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TRANSCRIPT
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Schizophrenia Spectrum and
Other Psychotic Disorders
Britta Ostermeyer, MD, MBA Professor and Chairman
Department of Psychiatry and Behavioral Sciences
University of Oklahoma
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Learning
Objectives
At the end of this class, the audience will be able to:
1) Explain symptoms of psychosis
2) Name the DSM-5 psychotic disorders and the symptoms
3) Identify the differences between the DSM-5 psychotic disorders
4) Name first and second generation antipsychotics and
know their main side-effects
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Psychosis
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Positive Symptoms: Excess/Distortion of Normal Function
• Thought content: delusions
• Perception: hallucinations
• Language/thought process:
disorganized speech
• Behavior:
disorganized/catatonic behavior
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Negative Symptoms: Poverty/Restrictions
• Emotional expression: flat affect
• Thought and speech: alogia
• Initiation of behavior: avolition
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Bizarre Delusions: Implausible
• Thought withdrawal
• Thought insertion
• Delusions of control
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Command Hallucinations
Suicide 52%
Unspecified 17%
Non-violent acts 14%
Injury to self or others 12%
Homicide 5%
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Compliance with Commands
• Hallucinated-related delusion
• Familiar voice
• Less dangerous commands
• History of compliance
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Patient’s Mother God by Michelangelo
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Differential Diagnosis
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Differential Diagnosis
• Substance abuse
• Medical causes
• Severe depression with psych features
• Cluster A Personality Disorders
- Paranoid Personality Disorder
- Schizoid Personality Disorder
- Schizotypal Personality Disorder
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Psychotic
Disorders
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Schizophrenia Spectrum and Other
Psychotic Disorders-1
• Schizotypal (Personality) Disorder
• Delusional Disorder
• Brief Psychotic Disorder
• Schizophreniform Disorder
• Schizophrenia
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Schizophrenia Spectrum and Other
Psychotic Disorders-2
• Schizoaffective Disorder
• Substance/Medication-Induced Psychotic Disorder
• Psychotic Disorder Due to Another Medical Condition
• Catatonia
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Case: Mr. Lucas
Mr. Lucas is a 19 yo college sophomore who “does not fit in” as
per his mother who is taking him to see you at your new primary
care clinic. Mom says he is odd and preoccupied with “laboratory
worriers.” He spends hours drawing weird looking soldiers with
“three eyes.” Mom explains that he is different, always suspicious
of others, and does not seem to like people. Mr. Lucas lives by
himself in an off-campus apartment. Mom says that he has been
shy, quiet, and reserved since childhood. He has no close friends,
never dated anybody, and “is fascinated by ghosts and telepathy.”
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Schizotypal Personality Disorder-1
A. Social and interpersonal deficits marked by discomfort and
reduced capacity for close relationships; cognitive and
perceptional distortions, eccentricities of behavior, beginning in
early childhood, 5 or more:
1. Ideas of references
2. Odd beliefs, magical thinking influencing behavior,
inconsistent with norms (telepathy)
3. Unusual perceptional experiences, bodily illusions
4. Odd thinking and speech
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Schizotypal Personality Disorder-2
5. Suspiciousness or paranoid thinking
6. Inappropriate or constricted affect
7. Odd, eccentric behavior or appearances
8. Lack of close friends/confidants
9. Excessive social anxiety associated with paranoid
fears rather than negative self judgment
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Case: Mr. Thompson
Your first patient this morning is Mr. Thompson, who is a 51 yo school bus
driver, coming in for “bugs in my bowels.” You open his EMR chart and realize
that your colleagues have been seeing the patient for several months related
to a CC of “bugs in my bowels.” He was worked up but all tests are normal,
including blood work, stool samples as well as an abdominal U/S and CT. Last
year, he even had a colonoscopy, which was normal as well. As you walk into
the exam room, Mr. Thompson greets you with an old glass full with feces
stating “they are all in here, I know it.” He has no hx of voices, visions, PI, or
mood sx. As per his chart, he is in good standing with his employer.
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Delusional Disorder
• 1 or more delusions
• 1 month or longer
• Schizophrenia criterion A never met
• Functioning not markedly impaired
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Case: Mr. Smith
Mr. Smith is a 26 yo OU mechanical engineer student who was
brought to your ER by campus police who found him at 12:35am
sitting outside his classroom building crying and shouting “leave me
alone.” Upon arrival, he is scanning the room stating, “I have voices
and visions that scare me.” One week ago, he started to hear the
voice of an unknown male telling him that he is “dirty.” He is also
seeing “grey shadows or ghosts that fly around the room.” O/E, he
looks disheveled, there is a smell of body odor, and he is unshaven.
His Utox is negative, he has no known medical illnesses.
