NRG6503advpsy
AS12
ManagementofPsychoticdisorders2020.pptxManagement of Psychotic disorders
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Schizophrenia spectrum and other psychotic disorders
Approximately 1.9 million Americans suffer from schizophrenia.
It is the most chronic and disabling of the severe mental disorders.
10th leading cause of disability in the world
Symptoms of schizophrenia affect multiple areas of functioning
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DSM related disorders
Schizotypal personality disorder
Delusional disorder
Brief psychotic disorder
Schizophreniform disorder
Schizoaffective disorder
Substance/medication induced psychotic disorder
Psychotic disorder due to another medical disorder
Catatonia associated with another mental disorder
Catatonic disorder due to another medical conditions
Unspecified Catatonia
Incidence/demographics
Schizophrenia occurs less often in women
Worldwide 15-44 years old
Men onset 18 to 25, tend to have more negative symptoms and a poor prognosis and more hospitalizations and more cognitive impairment
Women onset ages 25 to 35
Usually have less premorbid dysfunction and more dysphoria
Natural History of Schizophrenia APA Text book of pschiatry
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Age 10 15 17 20
Disease Onset
First Treatment
Undetected/Untreated Illness
Phase
Premorbid
•
Mild nonspecific
symptoms
Prodromal
•
Brief / attenuated
positive symptoms
and/or functional
decline
Active
•
Psychotic, negative,
cognitive, and mood
symptoms
Remission
•
Psychotic symptoms
resolve to varying
extents between
episodes
Chronic/
Residual
•
Ongoing negative
symptoms,
cognitive/social
deficits, and
functional decline
Course: Prodromal Period
Schizophrenia is often preceded by a prodromal period, which may be a year or more in length.
Prodromal period may last only weeks but usual length is between 2 to 5 years.
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Prodromal Period: Symptoms
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The prodrome is associated with severe impairment and nonspecific symptoms such as sleep disturbance, poor concentration, and social withdrawal.
Later in the prodrome, positive symptoms such as perceptual abnormalities, suspiciousness, and ideas of reference emerge.
For example, prodromal individuals may believe they have special gifts, such as the ability to communicate with inanimate objects.
Risk Factors of Schizophrenia
High risk factors:
Males
Persons living in urban situations rather than rural environments
Persons with a personal of family history of migration
Genetic loading ie a relative with the disorder
Prenatal malnutrition or exposure to a virus or the flu
OB complications in the mother
CNS infection in childhood
.
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Dimensions of Schizophrenia
. 2009;110(1-3):1-23.
Positive
Symptoms
Motor
Symptoms
Mood
Symptoms
Cognitive
Deficits
Disorganization
Negative
Symptoms
Different Underlying
Pathophysiology and
Treatment Response
Schizophrenia
Constellation of symptoms
A disease of information processing
Behavioral and cognitive symptoms
Interpersonal relationship issues 60-70% do not marry
Downdrift in functionality ie difficulty holding a job
Self care deficits
Symptom clusters
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Diagnosis of Schizophrenia
DSM 5 diagnosed as a disturbance that:
Is not due to substance use or a general medical condition such as a brain tumor.
Two or more of the following symptoms are present for at least one month:
delusions or hallucinations,
disorganized speech,
disorganized or catatonic behavior, or
negative symptoms.
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Schizophrenia: Differential Diagnosis
.
Among the many medical conditions with associated psychotic symptoms are
cerebral tumors, Epilepsy
Cushing’s syndrome and vascular dementia
AIDS/Neurosyphilis
Wernike –Korsakoff syndrome
Substance induced psychotic disorder
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Etiology: Biochemical Alterations
Dopamine hypothesis states that psychotic symptoms result from excess dopaminergic activity in the brain.
The dopamine hypothesis rests upon two observations:
Effective medications for managing psychotic symptoms have antagonist action on the dopamine type 2 (D2) receptor.
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Biochemical Alterations (con’t)
Dopamine dysregulation is intrinsic to schizophrenia (rather than a medication side effect) and predates the first psychotic episode.
Serotonin excess is hypothesized to cause both positive and negative symptoms of schizophrenia.
The inhibitory amino acid neurotransmitter y-aminobutyric acid (GABA) has been implicated in schizophrenia.
