1

THE PHILIPPINE COLLEGE OF PSYCHOPHARMACOLOGY

2010

PSYCHOSIS(Featuring the HDL method)

TEACHING MODULE FOR THEPRIMARY CARE PHYSICIANS

2

OBJECTIVES

At the end of the module, the familyphysician is expected to:

1. identify the core psychotic symptoms, specifically that of schizophrenia using the HDL method.

2. prescribe the appropriate antipsychotic medications using the STEPS approach.

3. refer to a psychiatrist, if needed.

3

FORMAT OF ACTIVITIES

• Case presentation

• Lecturettes

• Interactive sessions

• Summary

4

WHY PSYCHIATRY FOR GPs?

• Most psychiatric patients first seen by GPs

• GPs need updated skills and knowledge to help psychiatric patients better

• More easy, quick, diagnostic tools for GPs now available

• Presence of new drugs which are safe, tolerable, effective, priced right, and simple to use by GPs

5

INTERACTIVE SESSION 1

• “What is your most unusual experience?”

(Unusual vs Usual)

• “What makes you different from others?

(Unique vs Common)

• “Do you hear voices?”

(Abnormal vs Normal)

6

CASE PRESENTATION

• A 21-year old male, single, college student, suddenly runs out of his classroom. He shouts, ‘ back off ’ at a friend who follows him. He is convinced that his teachers and classmates intend to kill him. He hears the mocking voices of his teachers coming from the electric fan and on the classroom walls, talking about him and calling him nasty names.

7

CASE PRESENTATION• The patient is brought to a GP. PE and lab

tests for illegal drugs are normal. He looks blankly at the walls. He is inattentive and responds irrelevantly to questions. He mumbles incoherently, “A,B, (ZTE) F,G”. He accuses his parents and the doctor to be in a plot to kill him. He cannot be convinced otherwise.

• Judgement, impulse control, and insight are poor. Sensorium is intact.tt

8

CASE PRESENTATION

• Background: socially withdrawn and avoids group activities; with few friends and lacks initiative. An only child who relates poorly to parents who are very busy. Father is very critical and mother is overprotective. Mother had a history of similar difficulties.

• The current episode is his second in two years. No meds for three months

9

Case Summary

• A young man’s second episode of behavioural changes like blank stares, hearing voices, fixed ideas of being harmed, and irrelevant speech. These occur in the background of poor family bonding and lack of social interactions. There is a positive family history of psychiatric illness. No maintenance meds.

10

LECTURETTE

Identifying Core Symptoms of Psychosis

• Positive Symptoms: HDL method *

Hallucinations – most important ; usually auditory, multiple voices talking about the patient

Delusions - persecutory, bizarre, systematized

Looseness of associations – irrelevant speech, hard to understand

* hallucinations and delusions should be present

11

LECTURETTE

• Negative Symptoms: 4 As *

Alogia - limited speech ; tendency to mutism

Affective blunting – flat; blank stares; no emotion

Avolition – unexplained lack of initiative

Anhedonia – pervasive lack of interest / pleasure unrelated to depression

* 2 or more enhance the diagnosis

12

LECTURETTE

• Other Features: (exclusion criteria) *

At least six months duration

Social/occupational dysfunction

No mood disorder *

No substance abuse / medical condition *

13

INTERACTIVE SESSION 2

• Positive symptoms of our patient:

What is the H?

What is the D?

What is the L?

14

INTERACTIVE SESSION 3

• Negative symptoms of the patient:

Name at least 2 As:

A?

A?

15

LECTURETTE

• Other features present in our patient:

Poor functioning: school, parents, peers

Positive family history (mother)

Second episode in two years

High emotional expressivity (or ‘High EE’)- overcritical and overprotective parents

16

PSYCHOTIC?

Positive and negative symptoms plusimpaired functioning but no mood symptoms

Due to substance ←↓→ Due to medical illness?abuse? If no

↓ Ask duration

< 1month ← ↓ → < 6 months Brief Psychotic Schizophreniform

Disorder Disorder> 6 months

Schizophrenia

18

LECTURETTE

• Treatment Strategies: (including the STEPS approach)

1. Antipsychotic Drugs: Typicals

Atypicals

2. Day-to-Day Management:

family cooperation/involvement

approach of physician

19

THE STEPS APPROACH IN PSYCHOSIS

• Typical Antipsychotics: Examples chlorpromazine (Thorazine), haloperidol (Haldol)

fluphenazine decanoate (Modezine)

Safe in short-term; TD a problem in long-term Tolerable, but EPS a concern Effective, but less with (-) symptoms Price inexpensive (P20-30/day) Simple, not very (2-3x a day, except depots)

20

Average Doses of Typicals

• Chlorpromazine (Thorazine) 100-400 mg/day

• Haloperidol (Serenace, Haldol) 2-4 mg/day

• Fluphenazine Decanoate (Modezine) 12.5 – 25 mg/month (0.5 -1.0 cc) IM (long-acting)

21

Treatment for EPS

• Biperiden (Akineton) One ampoule (1 cc or 5 mg) IM or slow IV

then 1 tablet/day ( 2 mg) as maintenance (‘Cabuquit’s cocktail’)

• Diphenhydramine (Benadryl)One ampoule ( 1cc or 50 mg) IM or slow IV then 1 capsule/day (50 mg); sedating

22

USING THE STEPS APPROACH

• Atypical Antipsychotics: Examples

aripiprazole (Abilify), clozapine (Ziproc), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Aspidon)

Safe in short-term and long-term

Tolerable, except for weight gain and DM; less EPS

Effective, for both (+) and (-) symptoms

Price expensive ; generics more affordable

Simple (usual OD dosing)

26

USING THE STEPS APPROACH The fine art of choosing the best drugs (PCPsych) (5 – finest ; 1- not so fine)

Drugs S T E P S

CLZ 3 3 5 4 3

OLZ 3 2 4 2 4

QUE 4 3 4 3 3

RIS 4 3 4 4 4

ARI 4 3 4 3 4

27

LECTURETTE

• When to refer?

Diagnosis is vague or confusing

Psychiatric emergency

Need for psychotherapy

Poor response to treatment

GP feels “burnt out”/overwhelmed

28

LECTURETTE

• What to say to the patient?

Do you acknowledge failure?Should you imply referral is a “last resort?”Is the referral a rejection of the patient?Is the psychiatrist the more appropriate

doctor to deal with the problem? (suggest it is a team approach)

29

SUMMARY

• Core features of psychosis are HDL: hallucinations, delusions, and looseness of associations

• Except for their price, atypicals can be first line drugs for psychosis; typicals remain good choices, inexpensive but with tolerability issues

• Primary care physicians can be effective partners of psychiatrists in treating patients with psychosis

30

THANK YOU FOR LISTENING

Do you hear the gears talking to you?