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Brief Psychotic Disorder
• Presence of 1 or more, at least 1 must be 1., 2., or 3.:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
• 1 day - 1 month
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Case: Mr. Lee
Mr. Lee is a 22 yo college freshman who was taken to your ER by his
GF and mother. He states that he came bc of “migraines and spiritual
feelings” for the past 3 months. He reports his headache is really bad
when he hears “voices that make me feel guilty.” For the past 3
months, he has been hearing strangers commenting “on my past
sins.” He states no mood changes, no anxiety, and no substance
abuse. His GF reports that Mr. Lee has become socially “very isolated
and quiet” after having previously been “fun and outgoing. “
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Schizophreniform Disorder
• 2 (or more) for 1 month, one must be 1.,2.,or 3.:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
• 1 month - 6 months
• Schizoaffective Disorder, bipolar ruled out
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Case: Mr. Jones
Mr. Jones is a 28 yo WM who is brought into your ER by his family
with a CC of “They are after me, you are one of them.” He has had
paranoid ideations since about age 21. At home, he pushed his
mother against the wall shouting at her over and over that she is to
quit her job as a spy for the Cuban government. He also has been
pacing in the garden while loudly arguing with himself. In the EC,
he reports that he is seeing Cuban soldiers who want to kill him. As
you inquire further, Mr. Jones tells you, “They are after me bc I am a
white man. And I am refusing to belong to their army of the devil.”
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Schizophrenia
• 2 (or more) for 1 month, one must be 1.,2.,or 3.:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
• Functional impairment
• 6 months or longer
• Schizoaffective Disorder, bipolar ruled out
• Not due substance or medical condition
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Movie: “A Beautiful Mind”
Professor Nash’s Mental Illness
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Video Clip
Russell Weston,
Capitol Shooting, 1998
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Schizophrenia
Good Prognostic Factors
Female
Good premorbid functioning
Acute onset
Late onset
Obvious predisposing factors/stressors
Positive sx
Mood sx
Fhx of mood ds
Good support
Married
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Schizophrenia
Poor Prognostic Factors
Male
Poor premorbid functioning
Insidious onset
Early onset, < age 20
No obvious predisposing factors/stressors
Negative sx
Soft neuro signs
No mood sx
No Fhx of mood ds
Poor support
Single
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Schizophrenia
Lifetime prevalence: 1%
Most common hallucination: Auditory
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Case: Ms. Dee
Ms. Dee is a 32 yo homemaker who was taken to your ER via police after she
attacked her HB at home. She hit him with a frying pan. She is agitated and
states that her HB is “in cahoots with the CIA.” She says, “He is arranging for
them to come and get me!” Her HB tells you that for the past one week, the
patient is enormously irritable, not sleeping at night, is talking fast on the
phone for hours, and is shouting or hitting him. As you obtain some past hx
from her HB, he tells you that she has had times in the past during which she
was hearing voices, believing that she is talking to the CIA but otherwise had a
normal mood and was calm during those times. These psychotic episodes
with normal mood lasted about 3 weeks. She has no medical problems.
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Schizoaffective Disorder-1
• Major mood episode (major depressive or manic) concurrent
with psychotic symptoms of schizophrenia
and
• Psychotic symptoms of delusions or hallucinations for 2 weeks
or more in the absence of major mood symptoms
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Schizoaffective Disorder-2
Specify If:
Bipolar type
Depressive type
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Schizoaffective Disorder
Lifetime prevalence: 0.3%
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Case: Ms. Watson
Ms. Watson is a 41 yo court reporter who is brought to your ER by her
sister for voices and agitation. The sister tells you that Ms. Watson lost
her job 4 weeks ago. Since then “is partying with different guys and
never home.” The sister says that Ms. Watson has “totally changed for
the worse over the past 4 weeks and believes that she is taking “some
drugs or so.” She stated that she saw a “pipe in her room.” As a savvy
ER doc, you had already ordered a utox prior to talking to the sister as
the patient is very agitated, covering her ears with her hands, and
yelling “I want them to shut up!” Her utox comes back positive for
cocaine and cannabis.
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Substance/Medication- Induced
Psychotic Disorder
• Delusions and/or hallucinations
• Evidence from hx, PE, or lab findings of both:
1. Sx developed during or soon after substance
intoxication, w/d, or after exposure to a medication
2. Substance is capable of producing the sx
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Case: Ms. Wu
While you are on your psych CL rotation at Presbyterian Hospital,
you are being asked to consult on Ms. Wu for paranoid behavior by
neurology. You are told by the neuro intern that she is refusing all of
her meds and appears paranoid and distrustful towards nursing staff.
Ms. Wu was admitted for the first time for tx of progressive MS with IV
solumetrol. When you arrive at her bedside, you find a suspicious
and paranoid patient who is guarded and not talking to you. You talk
to her brother and father who tell you that the patient has been
hearing some voices.
