Psychosis Madeline Goodman D.O. April 28, 2010

Common in both the medical and psychiatric settings Common in both the medical and psychiatric settings First break is poorly understood First break is poorly understood 3-5% of the population 3-5% of the population Responds well to treatment Responds well to treatment

Disturbance in perception of realty as evidenced by hallucinations, delusions and thought disorganization (Up to Date 2007) Disturbance in perception of realty as evidenced by hallucinations, delusions and thought disorganization (Up to Date 2007)

Auditory Auditory Visual Visual Tactile Tactile Olfactory Olfactory Gustatory Gustatory

Primary Psychotic Disorder Primary Psychotic Disorder Schizophrenia Schizophrenia Schizoaffective Disorder Schizoaffective Disorder

Primarily Medical Disorders Primarily Medical Disorders Delirium Delirium Neoplasm of the Central Nervous System Neoplasm of the Central Nervous System ETOH Withdrawal ETOH Withdrawal tactile being the most common bugs crawling on their skin

Fixed False Belief that is not typical of patients faith, culture or family. Fixed False Belief that is not typical of patients faith, culture or family. Cultural Cultural Religious Religious

Looseness of Association Looseness of Association Nonsensical speech Nonsensical speech Bizarre Behavior Bizarre Behavior High level of functional impairment High level of functional impairment High risk of agitated or aggressive behavior High risk of agitated or aggressive behavior Difficult to obtain coherent history Difficult to obtain coherent history Unable to consent to treatment Unable to consent to treatment

Acute state of anxiety Acute state of anxiety Heightened emotional arousal Heightened emotional arousal Increased motor activity Increased motor activity Commonly seen in both psychiatric and medical conditions Commonly seen in both psychiatric and medical conditions Patients awareness Patients awareness External factors External factors Treat both anxiety and psychosis Treat both anxiety and psychosis

Acts or threats of violence Acts or threats of violence Common in acute psychotic states Common in acute psychotic states Persecutory delusions, thought disorganization, poor impulse control Persecutory delusions, thought disorganization, poor impulse control Never challenge the delusions Never challenge the delusions

Severe Severe Chronic Chronic Social, occupational and scholastic deterioration Social, occupational and scholastic deterioration Prevalence rate 1.1% (NIMH) Prevalence rate 1.1% (NIMH)

Urban Living Social Disadvantage Childhood Trauma Poverty Genetic Links Twin and adoption studies have shown high rate of heritability

Add to normal experience Add to normal experience Hallucinations Hallucinations Delusions Delusions Thought disorganization Thought disorganization Highly correlated to Hospital admission Highly correlated to Hospital admission

Take away from normal experience Take away from normal experience Loss of motivation Loss of motivation Anhedonia Anhedonia Alogic Alogic Asociality Asociality Moderately correlated with functional impairment Moderately correlated with functional impairment

Loss of basic domains of intellectual functioning Loss of basic domains of intellectual functioning Memory Memory Attention Attention Verbal processing Verbal processing Executive Functioning Executive Functioning

Hospitalization Psychotherapy Group Home Living Community Teams Antipsychotic Medication Atypical vs. Typical agents Metabolic Syndromes Side effects may decrease compliance Long acting preparations may be better for non-adherence to medication

Maine Medical Center Peer Program Early treatment with antipsychotic medication can decrease the severity of the illness Education Teaching children who might be predisposed to avoid street drugs

Discreet sustained period of elevated or irritable mood Discreet sustained period of elevated or irritable mood Decreased need for sleep Decreased need for sleep Increased in goal directed activities Increased in goal directed activities Grandiosity Grandiosity Rapid/pressured speech Rapid/pressured speech Poor Judgment Poor Judgment Engaging in high risk behaviors Engaging in high risk behaviors

Antipsychotics Antipsychotics Benzodiazepines Benzodiazepines Anti-convulsants Anti-convulsants Electroconvuslive Therapy Electroconvuslive Therapy

Lithium Carbonate BUN, Creatinine, GFR, TSH Lithium levels every three months in the first year along with BUN and Creatinine, then every six months. TSH should be evaluated yearly

Liver Function CBC Can decrease Platlets V.A. level every three months for the first year and then every six months. Recheck LFT’s and CBC every six months

Can slow down mania Help with sleep Decrease anxiety

Mood Congruent Mood Congruent Nihilistic thinking Nihilistic thinking Responds best to combination therapy Responds best to combination therapy

Antidepressant Plus Antipsychotic Psychotherapy Benzodiazepine

Diagnostic criteria for Schizophrenia and Mood Disorder Diagnostic criteria for Schizophrenia and Mood Disorder Both sets of symptoms prominent in the course of the illness Both sets of symptoms prominent in the course of the illness Two week period free from prominent mood symptoms Two week period free from prominent mood symptoms

40% experience psychotic symptoms 40% experience psychotic symptoms Behavioral disturbance associated with psychosis Behavioral disturbance associated with psychosis Lewy Body Type associated visual hallucinations Lewy Body Type associated visual hallucinations Treatment with antipsychotics Treatment with antipsychotics Black Box Warning! Black Box Warning! Increased mortality in this population Increased mortality in this population

Delirium Delirium Acute change in mental status Acute change in mental status This is a true medical emergency This is a true medical emergency Inability to focus and maintain attention Inability to focus and maintain attention Disorientation Disorientation Memory impairment Memory impairment Language disturbance Language disturbance

Medical conditions Medical conditions Medications Medications ETOH Withdrawal ETOH Withdrawal Substance Abuse Substance Abuse

Non-bizarre delusions Does not respond to antipsychotic medication

Believe that bugs are infesting their bodies Multiple visits to PCP, dermotologist Can respond to low dose antipsychotic

Many causes of psychosis Can be challenging to diagnose but in most instances is highly treatable Difficulty arises when patients become non-compliant Delirium IS a medical emergency!

Lets Take a 10 minute break!