psychotic disoder.............. (2).pptx

Psychiatric nursing students of university

1. Psychotic Disorders (For 3 rd year BSc. midwifery students) By Takele T ( MSc , assist professor, PhD candidate) 5/13/2024 1

2. Objectives Describe the concept psychosis –acute and chronic Discuss each psychotic disorders and Explain the difference and similarity between them List differential diagnosis for each psychotic disorders Plan management 5/13/2024 2

3. Definition of Psychosis Psychotic means grossly impaired reality testing. With gross impairment in reality testing: persons incorrectly evaluate the accuracy of their perceptions and thoughts Hallucinations , delusions, bizarre behavior, and incoherent speech are considered direct evidence of psychosis. 5/13/2024 3

4. Types of psychotic disorders Schizophrenia Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Brief Psychotic Disorder Shared Psychotic Disorder Substance induced psychotic disorders Psychotic Disorder due to general medical condition 5/13/2024 4

5. What is schizophrenia Schizophrenia is a serious brain disorder that distorts the way a person thinks, acts, expresses emotions, perceives reality, and relates to others.. The expression of these manifestations varies across patients and over time, but the effect of the illness is always severe and is usually long lasting. 5/13/2024 5

6. DX Based on the psychiatric history and mental status examination (MSE). There is no laboratory test for schizophrenia No clinical sign or symptom is pathognomonic for schizophrenia; every sign or symptom seen in schizophrenia occurs in other psychiatric and neurological disorders. 5/13/2024 6

7. Epidemiology The lifetime prevalence of schizophrenia is about 1 percent Schizophrenia is found in all societies and geographical areas, and incidence and prevalence rates are roughly equal worldwide. 5/13/2024 7

8. Epid…. Gender and Age Schizophrenia is equally prevalent in men and women. Onset is earlier in men than in women. The peak ages of onset are 10 to 25 years for men and 25 to 35 years for women. Onset of schizophrenia before age 10 or after age 60 is extremely rare. 5/13/2024 8

9. Clinical Picture DSM-V (Diagnostic and Statistical Manual APA) A- Characteristic symptoms : Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., affective flattening, alogia , 5/13/2024 9

10. Cont…. B-Social/occupational dysfunction: C-Duration: 6months D-Schizoaffective and mood disorder exclusion: E-Substance/general medical condition exclusion: F- Not relationship to a pervasive developmental disorder 5/13/2024 10

11. Symptoms of Schizophrenia Positive symptoms :are exaggerated behaviors delusions, hallucinations, disorganized speech, bizarre behavior. Negative symptoms :loss of behaviors such as loss of affect, inability to maintain social contacts impaired decision making and inability to maintain attention. 5/13/2024 11

12. Positive symptoms the word positive does not mean "good." Rather, it refers to obvious symptoms that are not present in people without schizophrenia Negative symptoms the word negative does not mean "bad," but reflects the absence of certain normal behaviors in people with schizophrenia Positive symptoms are generally more responsive to treatment than negative symptoms 5/13/2024 12

13. Etiology “ multifactorial = genetic + environmental factors” Environmental factors Biological factors  prenatal and post natal complications such as maternal infections and obstetric complications associated with hypoxia 5/13/2024 13

14. Genetics Prevalence in General population = 1% Non twin siblings of schizophrenia patient = 8% Child with one parent with schizophrenia = 12% Di zygotic twin of a schizophrenia patient = 12% Child with two parent with schizophrenia = 40% Mono zygotic twin of schizophrenia patient = 47% 14 5/13/2024

15. . The revised dopamine hypothesis suggested that the positive symptoms of schizophrenia were likely due to increases in dopamine activity in the mesolimbic areas of the brain , particularly in the nucleus accumbens (most likely involving D2 and D3 receptors) the negative symptoms were thought to be associated with a decrease in dopamine in the mesocortical region and/or prefrontal cortices (PFC), possibly linked more to D1 and/or D4 receptors 5/13/2024 15

16. FOUR DOPAMINE PATHWAYS IN THE BRAIN ( i ) Nigrostrial Pathway : Substantia Nigra to Basal Ganglia (movement) (ii) Mesolimbic Pathway : Venteral Tegmental Area (VTA) of the Brainstem to Limbic Systems of the Brain (Positive schizophrenia symptoms) 16 5/13/2024

