Psychotic Disorders

Definition
- characterized by a significant impairment in reality testing
Age of onset:
- Peak onset – 20s (but can begin at any age)
- Rare before puberty (v. rare < 10yrs or > 60yrs)
- M: 10 – 25yrs
- F: bimodal distribution: 25 – 35yrs and middle age (> 40yrs) (?? b/c of oestrogen)
  - Early onset related to worse prognosis (therefore Ms have worse prognosis)
  - Onset after 45yrs = late onset schizophrenia

Signs and Symptoms

can be grouped into the following categories:

Positive Symptoms – Presence of Something That Should Be Absent

Acute Onset:
- Rapid development of symptoms.
Prominent Delusions & Hallucinations:
- Delusions: Paranoid in nature.
- Hallucinations: Voices often exhortatory (encouraging or advising the patient).
Thought Disorder (Disorganized Behavior):
- Wild trains of thought.
- Garbled sentences.
- Irrational conclusions.
- Feelings that thoughts are inserted or withdrawn by an outside agency.
Abnormal Behaviors:
- Stereotyped movements.
- Occasionally aggressive or agitated.
Clothing & Appearance:
- Unusual dress or grooming habits.
Social & Sexual Behavior:
- Inappropriate or unusual social or sexual behaviors.

Negative Symptoms – Absence of Something That Should Be Present

Associated with Muscarinic Receptors:
- Slow, insidious onset; often diagnosed in retrospect.
- Relative absence of acute symptoms.
Affective Flattening/Blunting:
- Decreased intensity of emotional response.
- Unchanging facial expression.
- Decreased spontaneous movements.
- Paucity of gestures.
- Affective nonresponsivity.
- Inappropriate affect.
- Lack of vocal inflections.
Alogia:
- Decreased amount of spontaneous speech or tendency to produce empty/impoverished speech.
- Poverty of speech.
- Poverty of content of speech.
- Blocking.
- Increased response latency.
Avolition (Apathy):
- Loss of ability to initiate and complete goal-directed behavior.
- Impaired grooming and hygiene.
- Decreased persistence at work or school.
- Physical anergia.
Anhedonia – Asociality:
- Inability to experience pleasure.
- Decreased recreational interests/activities.
- Few relationships with friends/peers.
- Social withdrawal.
- Impaired intimacy/closeness, little sexual interest/activity.

Cognitive Deficits

Problems with:
- Attention.
- Concentration.
- Memory.
- Language.
- Abstraction.
- Executive functioning.
- Speed of processing.

Mood Disturbances

Depression.
Anxiety.

Lack of Insight

Common among patients experiencing these symptoms.

Clinical Course

3 stages of SCZ:

Prodromal phase

insidious onset of symptoms – over mths – yrs
subtle behavioural changed
- social withdrawal
- work impairment
- affective blunting
- avolition
- strange ideation

Active phase
- psychotic symptoms dvlp → eventually lead to medical intervention

Residual phase
- active-phase symptoms are absent or no longer prominent
- often role impairment, negative symptoms or attenuated positive symptoms
- acute symptoms can re-emerge during this phase = acute exacerbation

