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Psychosis: Clinical Features and Differential Diagnosis (Differential…
Psychosis:
Clinical Features and Differential Diagnosis
Definition
Syndrome
Characterized by:
Loss of Reality Testing
Impaired mental functioning
Often Altered mood and affect
Dopamenergic Projections to the temporal and frontal lobes are most affected.
Patients
incorrectly evaluate
the accuracy of their perceptions and thoughts and
make incorrect inferences
about their external reality."
Heterogeneous condition
Syndrome - Grp of Signs and Actions that together make a recognizable condition/disorder
Warrants a diagnosis
Clinical Features
NEGATIVE SYMPTOMS
Avolution
Diminished emotional expression
POSITIVE SYMPTOMS
Delusions:
Fixed, False Belief by
incorrect inferences
about external reality and held from
despite contrary evidence
Hallucinations
:
False Sensory perception
not associated with external stimuli
Thought Disorder
:
Non-goal orientated
flow of ideas, symbols or associations
Word-salad, tangengiality, flight of ideas, blocking
Dis-organised Speech
Dis-organised/Catatonic behavior
Differential Diagnosis
Anxiety Disorder
PTSD + traumatic Hallucinatiosn, Dissocative Disorders
? Traumatic Stressors, other Sx
Mood Disorder
MD with Psychosis,Bipolar(manic/dep with psychosis, mood congruent delusions
Personality
? Long standing pervasive and Maladaptive Traits
Schizoid,Schizotypal, paraniod,Borderline, OCD
Substance
Illicit
Amphetamines,Cocaine, withdrawal(benzo/barb), hallucinogens (LSD,PCP, Alcohol)
Therapeutic:
Steroids, anticolinergics,5Ht Antagonists
Primary Psychotic Disorder
Brief Psychotic episode,
Shizophreniform
Schizophrenia
Schizoaffective
Medicial
Dementia, Delirium,Head trauma,TL Epilepsy, CVD,Metabolic (Cushings/thyroid), Deficiency
Suggestive Features:
Medical Cause, Sudden Onset, Old age, First episode,current Illness/injury, Neurological Sx
Miscellaneous
Malingering/factitious
Delusional
Shared Psychotic disorder
CO- MORBIDITY IS THE RULE
MSE SIGNS
Appearance
: Range from Disheveled to disorganized
Behavior:
Range from immobile to excessive movement
Co-operation:
Un-Cooperative
Speech:
High/Low rate
Loud/soft Volume
Monotonours/tremulous
Minimal/voluble quantity)
Not- ease of conversation
Mood:
Happiness: Ecstatic/depressed
Irritability: explosive, irritable/calm
Stability
Affect
Range (restricted/flat/blunted/expansive
text
Thought Content:
Thought Disorder: Fromaultion and coherence disorder
Perceptional Abnormalities:
Illusions
Hallucinations
Disrealisation/Depersonalize
Judgment
- Imparied
Insight
:Impaired
Cognition:
Low Orientation
Poor Memory
Poor Exectutive Function
RISK
:
Self and Others
Mechanisms
Diathesis-Stress Model
Generic/Aquired
Person acted upon by stress and disease onset ensues
*Determined by:
Childhood development
perinatal Factors
Sex and Age
Social, Psycho-dynamic and interpersonal factors
Life events
Structural brain Abnormality
Neuro -developmental
Pruning
Fixed Brain lesion in early life interacts with certain maturational events that occur much later.
Neuro-degenerative
Brain changes over the course of disease = onset and worse prognosis
Exogeneoues Substances
Hallucinogens: LSD, PCP & Ketamine
Amphetamines
Genetic Factors
Mutation & Inherited
Nature vs Nuture
Susceptibility changes with number of inherited mutations
Neurotransmitter Pathways
DA
High DA in
mesolimbic
-
(Positive Symptoms)and
mesocortical
(Negative Symptoms)
Evidence: Amphetamine Increase DA = psychosis
GLUT
Low NMDA rec activity on inhibitory GABA Neurons in Prefrontal Cortex
Evidence: PCP/Ketamine decrease Glu = psycosis
GABA
- low neurons in hippo campus
5-HT
- LSD Increases 5HT= Psychosis
LEADING TO: HYPO FRONTALIITY FAILURE OF TO ACTIVATE THE DORSLATERAL CORTEX