Psychotic Disorders. Jirayu Reungyos, M.D. Department of Psychiatry Faculty of Medicine, Chiang Mai University. For MSY3, 2014

Transcription

1 Psychotic Disorders Jirayu Reungyos, M.D. Department of Psychiatry Faculty of Medicine, Chiang Mai University For MSY3, 2014

2 Psychotic Disorders: Introduction Psychotic symptoms Delusions: fixed false believes, eg.; persecutory delusion, grandiose delusion, bizarre delusion (eg, thought broadcasting, delusion of reference) Prominent hallucinations: prominent perceptions w/o sensory stimuli, eg.; auditory hallucination, visual hallucination

3 Psychotic Disorders: Introduction Psychotic symptoms (cont.) Disorganized speech: dissociation of the topics, phrases, and/or sentences while talking Disorganized or catatonic behavior: osocially inappropriate behavior omotor and/or posture abnormality not caused by substance or physical illnesses

4 Psychotic Disorders: Introduction Psychotic symptoms (cont.) Negative symptoms oi.e., Diminished emotional expression or avolition

5 Psychotic Disorders: Introduction High prevalence and severely impaired functioning Schizophrenia: chronic course of illness with early onset 30% of psychotic patients are schizophrenic (largest proportion)

6 Classification of Schizophrenia & Other Psychotic Disorders (DSM-5) Schizophrenia (SCZ) Schizophreniform disorder Schizoaffective disorder Delusional disorder (rare) Brief psychotic disorder Shared psychotic disorder (very rare) Psychotic disorder due to a general medical condition Substance-induced psychotic disorder Psychotic disorder not otherwise specified (NOS), eg, postpartum psychosis (rare)

7 Psychotic Disorders: Introduction 3 Classification of Schizophrenia & Other Psychotic Disorders (DSM-IV) * Schizophrenia (SCZ) Schizophreniform disorder Schizoaffective disorder Delusional disorder (rare) Brief psychotic disorder Shared psychotic disorder (very rare) Psychotic disorder due to a general medical condition Substance-induced psychotic disorder Psychotic disorder not otherwise specified (NOS), eg, postpartum psychosis (rare)

8 SCZ: Nature

9 Schizophrenia : symptom Timothy C Crow (1980): Positive symptoms, eg, delusions, hallucinations, loosening of association Negative symptoms, eg, affect flattening, poverty of speech, loss of drive Positive and negative symptoms may be different in the respects of pathophysiology, course, prognosis, and treatment response

10 SCZ: Etiology Not yet known clearly Risk factors frequently mentioned: 1. genetic factors 2. gestational and labor complications 3. winter birth 4. old age father (Note: no supporting evidence for psychosocial factors) Schizophrenia is a brain disease

11 SCZ: Etiology Genetic risk for Schizophrenia prevalence Normal population 1% Non-twin sibling 8% 1 SCZ parent 12% Dizygotic twin 12% 2 SCZ parents 40% Monozygotic twin 47%

12 SCZ: Pathophysiology 1 Not yet known clearly Abnormalities frequently studied: 1. Neurochemical disturbances: A. dopamine hypothesis: o 1. dopamine hyperactivity in mesolimbic pathways --> positive symptoms o 2. dopamine hypoactivity in prefrontal region (mesocortical pathways) --> negative symptoms B. other neurotransmitters, eg, serotonin, norepinephrine, GABA, glutamate, acetylcholine and nicotine

13 Dopamine Hypothesis of Schizophrenia Mesocortical pathway Hypoactivity: negative symptoms amotivation cognitive deficits Nigrostriatal pathway (part of EP system) Tuberoinfundibular pathway (inhibits prolactin release) Mesolimbic pathway Hyperactivity: positive symptoms *

14 Pathway Normal people Schizophrenia Dopamine role Typical antipsychotic Mesolimbic Dopamine Positive symptom positive symptom Mesocortical Dopamine Negative symptom negative symptom Tubero infundibular Inhibit prolactin release Hyper prolactinemia Nigrostriatal Initiate movement EPS

15 SCZ: Pathophysiology 2 2. Neuropathology and brain imaging: : no abnormality found after 1970 s: available of CT scan and MRI lateral ventricle enlargement and others

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17 SCZ: Pathophysiology 3 3. Other biological abnormalities, eg, Other brain neuropathology, eg, reduced symmetry, decreased size of limbic system Brain metabolism Electrophysiology Eye movement dysfunction Psychoneuroimmunology Psychoneuroendocrinology

18 SCZ: Diagnosis DSM-5 Diagnostic criteria for SCZ A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3) : 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g. frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition)

19 SCZ: Diagnosis B. Social/occupation dysfunction C. A total duration of illness 6 months [prodromal + acute (at least 1-month period or less if successfully treated) + residual phases] D. Exclusion of schizoaffective disorder and mood disorders with psychotic features E. Not caused by a substance/general medical condition F. For a patient with pervasive developmental disorder, s/he must have 1 month (or less if treated) of prominent delusions or hallucinations

20 SCZ: Course 1. Complete remission (8.2%) 2. Relapse with complete remission in between (39.3%) 3. Relapse with partial remission in between (44.3%) 4. Continuous illness (8.2%)

21 SCZ: SCZ: Course Course Onset: late adolescence or early adulthood male: years of age female: years of age rare before 10 or after 60 years old Deterioration of social and occupational dysfunction, esp. in the first 5-10 years of illness High expressed emotion (EE) family relapse rate

22 Antipsychotics Typical vs. atypical antipsychotics Conventional (classical) vs. newer antipsychotics First- vs. second-generation antipsychotics

23 Treatment overview : history 30s 50s 60s 70s 80s 90s ECT Chlorpromazine Haloperidol Clozapine Fluphenazine Risperidone Thioridazine Olanzapine Loxapine Quetiapine Perphenazine Ziprasidone Aripiprazole Paliperidone First-generation antipsychotics Second-generation antipsychotics

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25 SCZ: Psychosocial Treatment Supportive psychotherapy + Acute phase: psychoeducation for patient s relatives or caregivers Stabilization phase: psychoeducation for patients Stable phase: basic skill training, social skill training, and occupation training if needed and possible Others, eg., family therapy, cognitive therapy