Types of delusions and hallucinations

Persecutory delusion	Belief that one is being targeted, harmed, or conspired against by others.
Grandiose delusion	Belief that one possesses exceptional abilities, wealth, power, or fame that is not supported by evidence
Erotomanic delusion	Belief that someone, usually of higher social status, is in love with the individual, despite no evidence to support it.
Somatic delusion	Belief that one has a physical illness or defect that is not present or exaggerated.
Jealous delusion	Belief that one’s partner or spouse is being unfaithful, often without any evidence.
Reference delusion	Belief that neutral or random events, objects, or people have a significant personal meaning or are directed at the individual.
Control delusion	Belief that one’s thoughts, feelings, or actions are being controlled by an external force or influence.
Thought broadcasting delusion	Belief that one’s thoughts are being broadcasted to others or that others can hear one’s thoughts.
Thought insertion delusion	Belief that thoughts are being inserted into one’s mind by an external force or entity.
Thought withdrawal delusion	Belief that thoughts are being removed or taken away from one’s mind by an external force or entity.
Nihilistic delusion	Belief that oneself, the world, or others do not exist or that significant aspects of reality are coming to an end.
Cotard delusion	Belief that one is dead, does not exist, or has lost one’s internal organs or body parts.
Capgras delusion	Belief that a loved one, usually a family member or close friend, has been replaced by an identical imposter.
Religious delusion	Belief that one has a special religious mission, is divinely chosen, or has a unique connection to a religious figure or deity.
Control delusion	Belief that external forces or agencies are controlling or manipulating one’s thoughts, emotions, or actions.
Auditory hallucinations	Hearing sounds, voices, or noises that are not actually present.Example: Hearing voices that comment on one’s actions or have conversations with the individual.
Visual hallucinations	Seeing objects, people, or things that do not exist in reality. Example: Seeing a person or animal that others cannot perceive
Olfactory hallucinations	Sensing smells or odors that are not present. Example: Smelling a strong scent of roses when there are no roses nearby
Gustatory hallucinations	Experiencing tastes in the absence of any external stimuli. Example: Tasting a metallic or bitter flavor without having consumed anything that would cause it
Tactile hallucinations	Feeling physical sensations on the body without any external cause .Example: Sensation of insects crawling on the skin when there are no insects present
Somatic hallucinations	Perception of physical experiences within the body. Example: Feeling internal organs shifting or being manipulated.
Proprioceptive hallucinations	False perception of the body’s position or movements. Example: Sensation of floating or being suspended in mid-air.
Hypnopompic hallucinations	Hallucinations that occur during the transition from sleep to wakefulness. Example: Seeing shadowy figures or hearing voices upon waking up.
Hypnagogic hallucinations	Hallucinations that occur while falling asleep or waking up. Example: Seeing vivid dream-like images upon waking up or just before falling asleep.
Kinesthetic hallucinations	Sensation of bodily movement without any actual physical movement Example: Feeling as if one is spinning or being pulled in a particular direction

Differential Dx

Psychiatric illness:
- Schizophreniform disorder = same symptoms for 1 – 6 months
- Schizoaffective psychosis = schizophrenia + mood disorder (majn feature is psychosis)
- Brief psychotic disorder (brief reactive psychosis) = < 1 month, usually stress related
  - Return to normal functioning
  - Not due to substance abuse
- Delusional disorder – non bizarre delusions > 1mth, functioning not significantly impaired
- Mood (affective) disorders
  - Bipolar disorder with psychotic features
  - MDD with psychotic features – maj. feature is depression
- Personality disorders e.g. schizotypal
- Panic disorder

Drug or substance-induced psychoses:
- Stimulants (e.g., cocaine, amphetamines)
- Hallucinogens (e.g., LSD)
- alcohol withdrawal

Organic mental disorders:

Endocrine – thyroid, parathyroid, adrenal
Hepatic or uraemic encephalopathy
Infectious – HIV, encephalitis, lyme, prion
Inflammatory/demyelinating – anti NMDA encephalitits, SLE, MS
Metabolic – Wilsons, acute intermittent porphyria
Neurodegenerative – alzheimers, Lewy body, parkinsons, huntingtons
Neurological – TBI, space-occupying, seizures, stroke
Vitamin B12 deficiency

Diagnosis

History should cover the following:
- S&S of psychosis – incl duration
- Risk Ax for suicide & violence
  - Generally higher in young M pts
  - Ask about availability of a means for committing suicide
  - ? plan for suicide
- Ax insight & willingness to take meds
- Substance use Hx
- Medical Hx
  - Risk factors for schizophrenia
    - Obstetric Hx
    - Head injuries
    - Past neurological Hx
    - Family Hx
- Developmental Hx
  - ? highest level of functioning
  - academic progress at school
- Past psychiatric Hx
- Strengths/weaknesses of family/carer
- Mental state exam
- Cognitive Ax

Physical exam:

Weight
Height
BMI
Pulse
Evidence of organic illness
Evidence of substance abuse
Stigmata of alcoholic liver disease

Rule out organic causes:

BSL + MSU
Urine Drug Screen
FBC / UEC/ LFTs / TFTs / CMP / VDRL / HIV
ECG / CXR / CT head if indicated by Hx/Ex
Head MRI if first episode psychosis

Management

Initial (prodrome) period
- Should be referred to specialist for close monitoring & intervention (psychological + low dose pharmacoTx)
Active phase
- Intensive intervention by specialist early-intervention teams
  - Multimodal Mx
- N.B. pts may require to wait ~ 6mths for referral to see psychiatrist
Residual phase
- Maintenance Tx using drugs & psychosocial methods

Antipsychotic drugs

Rationale for use:

relief from hallucinations, delusions or abnormal

behaviour/thought; tranquilising and sedation in very disturbed or aggressive pt

many SE, so just use for psychotic illnesses

Generally divided into:

First-generation (typical) antipsychotics

Potency & incidence of sedation:
- Low potency & > sedating: chloropromazine, thioridzine
- Mod potency & sedation: Trifluroperazine
- High potency & less sedating: Haloperidol, Thiothixene
Action: improve +ve symptoms & ↓relapse post acute ep, Similar risk weight gain/metabolic disturbance as 2nd gen

Second generation
- - aripiprazole (abilify)
- - clozapine
- - olanzapine
- - quetiapine
- - risperidone
- - paliperidone
- Metabolic problems more common with olanzapine, then quetiapine and risperidone – should have regular monitoring
- Extrapyramidal effects are less prominent than first generation
  - Less common with quetiapine
- Prolactin elevation – risperidone, paliperidone, less with others
  - Check level if develops sexual dysfunction or galactorrhea

Behavioural effects:

↓spontaneous motor activity
- in large doses → catalepsy (sustained immobility)
state of apathy
↓initiative
displays few emotions
slow to respond to external stimuli
tends to drowse off
easily aroused
can respond to questions accurately with no marked loss of intellectual function
aggressive tendencies – strongly inhibited
antiemetic effects also present

Adverse effects:

Extrapyramidal side-effects:
- incidence of extrapyramidal side-effects is less with atypical antipsychotics Its esp. low with Clozapine, Aripiprazole & Zotepine

Acute dystonias:	Occur in first few weeks Decline with time Reversible with removal of drug Involuntary mvts: – Restlessness – Muscle spasms – Protruding tongue, – Fixed upward gaze – Torticollis PD symptoms: Rigidity, ↓mvt, late tremor
Tardive dyskinesias	Develops after months-yrs Disabling & often irreversible → maj problem with 1^st generation antipsychotics Often gets worse when antipsychotic Tx is stopped Resistant to Tx Syndrome consists of: – Involuntary mvts (face & tongue + trunk & limbs)

Endocrine effects:
- Dopamine released by tuberohypophyseal pathway → inhibit prolactin secretion via D₂ Rcs
  - Antipsychotics → blocking D₂ Rcs → ↑plasma [prolactin] → breast swelling, pain & lactation (can occur in Ms & Fs)
- ↓growth hormone secretion – not clinically significant
Other effects:
- Sedation: via H₁ Rc block
- Anticholinergic effects: via muscarinic Rc block
  - Blurred vision, dry mouth & eyes, constipation, urinary retention & ↑intraoccular pressure
- Orthostatic hypotension: via α-adrenoRc block
- Weight gain: via 5-HT block

Idiosyncratic/Hypersensitive reactions resulting in:
- Jaundice
- Leukopenia & agranulocytosis – rare but can be fatal
- Urticarial skin reactions

Neuroleptic malignant syndrome
- psychiatric emergency
  - hypothesis: due to strong DA blockade; increased incidence with high potency and depot antipsychotics
- risk factors
  - medication factors: sudden increase in dosage, starting a new drug
  - patient factors: medical illness, dehydration, exhaustion, poor nutrition, external heat load, male, young adults
- clinical features
  - tetrad: mental status changes (usually occur first), fever, rigidity, autonomic instability
  - develops over 24-72 h
  - labs: increased creatine phosphokinase, leukocytosis, myoglobinuria
- treatment:
  - supportive – discontinue antipsychotic drug, hydration, cooling blankets, dantrolene (hydantoin derivative, used as a muscle relaxant), bromocriptine (DA agonist)
  - mortality: 5%

