Schizophrenia and Other Psychotic Disorders

1. Schizophrenia and Other Psychotic Disorders Anita S. Kablinger MD Associate Professor Departments of Psychiatry of Pharmacology LSUHSC-Shreveport

2. 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

3. 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 Differential Diagnosis

4. PSYCHOSIS Mood disorders Substance induced “organic” mental disorders “Functional” disorders Delirium Dementia Amnestic d/o Schizophrenia “spectrum” disorders

5. Personality disorders Schizoid Schizotypal Paranoid Borderline Antisocial Miscellaneous PTSD Dissociative disorders Malingering Culturally specific phenomena: Religious experiences Meditative states Belief in UFO’s, etc Differential Diagnoses: (Cont)

6. 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

7. 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.

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

9. Schizophrenia Diagnostic features

10. 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

11. 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

12. Clinical features:Formal Thought Disorders • Neologisms • Tangentiality • Derailment • Loosening of associations (word salad) • Private word usage • Perseveration • Nonsequitors

13. Paranoid/persecutory Ideas of reference External locus of control Thought broadcasting Thought insertion, withdrawal Jealousy Guilt Grandiosity Religious delusions Somatic delusions Clinical features:Delusions

14. Clinical features:Hallucinations • Auditory • Visual • Olfactory • Somatic/tactile • Gustatory

15. Clinical features:Behavior • Bizarre dress, appearance • Catatonia • Poor impulse control • Anger, agitation • Stereotypies

16. Clinical features:Mood and Affect • Inappropriate affect • Blunting of affect/mood • Flat affect • Isolation or dissociation of affect • Incongruent affect

17. Positive symptoms Delusions Hallucinations Behavioral dyscontrol Thought disorder Negative symptoms (Remember Andreasen’s “A”s) Affective flattening Alogia Avolition Anhedonia Attentional impairment Positive vs. negative symptoms

18. Psychotic Disorders Onset Symptoms Course Duration

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

20. Some factors rejected as causal • “Schizophrenogenic Mother” • “Skewed” family structure

21. 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

22. 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

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

24. Physiologic studies:PET and SPECT • Generally normal global cerebral flow • Hypofrontality • Failure to activate dorsolateral prefrontal cortex (problem-solving, adaptation, coping with changes)

25. Biochemical factors:The dopamine hypothesis • All typical antipsychotics block D2 with varying affinities • Dopamine agonists can precipitate a psychosis • Amphetamines • Cocaine • L-dopa

26. Dopamine systems Clinical implications Functions Cell bodies Projections

27. Low potency: Chlorpromazine Thioridazine Mesoridazine High potency: Haloperidol Fluphenazine Thiothixene Loxapine (mid) Typical Neuroleptics

28. Neuroleptic (typicals):side effects • Acute dystonia • Parkinsonian side effects (EPS) • Akathisia • Tardive dyskinesia • Sedation, orthostasis, QTC prolongation, anticholinergic, lower seizure threshold, increased prolactin

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

30. 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

31. Atypical Antipsychotics: Side Effects • Sedation • Hyperglycemia, new-onset diabetes • Anticholinergic effects • Less prolactin elevation • QTC prolongation • Some EPS • Increased lipids

32. 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