Other Psychotic Disorders

Other Psychotic Disorders: Brief Psychotic Disorder; Substance/Medication-Induced Psychotic Disorder; Psychotic Disorder d/t Another Medical Condition

1. Other Psychotic Disorders University of Massachusetts, Amherst Nursing 690 Donna Petko, MSN, RN, APN, FNP-BC March 30, 2015

2. Objective p revalence d iagnostic criteria d evelopment f unctional consequences c ultural issues measurements diagnostic features specifiers severity levels differential diagnoses ICD-10 coding To increase understanding of Other Psychotic Disorders listed in the DSM-5 (APA, 2013):

3. Other Psychotic Disorders

4. Other Psychotic Disorders Consist of the following (APA, 2013): Brief Psychotic D isorder Substance/Medication-Induced Psychotic D isorder Psychotic Disorder d/t Another Medical Condition

5. Brief Psychotic Disorder Prevalence (APA, 2013): m ay account for 9% of cases of first-onset psychosis (US) m ore common in developing countries m ore common in females than males: 2 to 1

6. Brief Psychotic Disorder cont. Diagnostic Criteria (APA, 2013): Presence of 1 or more of the following: Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behaviors Duration ≥1 day to < 1 month Not better explained by: M ajor depressive, bipolar disorder with psychotic features Another psychotic disorder (schizophrenia or catatonia) Not attributable to substance use, another medical condition

7. Brief Psychotic Disorder cont. Development and course (APA, 2013): May appear in adolescence/early adulthood Onset can occur throughout lifespan Average age of onset mid 30s Diagnosis requires full remission of all symptoms and eventual return to premorbid level of functioning within 1 month of onset

8. Brief Psychotic Disorder cont. Functional Consequences (APA, 2013): Despite high rates of relapse, outcome is excellent in social functioning and symptomatology, for most individuals Cultural Issues (APA, 2013): Cultural and religious backgrounds must be considered E.g., some individuals report hearing voices in religious ceremonies but these do not persist and are not perceived as abnormal by the individual’s community

9. Brief Psychotic Disorder cont. Measurements: Clinician-Rated Dimensions of Psychosis Symptom Severity (APA, 2013 ) 5-point scale Covers 8 domains: delusions , hallucinations, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mania Useful in treatment planning, prognostic decision-making, and research on pathophysiological mechanisms Use at regular intervals; the higher the score, the worse the functioning

10. Brief Psychotic Disorder cont. Diagnostic Features (APA, 2013): Sudden onset of at least one positive symptom: delusions, hallucinations, disorganized speech, or grossly abnormal psychomotor behavior, including catatonia ≥ 1 day to < 1 month Specifiers: w ith marked stressors w ithout marked stressors w ith postpartum onset w ith catatonia

11. Brief Psychotic Disorder cont. Severity Levels (APA, 2013): Severity is rated by quantitative assessment: Clinician-Rated Dimensions of Psychosis Symptom Severity Differential Diagnoses (APA, 2013): Other medical conditions Substance-related disorders Depressive/bipolar disorders Other psychotic disorders Malingering/factitious disorders Personality disorders

12. Brief Psychotic Disorder cont. ICD-10 Coding (APA, 2013): 298.8 (F23)

13. Substance/Medication-Induced Psychotic Disorder Prevalence (APA, 2013): Unknown in general population Between 7-25% of individuals presenting with first episode in various settings are reported to have SMIPD

14. Substance/Medication-Induced Psychotic Disorder cont. Diagnostic Criteria (APA, 2013): Presence of 1 or both of the following: Delusions Hallucinations Evidence from H x , PE, or labs of both 1 & 2: Symptoms in criterion A developed during/soon after substance/medication intoxication, exposure or withdrawal Involved substance/medication capable of producing symptoms in criterion A

15. Substance/Medication-Induced Psychotic Disorder cont. Diagnostic Criteria cont. (APA, 2013): The disturbance: not better explained by other psychotic disorder that is not substance/medication-induced does not occur exclusively during the course of a delirium causes clinically significant distress/impairment in social, occupational, or other areas of functioning

16. Substance/Medication-Induced Psychotic Disorder cont. Development and course (APA, 2013): Onset may vary based on substance E.g., smoking a high dose of cocaine may induce psychosis within minutes Substance/medication-induced psychotic disorder may persist even when offending agent is removed E.g., amphetamines may induce psychotic states lasting weeks or longer Polypharmacy may cause psychosis

