Psychosis

1. 1 DELUSIONAL DISORDERS & ACUTE & TRANSIENT PSYCHOSIS

2. INDEX Definition of psychosis Types Delusional disorders Epidemiology Aetiology Associated medical conditions Clinical types Clinical Features Differential diagnosis Course and prognosis Management Acute & Transient psychotic disorders Types Differential diagnosis Prognosis Treatment 2

3. DEFINITION Psychosis – Gross impairment in reality testing( ‘not in contact’ with reality ) Marked disturbance in personality, with impairment in social, interpersonal, occupational functioning. Marked impairment in judgement & absent understanding of current symptoms & behaviour ( loss of insight ) Presence of characteristic symptoms like delusions & hallucinations. 3

4. TYPES OF NON-ORGANIC PSYCHOSIS Delusional disorders Acute & Transient psychotic disorders Schizoaffective disorders Postpartum psychosis 4

5. 5 DELUSIONAL DISORDERS

6. DELUSIONAL DISORDERS A group of disorders where long standing, non-bizarre delusions are the primary or only manifestation of the illness. Included in ICD-10 Must be persistent for atleast 3 months . 6

7. EPIDEMIOLOGY Prevalence rate- 0.24%-0.3% Late middle age (42-15 years) Female:Male – 3:1 More common among relatives of Schizophrenia 7

8. AETIOLOGY/RISK FACTORS Social isolation Migration Sensory impairment( deafness>blindness ) Celibacy Widowhood Very common among substance abusers(cocaine) . 8

9. ASSOCIATED MEDICAL CONDITIONS Multiple sclerosis Vitamin deficiency(B12 & nicotinic acid) Hepatitis Hypothyroidism Diabetes mellitus Dementia 9

10. CLINICAL TYPES Somatic type Persecutory type Grandiose type Jealous type Erotomanic type 10

11. SOMATIC TYPE Also called Monosymptomatic hypochondriacal psychosis. Delusions related to body. Eg . – patient might feel that foul smell emanates from them. That some of their body parts are mishapen ( eg . nose) or non-functioning( eg . intestine). That lice or other parasites have infested their body. 11

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13. PERSECUTORY TYPE Most common type Patient believes that he is conspired against & harassed or bodily injured, spied or followed or poisoned by others. Resentful, may resort to legal methods in order to be redressed. OR May resort to violence against his alleged persecutors. 13

14. GRANDIOSE TYPE Exalted ideas about oneself, of birth, possessions & achievements. In a religious context may believe that they are the chosen prophets of GOD & have mysterious powers to head the masses. 14

15. JEALOUS TYPE More common in males. Also called- Sexual jealousy, erotic jealousy, morbid jealousy, psychiatric jealousy, Othello syndrome. Allegations of infidelity are made against the spouse supported by evidence collected in the form of changes & manner of dress, behaviour or remarks made by the partner. The inferences drawn are wrong & not factual. Held firmly on inadeguate grounds & are unchanged even in the face of evidence that they are false. 15

16. Cont.. Other secondary delusions may be present like he is drugged or poisoned to be put to sleep or to lose virility. Mood- sadness, misery, apprehension, rage. Patient resorts to spying or coercing confession from the partner often through violence that they are true. Elaborate steps are taken to catch the paramour ‘red handed’ & private detectives may be engaged to watch the movements of his spouse. 16

17. Cont.. He promises ‘to forget the whole thing & forgive them’&’not to persue the matter anymore’ once she confesses. The unsuspecting wife is a bid to put an end to further turmoil ‘confesses’ which aggravates her partner’s suspicion who attempts to coerce her more with greater fervor. Very resistent to treatment Continues till divorce or separation or death of spouse. 17

18. Cont.. Assaults often continued even after separation as he pleads his wife to come back and live together again. Potentially dangerous & may lead to suicide or homicide. 18 Delusion of infidelity

19. EROTOMANIC TYPE More prevalent in females. Also known as- Clerambault’s Syndrome Patient believes that another person, usually of a higher status or endowed with greater qualities, is loving her. Persue their objects of delusion physically or through letters & presents. Very often the affected woman is not attractive, hails from a poor socio-economic strata & works at a lower level job. If males affected- may be violent or aggressive with the objects of love. 19

20. CLINICAL FEATURES Presence of delusion- single or a set of related delusions for atleast 3 months- Well systematised Non-bizarre Involve situations which can occur in normal life ‘Encapsulated’ – they do not affect the other life spheres of the patient. 20

21. Cont.. Hallucinations are absent.If present, are transient & rudimentary & are auditory, tactile or olfactory. Only when the area of delusion is probed or confronted , the dysfunction becomes evident. 21