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Psychotic Disorder Due
to Another Medical Condition
• Hallucinations or delusions
• Evidence from hx, PE, or lab findings that sx is direct
pathophysiological consequence of another medical
condition
• Not better explained by another mental disorder
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Case: Ms. Max
Ms. Max is a 39 yo WF coming into your EC via ambulance. She has a hx of
bipolar 1 disorder with multiple hospitalizations due to manic episodes,
including psychotic features of religious delusions and auditory and visual
hallucinations. She is living in an assisted living facility, where the medication
is offered to the residents. Presently, she is on Risperidone 1 mg po qhs and
Risperdal Consta 37.5 mg IM q 2 weeks, the latter since March 2014. You are
told by EMS that she progressively declined at her assisted living home
showing less mimicry, staring, negativism, mutism, and immobility. When she
was found stuporous on the floor of her room, staff called 911. O/E, you find a
stuporous woman on the stretcher. There were no signs of autonomic
dysregulation; her VS are normal, and she is afebrile.
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Catatonia
3 (or more) symptoms:
1. Stupor
2. Catalepsy (passive induction of a posture held against gravity)
3. Waxy flexibility (slight, even resistance to positioning by examiner)
4. Mutism
5. Negativism (opposition or no response)
6. Posturing (spontaneous, active maintenance of a posture against
gravity)
7. Mannerism (odd, circumstantial caricature of normal actions)
8. Stereotypy (repetitive, abnormal frequent, non-goal directed
movements
9. Agitation, not influenced by external stimuli
10. Grimacing
11. Echolalia (mimicking another’s speech)
12. Echopraxia (mimicking another's movements)
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Treatment of Psychotic
Disorders
• Therapy
• Medications
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Therapy
• Supportive Individual Psychotherapy
• Social Skills Training
• Family-Oriented Therapy
• Case Management
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First Generation:
Typical Antipsychotics
Low Potency
• Chlorpromazine (Thorazine)
• Chlorprothixene (Taractan, Truxal)
• Levomepromazine (Levoprome)
• Mesoridazine (Serentil)
• Thioridazine (Mellaril)
Medium Potency
• Loxapine (Loxitane)
• Molindone (Moban)
• Perphenazine (Trilafon)
• Thiothixene (Navane)
High Potency
• Droperidol (Dehydrobenzperidol)
• Fluphenazine (Prolixin)
• Haloperidol (Haldol)
• Pimozide (Orap)
• Prochlorperazine (Compro)
• Trifluoperazine (Stelazine)
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IV Haldol
• Not IV push, very slowly
• Increased risk of torsade de pointes
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Extrapyramidal Symptoms (EPS)
1. Dystonia (acute, early)
• Involuntary contractions
• Tongue, throat, eyes, neck, back
• Benadryl 50 IM
2. Akathisia
• Restlessness, often mistaken for agitation
• Decrease dose, switch to atypical
• Ativan, B-blocker
3. Parkinsonian Symptoms
• Cogentin, switch to Seroquel
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Extrapyramidal Symptoms (EPS)
4. Tardive Dyskinesia
Facial
• Perioral movements, tics, eye blinking
Extremities
• Wormlike movements
• Toe bending or jerking
Trunk
• Torticollis
• Trunk or pelvic thrusting, rocking
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Tardive Dyskinesia
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Tardive Dystonia: Torticollis
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AIMS Evaluation
(Abnormal Involuntary Movement Scale)
Twice yearly to monitor for Tardive Dyskinesia:
1. Facial Muscles
2. Lips/Perioral Area
3. Jaws
4. Tongue
5. Upper Extremities
6. Lower Extremities
7. Neck/Shoulders/Hips
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Antipsychotics + Added Benzo
Ativan or Klonopin
• Much faster control of psychosis
• Keeps dose of antipsychotics down
• Treats potential antipsychotic SEs, e.g. akathisia, acute dystonia
• Add Ativan to IM Haldol
• Ativan: treatment for catatonia
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Treatment of Tardive Dyskinesia
• Taper antipsychotic
• Caution b/c of withdrawal dyskinesias
• Switch to Seroquel
• Clozaril
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Second Generation:
Atypical Antipsychotics
• Aripiprazole (Abilify)
• Asenapine (Saphris)
• Clozapine (Clozaril)
• Iloperidone (Fanapt)
• Lurasidone (Latuda)
• Olanzapine (Zyprexa)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)
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Metabolic Syndrome
• Abdominal obesity
• Elevated triglycerides
• Low HDL
• Elevated blood pressure
• Elevated fasting glucose
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Long Acting Therapy
Typical Depot Injections:
• Haloperidal Decanoate (Haldol), monthly
• Fluphenazine Decanoate (Prolixen), every 3 weeks
Atypical Depot Injections:
• Aripiprazole (Abilify Maintena), monthly
• Olanzapine (Relprevv), every 2 to 4 weeks
• Paliperidone Palmitate (Invega Sustenna), monthly
• Paliperidone Palmitate (Invega Trinza), every 3 months
• Risperidone Consta (Risperdal Consta), every 2 weeks
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Professor Nash Accepting The Nobel
Prize in Stockholm
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Learning
Objectives
At the end of this class, the audience will be able to:
1) Explain symptoms of psychosis
2) Name the DSM-5 psychotic disorders and the symptoms
3) Identify the differences between the DSM-5 psychotic disorders
4) Name first and second generation antipsychotics and
know their main side-effects