Psychotic
disorders
Heidi Combs, MD
At the end of this session you will
be able to:
Appreciate the prevalence of various
psychotic illnesses
Describe the key features of various psychotic
illnesses
Understand how to differentiate between
psychotic illnesses
Select psychopharmacologic treatment for
various psychotic illnesses
Apply general principles on how to approach a
patient with psychosis
Lets start with a case
29 yo woman was brought to the emergency
room by the police after she started
screaming at Starbucks then threw coffee at
the barista. In the emergency room she stated
I need to be taken to jail. I think I
contaminated someone with a virus and I
need to go to jail. Dont get near meI will
make you sick too.
Other information
gathered
Blood work revealed mildly elevated WBC at
11.2, mild hypokalemia at 3.2, otherwise all
labs including lfts, lytes unremarkable.
Utox is negative
BP: 135/78, HR 82 and regular, physical exam
unremarkable
Pt is fully oriented and has not exhibited a
waxing/waning level of consciousness
The patient appears psychotic
Given the information you have what
diagnoses are on your differential?
Cast a broad differential dx net
Differential Diagnoses for psychotic
disorders
Mood Disorders with Psychotic Features
Schizophrenia and Schizophreniform Disorder
Substance-Induced Psychotic Disorder
Delusional Disorder
Psychotic Disorder due to General Medical
Condition
Shared Psychotic disorder (Folie a Deux)
Psychotic Disorder NOS
Other diagnoses that can
masquerade as psychotic illnesses
Delirium- pts often have paranoia, visual
hallucinations
Paranoid personality disorder and schizotypal
personality disorder can dance very near the
edge of psychosis
Obsessive compulsive disorder- at times
obsessions can be difficult to discern from
psychosis
Borderline Personality
disorder
When dysregulated a
borderline patient can
appear paranoid and
think they hear people
talking trash about
them
So how do you figure out how to
identify the diagnosis?
?
Are psychotic sx only
present when mood
symptoms present?
Does the patient
have a medical
condition that can
cause psychosis?
?
Is the patient using
drugs/ETOH- if yes
need to have sx
present after at least
a month of sobriety
otherwise is
attributed to
substance(s)
?
Does the patient have prominent negative
symptoms?
Is the patient delusional or psychotic?
What is the nature of the psychotic
symptoms? Are they mood congruent
(depressive themes associated with the
psychosis) or incongruent?
A word about
hallucinations
Hallucinations are defined as false sensory
perceptions not associated with real external
stimuli.
A word about delusions
Delusions are defined as a false believe based
on incorrect inference about external reality
that is firmly held despite what most everyone
else believes and despite what constitutes
incontrovertible and obvious proof of
evidenced to the contrary.
Always keep in mind cultural norms
?
Mood
incongruent
Mood incongruent
themes include
delusions of control,
persecution, thought
broadcasting and
thought insertion.
Mood congruent
Delusions or
hallucinations consistent
with themes of a
depressed mood such as
personal inadequacy,
guilt, disease, death,
deserved punishment. For
manic mood themes of
worth, power, knowledge,
special relationship to a
deity.
Psychotic
illnesses
Mood disorders with psychotic
features
Major depressive
disorder with
psychotic features
Bipolar disorder,
manic or mixed
Schizoaffective
disorders
Major depressive disorder (MDD)
with psychotic features
Patient meets criteria for major depressive
episode and also has psychotic symptoms
while depressed
Does not have psychotic symptoms during
times of euthymia
Psychotic features occur in ~18.5% of
patients who are diagnosed with MDD
Ohayon MM, Schatzberg AF. Prevalence of depressive episodes with psychotic features in the general population.
Am J Psychiatry 2002;11:185561
Treatment- Meds
Cornerstone of treatment is initiation of
antidepressants but need antipsychotic as
well
Antidepressant-antipsychotic cotreatment was
superior to monotherapy with either drug
class in the acute treatment of psychotic
depression.
See psychopharm lecture for how to select an
antidepressant and antipsychotic
Arusha Farahani, Christoph Correll Are Antipsychotics or Antidepressants Needed for Psychotic Depression? A
Systematic Review and Meta-Analysis of Trials Comparing Antidepressant or Antipsychotic Monotherapy With
Combination Treatment J Clin Psychiatry 20
Treatment- ECT
ECT is very effective
for psychotic
depressionparticularly in elderly
and pregnant.
