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”
 Mood and Affect
 Affective flattening
 Anhedonia
 Inappropriate Affect
 Thought
 Thought Process
 Content
 Thought Process
 Associative disorders
 Circumstantial
Thinking
 Tangential thinking
Other associative problems
Perseveration
Distractibility
Clanging
Neologisms
 Thought Content
Phenomenology
Thought content
Hallucinations
Delusions
 Cognitions
Subtle impairments
 Frontal lobe function
Associative thinking
Positive versus Negative Sxs
Positive
 Hallucinations
 Delusions
 Bizarre behavior
 Associative disorders
 Negative Symptoms
Alogia
Affective flattening
Anhedonia
Avolition/apathy
Epidemiology
 Epidemiology
~1% prevalence
Genders
 Age of onset
Socioeconomic
Pathology
 Anatomic
Widened ventricles
Decreased size
certain regions
 Histology
Abnormalities of
cytoarchitecture
 Alignment
 Amount
 Pathology
Neurophysiology
 Hypofrontality
 More Neurophysiology
 Other neurological changes
 Eye movements
 Blink rate
 Sleep disorders
 Etiology
Dopamine
 Dopamine Hypothesis
Metabolites
Dopamine receptor agonists
Action of antipsychotics
 Other Transmitters
Glutamate
 Primary excitatory transmitter
 May relate to glutaminergic tone
 NMDA receptor antagonists
PCP
 Neurodegenerative theories
 Evidence for cell loss
 Reduced neuronal
densities
 Etiology
Neurodevelopmental Theories
Abnormalities of
cytoarchitecture
Absence of gliosis
 Genetics
Genetic Theories
Family studies
 1o relatives = 5%
 Dizygotic twins = 10%
 Monozygotic twins = 50%
Adoption studies
 Greater risk
Possible Environmental Culprits
Bad parenting
Social/economic
Viral
Allergic/Antibodies
Etiology
Diagnosis
 Diagnosis
Schizophrenia: DSM-IV
“A” Criteria
 = Psychosis
Duration
 6 months
Global Criteria
 Diagnosis
“A Criteria”
 Two or more:
Delusions
Hallucinations
Disorganized speech
Disorganized behavior
Negative symptoms
 Schizophrenia Subtypes
Catatonic
 Movement
Disorganized
 Process
Paranoid
 Content
Undifferentiated
Residual
 Differential
Delirium
Dementia
Medication-induced
Other Psychiatric Illnesses
 Comorbidity
Depression
Substance Abuse
Course and Prognosis
Course of Schizophrenia
 Prognosis
Usually deteriorates
~ exacerbations w/ incomplete recovery
Symptoms change over time
 Outcome

Good Bad Intermediate

 Positive Predictors
Acute onset
Short duration
Good premorbid functioning
Affective symptoms
Good social functioning
High social class
Neg fam hx psychotic
No structural
 Poor Predictors
Insidious onset
Long duration
Family hx of psych illness
Obsessions/Compulsions
Assaultive Behavior
Poor premorbid functioning
Neurological/anatomic abn.
Low social class
Treatment
 Antipsychotic Medications
Phenothiazines
 Chlorpromazine
Butyrophenones
 Haloperidol
Atypicals
 Clozapine
 Antipsychotics
Mechanism of actions
 Dopamine blockade
 D-2 and analogues
 Antipsychotics: Indications
Acute psychosis
Prevention of relapse
Also used in other disorders
 Acute mania
 Anxiety/insomnia
 Aggressive disorders
 Antipsychotics: Side Effects

Anticholinergic
Extrapyramidal (Parkinson’s-like)
 Other effects
Dopaminergic
 Tardive dyskinesia
 NMS
Idiopathic
 Hematologic
Clozapine
 Rashes, skin pigmentary, temperature
dysregulation
 Antipsychotics
Approach
 Lower doses usually adequate
 Adjust to side effects
 Evaluate for TD
How long?
 1st episode
 Maintenance
 Other Treatments
Electroshock
Other tranquilizers
 Psychosocial Treatments
Supportive
Social/educative
Family
 Other Diagnosis
Schizophreniform
Schizoaffective
Brief Psychotic
Delusional Disorders
Shared Psychoses
Psychosis due to somethin’ else