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Neuropathology
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Smaller frontal and temporal lobes
Cerebral Ventricular enlargement
Cellebllar atrophy
Polygenic SNP defect; Single nucleotide polymorphism-a different
Chromosome 6p24-22 have been implicated
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Chronic Relapsing/Residual Symptoms
Nonadherence following Response
Prodrome
First Episode
Treatment Resistance
Progressive Brain Tissue Loss
First
Episode
Second
Episode
Third
Episode
Fourth
Episode
Premorbid
Level of Functioning (%)
100
90
80
70
60
50
40
30
20
10 0
Age (years)
Nasrallah HA, et al. Contemporary Diagnosis and Management of the Patient with Schizophrenia. Second Edition. Newton, PA: Handbooks
Functional changes and brain loss after First episode
Clinical Presentation
The symptoms of schizophrenia have been divided into three types:
Positive-psychotic dimension
Negative Symptoms
Disorganization
POSITIVE-presence of something that should be absent ie voices
Negative-Absence of something that should be present ie motivation
Disorganization ie disorganized speech and behavior and inappropriate affect
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Positive Symptoms
Caused by increased dopamine in the mesolimbic pathway
Hallucinations
Delusions/suspiciousness
Referential thinking ie thought broadcasting
Grandiosity/disorganized behavior
Clinical Presentation: Positive Symptoms
Positive symptoms involve additions to normal experiences and consist of hallucinations and delusions.
Although delusions of control, thought broadcasting, and thought insertion are traditionally associated with schizophrenia, the most common delusions are those of reference or persecution.
While hallucinations may involve any of the senses, auditory hallucinations are by far the most common.
Voices conversing among themselves or commenting upon the person’s behavior are considered characteristic, but threatening or accusatory auditory hallucinations are more common.
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hallucinations
Cenesthetic hallucination-sensation of an altered state in body organs for examination a burning sensation in the brain cutting sensation in bones
Hypnopompic hallucination is one that occurs when one is awake
Terms to know: Neologism, clang associations, echolalia, catalepsy (waxy flexibility) and Capgras syndrome-a familiar person has been replaced by an imposter
Negative symptoms
Decrease or loss of normal functioning respond to atypical anti psychotics
Affective flattening/alogia/poverty of speech
Avolition/Apathy
Abstract thinking problems
Anhedonia/difficulty with attention
Clinical Presentation: Cognitive Symptoms
IQ is one of the strongest predictors of outcome
Cognitive symptoms include memory and attention deficits, language difficulties, and problems with executive functioning.
Problems with executive functioning are evidenced by difficulties in:
Ordering sequential behaviors
Establishing goal-directed plans
Maintaining task when interrupted
Monitoring personal behavior
Associating knowledge with required responses
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Cognitive Symptoms (con’t)
Current literature indicates that cognitive impairment of some magnitude is all but universal in persons with schizophrenia.
Cognitive deficits are present throughout the disease course, although they can be improved somewhat with antipsychotic treatment.
Cognitive impairment is associated with poorer outcomes in social and vocational areas.
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Clinical Presentation: Disorganization
Disorganization includes: formal thought disorder, derailment, poverty of speech, or behavioral disorganization.
Formal thought disorder is a lack of progressive goal-directed thought processes, includes derailment and poverty of speech.
Derailment is a pattern of speech in which a person’s ideas slip off track onto another unrelated or obliquely related topic; derailment is also known as “loosening of associations.”
Poverty of speech is the Inability to start or take part in a conversation, particularly small talk.
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Disorganization (con’t)
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Behavioral disorganization ranges from inappropriate affect to attire inappropriate to the season/activity.
Presence of disorganization is associated with poor outcomes.
Clinical Presentation: Motor Symptoms
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Simple slowing of psychomotor activity, to isolated posturing, to states of catatonia.
Catatonic symptoms are rarely observed in today’s clinical practice.
When they do occur, catatonic syndromes involve echolalia, echopraxia, waxy flexibility, and automatic obedience.
First psychotic episode may be insidious or acute and herald's onset of schizophrenia typically occurring between the ages of 15 and 45 years.
First Psychotic Episode
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Course
Course is one of symptom exacerbations and remissions.
Positive symptoms appear to plateau within five to ten years of diagnosis but negative symptoms become more pronounced as the disease progresses. Patients become increasingly socially disabled over time.
Negative symptoms, poor social support and social withdrawal, are indicators of a poor outcome with cognitive deficits being more predictive of poor community functioning than symptom level.
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Course (con’t)
Women have more rapid responses to medications, more improvement regardless of stage of illness, and require lower medication doses than men with schizophrenia.
Women have more dystonia, parkinsonism, akathisia, and TD, and experience higher medication-related prolactin elevations.
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Folie a Deux
No longer in the DSM 5
Its characteristic feature is transmission of delusions from “inducer” (primary patient), who is the “originally” ill patient and suffers from a psychotic disorder, to another person who may share the inducer's delusions in entirety or in part.
involves a paranoid delusion in most cases.
