Introduction to Psychotic Disorders and Secondary=Organic Psychotic Disorders

Содержание

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מבנה ההרצאה What is Psychosis? Symptoms DDX

מבנה ההרצאה

What is Psychosis?
Symptoms
DDX

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Psychosis Inability to distinguish between the reality and the inner world

Psychosis

Inability to distinguish between the reality and the inner world and

stimuli
OR- PROFESSIONALLY STATED-
Severely impaired judgement, reality testing and behavior, accompanied by hallucinations and/or delusions
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Why does it happen? Dopaminergic Theory Increasing levels of dopamine in

Why does it happen?

Dopaminergic Theory
Increasing levels of dopamine in the brain

can cause psychosis
Drugs that bind with dopamine receptors and block them can reduce positive psychotic symptoms.

Glutamate Theory
Blocking NMDA receptors with ketamine causes psychosis

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סימפטומים Signs of psychosis Hallucinations Delusions Bizarre or disorganized behavior Impaired

סימפטומים

Signs of psychosis
Hallucinations
Delusions
Bizarre or disorganized behavior
Impaired thought process
Impaired speech output
Abnormal movements

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הזיוHallucinationsת Abnormal perceptional experience unrelated to external stimuli 5 senses

הזיוHallucinationsת

Abnormal perceptional experience unrelated to external stimuli
5 senses

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Reasons for Hallucinations Primary psychiatric disorders Brain pathology Substances Disorders of cranial nerves Delirium Dementia

Reasons for Hallucinations

Primary psychiatric disorders
Brain pathology
Substances
Disorders of cranial nerves
Delirium
Dementia

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Auditory Hallucinations Primary psychotic disorders- human voices, noises, command hallucinations. Usually

Auditory Hallucinations

Primary psychotic disorders- human voices, noises, command hallucinations. Usually perceived

as coming from outside!
Substances- both intoxication and withdrawal. All types of voices and noises
CN7 tumors- tinnitus, music, vague noises. Usually perceived as coming from within!
Epilepsy and brain neoplasms- All types of voices and noises
Delirium and dementia- usually unclear voices and unformed phrases
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Taste Hallucinations Usually epilepsy and brain pathology Very rare in primary

Taste Hallucinations

Usually epilepsy and brain pathology
Very rare in primary psychiatric disorders
Do

not perceive taste or perceive he “wrong” taste
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Smell Hallucinations Usually epilepsy and brain pathology Rare in primary psychiatric

Smell Hallucinations

Usually epilepsy and brain pathology
Rare in primary psychiatric disorders- possible

in psychotic depression and in delusional disorder (halithosis)
Usually- unpleasant smells (decay, burned rubber)
Usually- patients perceive themselves as the source of the smell
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Somatic and Tactile Hallucinations Usually epilepsy and brain pathology In primary

Somatic and Tactile Hallucinations

Usually epilepsy and brain pathology
In primary psychiatric disorders-

possible in delusional disorder (parasitosis)
Substance- related: intoxication (cocain), withdrawal (alcohol)
DDX: peripheral neuropathy
Sense of “electricity”, “bugs crawling”, “worms”, “touch”, change in body shape
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Visual Hallucinations Usually epilepsy and brain pathology, migraines, visual impairment In

Visual Hallucinations

Usually epilepsy and brain pathology, migraines, visual impairment
In primary psychiatric

disorders- possible in schizophrenia (rare! Usually simple geometrical forms)
Substance- related: intoxication (LSD), withdrawal (alcohol). Sometimes- with full insight
Delirium and dementia (DWLB). Usually people, sometimes familiar, or animals
DDX: flashbacks of PTSD, pseudohallucinations of Cluster B personality disorders, dissociation, bereavement
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Lhermitte's peduncular hallucinosis Rare neurological disorder Visual hallucinations- vivid, detailed, often

