Mkgrady8 Neuro 5 Psychiatric Disorders

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schizophrenia: prevalence

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1% of pop; high genetic component

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schizophrenia: age

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peak onset 18-25 y/o males and 25-35 for females; women have a bimodal distribution with a second peak appearing in middle age; onset after age 45 is considered late onset (very rare after age 60) generally paranoid, better prognosis; childhood onset is rare but does occur; 90% of pts in treatment are ages 15-55; equal rates in men and women but outcomes are better for women

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schizophrenia: substance use

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cigarette smoking= 75-90% of pts smoke (there may be brain abnormalities in nicotinic receptors in schizophrenia), increases the metabolism of some antipsychotics, nicotine appears to improve some cognitive impairments (may decrease positive symptoms); alcohol= 30-50% meet criteria for abuse or dependence; cannabis and cocaine are the 2 other commonly used drugs (high cannabis use increases rick of developing schizophrenia by 6x); alcohol and drug use are associated with a poor prognosis

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schizophrenia: socioecenomic and cultural factors

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in industrialized nations a disproportionate number of pts are in the low SE groups= downward drift hypothesis vs. social causation hypothesis; recent immigrants have a higher rate suggesting the stress of abrupt cultural change as a risk; population density-prevalence rises with increasing density in cities of > 1 million

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schizophrenia: economics

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onset at a young age, requires life long care; accounts for 2.5% of all health care expenditures; 75% of pts are unemployed; direct and indirect costs > $50 billion annually; half of psychiatric beds occupied by these pts; 40-60% are re admitted within 2 yrs of their first hospitalization; 1/3 to 2/3 of the homeless have schizophrenia

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schizophrenia: etiology

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not a single disease but a group of disorders with heterogeneous cases

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stress-diathesis model

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the person has a specific vulnerability (diathesis) that when acted on by a stress leads to the development of schizophrenia; the stress can be environmental or biological or both

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schizophrenia: genetic factors

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significant genetic contribution to some, perhaps all, forms of schizophrenia, involving multiple genes; paternal age= direct correlation of increased risk with advanced paternal age (perhaps spermatogenesis in older men is subject to greater epigenetic damage)

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schizophrenia: neurobiology

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this is a complex neurodevelpomental disorder without one cause, defect, or manifestation; research implicates dysfunction in certain areas of the brain, primarily in the limbic system and basal ganglia including the cerebral cortex, thalamus, and brainstem; some pts have loss of brain volume believed to be due to reduced density of axons, dendrites, and synapses

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We now have evidence that multipleneurotransmitters are involved in the pathophysiology of schizophrenia, but foryrs hypotheses focused on a single one, and that is what early antipsychoticstargeted. Newer drugs also affect thisneurotransmitter as well as others. Which one has its own hypothesis? a. serotonin b. GABA c. Dopamine d. Acetylcholine

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C dopamine

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the dopamine hypothesis of schizophrenia

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disease results from too much dopaminergic activity as evidenced by= dopamine receptor antagonists are effective antipsychotics, drugs that increase dopamine (amphetamines) are psychotomimetics; this basic theory doesn't speculate on whether the dopaminergic hyperactivity is due to excessive release of dopamine receptors, hypersensitivity of receptors, or some combination; it has become clear in recent yrs that the dopamine hypothesis is not sufficient

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newer theories

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SHE BARELY TOUCHED ON THESE (JUST KNOW DOPAMINE); posit serotonin excess= the serotonin antagonist activity of clozapine and other atypical antipsychotics support this as does the psychotomimetic effect of the serotonin agonist LSD; a single neuron can contain more than one neurotransmitter and can have receptors for 6 or more neurotransmitters; norepi likely modulates the dopaminergic system, and the prominent feature of anhedonia suggests dysfunction in the norepi reward neural system; GABA has a regulatory effect on dopamine activity and the loss of GABAergic neurons seen in the hippocampus of some pts could lead to hyperactivity of dopaminergic neurons; glutamate is implicated because phencyclidine (PCP) a glutamate antagonist causes psychosis so new drugs are in development that influence glutamate; acetylcholine and nicotine are suspected as postmortem studies show decreased muscarinic and nicotinic receptors (important in cognition); substance P and neurotensin are 2 neuropeptides with altered concentrations in psychosis