Shared psychotic disorder is mostly observed among people who live in close proximity and in close relationship
Treatment
The majority of patients with folie à deux require multiple treatments including separation,
antipsychotics,
individual and group psychotherapy, and family therapy.
Physical Health Promotion
Patients have higher mortality and morbidity than the general population; only ¼ of which is explained by their higher rates of suicide and accidents.
Mortality rates are approximately double those of the general population and their lifespans are 15 to 20 years shorter.
Excess mortality is linked to increased prevalence of several medical conditions associated with a shorter lifespan (diabetes and cardiovascular disease), high rates obesity, smoking, sedentary lifestyle, and poor diet.
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Physical Health Promotion (con’t)
Patients with schizophrenia are often not diagnosed, or are diagnosed later than the general population, with cardiovascular diseases due to inadequate symptoms reporting or poor access to care.
Patients with schizophrenia experience increased rates of treatment complications than the general population due to the interactions of psychiatric and medical treatments.
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Delusional disorder
Characterized by the presence of well systemized delusions
Delusions have lasted for at least one month
Behavior is not odd apart from the delusion
Erotomanic type-another person is in love with them
Grandiose type-conviction of having some great but unrecognized talent /discovery or insight
Jealous-partner is unfaithful
Persecutory-they are being conspired against, spied on, poisoned
Somatic- delusion involves bodily functions or sensations
Mixed- no one delusional belief predominates
Unspecfied
Specifiers- Bizarre content when implausible or not understandable ie organs removed by aliens
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Delusional disorder
Rare only 2% of the population
Must establish a therapeutic relationship
Gently challenge the delusions
Psychopham can be offered
Schizophreniform Disorder
Have symptoms of schizophrenia but less than 6 months in duration
Poor Prognosis Indicators
Early onset
Absence of precipitating factor(s)
Insidious onset
Poor premorbid function
Withdrawn and/or autistic symptoms
Being single, divorced or widowed
Presence of a family history of schizophrenia
Poor support system
History of prenatal trauma
Multiple relapses
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Goals to Recovery
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Recovery domains include: Socialization, symptoms, and community functioning.
Recovery is fostered through treatments targeted at symptom management, and by additional attention to fostering engagement in work and community life.
Recovery outcomes: independent living, work or school involvement, symptom reductions, and having friends.
Treatment: Pharmacotherapy
Antipsychotic medications are the mainstay of schizophrenia treatment.
Antipsychotic medications have been divided into two categories on based on similarities in mechanism of action.
Typical (first generation)
Atypical (second generation)
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First Generation Antipsychotics
The older, typical, or first generation antipsychotic (FGA) medications include perphenazine (Trilafon), thioridazine (Mellaril), and chlorpromazine (Thorazine).
These medications act primarily to block dopamine receptors and increase dopamine destruction.
This mechanism of action is thought to explain the effectiveness of these medications in reducing the positive symptoms of schizophrenia.
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Second Generation Antipsychotics
During the past 20 years, additional atypical or second generation antipsychotic (SGA) medications were introduced.
Clozapine (Clozaril) was the first of these medications.
It was followed by risperidone (Risperdal), olanzapine (Zyprexa), and quetiapine (Seroquel).
Ziprasidone (Geodon) and aripiprazole (Abilify) are the most recent introductions.
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Why SGAs are better than FGAs
Less TD
Less
Nonadherence
Less
Depression
Better
Cognition
Fewer EPS
Fewer
Negative
Symptoms
Greater Ease of
Obtaining Antipsychotic
Effect without EPS
National Institute of Mental Health (NIMH) Clinical Antipsychotic Trial for Intervention Effectiveness (CATIE) study
CATIE Study
Overall, olanzapine had the longest time to discontinuation in phase 1, but it was associated with significant weight and metabolic concerns.
Perphenazine was not significantly different in overall effectiveness, compared with quetiapine, risperidone, and ziprasidone.
Also, perphenazine was found to be the most cost-effective drug.
Clozapine was confirmed as the most effective drug for individuals with a poor symptom response to previous antipsychotic drug trials, although clozapine was also associated with troublesome adverse effects.
SGA’s (con’t)
All SGAs have an antagonist function against serotonin as well as dopamine.
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APA guidelines summary
The guideline reaffirms that patients diagnosed with schizophrenia should be treated with an antipsychotic medication
For patients whose symptoms have improved, treatment should continue with the same antipsychotic and should not be switched.