Lhermitte's peduncular hallucinosis

Rare neurological disorder
Visual hallucinations- vivid, detailed, often moving, exclusively

in the dark
Last minutes
Dream like state with intact mentation
Very realistic
Usually consist of familiar people, places or objects
Causes:
Lesions in the thalamus, brainstem (compression by tumors), substantia nigra pars reticulata
Aura of basilar migraine localizable to the brainstem
After vertebral angiography
Vertebrobasilar insufficiency
Severe hypoplasia of vertebral artery
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MORE RECENTLY ALSO DIAGNOSED IN PATIENTS WITH MS, FRONTAL AND OCCIPITAL

MORE RECENTLY ALSO DIAGNOSED IN PATIENTS WITH MS, FRONTAL AND OCCIPITAL

LOBE CHANGES, TEMPORAL ARTERITIS, AND PITUITARY TUMORS
WHY? BRAIN COMPENSATES FOR SENSORY DEPRIVATION
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Release Hallucinations ANY MODALITY BUT VISUAL MOST COMMON: DEPENDS ON END

Release Hallucinations

ANY MODALITY BUT VISUAL MOST COMMON: DEPENDS ON END ORGAN

AFFECTED
LESIONS ANYWHERE FROM THE EYE TO THE OCCIPITAL CORTEX
USUALLY REPETITIOUS AND NONTHREATENING BUT IRRITATING
AWARENESS THAT THEY ARE NOT REAL
MODIFIED BY CHANGING VISUAL INPUT
THESE ARE MUCH MORE COMMON THAN THOUGHT AND UNDERREPORTED BECAUSE PEOPLE DO NOT WANT TO BE CONSIDERED “CRAZY.”
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Out of Body Experiences Sleep Substances General anesthesia Neurological disorders

Out of Body Experiences

Sleep
Substances
General anesthesia
Neurological disorders

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Autoscopic psychosis The experience in which an individual perceives the surrounding

Autoscopic psychosis

The experience in which an individual perceives the surrounding environment

from a different perspective, from a position outside of his or her own body
Autoscopic experiences are hallucinations
Experiences - are characterized by the presence of the following three factors:
Disembodiment,
impression of seeing the world from an elevated and distanced visuo-spatial perspective or extracorporeal, but egocentric visuo-spatial perspective;
impression of seeing one's own body from this perspective (autoscopy).
Heautoscopy - reduplicative hallucination of "seeing one's own body at a distance”.  It can occur as a symptom in schizophrenia  and epilepsy
Polyopic heutoscopy - more than one double is perceived. Can result from a tumor in the insular region of left temporal lobe
Negative autoscopy (or negative heautoscopy) - the sufferer does not see his or her reflection when looking in a mirror
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Migraine with Aura Micropsy Macropsy Distortions Flashes Geometrical shapes

Migraine with Aura

Micropsy
Macropsy
Distortions
Flashes
Geometrical shapes

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Hypnagogic/ Hypnapompic Hallucinations Only upon falling asleep/ waking up Very common

Hypnagogic/ Hypnapompic Hallucinations

Only upon falling asleep/ waking up
Very common
Normal phenomenon!
Seconds to

minutes
Usually eith full insight
Narcolepsy
Children
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Illusions Unrealistic interpretation of realistic stimulus Normal! Common in the dark

Illusions

Unrealistic interpretation of realistic stimulus
Normal!
Common in the dark

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הזיות Substance- Induced Visual Experiences Hallucinogens Intoxication- stimulants, cocaine, alcohol Withdrawal- alcohol, BZ

הזיות Substance- Induced Visual Experiences

Hallucinogens
Intoxication- stimulants, cocaine, alcohol
Withdrawal- alcohol, BZ

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Delirium Tremens

Delirium Tremens

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Treatment Options ORGANICALLY BASED HALLUCINATIONS ARE USUALLY SELF-LIMITING. With either end

