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Psychotic Disorders

Psychotic Disorders. Archetype. Schizophrenia. Phenomenology. The mental status exam Appearance Mood Thought Cognition Judgment and Insight. Appearance. Motor disturbances Catatonia Stereotypy Mannerisms Behavioral problems Hygiene Social functioning “Soft signs”.

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Psychotic Disorders

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  1. Psychotic Disorders

  2. Archetype • Schizophrenia

  3. Phenomenology • The mental status exam • Appearance • Mood • Thought • Cognition • Judgment and Insight

  4. Appearance • Motor disturbances • Catatonia • Stereotypy • Mannerisms • Behavioral problems • Hygiene • Social functioning • “Soft signs”

  5. Mood and Affect • Affective flattening • Anhedonia • Inappropriate Affect

  6. Thought • Thought Process • Content

  7. Thought Process • Associative disorders • Circumstantial Thinking • Tangential thinking

  8. Other associative problems • Perseveration • Distractibility • Clanging • Neologisms

  9. Thought Content • Phenomenology • Thought content • Hallucinations • Delusions

  10. Cognitions • Subtle impairments • Frontal lobe function • Associative thinking

  11. Positive versus Negative Sxs • Positive • Hallucinations • Delusions • Bizarre behavior • Associative disorders

  12. Negative Symptoms • Alogia • Affective flattening • Anhedonia • Avolition/apathy

  13. Epidemiology

  14. Epidemiology • ~1% prevalence • Genders • Age of onset • Socioeconomic

  15. Pathology

  16. Anatomic • Widened ventricles • Decreased size certain regions

  17. Histology • Abnormalities of cytoarchitecture • Alignment • Amount

  18. Pathology • Neurophysiology • Hypofrontality

  19. More Neurophysiology • Other neurological changes • Eye movements • Blink rate • Sleep disorders

  20. Etiology • Dopamine

  21. Dopamine Hypothesis • Metabolites • Dopamine receptor agonists • Action of antipsychotics

  22. Other Transmitters • Glutamate • Primary excitatory transmitter • May relate to glutaminergic tone • NMDA receptor antagonists • PCP

  23. Neurodegenerative theories • Evidence for cell loss • Reduced neuronal densities • Etiology

  24. Neurodevelopmental Theories • Abnormalities of cytoarchitecture • Absence of gliosis

  25. Genetics • Genetic Theories • Family studies • 1o relatives = 5% • Dizygotic twins = 10% • Monozygotic twins = 50% • Adoption studies • Greater risk

  26. Possible Environmental Culprits • Bad parenting • Social/economic • Viral • Allergic/Antibodies

  27. Etiology Function Neurodevelopment Genetics Environment

  28. Diagnosis

  29. Diagnosis • Schizophrenia: DSM-IV • “A” Criteria • = Psychosis • Duration • 6 months • Global Criteria

  30. Diagnosis • “A Criteria” • Two or more: • Delusions • Hallucinations • Disorganized speech • Disorganized behavior • Negative symptoms

  31. Schizophrenia Subtypes • Catatonic • Movement • Disorganized • Process • Paranoid • Content • Undifferentiated • Residual

  32. Differential • Delirium • Dementia • Medication-induced • Other Psychiatric Illnesses

  33. Comorbidity • Depression • Substance Abuse

  34. Course and Prognosis

  35. Course of Schizophrenia Premorbid Prodr. Acute Stable/Residual 10 20 30

  36. Prognosis • Usually deteriorates • ~ exacerbations w/ incomplete recovery • Symptoms change over time

  37. Outcome

  38. Positive Predictors • Acute onset • Short duration • Good premorbid functioning • Affective symptoms • Good social functioning • High social class • Neg fam hx psychotic • No structural

  39. Poor Predictors • Insidious onset • Long duration • Family hx of psych illness • Obsessions/Compulsions • Assaultive Behavior • Poor premorbid functioning • Neurological/anatomic abn. • Low social class

  40. Treatment

  41. Antipsychotic Medications • Phenothiazines • Chlorpromazine • Butyrophenones • Haloperidol • Atypicals • Clozapine

  42. Antipsychotics • Mechanism of actions • Dopamine blockade • D-2 and analogues

  43. Antipsychotics: Indications • Acute psychosis • Prevention of relapse • Also used in other disorders • Acute mania • Anxiety/insomnia • Aggressive disorders

  44. Antipsychotics: Side Effects • Anticholinergic • Extrapyramidal (Parkinson’s-like)

  45. Other effects • Dopaminergic • Tardive dyskinesia • NMS • Idiopathic • Hematologic • Clozapine • Rashes, skin pigmentary, temperature dysregulation

  46. Antipsychotics • Approach • Lower doses usually adequate • Adjust to side effects • Evaluate for TD • How long? • 1st episode • Maintenance

  47. Other Treatments • Electroshock • Other tranquilizers

  48. Psychosocial Treatments • Supportive • Social/educative • Family

  49. Other Diagnosis • Schizophreniform • Schizoaffective • Brief Psychotic • Delusional Disorders • Shared Psychoses • Psychosis due to somethin’ else

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