Clozapine—recommended as the first choice for treatment-resistant schizophrenia, patients with high suicide risk, and patients with a high risk of aggressive behavior
Long-acting injectable antipsychotics for those who prefer them
or if they have a history of poor or uncertain adherence
VMAT 2 medications
Reversible inhibitor of the vesicular monoamine-transporter-2
Indicated for
Moderate to severe tardive dyskinesia
Examples of VMAT 2 medications
Ingrezza – Valbenazine-$7,039 per month
Astuedo- dutetrabenzanine-$5750
Xenazine-Tetrabenazine
Above may be covered by Commercial Insurance
Psychosocial Treatment
Clients who are experiencing a first episode of psychosis; use of cognitive-behavioral therapy for psychosis; psychoeducation; and supported employment services
Assertive community treatment interventions if there is a "history of poor engagement with services leading to frequent relapse or social disruption
Family interventions are recommended for patients who have ongoing contact with their family
Patients should also receive interventions "aimed at developing self-management skills and enhancing person-oriented recovery." They should also receive cognitive remediation, social skills training, and supportive psychotherapy
Comparison of FGAs and SGAs
Generally, extrapyramidal symptoms are greater with risperidone and olanzapine, and less with quetiapine and aripiprazole.
Weight gain appears to be substantial with olanzapine and clozapine, moderate with risperidone and quetiapine, and least with ziprasidone and aripiprazole.
Rates of diabetes mellitus induction are highest with olanzapine and clozapine and lowest with ziprasidone and aripiprazole.
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Extrapyramidal Symptoms
Extrapyramidal side effects (EPSs) occur in approximately 60% of patients treated with antipsychotic medications.
Acute EPSs include medication-induced Parkinsonism, dystonia, akathisia, and neuroleptic malignant syndrome.
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Extrapyramidal Symptoms (con’t)
These side effects occur within the first days or weeks of treatment, are dose dependent, and are reversible if the medication is reduced or discontinued.
A chronic EPS is Tardive dyskinesia (TD), which occurs after months or years of medication exposure and may be irreversible even if medication is discontinued.
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Medication Induced Parkinsonism
Symptoms include bradykinesia, tremor, rigidity, and akinesia.
The first clinical consideration is to distinguish these symptoms from negative symptoms.
Parkinsonian side effects, unlike negative symptoms, usually respond to a reduction in antipsychotic medication or to the addition of an anticholinergic antiparkinsonian medication, such as trihexyphenidyl (Artane) or benztropine (Cogentin). Austedo/Ingrezza new medications
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Anti-Parkinsonian Medications (con’t)
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Common side effects include: dry mouth, nausea, blurred vision, dizziness, and are often more common in elderly persons.
Clients receiving trihexphenidyl should be monitored for increased intraocular pressure at regular intervals, as closed angle glaucoma has been reported with this medication.
Benztropine
Benztropine is an anticholinergic and antihistamine.
Common side effects include dry month, blurred vision, and urinary retention.
Clients prescribed benztropine are instructed to promptly report gastrointestinal complaints, fever, or heat intolerance, as the administration of this medication is concomitantly associated with paralytic ileus and hyperthermia, which have been fatal in some persons.
Benztropine is also associated with glaucoma.
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Dystonia
Dystonia involves spastic contraction of muscle groups, most commonly in the neck, eyes, and torso that are sudden, dramatic and frightening.
It occurs in approximately 10% of patients upon initiation of antipsychotic therapy.
APA guidelines recommend oral maintenance anticholinergic antiparkinsonian medications for patients who have experienced dystonia in the past.
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Akathisia
Akathisia is marked by sensations of restlessness, pacing, and an inability to sit still.
Occurs in up to 30% of patients treated with antipsychotic medication.
Increased motor activity must be differentiated from the agitation accompanying psychosis.
Akathisia may respond to a reduction in antipsychotic medication or to the addition of trihexyphenidyl, benztropine, or lorazepam.
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Neuroleptic Malignant Syndrome
NMS is a rare but potentially fatal form of acute EPS.
It appears to be a reaction to acute dopamine depletion.
It has been reported with virtually all Dopamine D2 receptor antagonists, including risperidone, clozapine, and ziprasidone.
Incidence of NMS ranges from 0.5% to 2.4%.
An increased dose of a neuroleptic, abrupt withdrawal of dopamine agonists, dehydration, electrolyte imbalance, and concurrent use of lithium and tricyclic antidepressants can trigger NMS.
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Presentation of NMS
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Fever, skeletal muscle rigidity, altered mental status, and autonomic dysfunction.
Creatinine phosphokinase and WBC counts are usually elevated.