Treatment Options

ORGANICALLY BASED HALLUCINATIONS ARE USUALLY SELF-LIMITING. With either end organ

or central nervous system changes, they disappear after a few days, months, or years. THE FIRST STEP IS TO REASSURE THE PATIENT.
INTERVENTIONS:
CHANGE PATIENT’S ENVIRONMENT
HASTEN END ORGAN CHANGE, E.G., CATARACT REMOVAL
GOOD MEDICAL MANAGEMENT OF CNS RISK FACTORS, E.G., HTN, DM, ET AL.
MEDICATIONS: DO NOT ROUTINELY USE CLASSIC NEUROLEPTICS
PEDUNCULAR HALLUCINOSIS: CLOZAPINE
RELEASE HALLUCINATIONS: CARBAMAZEPINE, GABAPENTIN, MELPERONE, VALPROATE, CISAPRIDE
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Delusions False belief, based on the incorrect interpretation of the external

Delusions

False belief, based on the incorrect interpretation of the external reality,

not in cultural context, not challengeable by rational explanations, affects the persons behavior and actions
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Types of Delusions Paranoid/persecutory Ideas of reference External locus of control

Types of Delusions

Paranoid/persecutory
Ideas of reference
External locus of control
Thought broadcasting
Thought insertion,

withdrawal
Jealousy
Guilt
Grandiosity
Religious delusions
Somatic delusions
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Disorders of Thought Alogia (also poverty of speech) – A poverty

Disorders of Thought

Alogia (also poverty of speech) – A poverty of speech, either in

amount or content; it can occur as a negative symptom of schizophrenia
Blocking – An abrupt stop in the middle of a train of thought; the individual may or may not be able to continue theidea.  This is a type of formal thought disorder that can be seen in schizophrenia
Circumstantiality (also circumstantial thinking, or circumstantial speech) – An inability to answer a question without giving excessive, unnecessary detail. This differs from tangential thinking, in that the person does eventually return to the original point
Clanging or Clang association – Ideas that are related only by similar or rhyming sounds rather than actual meaning.  This may be heard as excessive rhyming and/or alliteration. e.g.
"Many moldy mushrooms merge out of the mildewy mud on Mondays." "I heard the bell. Well, hell, then I fell.“
Derailment (also loose association and knight's move thinking) – Ideas slip off the topic's track on to another which is obliquely related or unrelated .
"The next day when I'd be going out you know, I took control, like uh, I put bleach on my hair in California."
Distractible speech – During mid speech, the subject is changed in response to a stimulus. e.g.
"Then I left San Francisco and moved to... where did you get that tie?"
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Disorders of Thought Echolalia – Echoing of another's speech that may

Disorders of Thought

Echolalia – Echoing of another's speech  that may only be

committed once, or may be continuous in repetition. This may involve repeating only the last few words or last word of the examiner's sentences. This can be a symptom of Tourette's Syndrome. e.g.
"What would you like for dinner?", "That's a good question. That's a good question. That's a good question. That's a good question."
Evasive interaction – Attempts to express ideas and/or feelings about another individual come out as evasive or in a diluted form, e.g.:
"I... er ah... you are uh... I think you have... uh-- acceptable erm... uh... hair.“
Flight of ideas – Excessive speech at a rapid rate that involves fragmented or unrelated ideas.  It is common in mania. "His boss was a wheelchair"
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Disorders of Thought Illogicality – Conclusions are reached that do not

Disorders of Thought

Illogicality – Conclusions are reached that do not follow logically

(non-sequiturs or faulty inferences). e.g.
"Do you think this will fit in the box?" draws a reply like "Well duh; it's brown, isn't it?“
Incoherence (word salad) – Speech that is unintelligible because, though the individual words are real words, the manner in which they are strung together results in incoherent gibberish,  e.g. the question "Why do people comb their hair?" elicits a response like
"Because it makes a twirl in life, my box is broken help me blue elephant. Isn't lettuce brave? I like electrons, hello please!"
Loss of goal – Failure to follow a train of thought to a natural conclusion. e.g. "Why does my computer keep crashing?", "Well, you live in a stucco house, so the pair of scissors needs to be in another drawer."
Neologisms – New word formations. These may also involve elisions of two words that are similar in meaning or in sound. e.g. "I got so angry I picked up a dish and threw it at the geshinker."
Perseveration – Persistent repetition of words or ideas even when another person attempts to change the topic e.g.
"It's great to be here in Nevada, Nevada, Nevada, Nevada, Nevada." This may also involve repeatedly giving the same answer to different questions. e.g. "Is your name Mary?" "Yes." "Are you in the hospital?" "Yes." "Are you a table?" "Yes." Perseveration can be an indication of organic brain disease such as Parkinson's.
Phonemic paraphasia – Mispronunciation; syllables out of sequence. e.g.
"I slipped on the lice and broke my arm."
Pressure of speech – Unrelenting, rapid speech without pauses.  It may be difficult to interrupt the speaker, and the speaker may continue speaking even when a direct question is asked.
Self-reference – Patient repeatedly and inappropriately refers back to self. e.g.
"What's the time?", "It's 7 o'clock. That's my problem.”
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Disorders of Thought Semantic paraphasia – Substitution of inappropriate word. e.g.