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schizophrenia: the limbic system

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post mortem studies show decreased size in this region including the amygdala, hippocampus, and parahippocampal gyrus; disorganization of neurons within the hippocampus has also been reported; the limbic system is important in controlling emotions

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schizophrenia: basal ganglia and cerebellum

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many antipsychotic drug naive schizophrenia pts show odd movements= awkward gait, facial grimacing, and stereotypies; movement disorders involving the basal ganglia are more commonly associated with psychosis than are other neurological disorders

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schizophrenia: cerebral ventricles and symmetry

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lateral and 3rd ventricle enlargement and some degree of reduction in cortical volume; reduced symmetry present in several brain areas including temporal, frontal, and occipital lobes= believed by some to originate during fetal life and to be indicative of a disruption in brain lateralization during neurodevelopment

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schizophrenia: prefrontral cortex and thalamus

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prefrontal cortex= postmortem studies show anatomical abnormalities in this region and imaging has shown functional deficits and some symptoms of illness are shared with pts with frontal lobe syndromes and those who underwent prefrontal lobotomies yrs ago; thalamus= some pts (including antipsychotic naive) have shown volume shrinkage or neuronal loss in particular thalamic subnuclei

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schizophrenia: EEGs, sounds, and complex partial epilepsy

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many schizophrenic pts have abnormal EEGs; they also have an inability to filter out irrelevant sounds and are extremely sensitive to background noise; complex partial epilepsy= schizophrenia like psychoses occur more commonly than expected particularly with a left sided seizure focus, medial temporal location of lesion, and early onset of seizures

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schizophrenia: eye movement dysfunction

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50-85% of pts, 25% of other psych pts, and 10% of controls; inability to accurately follow a moving visual target, independent of drug treatment and also found in first degree relatives of pts; eye movement is partly controlled by centers in the frontal lobes, a disorder in eye movement is consistent with theories that implicate a frontal lobe pathological process in schizophrenia

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schizophrenia: psychosocial factors

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many theories over the yrs blamed the family, especially the mother for the development of schizophrenia, these have been largely discredited; it has been shown that pts living with parents or other caretakers with high levels of expressed emotion (criticism, hostility, over involvement) have high relapse rates

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schizophrenia diagnosis: characteristic symptoms

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KNOW THESE (A) AND THE NEXT SLIDE (B); 2 or more of the following, each present for a significant portion of time during a 1 months period (or less if successfully treated)= delusions, hallucinations, disorganized speech (i.e. frequent derailment or incoherence), grossly disorganized or catatonic behavior, negative symptoms (i.e. affective flattening, alogia, or avolition); only one of these is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person's behavior or thoughts, or 2 or more voices conversing with each other

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schizophrenia diagnosis: social/occupational dysfunction

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for a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement)

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schizophrenia diagnosis: duration

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continuous signs of the disturbance persist for at least 6 months; this 6 month period must include at least 1 months of symptoms (or less if successfully treated) that meet criterion A (i.e. active phase symptoms) and may include periods of prodromal or residual symptoms; during these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or 2 or more symptoms listed in criterion A presented in an attenuated form (e.g. odd beliefs, unusual perceptual experiences)

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schizophrenia diagnosis: schizoaffective and mood disorder exclusion

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both have been ruled out because either 1. no major depressive, manic, or mixed episodes have occurred concurrently with the active phase symptoms or 2. if mood episodes have occurred during active phase symptoms their total duration has been brief relative to the duration of the active and residual periods

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schizophrenia diagnosis: substance/general medical condition exclusion

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the disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition

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schizophrenia diagnosis: relationship to a pervasive developmental disorder

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if there is a history of autistic disorder or another pervasive developmental disorder, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated)