Complications such as rhabdomyolysis, disseminated intravascular coagulation, and renal failure result in death in 20% of cases.
Treatment of NMS is extensive, and hospitalization is required.
Treatment of NMS
After immediate discontinuation of the offending agent, dopamine agonists are given to reverse receptor blockade.
Dantrolene sodium is used to reduce fever and muscle rigidity.
Urine alkalinization with high volumes of crystalloids may prevent renal failure, however, hemodialysis is sometimes required.
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Tardive Dyskinesia (TD)
TD is a movement disorder associated with chronic neuroleptic treatment and advanced age.
It is a concern in patients receiving antipsychotic medications.
Although there is less of a risk than with FGAs, a number of studies have implicated SGAs such as risperidone, olanzapine, and ziprasidone in the disorder.
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Tardive Dyskinesia (con’t)
TD is characterized by rapid, writhing, involuntary movements that affect the orofacial region in 75% of cases, the limbs in 50% of cases, and the trunk in 25% of cases.
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Tardive Dyskinesia (con’t)
Puckering, lip smacking, chewing, and jaw clenching are common.
Tongue protrusion and licking the lips also appear as the condition progresses.
Treatment involves stopping the offending agent if possible.
Providers should strive to identify and prescribe the lowest dose of antipsychotic medication needed to control symptoms and should reevaluate the dose at least annually.
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AIMs q 6 months
Looks at Facial and oral movements
Extremity Movements
Trunk movements
Overall severity of movements
Dental status
Psychosocial Interventions
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Goal: Improvement of coping resources and system supports to protect against environmental stressors.
APA recommends the addition to pharmacology of psychosocial interventions such as Social Skills Training (SST), Vocational Rehabilitation, and Assertive Community Treatment (ACT).
Outcomes
Long-term outcomes vary between recovery and incapacitation.
Ten to fifteen percent of those diagnosed with schizophrenia have no further episodes.
Most have exacerbations and remissions throughout their lifetime.
10% to 15% are chronically and severely psychotic.
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Obesity
Rates of obesity, dyslipidemia, glucose dysregulation, and type II diabetes are higher in persons with schizophrenia than the general population.
Combine to increase their risk for cardiovascular disease approximately twelve-fold over that of the general population.
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Cardiovascular Disease
Cardiovascular disease contributes the greatest number of excess deaths in women with schizophrenia, while
suicide contributes the greatest number of excess deaths among men.
Metabolic syndrome -Abdominal obesity, excess visceral fat (as opposed to subcutaneous fat), increases the circulatory workload, leading to an increased likelihood of type II diabetes, hypertension, and elevated triglycerides, all of which ultimately increase cardiovascular mortality and morbidity.
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Nicotine/Smoking
Approximately 70% to 80% of patients with schizophrenia smoke (most consume more than 20 cigarettes/day).
They are 5 times more likely to smoke than the general population.
Smoking reduces plasma levels of many FGAs and SGAs, including haloperidol, olanzapine, and clozapine by approximately 1/3 through enzyme induction of cytochromeP450.
Plasma levels of risperidone, aripiprazole, quetiapine, and ziprasidone are metabolized through cytochromeP2D6 and YP3A and are unaffected by smoking.
Treatment: Smoking cessation.
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Pregnancy
Care of a pregnant woman with schizophrenia is complex and requires attention to both prenatal care and psychiatric management.
Data indicate a relatively low risk of fetal harm with SGA’s.
Adjunctive medications such as mood stabilizers and benzodiazepines are associated with serious fetal malformations and behavioral effects.
For example, lithium is associated with a 2 to 3 times increased risk of major birth defects including Epstein’s anomaly, while lorazepam and other benzodiazepines are associated with birth defects.
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Substance Abuse Disorders
20% to 65% of patients with schizophrenia have a comorbid substance abuse disorder.
Alcohol, nicotine, and cannabis are the most common drugs of abuse.
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Suicide
Suicide is leading cause of premature death in schizophrenia.
Risks specific to schizophrenia: young age at onset, high socioeconomic status, high intelligence, high aspirations, chronic course, greater insight, and higher premorbid achievement.
Approximately 50 % of persons with schizophrenia attempt suicide at least once and 10-15% die by suicide.
Protective factors include family support, social connectedness, and treatment with clozapine.
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Adherence to Treatment/Treatment
Rates of adherence to antipsychotic medications range from 11% to 80% with average rates of 50%.
Voc rehab; CBT, Social skills training and ACT
The Assertive Community Tx –clients assigned to a multidisciplinay team. Services are available 24-7.
Use of LAI medications can prevent relapse and should be considered early in the course of treatment.
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