Disorders of Thought
Semantic paraphasia – Substitution of inappropriate word. e.g.
"I slipped on

the coat, on the ice I mean, and broke my book.“
Stilted speech – Speech characterized by the use of words or phrases that are flowery, excessive, and pompous  e.g.
"The attorney comported himself indecorously."
Tangentiality – Wandering from the topic and never returning to it or providing the information requested.  e.g.
in answer to the question "Where are you from?", a response "My dog is from England. They have good fish and chips there. Fish breathe through gills."
Word approximations – Old words used in a new and unconventional way. e.g. “His boss was a seeover”
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Behavior Bizarre dress and appearance Catatonia Loss of impulse control Aggression

Behavior

Bizarre dress and appearance
Catatonia
Loss of impulse control
Aggression and extreme irritability
Stereotypic speech

and behavior
Mannerisms
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Catatonia Stupor (i.e., no psychomotor activity; not actively relating to environment)

Catatonia

Stupor (i.e., no psychomotor activity; not actively relating to environment)
Catalepsy (i.e., passive induction

of a posture held against gravity)
Waxy flexibility (i.e., slight, even resistance to positioning by examiner)
Mutism (i.e., no, or very little, verbal response [exclude if known aphasia])
Negativism (i.e., opposition or no response to instructions or external stimuli)
Posturing (i.e., spontaneous and active maintenance of a posture against gravity)
Mannerism (i.e., odd, circumstantial caricature of normal actions)
Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements)
Agitation, not influenced by external stimuli
Grimacing
Echolalia (i.e., mimicking another's speech)
Echopraxia (i.e., mimicking another's movements)
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Mood and Affect Inappropriate affect Blunting of affect/mood

Mood and Affect

Inappropriate affect
Blunting of affect/mood

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מצב פסיכוטי פרנואידי- הדגמה Movie

מצב פסיכוטי פרנואידי- הדגמה

Movie

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DDX Basis- primary versus secondary psychosis!

DDX

Basis- primary versus secondary psychosis!

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DDX- Primary Psychosis Schizophrenia, schizophreniform Schizoaffective Brief Psychotic disorder Delusional disorder Affective psychosis (depression, mania)

DDX- Primary Psychosis

Schizophrenia, schizophreniform
Schizoaffective
Brief Psychotic disorder
Delusional disorder
Affective psychosis (depression, mania)

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DDX- Secondary Psychosis Substance/ Medication- induced Psychosis secondary to another medical

DDX- Secondary Psychosis
Substance/ Medication- induced
Psychosis secondary to another medical condition (neurological,

endocrinological, metabolic, infectious)
Delirium
Dementia
Not psychosis (personality disorder- cluster A/B, dissociation, culture- bound, PTSD, malingering, psedohallucinations of cluster B)
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Workup- Always Rule Out Secondary Cause!"אורגנית" Good anamnesys Thorough physical and

Workup- Always Rule Out Secondary Cause!"אורגנית"

Good anamnesys
Thorough physical and

neurological exam
Lab and imaging:

CBC
Complete chemistry
Thyroid functions
Vitamin B12 and folic acid
RPR, VDRL
ETOH
Urine and culture- especially in the elderly
Urine tox screen

CSF/LP
HIV serology
Autoimmune panel

CT or MRI
EEG

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Secondary Psychotic Disorders Psychotic Disorder due to Another Medical Condition Substance Induced Psychotic Disorder Delirium Dementia