17. Substance/Medication-Induced Psychotic Disorder cont. Functional Consequences (APA, 2013): Typically severely disabling and seen more in ER Disability is typically self-limited and resolves when offending agent is removed Cultural Issues (ISMP, 2003): Some cultures/races respond differently to medications based on genetic differences Practices such as fasting may alter medication levels

18. Substance/Medication-Induced Psychotic Disorder cont. Measurements: Clinician-Rated Dimensions of Psychosis Symptom Severity (APA, 2013) 5-point scale 8 domains: delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mania Useful in treatment planning, prognostic decision-making, and research on pathophysiological mechanisms Use at regular intervals; the higher the score, the worse the functioning

19. Substance/Medication-Induced Psychotic Disorder cont. Diagnostic Features (APA, 2013): Prominent delusions/hallucinations (Criterion A) d /t physiological effects of substance/medication m ust be evidence in Hx , PE, or labs of both: s ymptoms in criterion A developed during or soon after use i nvolved substance/medication is capable of producing symptoms in criterion A Not better explained by a psychotic disorder that is not substance/medication-induced Does not occur exclusively during course of a delirium Causes clinically significant distress/impairment

20. Substance/Medication-Induced Psychotic Disorder cont. Specifiers (APA, 2013): w ith onset during intoxication w ith onset during withdrawal Severity Levels (APA, 2013): Severity is rated by quantitative assessment: Clinician-Rated Dimensions of Psychosis Symptom Severity Differential Diagnoses (APA, 2013): Substance intoxication or substance withdrawal Primary p sychotic disorder Psychotic disorder due to another medical condition

21. Substance/Medication-Induced Psychotic Disorder cont. ICD-10 (APA, 2013, p. 111):

22. Psychotic Disorder d/t Another Medical Condition Prevalence (APA, 2013): Estimated lifetime prevalence 0.21-0.54% Ages 65+ have > prevalence 0.74% More common in untreated endocrine, metabolic, autoimmune disorders; temporal lobe epilepsy Among older individuals, may be higher in females, but unclear

23. Psychotic Disorder d/t Another Medical Condition cont. Diagnostic Criteria (APA, 2013: Prominent hallucinations or delusions Evidence from H x , PE, or labs indicating direct pathophysiological consequence of another medical condition The disturbance: not better explained by another mental disorder does not occur exclusively during course of delirium causes clinically significant distress/impairment in social, occupational, or other areas of functioning

24. Psychotic Disorder d/t Another Medical Condition cont. Development and course (APA, 2013): May be a single transient state or recurrent Treatment of underlying medical condition usually rectifies, but not always: E.g., psychotic symptoms may persist after brain injury Condition may be long term in chronic conditions like MS Older adults have higher prevalence of the disorder d/t increasing medical burden, advanced age, cumulative effects of age-related processes Younger age groups more affected by epilepsy, head trauma, autoimmune, and neoplastic events

25. Psychotic Disorder d/t Another Medical Condition cont. Functional Consequences (APA, 2013): Typically severe due to another medical condition Varies considerably by the type of condition Likely to improve with successful resolution of condition Cultural Issues (ISMP, 2003): Some cultures/races respond differently to medications based on genetic differences Practices such as fasting may alter medication levels Individuals may not take medications to treat medical conditions d/t cultural norms/expectations

26. Psychotic Disorder d/t Another Medical Condition cont. Measurements: Clinician-Rated Dimensions of Psychosis Symptom Severity (APA, 2013) 5-point scale Covers 8 domains: delusions, hallucinations, disorganized speech, abnormal psychomotor behavior, negative symptoms, impaired cognition, depression, and mania Useful in treatment planning, prognostic decision-making, and research on pathophysiological mechanisms Use at regular intervals; the higher the score, the worse the functioning

27. Psychotic Disorder d/t Another Medical Condition cont. Diagnostic Features (APA, 2013): Prominent delusions/hallucinations Evidence from Hx , PE, labs that disturbance is result of pathophysiological consequence of another medical condition N ot better explained by another mental disorder Doe not occur exclusively during course of delirium Causes clinically significant stress or impairment in social, occupational, or other areas of functioning