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A 25 y/o married man who is employed at a hardwarestore develops psychotic symptoms during a 2 week period after his father’ssudden death. He feels sadness and hearshis father’s voice telling him to join him. He has no prior psychiatric history, but family history is notable for abrother with schizophrenia. Which of thefollowing is the poorest prognostic sign for this pt? a. depression b. family history c. marital status d. acute onset

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B family history

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schizophrenia: good prognosis

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KNOW THESE; late onset; obvious precipitating factors; acute onset; good premorbid social, sexual, and work histories; mood disorder symptoms (especially depressive symptoms); married; family history of mood disorders; good support systems; positive symptoms

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schizophrenia: poor prognosis

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KNOW THESE; young onset; no precipitating factors; insidious onset; poor premorbid social, sexual, and work histories; withdrawn, autistic behavior; single, divorced, or widowed; poor support systems; negative symptoms; neurological signs and symptoms; history of perinatal trauma; no remission in 3 yrs; many relapses; history of assultiveness; family history of schizophrenia

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schizophrenia: psychological testing

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a brain disease that disrupts the normal functioning of many cognitive abilities; vigilance, memory, and concept formation are most affected and consistent with frontotemporal cortical defects; frequently there are impairments in attention, retention time, and problem solving ability; motor ability is also impaired; IQ is lower at onset of illness and may deteriorate with progression of the disorder; projective tests may indicate bizarre ideation

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schizophrenia: mental status exam: appearance and motor behavior

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appearance= hygiene may be poor, dress may be odd; motor behavior= eye contact may be poor or pt may state or look around the room if paranoid, psychomotor agitation or retardation may be present, evaluate for posturing, grimacing, echopraxia, echolalia; look for medication side effects, EPS< or TD

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schizophrenia: mental status exam: mood

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pt report of recent mood; affect= what the examiner sees= sad, tearful, blunted, flat, agitated, reactive, appropriate, inappropriate, congruent (or not) with mood; speech= spontaneous or not, rate, tone, volume, rhythm

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schizophrenia: mental status exam: perceptual disturbances- hallucination

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auditory= most common, frequently derogatory; visual= also consider substance use or med side effect, can be seen in some forms of dementia; tactile= uncommon, consider cocaine or delirium; gustatory and olfactory= uncommon in schizophrenia- consider neurologic disorder

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schizophrenia: mental status exam: thought content- delusions (fixed, false beliefs)

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paranoid= being watched, followed, listened to, spied on, poisoned, plotted against; somatic= believing one is infested with parasites, indies are being eaten, or has HIV even in face of repeated negative tests

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schizophrenia: mental status exam: delusions

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of control= a person or force is controlling one's mind or body; thought broadcasting= one's thoughts are being broadcast out loud; thought withdrawal= others are taking thought out of one's mind; thought insertion= others are putting thought in one's mind; ideas of reference= events have to do with you i.e. newscaster gave a message aimed at you on the news

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schizophrenia: mental status exam: form of thought

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looseness of associations= no relationship between one statement and the next; word salad= incomprehensible speech; neologisms= words made up by the pt; circumstantiality= excessive detail, loss of goal directed thinking; tangentiality= pt loses the thread of conversation and pursues tangents; echolalia; mutism

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schizophrenia: mental status exam: thought process

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disorders of thought process concern the way in which ideas and languages are formulated; flight of ideas, circumstantiality, perseveration; thought blocking, idiosyncratic associations; impaired attention and poor abstraction; poverty of thought content; thought control, thought broadcasting

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schizophrenia: mental status exam: violence risk factors

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persecutory delusions, prior episodes, neurological deficits; is not uncommon among untreated pts with schizophrenia= poor impulse control, paranoia, auditory hallucination may be command, mothers are the main recipients of violence followed by other family members

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schizophrenia: mental status exam: homicide

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is uncommon but always assess for ideation; possible predictors= previous history of violence, dangerous behavior while hospitalized, hallucinations or delusions involving violence

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schizophrenia: mental status exam: suicide

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always a risk so always assess; look for depression that may be misdiagnosed as flat affect or med side effect; up to 80% of pts may have a major depressive episode at some time in their lives; antidepressant meds can help depression in pts with schizophrenia; 20-50% of pts attempt suicide, 10-13% commit suicide