17. (iii) Mesocortical Pathway : VTA to Frontal Cortex (Negative &Cognitive schizophrenia symptoms) (iv) Tuberoinfundibular Pathway : Hypothalamus to Anterior Pituitary Gland ( Prolactin secretion) 17 5/13/2024

18. 5/13/2024 18

19. Sub-Types of Schizophrenia 1 . Paranoid Subtype Pre-occupation with one or more delusions of persecutions or grandeur Frequent auditory hallucinations 19 5/13/2024

20. First episode of illness at an older age Show less regressions of their mental faculties, emotional responses and behaviors than the other types do.  Comparing to other sub-types paranoid type show better outcome 20 5/13/2024

21. 2. Disorganized Subtype Disorganized thought, speech, and behaviour Affective flattening Marked regression to primitive /childhood state Onset before the age of 25 Poor outcome 21 5/13/2024

22. 3 . Catatonic Subtype Marked disturbance of motor activity that is apparently purposeless and not influenced by external stimuli Motoric immobility evidenced by stupor, waxy flexibility Negativism , rigidity Peculiarities of voluntary movement e.g. mannerisms Echolalia or echopraxia Two of the above symptoms are required. 22 5/13/2024

23. 4. Undifferentiated Subtype Criterion A symptoms are present, but the criteria are not met for the paranoid, disorganized, or catatonic behavior. 23 5/13/2024

24. 5. Residual Subtype Presence of continuing evidence of schizophrenia symptoms in the absence of active symptoms. Presence of Emotional blunting, social withdrawal, odd beliefs. 24 5/13/2024

25. Differential diagnosis Brief Psychotic disorder Schizophreniform disorder Schizoaffective disorder Delusional disorder Mood disorders Personality disorder Malingering, Factitious disorder 5/13/2024 25

26. Prognosis A reasonable estimate is that 20 to 30 percent of all schizophrenia patients are able to lead some what normal lives. About 20 to 30 percent of patients continue to experience moderate symptoms, and 40 to 60 percent of patients remain significantly impaired by their disorder for their entire lives. 5/13/2024 26

27. Treatment…. Antipsychotics diminish psychotic symptom expression and reduce relapse rates. Approximately 70 percent of patients treated with any antipsychotic achieve remission. 5/13/2024 27

28. Phases of Treatment in Schizophrenia Treatment of Acute Psychosis focuses on alleviating the most severe psychotic symptoms . lasts from 4 to 8 weeks. Treatment During Stabilization and Maintenance Phase to prevent psychotic relapse and to assist patients in improving their level of functioning. 5/13/2024 28

29. Typical/ classicaL Neuroleptics Low potency : Chlorpromazine Thioridazine High potency: Haloperidol Fluphenazine 5/13/2024 29

30. Atypical Antipsychotics: Risperidone Olanzapine Quetiapine Clozapine 5/13/2024 30

31. Conventional antipsychotics Generic name Chlorpromazine (Thorazine ) Fluphenazine (Prolixin ) Haloperidol (Haldol) Loxapine (Loxitane) Mesoridazine (Serentil) Perphenazine (Trilafon) Thiorizadine (Mellaril ) Thiothixene (Navane) Trifluoperazine (Stelazine) Daily Oral Dose Range 200-1500 2-20 2-20 20-200 50-400 4-48 200-800 2-30 5-50 5/13/2024 31

32. Neuroleptic (typicals): side effects Acute dystonia Akathisia Tardive dyskinesia Sedation, anticholinergic, lower seizure threshold, increased prolactin 5/13/2024 32

33. Atypical Antipsychotics: Side Effects Sedation Hyperglycemia, new-onset diabetes Anticholinergic effects Less prolactin elevation Some EPS Increased lipids 5/13/2024 33

