Schizophrenia and Other Psychotic Disorders

Anita S. Kablinger MD
Associate Professor Departments of Psychiatry of Pharmacology

LSUHSC-Shreveport

What is Psychosis?
Generic term Break with Reality Symptom, not an illness Caused by a variety of conditions that affect the functioning of the brain. Includes hallucinations, delusions and thought disorder

Differential Diagnosis

Medical/surgical/ substance-induced
Psychotic d/o due to GMC Dementias Delirium Medications Substance induced Amphetamines Cocaine Withdrawal states Hallucinogens Alcohol

Mood disorders
Bipolar disorder Major depression with psychotic features

Mood disorders

Functional disorders
Schizophrenia spectrum disorders

P S Y C H O S I S

Substance induced

organic mental disorders

Delirium Dementia Amnestic d/o

Differential Diagnoses: (Cont)

Personality disorders
Schizoid Schizotypal Paranoid Borderline Antisocial

Miscellaneous
PTSD Dissociative disorders Malingering Culturally specific phenomena: Religious experiences Meditative states Belief in UFOs, etc

Workup of New-Onset Psychosis: Round up the usual suspects

Good clinical history Physical exam, ROS Labs/Diagnostic tests:

Metabolic panel CBC with diff B12, Folate RPR, VDRL Serum Alcohol Urinalysis Thyroid profile
URINE DRUG SCREEN!!!

CSF/LP HIV serology CT or MRI EEG

Talking Points

Schizophrenia is not an excess of dopamine. The differentiation between functional and organic is artificial. Schizophrenia and other psychiatric illnesses are syndromes. Schizophrenia is a diagnosis of exclusion.

Talking Points
1% prevalence Early onset, M>F Early, aggressive treatment decreases long-term problems Multiple subtypes- catatonic, disorganized, paranoid, undifferentiated, residual

Schizophrenia
Diagnostic features

DSM-IV Diagnosis of Schizophrenia

Psychotic symptoms (2 or more) for at least one month

Hallucinations Delusions Disorganized speech Disorganized or catatonic behavior Negative symptoms

Diagnosis (cont.)
Impairment in social or occupational functioning Duration of illness at least 6 mo. Symptoms not due to mood disorder or schizoaffective disorder Symptoms not due to medical, neurological, or substance-induced disorder

Clinical features: Formal Thought Disorders

Neologisms Tangentiality Derailment Loosening of associations (word salad) Private word usage Perseveration Nonsequitors

Clinical features: Delusions

Paranoid/persecutory Ideas of reference External locus of control Thought broadcasting Thought insertion, withdrawal Jealousy Guilt Grandiosity

Religious delusions Somatic delusions

Clinical features: Hallucinations

Auditory Visual Olfactory Somatic/tactile Gustatory

Clinical features: Behavior

Bizarre dress, appearance Catatonia Poor impulse control Anger, agitation Stereotypies

Clinical features: Mood and Affect

Inappropriate affect Blunting of affect/mood Flat affect Isolation or dissociation of affect Incongruent affect

Positive vs. negative symptoms

Positive symptoms
Delusions Hallucinations Behavioral dyscontrol Thought disorder

Negative symptoms (Remember Andreasens As)

Affective flattening Alogia Avolition Anhedonia Attentional impairment

Psychotic Disorders
Onset

Symptoms
Many

Course
Chronic

Duration
>6 months

Schizophrenia Delusional disorder Brief psychotic disorder

Usually insidious

Varies Delusions (usually only insidious) Sudden Varies

Chronic

>1 mo.

Limited

<1 mo.

Psychosocial Factors
Expressed emotion Stressful life events Low socioeconomic class Limited social network

Some factors rejected as causal

Schizophrenogenic Mother Skewed family structure

Genetic factors: (The evidence mounts)

Monozygotic twins (31%-78%) vs dizygotic twins 4-9% risk in first degree relatives of schizophrenics Adoption studies Linkage, molecular studies

Genetics of Schizophrenia: The take-home message

Vulnerability to schizophrenia is likely inherited Heritability is probably 60-90% Schizophrenia probably involves dysfunction of many genes

Anatomical abnormalities
Enlargement of lateral ventricles Smaller than normal total brain volume Cortical atrophy Widening of third ventricle Smaller hippocampus

Physiologic studies: PET and SPECT

Generally normal global cerebral flow Hypofrontality Failure to activate dorsolateral prefrontal cortex (problem-solving, adaptation, coping with changes)

Biochemical factors: The dopamine hypothesis

All typical antipsychotics block D2 with varying affinities Dopamine agonists can precipitate a psychosis

Amphetamines Cocaine L-dopa

Dopamine systems
Cell bodies Projections Functions Clinical implications

Nigrostriatal Mesolimbic Mesocortical

Substantia Nigra

Caudate and putamen

Accumbens amygdala Olfactory tubercle

Movement
Emotions, affect, memory

Extrapyramidal symptoms, dystonias, Tardive dyskinesia

Ventral tegmental area, subst. nigra

Ventral tegmental area

Positive symptoms

Prefrontal Cortex

Thought, volition, memory

Blockade here can worsen negative symptoms.

Typical Neuroleptics

Low potency:

High potency:

Chlorpromazine Thioridazine Mesoridazine

Haloperidol Fluphenazine Thiothixene Loxapine (mid)

Neuroleptic (typicals): side effects

Acute dystonia Parkinsonian side effects (EPS) Akathisia Tardive dyskinesia Sedation, orthostasis, QTC prolongation, anticholinergic, lower seizure threshold, increased prolactin

Atypical Antipsychotics:
Risperidone Olanzapine Quetiapine Clozapine Ziprasidone Aripiprazole (new-partial DA agonist)

Atypical antipsychotics:
Broader spectrum of receptor activity (Serotonin, dopamine, GABA) May be better at alleviating negative symptoms and cognitive dysfunction Clozaril (clozapine) associated with agranulocytosis, seizures

Atypical Antipsychotics: Side Effects

Sedation Hyperglycemia, new-onset diabetes Anticholinergic effects Less prolactin elevation QTC prolongation Some EPS Increased lipids

Psychosocial Treatment
Education, compliance #1 Hospitalize for acute loss of functioning Outpatient treatment is rehabilitative Psychoanalysis, exploratory therapies have limited value Families should be involved