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schizophrenia: mental status exam: sensorium and cognition

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usually oriented; memory as tested in formal MSE usually intact if pt can pay attention; there are subtle cognitive impairments in attention, executive function, working, and episodic memory; insight frequently impaired which can lead to non compliance; judgement may be impaired in some spheres

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schizophrenia: other findings

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localizing and non localizing neurological signs (also known as hard and soft signs) occur more frequently in people with schizophrenia than in other psychiatric pts; these signs are correlated with severity of illness, affective blunting,and poor prognosis; elevated eye blink rate, which is thought to reflect hyperdopaminergic activity; minor physical anomalies; compulsive water drinking (up to 10 L/d)

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schizophrenia: differential diagnosis

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secondary psychotic disorders due to a medical condition or substance; other psychotic disorder like schizophreniform, brief psychotic, schizoaffective, delusional; mood disorders; personality disorders; malingering (material goal) and factitious disorder (emotional goal)

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schizophrenia: course and prognosis

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prodromal syndrome may last a yr or more before the onset of overt psychosis; classic course one of exacerbations and remissions with progressive deterioration after each relapse; positive symptoms tend to become less severe with time but negative symptoms may worsen; in the 5-10 yrs after first hospitalization 10-20% of pts have a good outcome, more than 50% have a poor outcome

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schizophrenia: treatment

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complex, multifaceted illness requires a multifaceted approach; pharmacotherapy is the mainstay; psychosocial treatments augment the medication and most pts do better when they receive both; hospitalization is indicated for diagnostic evaluation, medication stabilization, and for safety due to suicidal or homicidal thoughts or inability to care for self; stays of 4-6 weeks with active behavioral approaches and establishment of an aftercare plan tend to give the best results

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schizophrenia: pharmacotherapy

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2 major classes= dopamine receptor antagonists (first generation antipsychotics, typical antipsychotics) (haloperidol, fluphenazine, thiothixene); serotonin dopamine receptor antagonists (second generation antipsychotics, atypical antipsychotics) (clozapine, risperidone, paliperidone, asenapine, lurasidone, olanapine, quetiapine, ziprasidone, aripiprazole)= these are considered first line agents by most psychiatrists (except clozapine which has significant side effects) because of the more benign side effect profile

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typical antipsychotics side effects

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extra pyramidal symptoms (EPS) parkinsonism (bradykinesia, tremor, rigidity)= treatment is anticholinergic meds like benztropine, but they can cause dry mouth, constipation, blurred vision, memory loss; akathisia= internal restlessness, inability to site still, very distressing to pts and treatment is beta blockers like propranolol; elevated prolactin= sexual dysfunction, menstrual irregulariteis, galactorrhea, osteoporosis; tardive dyskineisa= permanent movement disorder

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tardive dyskinesia (TD)

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a serious and likely permanent movement disorder related to therapy with dopamine blocking drugs; 20-30% of long term pts on typical antipsychotics exhibit symptoms; 3-5% of young pts per yr on typical antipsychotics develop TD; higher incidence in females, older age, organic, and affective mental illness

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atypical antipychotics

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decreased EPS and TD (primary benefit); do not cause elevated prolactin (except risperidone and paliperidone); were thought to be more effective at treating negative symptoms than typical antipsychotics although that now seems to not be the case; some are associated with weight gain and metabolic abnormalities (monitoring is needed)

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clozapine

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most effective antipsychotic drug; 0.3% risk of agranulocytosis in first yr, weakly WBC for first 6 mo then biweekly for 6 mo then q 4 weeks; higher risk of seizures than other drugs, almost 5% at doses > 600 mg (manage with AEDs); hypersalivation, sedation, postural hypotension, tachycardia, myocarditis, metabolic issues

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therapeutic principles for antipsychotic use