Clozapine monitoring

FBC – risk neutropenia, agranulocytosis
- Weekly first 18 weeks, then monthly
Myocarditis
- First month – Tempearture daily
- weekly ECG, CRP and troponin
- If any fevers do urgent ECG, CRP and troponin
- Monthly check for signs of heart failure and perform annual echo
Measure trough clozapine when steady dose – then every 6 months

Guidelines for pharmacological Tx:

Acute psychotic episode:

Behavioural emergency: start with high dose & titrate down
Schizophrenia: start with low dose & titrate up to optimal dose for pt

1st line Tx – oral form of 2^nd generation antipsychotics
- e.g. Risperidone, Olanzapine, Quetiapine, Amisulpride, Aripiprazole or Paliperidone
- N.B. QH has a Risperidone 1^st policy
- if a non-sedating antipsychotic is used – Tx anxiety, agitation & insomnia with a short-term benzodiazepine e.g. Diazepam
- monitor for AE of antipsychotics:
  - mvt disorders
  - rapid wt gain
  - undue sedation
  - hyperprolactinemia (→ breast enlargement) and/or galactorrhoea

2^nd line Tx – if the response to 1^st line Tx is unacceptable after 6 – 12 wks
- Alternate 2^nd generation antipsychotic OR
- Typical antipsychotic
  - E.g. Haloperidol, Chlorpromazine or Trifluoperazine

For Mx of negative symptoms:
- Clozapine
  - more effective against negative symptoms of schizophrenia
  - reserved for patients whose condition remains inadequately controlled despite previous use of two or more antipsychotics, of which at least one is atypical
  - AE – agranulocytosis, neutropenia, myocarditis & cardiomyopathy
    - blood tests to monitor plasma [clozapine] for the first 18 weeks, and less frequently thereafter
- Amisulpride

Maintenance therapy:

Aim – sustained control of psychotic symptoms → prevent relapse
Recommended to continue Tx with an AP for at least 1 – 2 yrs after initial psychotic episode
Multiple episodes – at least 5 yrs of Tx

Adjunctive drug therapy:

Mood stabilisers: lithium, valproate, carbamazepine → refer to Depression notes for MOA
Sedatives: benzodiazepines
Antidepressants

Early pharmacological & psychosocial Tx has shown benefits
Polypharmacy – best to avoid combining antipsychotics

Non-adherence improved by:

Depot administration – IM injections delivered either fortnightly or monthly
- typical antipsychotics – last ~ 4 wks
- Risperidone – last ~ 2 wks
Simplifying regimen
Monitoring

Psychosocial treatment

Reassurance
Support
Good doctor-pt relationship

Treatment setting

Hospital based
- when to admit a pt:
  - when illness is new → rule out DDx and to stabilise medications
  - special medical procedures e.g. ECT
  - is the pt is a danger to themselves or others e.g. aggressive behaviour
  - if pt is suicidal
  - pt is unable to care for themselves e.g. refusing to eat or take fluids
  - when medication side-effects become disabling or potentially life-threatening
- pt can be observed e.g. by nursing staff
- investigations – e.g. FBC, lithium levels etc
Community based
- pt’s are R/Vd in outpt clinics
- case managers
  - follow-up pt in the community
  - arrange clinic apptmts, blood tests, medications, assist with activities such as shopping etc