Secondary Psychotic Disorders

Psychotic Disorder due to Another Medical Condition
Substance Induced Psychotic

Disorder
Delirium
Dementia
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Psychotic Disorder due to Another Medical Condition Prominent hallucinations or delusions

Psychotic Disorder due to Another Medical Condition

Prominent hallucinations or delusions
There is

evidence from the history, physical examination, or laboratory findings that the disturbance is the direct physiological consequence of a general medical condition
The disturbance is not better accounted for by another mental disorder
The disturbance does not occur exclusively during the course of a delirium
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Psychotic Disorder due to Another Medical Condition Neurological conditions (e.g., neoplasms,

Psychotic Disorder due to Another Medical Condition

Neurological conditions (e.g., neoplasms, cerebrovascular

disease, Huntington's disease, multiple sclerosis, epilepsy (TLE), auditory or visual nerve injury or impairment, migraine with aura, central nervous system infections- especially HIV)

Endocrine conditions (e.g., hyper- and hypothyroidism, hyper- and hypoparathyroidism, hyper- and hypoadrenocorticism).
Metabolic conditions (e.g., hypoxia, hypercarbia, hypoglycemia, uremia, hepatic encephalopathy, vitamines deficiency)
Fluid or electrolyte imbalances, and autoimmune disorders with central nervous system involvement (e.g., systemic lupus erythematosus, Behcet)

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Over the counter: Dextromethorphan, cold medications Other: Steroids, Bupropion, Dostinex, antibiotics, antivirals, antimalarials

Over the counter: Dextromethorphan, cold medications
Other: Steroids, Bupropion, Dostinex, antibiotics, antivirals,

antimalarials
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Delirium 15-25% of patients on general medical wards, S/P surgery- even

Delirium

15-25% of patients on general medical wards, S/P surgery- even higher

percentages
Advanced age, any brain disorder and underlying dementia are risk
1 yr mortality rate for those w/ episode of delirium= up to 50%!
Recognizing and treating delirium is a medical urgency
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Delirium Perceptual disturbances are common; however, hallucinations also are frequent: Hallucinations:

Delirium

Perceptual disturbances are common; however, hallucinations also are frequent:
Hallucinations:

40% to 67%
Delusions: 25% to 50%
Psychotic symptoms are more commonly seen with hyperactive rather than hypoactive delirium
Visual > > auditory> other hallucinations
Paranoid delusions are the most common delusions
Clinical evaluation should help identify; dementia and delirium are often related
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Etiologies In general- delirium etiology =secondary psychosis etiology! Intracranial Causes: Seizures

Etiologies

In general- delirium etiology =secondary psychosis etiology!
Intracranial Causes: Seizures and Postictal

states Brain Trauma Neoplasms Infections Vascular Disorders (Vasculitis, CVA’s etc.)
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Etiologies cont’d Extracranial causes: Drugs/Medications- toxicity, intoxication, and w/d. Poisons (Carbon

Etiologies cont’d

Extracranial causes: Drugs/Medications- toxicity, intoxication, and w/d.
Poisons (Carbon Monoxide,

Heavy metals) Endocrine dysfunction
Liver dz, Kidney failure, Cardiac failure, Arrhythmias, Hypotension, Hypoxia Deficiency dz’s
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Etiologies cont’d Systemic Infections Electrolyte abnormalities Postoperative states Trauma

Etiologies cont’d

Systemic Infections
Electrolyte abnormalities
Postoperative states
Trauma

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Treatment of Delirium High Potency Antipsychotic+ antihistamine Supportive Care Find and Resolve Causative Factor(s)

Treatment of Delirium

High Potency Antipsychotic+ antihistamine
Supportive Care
Find and Resolve Causative Factor(s)

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Dementia as the Cause of Psychosis

Dementia as the Cause of Psychosis

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DSM-IV criteria for the diagnosis of Dementia of the Alzheimer's Type

DSM-IV criteria for the diagnosis of Dementia of the Alzheimer's Type
A.