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1. target the symptoms to be addressed 2. use a drug that has worked in the past if possible, choose a drug based on the side effect profile 3. minimum length of a med trial is 6 weeks at a therapeutic dose 4. rarely indicated to use more than one antipsychotic at a time 5. maintain pt on lowest effective dose

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schizophrenia pharmacotherapy: what if there is no response in the pt to the treatment

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major cause is non compliance, consider long acting injectable med; if pt is compliant switch to another drug, after 2 weeks failed frug trials consider clozapine bc it is the most effective drug but requires weekly white blood cell counts due to risk of agranulocytosis; sometimes augmenting an antipsychotic with a mood stabilizer such as lithium, valproate, or carbamazepine is helpful

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schizophrenia: electroconvulsive therapy

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ECT; can be beneficial in acute and chronic illness not responding to drug therapy; difficult to access, expensive; usually reserved for severe symptoms with very problematic behavioral issues

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schizophrenia: psychosocial therapies

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social skills training; family oriented therapies; NAMI (national alliance for the mentally ill); case management; assertive community treatment (ACT); group therapy, art therapy; cognitive behavioral therapy; individual psychotherapy, personal therapy; vocational therapy

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schizophreniform disorder

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similar to schizophrenia but symptoms last between 1 and 6 months; typical presentation is rapid onset without a significant prodrome with return to baseline functioning within 6 months; it pt does not have good prognostic features, may have early schizophrenia

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schizophreniform: good prognostic features

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onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; confusion or perplexity at the height of the psychotic episode; good premorbid social and occupational functioning; absence of blunted or flat affect

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schizphreniform disorder: course and treatment

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course= 60-80% progress to schizophrenia; treatment= initial hospitalization for evaluation and stabilization followed by 3-6 month course of antipsychotic meds

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schizoaffective disorder: what is it, epidemiology

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has features of both schizophrenia and affective (mood) disorders; lifetime prevalence of 0.5-0.8%; depressive type may be more common in older pts, bipolar in younger; slightly higher rates in females than males, age of onset later in women; men may exhibit antisocial behavior and flat or inappropriate affect

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schizoaffective disorder: etiology theories

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a type of schizophrenia or a type of mood disorder; simultaneous expression of schizophrenia and mood disorder; a distinct 3rd type of psychosis; a heterogeneous group of disorders encompassing all of the above (most likely)

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schizoaffective disorder: diagnostic criteria

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A. an uninterrupted period of illness during which, at some time, there is either a major depressive episode, a manic episode, or a mixed episode, concurrent with symptoms that meet criterion A for schizophrenia; note= the major depressive episode must include criterion A1 (depressed mood); B during the same period of illness there have been delusions or hallucinations for at least 2 weeks in the absence of prominent mood symptoms; C. symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness; D. the disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a med) or a general med condition

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schizoaffective disorder: course and treatment

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course= a chronic mental illness requiring long term treatment, pts with more mood symptoms do better than those with more psychotic symptoms; treatment is with an antipsychotic med and a mood stabilizer for the bipolar type or an antidepressant plus antipsychotic for the depressed type and psychosocial therapies for both

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A 33 y/o single female with no history of mentalillness works in a large bookstore where she meets a well known author at abook signing. She becomes convinced theyhave a special connection and when she hears him on a talk show a few dayslater, she believes he is sending her messages about their love. She begins writing him letters and sendinggifts, and attempts to visit him in a hotel in a nearby city several monthslater. She has been told by his attorneyand the police to stop contacting him, but believes these people areinterfering in a true love. Thisdescribes a delusional disorder of what subtype? a. erotomanic b. grandiose c. jealous d. persecutory

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A erotomanic

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delusional disorder: epidemiology

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rare, 0.025-0.03%; 1-2% of admissions to inpatient mental health facilities; mean age of onset is 40 y/o; slightly more females than males; females likely to have erotomanic delusions; males likely to have paranoid delusions

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delusional disorder: etiology

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unknown; it is not related to schizophrenia or mood disorders, studies do show an increased rate of delusional disorder, suspiciousness, jealousy, and secretiveness in family members of delusional disorder pts; important to rule out medical conditions which can have associated delusions, i.e. toxic metabolic disorders and especially CNS disorders such as Huntington's, CVA, dementia

