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Psychotic Disorders - Coggle Diagram
Psychotic Disorders
Schizophrenia
DSM 5 Schizophrenia
+2 of the following for >1 month
Delusions, hallucinations, disorganized speech, disorganized or catatonic behavior, negative symptosm
Functional impairment
Signs fo the disorder for >6 months including >1 month of active phase symptoms
Not due to mood disorder with psychotic features
Not due to a substance or another medical condition
If history of AD/Communication disorder
Diagnostic Considerations
No one symptom is pathognomic of schizophrenia, must take signs and symtpoms iin context of IQ, developmental level, culture, educational level
Symptoms
Negative Symptoms
Affective flattening alogia, avolition, anhedonia
Psositive symptoms
Delusions, ahllucinations, disorganized speech, catatonia
Cognitive symptoms
Attention, memory, executive fucntions
Mood Symptoms
Dysphoria, suicidality, hopelessness
Violence
Risk Factors
Untreated, active substance use, active alcohol use, past history of violence, persecutory or erotomaniac delusions, neurological deficits
Suicide
50% attempt, 10-15% succeed
Risk Factors
Undiagnosed depression, command auditory hallucinations, need to escape symptoms, young male, well educated, awarenss of losses
DDx
Psychotic disorder, mood Disorder, personality disorder, anxiety disorder, OCT, substance-induced, medical conditions, ASD, Factitiious disorder, malingering
Medical Conditions
Neurological, infectious, metabolic, auto-immune, poisoning, nutritional
Phases of Illnes
Prodrome
Lead in to schizophrenia
Makred by varaible symtpoms, may last a year or more, onset adolescence usually, often difficult to determine due to poor specificity
First episode of psychosis
Duration of untreated psychoss associated with worse outocme, associated with greatest potential for full reocvery to baseline
Relapses
Harder to treat, longer duration, less responsive to medication, less likely to return to baseline
Prognosis
Good
Late onset, precipitating factors, ancute onset, good pre-morbid, mood, married, family hx mood disorder, good support, positive symptom
Poor
Early onset, no precipitant, insidious onset, poor premorbid function, single, assaultiveness, family hx of schizophrenia, poor support symptoms, neurological symptoms, no remissions, many relapses
Assessment
Assessment of predisposing, precipitating, perpetuating and protective factors
Physical; with neurological exam, CBC lytes, bloodwork, HIV syphillis, weight, WC, BMi, urinalysis, drug screen, EKG, EEG, CT, MRI
Treatment
Pharmacological MEdication
Antipsychotic medication
Treat for a year, consider gradual superviiised discontinuation if patient has good insight and is symptom free after 1 year
2nd generation antipsychotics are first line
Stqart with ziprazidone, aripiprazole, lurazidone, asenapine
Lower doses in first episodes psychosis and the elderly
Clozapine for treatment resistance
Failure of 2 antipsychotic trials at full dose for 8 weeks
Side effects prevent dose escalation
Psychosocial Treatment
Strong support for
Family interventions, supported employment programs, CBT, some support for cognitive remediation, social skills training, life skills training
Etiology
Anatomical
Limbic System: Decreased amygdala, hippocampus, parahippocampal gyrus
Basal ganglia: Most drug naive patients have abnormal involuntary movements
CT Scan: Increased lateral and third ventricals, decreased cortical and cerebaellar volume
Prefrontal Cortex: Deficits in PFC function associated with impaired working memory and executive functions and emotional and affective processing
Temporal Cortex: impaired activation during auditory selective attention taks
Limbic cortex and mid brain: Less activation in right amydala, hippocampi, basal gnaglia, impaired emotional an affective processing
Disorder of cortical dysconnectivity
Dopamine
Overactivity of dopamine in certain areas such as mesolimbic/mesocortical areas
Pathways
Mesocotical Pathway
Cognition, negative symtposm
Tuberoinfundibular pathway
Sexual Side Effects
Nigrostriatal pathway
Motor Side-effects
Mesolimbic Pathway
Memory, emotional behaviors, psotiive symptoms
Serotonin
Modulates dopamine acitvity
REduces psychotic symptoms and prevents movement
Second generation anti-psychotics have potent 5HT-2 blockade
Glutamate
PCP, ketamine - Dissociative anaesthetics
PCP binds to NMDA glutamate receptors and inhibit glutamate release
DYsfunction in glutamate -> Diruption in DA levels
Viral
Most controlled neuro-immunological studies do not support this
Genetics
50% concordance in MZ twins, 40% if both parents are schizophrenia, 10% if DZ twin or other first degree relative
History
Emil Kraepelin
One of the first to characterize psychotic illness from Bipolar disorder
Eugene Bleurler
Shizophrenia = Split-mind
Most important symptoms
Autism, affective flattening, ambivalence, associations, hallucinations and delusions
Kurt Schneider
First Rank Symptoms
Own thoughts spoken aloud, running commentary, voices arguing, thought broadcasting
Ideas of pasivity
Made feelings, impulses, act
Somatic Passivity expereinces
Somatic Hallucinations
Delusional Perceptions
Normal stimulus given higher personalized or delusional interpretation
Epidemiology
Lifetime prevalence : 1%, equal in male and female, disproportionate to low SES< and most have concurrent medical illness, and most smoke