Psychosis NOT Schizophrenia: Case Studies in Psychosis, Differential Diagnosis and Treatment

1. Psychosis NOT Schizophrenia: Case Studies in Psychosis, Differential Diagnosis and Treatment Linda Barloon, RN, MSN, PMHNP-BC Consultation Psychiatry Houston Methodist Hospital

2. I have no conflicts of interest to disclose

3. Your patient has psychosis. Is it Schizophrenia? What history do you need? What assessments will help? What family history will help? What is your differential diagnosis? What are your treatment recommendations?

4. Psychosis • Disturbance in reality • Hallucinations • Delusions • DSM – gross impairment • of reality testing

5. Psychosis • Defining feature of schizophrenia • Kraeplin – may have disagreed, Dementia Praecox (dementia of the young) (Contemporary of Dr. Alzheimer)

6. Formal Thought Disorder • Disorganized thinking • Illogical thinking • Tangentiality • Perseveration • Neologisms • Thought blocking • Derailment

7. Psychosis • Also a feature of mood disoders • Substance disorders • Development and acquired disorders • Degenerative Neurological Disorders • Medical conditions

9. Primary Psychosis • Bipolar I disorder • Depression with psychotic features • Schizoaffective disorder • Schizophrenia • Delusional Disorder • Post Partum Psychosis • Post Traumatic Stress Disorder

10. Primary Psychiatric Disorders • More likely to have: • auditory hallucinations • prominent cognitive disorders • complicated delusions. • Poor insight

11. Hallucinations • Auditory – hearing voices or other things • Most consistent with primary psychiatric condition • Schizophrenia • Bipolar, manic • Unipolar, psychotic depression • Post Partum psychosis, etc.

12. Delusions • False Fixed Beliefs • Types of delusions include – persecutory, grandiose, religious, ideas of reference, Parasitosis (Ekbom syndrome) • May be bizzare • Confabulation – is not fixed and therefore not a delusion

13. Delusions • False Fixed Beliefs • Types of delusions include – persecutory, grandiose, religious, ideas of reference, Parasitosis (Ekbom syndrome) • May be bizzare • Confabulation – is not fixed and therefore not a delusion

15. Schizophrenia • Occurs in 1% of population • Onset usually in Teens and 20’s • Runs strongly in families • Positive Sx’s- depending on type of Schizophrenia- Thought disorg, AH’s , Paranoia, Complicated and fixed delusions • Negative Sx’s – low motivation, dimished affective response, • Poor functional outcomes.

16. Major Depression w/ Psychosis • Lifetime Prevalence 15% • 2X more common for women • Family Hx? • Mean age is 40, but can occur at any age • Depressive sx’s • Mood congruent psychotic sx’s • Guilt delusions – Almost Pathognoumonic for psychotic depressive condition

17. Bipolar Disorder • Manic sx’s • Course of illness • Family hx • Rare after age of 50 for onset of illness – • Grandiose delusions in manic or mixed states

19. Hallucinations • Visual • Charles Bonnet • Seizures – temporal lobe • Delirium • Dementia • Substance intoxication or withdrawal

20. Hallucinations • Gustatory – seizures • Olfactory– partial complex seizures, PTSD

21. Secondary (Organic) psychosis • Delusions – Less bizarre, Misidentification syndromes – up to 40% occur in neurological disorders Examples – Capgras syndrome – belief that a familiar person has been replace with an imposter Or Frégoli – belief that different people are in fact a single person who changes appearance Autonomic instability – pulse, blood pressure

22. Other Causes secondary Psychosis • Substances – stimulants, • Anticholinergic, • Dopaminergic drugs • Steroids

23. Other delusions • Are delusions of diagnostic significance? (Picardi et al) • Persecutory – across all psychiatric disorders, 45% in delusional disorder • Somatic Delusions - across all psychiatric disorders • Grandiose – bipolar manic and mixed primarily but not exclusively – • Guilt – MDD with psychotic fx, bipolar depression

24. Delusions and Dementia • 1/3 to1/2 of patients with dementia will have delusions • For Geriatric patients – include dementia in differential diagnosis for patients with psychosis

25. Case • Ms. J is a 25 year old female with no past psychiatric history • She has been working in retail for five years • Yesterday she began behaving oddly at work • Thinking that someone was out to kill her and hiding under her desk • Blood pressure is 180/110 • Pulse 96

26. Is this primary or secondary psychosis?

27. Complete H&P and medical work up

28. Case Cases are based upon real patients with names and details changed.

29. Case • Ms. K is 40 years old • She went to Mexico for a week with friends • She forgot to take her thyroid supplement with her • She got sick and dehydrated while there – maybe too much tequila

30. Case • When she returned from Mexico, she didn’t sleep for three days • She stayed up all night writing a book about a cure for bladder cancer • TSH is 45 (normal 0.4-4.0) • Na is 127 (135-145) • P – 95, BP - 136/90 • No fever

31. Is this primary or secondary psychosis?

32. Multifactorial Delirium • Myxedema Madness (Hypothyroid) • Insomnia • Hyponatremia • UTI • Poorly controlled hypertension

33. Remember • Patients with psychiatric conditions may also have medical conditions • Patients with medical conditions may also have psychiatric and substance use conditions

34. Case • Mr. P is a 62 year old male • He is brought to the hospital by the police because his neighbors called when they saw him outside his home waving a knife and yelling. • He reported that people were in his home trying to steal his belongings and when police enter the home they find no one.

35. Case • No prior psychiatric or substance abuse history • Adult son from out of town corroborates this • The pt has worked most his life as an accountant for an oil company, more recently working as a consultant • Divorced 10 years • No legal history • No military service • Lives in condo for 10 years

37. Hallucinations • Tell me about the people in your house? • What were they doing? • Did they say anything?

38. Case He had been seeing people in his home They were playing cards They did not speak and seemed to be friendly Eventually, they started to take his things And they continued to steal items even after confronted He got his shotgun but could not find the shells So he got his hunting knife and chased them out of the house

39. What history do you want? • Have you had any recent changes in vision? • Have you noticed any changes in memory? Ask the son • Head injuries? Seizures? • Any Depression? • Any problems with walking? Getting up from seated position? Tremors? Falls?

40. Case • CMP – normal • CBC – normal • UDS – negative • EKG – normal sinus rhythm • Physical exam normal – very mild bilateral hand tremor • MOCA – errors on visuo-spatial items, attention • TSH normal

41. MOCA – Montreal cognitive Assessment • Score 20 (Normal is 26 or higher out of 30) • Missing items under visuo-spatial and attention primarily

42. Case • In the Emergency Room was given Haldol 5mg, Ativan and Benadryl • And became more agitated, unable to sleep most of the night • - Neuroleptic sensitivity

43. What is the differential?

44. Dementia with Hallucinations

45. Dementia with Lewy Body • Ages 50-85 • More common in men than women • Men have worse prognosis

47. Dementia with Lewy Body - Pathology • Lewy Bodies in the cortex and brainstem – accumulation of abnormal proteins called synuclein. • May have amyloid deposits like in Alzheimers but few tangles • Lewy Bodies interfere with the production of dopamine. • LD decrease in acetylcholine in areas of the brain responsible for • Memory, thinking, and processing causing symptoms of dementia. • (similar to anticholinergic medications)

48. Lewy Body Dementia • Umbrella term • Parkinson Disease dementia • Dementia with Lewy Body

50. Dementia withLewy Body - Pathology • Imaging • MRI - Hippocampus volume – between normal and AD • PET scan – looks at metabolism of glucose – see hypoperfusion (decreased functioning in occipital lobes