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delusional disorder: clinical features

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appearance unremarkable, may be eccentric, odd, suspicious, or hostile, sometimes litigious; mental status exam remarkably normal except for the delusional system; the delusions are non bizarre and have been present at least a month; main defense mechanism or reaction formation, denial, and projection; multiple factors associated with formation of delusions

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delusional disorder subtypes

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erotomanic, grandiose, jealous, persecutory, somatic, mixed, unsepcified

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erotomanic type

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delusions that another person, usually of higher status is in love with the individual; more common in females, males may become aggressive

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grandiose type

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delusions of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person

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jealous type

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delusions that the individual's sexual partner is unfaithful, usually affects males

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persecutory type

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delusions that the person (or someone to whom the person is close) is being malevolently treated in some way; pt may be litigious or become aggressive

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somatic type

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delusions that the person has some physical defect or general medical condition

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mixed type

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delusions characteristic or more than one of the above types but no one theme perdominates

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delusional disorder: course and prognosis

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psychosocial stress may precede the onset; IQ may be lower than average; premorbid personality may be extroverted, dominant, hypersensitive; the initial concerns become more and more involved until delusional in quality; 50% recover at long term follow up; 20% have a decrease in symptoms; 30% have no change; good prognostic factors= high functioning, female, age <30, sudden onset, short illness, precipitating factors

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delusional disorder: treatment

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difficult to treat; try antipsychotic although pt may be resistant and it may not help; psychotherapy= the essential element is to establish a trusting relationship, pt may bot give up delusions but therapy may improve functioning

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A 28 y/o female from central America is broughtto the ER after an accident in which she witnessed the death of her 9 y/oson. She is shouting, confused, fearful,and appears to be hearing voices. Thereare no apparent physical injuries except minor abrasions and bruises. The most likely diagnosis is: a. Schizophreniform D/O b. Delusional D/O c. Schizophrenia d. Brief Psychotic D/O

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D brief psychotic D/O

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brief psychotic disorder

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an acute and transient psychotic disorder; uncommon, occurs more often among younger pts; higher incidence in women and people in developing countries, particularly those who have experienced disasters or major cultural changes (immigrants); often seen with personality disorders; psychodynamic formulations have emphasized the presence of inadequate coping mechanisms

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brief psychotic disorder: diagnostic criteria

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A. presence of one (or more) of the following symptoms= delusions, hallucinations, disorganized speech (e.g. frequent derailment or incoherence), grossly disorganized or catatonic behavior, note= do not include a symptom if it is a culturally sanctioned response pattern; B. duration of an episode of the disturbance is at least 1 day but less than 1 months, with eventual full return to premorbid level of functioning; C. the disturbance is not better accounted for by a mood disorder with psychotic features, schizoaffective disorder, or schizophrenia, and is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a med) or a general med condition; specify if with marked stressors, without marked stressors or with postpartum onset

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brief psychotic disorder: clinical features, course, and prognosis

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clinical features= labile mood, confusion, strange or bizarre behavior, screaming or muteness, impaired memory for recent events; course and prognosis= up to 50% are later diagnosed with a chronic disorder, good prognostic features indicating a high likelihood of recovery are= good premorbid adjustment, few premorbid schizoid traits, severe precipitating stressor, sudden onset of symptoms, affective symptoms, confusion and perplexity during psychosis, little affective blunting, short duration of symptoms, absence of schizophrenic relatives

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brief psychotic disorder: treatment

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hospitalization may be needed for eval and protection; pharmacotherapy with antipsychotics and adjunctive benzodiazepines may be needed until the pt has recovered; psychotherapy is beneficial in integrating the psychotic experience and exploring the precipitating stress, if present; exploration and development of coping strategies and strengthening the ego structure in individual therapy is helpful

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other psychotic disorder: what is it

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this category includes psychotic symptomatology (i.e. delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior) about which there is inadequate info to make a specific diagnosis or about which there is contradictory info, or disorders with psychotic symptoms that do not meet the criteria for any specific psychotic disorder