34. Medication-Related Movement Disorders: Acute Syndromes Can occur in 90% of all patients Dystonia : involuntary muscle spasms, abnormal postures Parkinsonism : rigidity, akinesia (slow movement), and tremor, masklike face, loss of spontaneous movements Akathisia : Inability to sit still, subjective restlessness Treatment Anticholinergic Medication for dystonia , parkinsonism ( Artane and Cogentin ) Akathisia does not usually respond to anticholinergic medication. Beta blockers have best success. 5/13/2024 34

35. Movement Disorders: Chronic Tardive Dyskinesia Irregular, repetitive involuntary movements of mouth, face, and tongue, Abnormal finger movements are common. Begin after 6 months , but also as antipsychotics are withdrawal Irreversible - controversy 5/13/2024 35

36. Movement Disorders: Chronic Etiology believed that chronic dopamine suppression in the EPS causes an overactivation of the system increases in antipsychotic meds, suppresses Treatment prevention by using lowest possible dosage, minimize use of PRN, closely monitor individuals in high-risk groups 5/13/2024 36

37. Neuroleptic Malignant Syndrome(NMS) It is a life-threatening complication of antipsychotic treatment. The symptoms include severe muscle rigidity mutism , agitation, high fever, sweating, increased blood pressure tachycardia. Treatment is supportive 5/13/2024 37

38. Long-acting injectable (depot) antipsychotics haloperidol and fluphenazine risperidone , olanzapine Injections every 2 weeks or 4 weeks Goal is to decrease non-adherence and thus reduce relapse 5/13/2024 38

39. Updated APA Practice Guidelines for Treatment of Schizophrenia guideline recommends that selection of an antipsychotic agent be guided by the patient's past medication history current symptoms co-occurring conditions other concurrent treatments, and preferences . second-generation agents should be considered first-line options for patients in the acute phase, mainly because of the decreased risk of extrapyramidal side effects and tardive dyskinesia, 5/13/2024 39

40. Dopamine Dopaminergic Neurons 'Negative' and positive signs Serotonin Serotonergic neurons Decreased dopaminergic transmission in mesocortical pathway Frontal cortex Limbic system Normal dopaminergic transmission in nigrostriatal pathway Increased dopaminergic transmission in mesolimbic pathway Raphe nuclei VTA S.nigra Serotonin secreted by neurons causes 5-HT2 receptor stimulation and subsequent inhibition of mesocortical dopaminergic neurons Intact extrapyramidal system 'Negative' signs Positive'signs 5/13/2024 40

41. Typical Antipsychotics Worsening in 'negative' signs EPS Improved 'positive' signs Worsening of negative symptoms due to blockade of the already decreased dopaminergic transmission in the mesocortical pathway 5/13/2024 41

42. Atypical antipsychotic drugs Infrequent extrapyramidal side-effects Potential improvement in 'negative' signs Improved 'positive' signs Improvement in 'negative' signs due to the much- increased dopaminergic transmission in mesocortical pathway) 5-HT2 receptor blockade (by SGAs) stops the inhibitory effect of the serotonergic neurons on mesocortical and nigrostriatal dopaminergic neurons (i.e. with subsequent increase in their firing rate) Increased dopaminergic firing rate in mesocortical and nigrostriatal pathways overrides the blockade by atypical APDs block postsynaptic D2 dopaminergic receptors 5/13/2024 42

43. Schizophreniform disorder Definition DSM-V-TR describes schizophreniform disorder as similar to schizophrenia, except that its symptoms last at least 1 month but less than 6 months. Patients with schizophreniform disorder return to their baseline level of functioning once the disorder has resolved 5/13/2024 43

44. Cont……….. Epidemiology The disorder is most common in adolescents and young adults and is less than half as common as schizophrenia. A lifetime prevalence rate of 0.2 percent and a 1-year prevalence rate of 0.1 percent have been reported . 5/13/2024 44

45. Cont……………… Diagnosis and clinical features Schizophreniform disorder is an acute psychotic disorder that has a rapid onset No progressive decline in social and occupational functioning. 5/13/2024 45

46. Cont……….. The initial symptom profile is the same as that of schizophrenia in that two or more psychotic symptoms ( hallucinations, delusions, disorganized speech and behavior, or negative symptoms ) must be present. 5/13/2024 46