28. Psychotic Disorder d/t Another Medical Condition cont. Specifiers (APA, 2013 ): Based on predominant symptom: With delusions With hallucinations Severity Levels (APA, 2013): Severity is rated by quantitative assessment: Clinician-Rated Dimensions of Psychosis Symptom Severity Differential Diagnoses (APA, 2013): Delirium Substance/medication-induced psychotic disorder Psychotic disorder

29. Psychotic Disorder d/t Another Medical Condition cont. ICD-10 (APA, 2013): Code based on predominant symptom: 293.81 (F06.2) with delusions 293.82 (F06.0) with hallucinations Coding note: Include the name of the other medical condition in the name of the mental disorder; the other medical condition should be coded and listed separately immediately before the psychotic disorder

30. Test Your Knowledge

31. Case Study A 50-year-old man, nonalcoholic, with uncontrolled diabetes mellitus and hypertension was admitted to the hospital with history of high-grade fever and cough with scanty expectoration, of 2 days’ duration; and burning micturition and ulcer over left foot. Clinically the patient was febrile and diagnosed to have community-acquired left lower lobe pneumonia with urinary tract infection and cellulites of left foot. Investigations revealed Hb was 10.4 g/dl, total leukocyte count was 9,500 cells/mm 3 with neutrophilia , E.S.R. was 60 mm at one hour, random blood sugar was 250 mg/dl, blood urea was 25 mg/dl, serum creatinine was 1.3 mg/dl with normal creatinine clearance, and serum electrolytes were within normal limits. Peripheral smear for malarial parasite was negative. Urine microscopy showed 15-18 pus cells/high power field. However, urine culture was sterile and urine ketone bodies were negative. Blood and sputum culture did not grow any organisms ( Moorthy , Raghavendra , & Venkatarathnamma , 2008, para. 3 ).

32. Case Study cont. Final diagnosis of type 2 diabetes mellitus with hypertension with community-acquired pneumonia and urinary tract infection and cellulites of left foot with ulcer was made. In view of multiple infections, intravenous amoxicillin (1 g) and clavulanic acid (200 mg) every 8 th hour were started and continued for 10 days. His general condition improved, and repeat chest x-ray showed resolution of pneumonia with better lung aeration. Cellulitis and urinary tract infection also showed improvement, and blood sugar and hypertension were under control. After 10 days, oral levofloxacin (500 mg/day) was started as a sequential therapy in view of persisting foot ulcer. On the third day of therapy, he became restless and speech became irrelevant and incoherent. Later he became abusive, violent and experienced visual hallucinations of people in his hospital room. Gradually his confusion worsened and he became more violent in nature. He slept very little ( Moorthy et al., 2008 , para. 3 ).

33. What do you think is causing the psychosis?

34. Case Study cont. Psychiatric evaluation was suggestive of acute psychosis. The diagnosis of acute psychosis cannot be attributed to the clinical diagnosis as the patient had good improvement following 10 days of intravenous amoxicillin and clavulanic acid therapy. Other conditions like hypoglycemia, dyselectrolytemia , diabetic ketoacidosis, and meningitis were ruled out. Other drugs the patient was receiving were insulin, enalapril , atorvastatin, which are not known to result in such psychosis. So the likely possibility of levofloxacin-induced acute psychosis was considered and levofloxacin was stopped. Within 48 h of stopping levofloxacin, repeat psychiatric evaluation revealed him to be alert and oriented with no further hallucinations. His speech was normal in flow and content, and his concentration and recall were intact. He did not require any antipsychotic medications ( Moorthy et al., 2008 , para. 3 ).

35. References American Psychiatric Association. (2013). Clinician-rated dimensions of psychosis symptom severity. Retrieved from http :// www.psychiatry.org / File%20Library / Practice/DSM/DSM-5/ ClinicianRatedDimensionsOf PsychosisSymptomSeverity.pdf American Psychiatric Association. (2013). Diagnostic and statistical manual of mental d isorders (5 th ed.). Washington D.C.: Author. Institute for Safe Medical Practices. (2003). Cultural diversity and medication safety. Retrieved from http ://www.ismp.org / newsletters/ acutecare /articles/20030904.asp

36. References cont. Moorthy , M. Raghavendra , N, & Venkatarathnamma , P.N. (2008). Levofloxacin-induced acute psychosis. Retrieved from http :// www.ncbi.nlm.nih.gov/pmc/articles/PMC2745871