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other psychotic disorder: expales include

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postpartum psychosis that does not meet criteria for mood disorder with psychotic features, psychotic disorder due to a general medical condition, or substance induced psychotic disorder; psychotic symptoms that have lasted for less than 1 month but that have not yet remitted so that the criteria for brief psychotic disorder are not met; persistent auditory hallucinations in the absence of any other feature; shared psychotic disorder; persistent non bizarre delusions with periods of overlapping mood episodes that have been present for a substantial portion of the delusional disturbance; situations in which the clinician has concluded that a psychotic disorder is present but is unable to determine whether it is primary, due to a general medical condition, or substance induced

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post partum psychosis

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occurs in 0.1% of pregnancies; 50-60% of pts have just has their first child; 50% of children have experienced perinatal complications; most cases represent an underlying mood disorder, usually bipolar disorder; 2/3 go on to have a mood episode within a yr; post partum psychosis is a psychiatric emergency because 5% commit suicide and 4% commit infanticide

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post partum psychosis: clinical features

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mean time to onset 2-3 weeks after delivery; symptoms= fatigue, insomnia, restlessness, emotional lability, progressing to suspiciousness, confusions, irrational statements, obsessive concern about the baby's health, delusions and or hallucinations; the mother may have thoughts of not loving or wanting the baby or thoughts of harming self or baby

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post partum psychosis: treatment

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hospitalization, meds, psychotherapy after the psychosis resolves, high rates of recovery

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secondary psychotic disorders: diagnostic criteria

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A. prominent hallucinations or delusions; B. there is evidence from the history, PE, or lab findings that the disturbance is the direct physiological consequence of a general med condition; C. the disturbance is not better accounted for by another mental disorder; D. the disturbance does not occur exclusively during the course of a delirium

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secondary psychotic disorders: substance induced psychotic disorder

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this category only applied to people with impaired reality testing; if apt has hallucinations or delusions but realizes they are due to a substance then he is diagnosed as having a substance related disorder, not a psychotic disorder

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secondary psychotic disorders: substance induced psychotic disorder diagnostic criteria

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A. prominent hallucinations or delusions; B. there is evidence from the history, physical exam, or lab findings of either 1. the symptoms in criteria A developed during or within a month of substance intoxication or withdrawal or 2. med use it etiologically related to the disturbance; C. the disturbance is not better accounted for by a psychotic disorder that is not substance related, evidence that the symptoms are better accounted for by a psychotic disorder that is not substance induced might include the following= the symptoms precede the onset of the substance use (or med use), the symptoms persist for a substantial period of time (e.g. about a month) after the cessation of acute withdrawal or severe intoxication, or are substantially in excess of what would be expected given the type or amount of the substance used or the duration of use, or there is other evidence that suggests the existance of an independent non substance related disorder (e.g. a history of recurrent non substance related episodes); D the disturbance does not occur exclusively during the course of a delirium; note= this diagnosis should be made instead of a diagnosis of substance intoxication or substance withdrawal only when the symptoms are in excess of those usually associated with the intoxication or withdrawal syndrome and when the symptoms are sufficiently severe to warrant independent clinical attention

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secondary psychotic disorders: differential diagnosis

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delirium (a clouding of consciousness and change in cognition which develops over a short period of time); dementia (multiple cognitive deficits with stable sensorium); other psychotic disorders

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secondary psychotic disorders: treatment

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treat the underlying med or substance condition; use antipsychotics and/or anxiolytics as needed to manage behavior

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catatonia: clinical picture dominated by 3 (or more) of the following symptoms

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stupor; catalepsy; waxy flexibility; mutism; negativism; posturing; mannerisms; stereotypy; agitation not influenced by external stimuli; grimacing; echolalia; echopraxia

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when can you see catatonia

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may occur in the context of a mental or med disorder; may be a med emergency secondary to dehydration, hyperpyrexia, exhaustion, and muscle breakdown= aggressive hydration, administer benzodiazepines, treat underlying mental or med conditions