of developing schizophrenia 4) Treatment of Delusional Disorder: - No real empirical studies done on treating Delusional Disorder - Delusional disorder generally has a poor response to antipsychotic medications, although these can be tried - It is often difficult getting a pt. to see a physician because they generally have poor insight into disorder - Psychotherapy, including family or couples therapy, may be beneficial. Group therapy is often not a good idea because pts. With delusional disorder tend to be somewhat suspicious 5) Delusional Disorder, erotomanic type, Hypertension, CAD
Case Three Answers: 1) The patient s changes in mood over the past two months may be attributed to a depressive episode (he has a personal and family history of depression, as well as the significant stress of his failing health). The patient s anemia secondary to chronic blood loss from esophageal or gastric ulcers may also explain his generalized weakness and lack of energy. The patient s low CD4 count indicates that he is at risk for opportunistic infections such as Candida, HSV, and CMV esophagitis, which likely caused his painful swallowing and further impacted his nutritional status. In addition, his lab findings and clinical presentation indicate UTI, which could also worsen his malaise. Less likely, but important causes to be ruled out are: malignancy, hypothyroidism, or TB. 2) The acute change in mental status following administration of Ciprofloxacin raises suspicion for medication-induced psychosis. However, the patient could also be experiencing delirium secondary to his UTI, which appears to be worsening. If the history had indicated continued drug abuse, we could also consider opiate-induced delirium. Given the patient s history of depression, he may also have developed depression with psychotic features. Other less likely causes of J s confusion and altered behavior are: viral encephalitis (patient is susceptible to opportunistic infection), and AIDS dementia (although changes would be more gradual). 3) Some features which point to a general medical cause of the patient s mental status change, rather than worsening depression are: a. the acute onset of the symptoms, b. the multiple medical concerns associated with the patient s HIV status, c. temporal association of change in mental status with infection and new medication. Other medical causes of psychosis include Addison s disease, CNS infections (encephalitis), CNS neoplasms, Cushing s disease, delirium, dementias, folate deficiency, Hungington s disease, multiple sclerosis, pancreatitis, paraneoplastic syndromes, pellagra, pernicious anemia, prophyria, SLE, temporal lobe epilepsy, thyrotoxicosis, Wilson s disease. Potential labs for psychosis workup: CCBC, blood chemistry, thyroid function panel, syphilis screening (RPR or VDRL), urinalysis with toxicology screen, blood alcohol level, serum medication levels, HIV test, EEG, Brain imaging 4) The salient points of the case are the following: a. Patients with psychiatric presentations such as depressed mood and psychosis may have organic factors that are contributing to or are solely responsible for the symptoms. In this patient s case, if the underlying medical cause of psychosis/ delirium is not addressed, he could injure himself or others, suffer consequences of dehydration, or aspiration. In addition, since the patient is severely immunosuppressed, infection could rapidly lead to sepsis and death. Mental status changes are often harbingers of worsening clinical status and cannot be ignored. b. Delirium must be treated by addressing the underlying medical issue- in this case, more effectively treating the infection, and/or discontinuing the offending medication, as well as continuing to orient the patient to his surroundings. It is important to recognize that patients with psychiatric diagnoses may also have changes in mental status due to other causes which will not respond to psychotropic medications.