The development of multiple cognitive deficits manifested by both:
1.Memory impairment (impaired ability to learn new information or to recall previously learned information)
2.One or more of the following cognitive disturbances:
(a) aphasia (language disturbance)
(b) apraxia (impaired ability to carry out motor activities depite intact motor function)
(c) agnosia (failure to recognize or identify objects despite intact sensory function)
(d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting)
B. The cognitive deficits in criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning.
C. The course is characterized by gradual onset and continuing cognitive decline.
D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following:
(1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson's disease, Huntington's disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor)
(2) systemic conditions that are known to cause dementia (e.g., hypothyroidism, vitamin B or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection)
(3) substance-induced conditions
E. The deficits do not occur exclusively during the course of a delirium.
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Alzheimer’s Disease Prevalence of psychotic symptoms: 16% to 70%; Median: 37%

Alzheimer’s Disease

 
Prevalence of psychotic symptoms: 16% to 70%; Median: 37% for

delusions; 4% to 76% (Median 23%) for hallucinations
Rates of psychoses: about 20% in early stages to 50% by third or fourth years of illness (Overall: 30% to 50%)
Most common in middle stages.
Hallucinations: visual> auditory> other
Hallucinations most commonly people from past, e.g., deceased relatives, intruders, animals, objects
Delusions: most common are false beliefs of theft, infidelity of one’s spouse, abandonment, house not one’s home, and persecution. Decreases in later stages
Different from misidentification syndromes which may be more cognitively- related: Capgras Syndrome (imposters), Phantom Boarder Syndrome(guest in house); Mirror Sign (mistakes self in mirror for someone else, TV or Magazine Sign (believes people on TV or in magazine are real)
Some evidence that psychotic symptoms are associated with a more rapid decline
Need to rule out underlying medical problems and visual difficulties
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Vascular Dementia Cache County study found prevalence of hallucinations similar between

Vascular Dementia
Cache County study found prevalence of hallucinations similar between

AD and VaD, but delusions were higher in AD (23% vs 8%)
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Lewy Body Dementia About half have visual hallucinations (up to 80%

Lewy Body Dementia
About half have visual hallucinations (up to 80% in

some studies), and it’s an early sign in
43%
Usually frightening people or animals
Auditory hallucinations (20%) and paranoid delusions(65%) are also common
Some texts say psychotic symptoms are more common than in AD
Avoid typical neuropeptics- severe EPS! Only low- dose atypicals!
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Parkinson’s disease Overall rates: 20 to 60% --- about ¼ have

Parkinson’s disease

Overall rates: 20 to 60% --- about ¼ have

hallucinations in PD, but ¾ have hallucinations with Parkinson’s Disease with Dementia (PDD). Thus, psychosis is more common in later stages of PD
Hallucinations much more common than delusions
Extrinsic causes > Intrinsic causes, i.e., hallucinations in PD most commonly secondary to dopaminergic agents (extrinsic). Need to assess onset of symptoms. Medications produce vivid visual hallucinations.
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Test Yourself

Test Yourself

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Symptoms of secondary psychoses accompany which disorder: 1. Delusional disorder 2.

Symptoms of secondary psychoses accompany which disorder:

1. Delusional disorder
2. Schizophrenia
3.

Depression
4. Alzheimer’s disease
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In delirium, what is the most common form of hallucinations? 1.

In delirium, what is the most common form of hallucinations?

1. Auditory
2.

Tactile
3. Visual
4. Olfactory
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In Alzheimer’s disease which of the following is true : 1.

In Alzheimer’s disease which of the following is true :

1. Auditory

hallucinations are the most common type of hallucination
2. Psychoses are most common in the early stages of the disorder
3. Delusions concerning theft are common
4. Misidentification syndromes are a type of delusion
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In Parkinson’s disease which of the following is true: 1. Extrinsic

In Parkinson’s disease which of the following is true:

1. Extrinsic causes

of hallucinations are greater than intrinsic causes
2. Rates of hallucinations are about 10%
3. The preferred treatment for hallucinations is risperidone
4. Rates of hallucinations are similar among those persons with and without dementia
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