47. Cont………………. negative symptoms are relatively uncommon in schizophreniform disorder and are considered poor prognostic features . By definition, patients with schizophreniform disorder return to their baseline state within 6 months. 5/13/2024 47

48. Cont……… Differential Diagnosis Secondary Psychosis ( detailed history and physical examination and, when indicated, performing laboratory tests or imaging studies).. Other psychotic syndromes Mood disorders with psychotic features . 5/13/2024 48

49. Cont………… Course and Prognosis Most estimates of progression to schizophrenia range between 60 and 80 percent . What happens to the other 20 to 40 percent is currently not known. 5/13/2024 49

50. Treatment . Hospitalization. a 3- to 6-month course of antipsychotic drugs (e.g., risperidone ). Several studies have shown that patients with schizophreniform disorder respond to antipsychotic treatment much more rapidly than patients with schizophrenia Psychotherapy 5/13/2024 50

51. Delusional Disorder Delusional disorder refers to a group of disorders, the chief feature of which is the presence of non bizarre delusion People suffering from this illness generally do not regard themselves as mentally ill and actively oppose psychiatric referral. Because they may experience little impairment, they generally remain outside hospital settings , 5/13/2024 51

52. Cont………….. They are more likely to have contacts with professionals such as lawyers and other medical specialists for health concerns. Nonbizarre delusions typically involve situations or circumstances that can occur in real life (e.g., being followed, infected, or deceived by a lover ) and are believable. 5/13/2024 52

53. Cont…………………… DELUSIONAL DISORDER A . Non bizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned,infected, loved at a distance,) of at least 1 month’s duration. B . Criterion A for schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present. 5/13/2024 53

54. Cont…………………… C. functioning is not markedly impaired and behavior is not obviously odd or bizarre. D . If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E . The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) 5/13/2024 54

55. Specify type (the following types are assigned based on the predominant delusional theme): Erotomanic type: delusions that another person, usually of higher status, is in love with the individual Grandiose type: delusions of inflated worth, power, knowledge, identity, or special relationship to famous person Jealous type: delusions that the individual’s sexual partner is unfaithful 5/13/2024 55

56. Cont……………………….. Persecutory type: delusions that the person (or someone to whom the person is close) is being malevolently treated in some way Somatic type: delusions that the person has some physical defect or general medical condition Mixed type: delusions characteristic of more than one of the above types but no one theme predominates 5/13/2024 56

57. course Delusional disorder does not lead to severe impairment or change in personality,but Suicide has often been associated with this disorder . In almost half of the cases, the delusion disappears at follow-up the more acute and earlier the onset of the illness, the more favorable the prognosis . 5/13/2024 57

58. TREATMENT Though generally considered resistant to treatment and interventions, the management is focused on managing the morbidity of the disorder by reducing the impact of the delusion on the individual’s (and family’s) life. An effective and therapeutic clinician patient relationship is important but difficult to establish. 5/13/2024 58

59. Cont………… Shared Psychotic Disorder In this disorder, the transfer of delusions takes place from one person to another. Both persons are closely associated for a long time and typically live together in relative social isolation. In its more common form, the individual who first has he delusion is often influential member of the close relationship with another individual 5/13/2024 59

60. Cont…………… The second individual is frequently less intelligent, more gullible, more passive, or more lacking in self-esteem than the primary case. If the two people involved are separated, the second individual may leave from the delusion. 5/13/2024 60

61. Cont………… An important feature in the diagnosis is that the person with shared psychotic disorder does not have a pre-existing psychotic disorder. The delusions themselves are often not as bizarre as those seen in individuals with schizophrenia. This condition is more common in people from low socioeconomic and in women . 5/13/2024 61

62. Course Though separation of the submissive person from the dominant person should resolve the psychosis, this probably occurs only in 10–40% of the cases . Differential Diagnosis Malingering, factitious disorder psychotic disorder due to a general medical condition substance-Induced psychotic disorder . 5/13/2024 62

63. Cont…………….. TREATMENT The initial step in treatment is to separate the affected person from the source of the delusions. Antipsychotic agents may be used if the symptoms have not become less intensive in a week after separation. Psychotherapy with the non delusional members of the individual’s family should be undertaken . 5/13/2024 63