Psychosocial education
- Educate family
  - Conducted over multiple sessions
  - Helps them to provide optimum amount of emotional & social stimulation
  - Prevents too much emotional stress being placed on pt → risk of relapse
Family intervention
- Informal: psychoeducation
- Formal: structured family therapy
- Education is provided
- Dealing with upsetting/traumatic events related to pt’s condition
- Identifying and rehearsing strategies to minimise family conflicts
- Developing problem-solving skills
- Impt to balance pt’s confidentiality & the family’s need to know
CBT
- Over multiple sessions
- ↓stress & intrusiveness of delusions & hallucinations
- Motivational interviewing strategies can be used to:
  - Improve compliance with Tx
  - Address concomitant substance use problem
Social skills training
- Focus: pt’s environmental & social functioning
- Improve social & self-care function
- Pt practices basics i.e. eye contact, speech volume, length of response & questioning etc
- Assist in establishing meaningful social, vocational roles & use of leisure time
- Sheltered employment is necessary for majority of sufferers

Disability support
- Case Mx
- Supported accommodation
- Supported employment

Tx of comorbidities
- High rates of substance abuse: includes alcohol, cigarettes, cannabis & stimulants
- Major depression + anxiety: V impt to recognise & Tx
- Maintain physical health
  - Liaise with GP
  - Minimise risk factors for CVD, DM etc
    - monitor BP, wt/BMI, lipids, plasma glucose
    - exercise, dietary modifications, smoking cessation
    - preventative health programs e.g. pap smears

Handling Hallucinations in Clinical Practice

1. Initial Assessment

History Taking:
- Onset: When did the hallucinations begin?
- Duration: How long do they last?
- Frequency: How often do they occur?
- Content: What is the nature of the hallucinations (visual, auditory, tactile, etc.)?
- Context: Are there specific triggers or situations associated with the hallucinations?
Medical History:
- Previous psychiatric history.
- Current medications and substance use (including alcohol and illicit drugs).
- History of head trauma or neurological conditions.
Mental Status Examination:
- Assess the patient’s orientation, memory, mood, and thought processes.
- Evaluate for the presence of delusions or other psychotic symptoms.

2. Differential Diagnosis

Psychiatric Conditions:
- Schizophrenia or other psychotic disorders.
- Severe depression with psychotic features.
- Bipolar disorder during manic or depressive episodes.
Neurological Conditions:
- Dementia, particularly Lewy body dementia.
- Parkinson’s disease.
- Epilepsy, particularly temporal lobe epilepsy.
Substance-Related:
- Intoxication or withdrawal from alcohol, benzodiazepines, or other substances.
- Side effects of medications.
Medical Conditions:
- Delirium, often secondary to an underlying medical condition.
- Thyroid dysfunction.
- Infectious causes (e.g., HIV, syphilis).

3. Immediate Management

Ensure Safety:
- Evaluate the risk of harm to self or others.
- Consider hospitalization if there is a significant risk.
Medication Review:
- Assess and adjust current medications that may contribute to hallucinations.
- Consider the use of antipsychotic medications for immediate symptom relief.

4. Long-Term Management

Psychiatric Referral:
- Refer to a psychiatrist for comprehensive evaluation and ongoing management if needed.
Psychotherapy:
- Cognitive-behavioral therapy (CBT) can help patients manage the distress associated with hallucinations.
Medication Management:
- Antipsychotic medications are commonly used for managing hallucinations in schizophrenia and other psychotic disorders.
- Regular follow-up to monitor the efficacy and side effects of medications.
Substance Use Treatment:
- Provide support for substance cessation if hallucinations are related to substance use.
- Referral to addiction services if necessary.
Support and Education:
- Educate patients and families about the nature of hallucinations and the importance of adherence to treatment.
- Encourage participation in support groups.

5. Monitoring and Follow-Up

Regular Assessments:
- Monitor symptom progression and response to treatment.
- Adjust treatment plans based on the patient’s progress and any new symptoms.
Interdisciplinary Approach:
- Collaboration with other healthcare professionals, including psychologists, social workers, and occupational therapists, for comprehensive care.

Key Points

Early identification and comprehensive assessment are crucial.
Safety of the patient and others is a priority.
Addressing underlying causes and providing appropriate referrals is essential.
Long-term management involves a combination of pharmacological and non-pharmacological approaches.
Continuous monitoring and support are vital for effective management.