22. DIFFERENTIAL DIAGNOSIS Paranoid schizophrenia Paranoid personality disorder Substance induced delusion Mood disorders 22

23. Features Paranoid schizophrenia Delusional disorder Paranoid personality disorder General behaviour Eccentricities , mannerisms, stereotypies , decreased self care, social withdrawal, guarded & evasive. Eccentricities, decreased social interaction. Restrained social interaction. Personality Disorganised Disturbed in delusional areas, normal in other areas. No deterioration. Thought disorder Delusions, loosening of association, formal thought disorder, delusions may be bizarre. Non- bizarre delusions, are well systematized. No other thought disorder. No thought disorder. 23

24. Hallucinations Auditory common Uncommon. If present, not persistent. absent Contact with reality Markedly disturbed Disturbed in areas of delusional beliefs. Intact Insight absent absent present Affect/ mood in relation to thought Often inappropriate Usually inappropriate Usually inappropriate 24

25. COURSE & PROGNOSIS About half the cases have a chronic & unremitting course In some, the symptoms occur periodically & intervals between the episodes are totally asymptomatic. Suicide is often associated. 25

26. MANAGEMENT Hospitalisation if severe impairment or suicidal/homicidal threats/ patient non-cooperative for treatment. Antipsychotic + Antidepressant. Antipsychotics control agitation & treat the psychotic features. Drug of choice- Pimozide 68% full remission, 22% partial remission. 26

27. Cont.. Antidepressants of SSRI group such as fluoxetine preferred. Many may be refractory to treatment. Electro convulsive treatment may be needed for secondary repression. Psychotherapy 27

28. ACUTE & TRANSIENT PSYCHOTIC DISORDERS These are psychotic disorders characterized by an abrupt (<48 hours) or an acute(</= 2weeks) onset of symptoms. Precipitated by visible stress like bereavement but can occur even if no evident stress. 28

29. TYPES Acute polymorphic psychotic disorder without symptoms of schizophrenia. Acute polymorphic psychotic disorder with symptoms of schizophrenia. Acute schizophrenia- like psychotic disorder. Other acute predominantly delusional psychotic disorders. 29

30. ACUTE POLYMORPHIC PSYCHOTIC DISORDER WITHOUT SYMPTOMS OF SCHIZOPHRENIA Acute onset within 2 weeks(from non-psychotic to psychotic state). Polymorphic picture(unstable and markedly variable clinical picture that changes from day to day or hour to hour). Several types of hallucinations and/or delusions, changing in both type or intensity from day to day or within the same day. Marked emotional turmoil(intense feelings of happiness & ecstasy to anxiety & irritability). 30

31. ACUTE POLYMORPHIC PSYCHOTIC DISORDER WITH SYMPTOMS OF SCHIZOPHRENIA Meets the descriptive criteria for acute polymorphic psychotic disorder but in which typically schizophrenic symptoms are also consistently present. If schizophrenic symptoms persist for > 1 month, diagnosis changed to schizophrenia. 31

32. ACUTE SCHIZOPHRENIA-LIKE PSYCHOTIC DISORDER Characterised by acute onset of a psychotic disorder in which psychotic symptoms are comparatively stable(& not polymorphic) & fulfill the criteria for schizophrenia but have lasted for < 1month.

33. OTHER ACUTE PREDOMINANTLY DELUSIONAL PSYCHOTIC DISORDERS Acute onset of a psychotic disorder in which comparatively stable delusions or hallucinations are the main clinical features but do not fulfil the criteria for schizophrenia. Delusions of persecution or reference are common & hallucinations are usually auditory. Criteria for acute polymorphic psychotic disorder or schizophrenia should not be fulfilled. 33

34. DIFFERENTIAL DIAGNOSIS Organic mental disorders Psychoactive substance use disorders Schizophrenia Mood disorders Delusional disorders 34

35. PROGNOSIS Good prognostic factors Well adjusted premorbid personality Absence of family history of schizophrenia Presence of severe precipitating stressor before th onset Sudden onset of symptoms Presence of affective symptoms, confusion, perplexity &/or disorientation in clinical pictuer . Short duration of symptoms First episode 35

36. TREATMENT Antipsychotics- mainstay of treatment. Used to control agitation & psychotic features. Oral or parenteral . Antidepressants as adjuvants . ECT- in case of marked agitation & emotional turmoil as well as in cases where there is a danger to self or others. Psychotherapy. 36

37. REFERENCE A short textbook of psychiatry- Niraj Ahuja (7 th edition) Concise textbook of psychiatry- Namboodiri (3 rd edition) Essentials of psychiatry- N.Kumar Kaplan & Sadock’s concise text book of clinical psychiatry 37

38. 38 THANK YOU!!!