64. Cont…… Brief Psychotic Disorder DIAGNOSIS Brief psychotic disorder is defined by DSM-V-TR as a psychotic disorder that lasts more than 1 day and less than a month. Moreover, the disorder may develop in response to severe psychosocial stressors or group of stressors. 5/13/2024 64

65. Cont…………………… BRIEF PSYCHOTIC DISORDER A. Presence of one (or more) of the following symptoms: (1) delusions (2) hallucinations (3) disorganized speech (e.g. Frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior Note: Do not include a symptom if it is a culturally sanctioned response pattern . 5/13/2024 65

66. Cont…………………………… B. Duration of an episode of the disturbance is at least 1 day but less than 1 month , with eventual full return to premorbid level of functioning. C. The disturbance is not better accounted for by a mood disorder with psychotic features, schizoaffective disorder, or schizophrenia and is not due to the direct physiological effects of a substance 5/13/2024 66

67. Cont………………. Specify if: With marked stressor (s) (brief reactive psychosis): if symptoms occur shortly after and apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person’s culture Without marked stressor (s): if psychotic symptoms do not occur shortly after, or are not apparently in response to events that, singly or together, would be markedly stressful to almost anyone in similar circumstances in the person’s culture With postpartum onset : if onset within 4 weeks postpartum 5/13/2024 67

68. Cont….. The DSM-V-TR diagnostic criteria specify the presence of at least one clear psychotic symptom lasting a minimum of 1 day to a maximum of 1 month. Furthermore, DSM-V-TR allows the specification of two additional features: the presence or the absence of one or more marked stressors and a postpartum onset. 5/13/2024 68

69. Cont…………… DSM-V-TR Once the duration criteria are met, other conditions such as etiological medical illnesses and substance-induced psychosis need to be excluded. 5/13/2024 69

70. Clinical features 5/13/2024 People suffering from this disorder usually present with an acute onset, manifest at least one major symptom of psychosis Affective symptoms, confusion, and impaired attention may be more common in brief psychotic disorders than in chronic psychotic conditions. 70

71. Cont…… The precipitating stressors most commonly encountered are major life events that would cause any person significant emotional turmoil. Such events include the death of a close family member or severe accidents. Rarely, it could be accumulation of many smaller stresses. 5/13/2024 71

72. Course Individuals with brief psychotic disorders generally have good prognosis , and European studies indicate that 50–80% of all individuals have no further major psychiatric problems. Occasionally, depressive Symptoms follow the resolution of the psychosis. Suicide is a concern during both the psychotic phase and post psychotic depressive phase. 5/13/2024 72

73. Prognosis Indicators of good prognosis- are good premorbid adjustment severe precipitating stressors sudden onset of symptoms little affective blunting short duration of symptoms absence of family history of schizophrenia 5/13/2024 73

74. Differential Diagnosis Major psychotic conditions Psychotic disorder due to a general medical condition, Substance-induced psychosis, factitious disorder with predominantly psychological signs and symptoms, and malingering. 5/13/2024 74

75. TREATMENT short-term hospitalization for a comprehensive evaluation and safety. Antipsychotic drugs are often most useful along with benzodiazepines. Long-term use of medication is often not necessary and should be avoided 5/13/2024 75

76. Cont……………………………. If maintenance medications are necessary, the diagnosis may need to be revised. the newer antipsychotic agents have a better neurological side effect profile and would be preferred over the typical agents. Psychotherapy is necessary to help the person reintegrate the experience of psychosis 5/13/2024 76

77. Postpartum Psychosis Postpartum psychosis ( puerperal psychosis) is an example of psychotic disorder not otherwise specified that occurs in women who have recently delivered a baby; the syndrome is most often characterized by the mother's depression, delusions, and thoughts of harming either her infant or herself. 5/13/2024 77

78. Psychotic Disorders Schizo-phrenia Usually insidious Many Chronic >6 months Delusional disorder Varies (usually insidious) Delusions only Chronic >1 mo. Brief psychotic disorder Sudden Varies Limited <1 mo. Onset Symptoms Course Duration 5/13/2024 78

79. THE END!! 5/13/2024 79

80. 5/13/2024 80