ECT
ECT in nonpsychotic depression versus
psychotic depression and found a remission
rate of 95% in patients with psychotic
depression compared with an 83% remission
rate in patients with nonpsychotic depression.
ECT treatments with bilateral or right
unilateral electrode configuration can be
superior to combination
Parker G, Roy K, Hadzi-Pavlovic D, et al. Psychotic (delusional) depression: A meta-analysis of physical treatments.
J Affect Disord 1992;24:1724.16. Petrides G, Fink M, Husain M,
Petrides G, Fink M, Husain M, et al. ECT remission rates
in psychotic versus nonpsychotic depressed patients: A
report from CORE. J ECT 2001;17:24453.
Bipolar I disorder, manic or mixed
with psychotic features
Patient had bipolar
disorder and is manic
or mixed and
exhibiting psychotic
features
Estimated to occur
in ~25% of Bipolar I
patients
Perl J, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population.Arch Gen
Psychiatry. 2007 Jan;64(1):19-28.
Treatment
Treat with mood stabilizer AND antipsychotic
If patient mixed or not responding to meds
consider ECT
Keep in mind catatonia which is most
commonly associated with bipolar disorder.
Cornerstone of treatment- benzodiazepines.
Schizophrenia
Schizophrenia
Two or more of the following present for a
significant portion of the time during a 1
month period:
Delusions*
Hallucinations* (See link on website for
examples)
disorganized speech*
grossly disorganized or catatonic behavior*
negative symptoms (affect flattening, alogia,
avolition, apathy)
*denotes positive symptoms
Schizophrenia
Only one criteria needed if delusions bizarre or
hallucinations consist of a voice keeping a running
commentary or two voices talking to each other
Must cause significant social/occupational
dysfunction
Continuous signs of disturbance for 6 months
< 6 months = schizophreniform
Schizophrenia subtypes
Paranoid: preoccupation with one or more
delusions or frequent auditory hallucinations
Disorganized: disorganized speech, behavior and
flat or inappropriate affect are all present
Catatonic: motoric immobility or excessive
activity, extreme negativism, peculiar
movements, echolalia or echopraxia
Epidemiology
It affects 1-2% of the population
Onset symptoms in males peaks 17-27 yrs
Onset symptoms in females: 17-37 yrs
Only 10% new cases have onset after 45 years
Presence of proband with schizophrenia
significantly increases the prevalence of schizoid
and schizotypal personality disorders,
schizoaffective disorder and delusional disorder
Etiology
Studies of monozygotic
twins suggest
approximately 50%
schizophrenia risk
genetic as there is 4050% concordance
Estimated: the other
50% due to as of yet
unidentified
environmental factors
including in utero
exposure
Pathophysiology
Possibly due to aberrant neuro-developmental
processes such as increase in normal ageassociated pruning frontoparietal synapses
that occur in adolescence and young
adulthood
Excessive activity in mesocortical and
mesolimbic dopamine pathways
Schizophrenia and
addiction
47 percent have met criteria for some form of
a drug/ETOH abuse/addiction.
The odds of having an alcohol or drug use
disorder are 4.6 times greater for people with
schizophrenia than the odds are for the rest of
the population: the odds for alcohol use
disorders are over three times higher, and the
odds for other drug use disorders are six times
higher
Regier et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the
Epidemiologic Catchment Area (ECA) Study. JAMA. 1990 Nov 21;264(19):2511-8.
Schizophrenia illness
course
Negative symptoms thought to be more
debilitating in regards to social and
occupational impairment
>90% of pts do not return to pre-illness level
of social and vocational functioning
10% die by suicide
Schizophrenia illness
course
Generally marked by chronic course with
superimposed episodes of symptom exacerbation
1/3 have severe symptoms & social/vocational
impairment and repeated hospitalizations
1/3 have moderate symptoms & social/vocational
impairment and occasional hospitalizations
1/3 have no further hospitalizations but typically
have residual symptoms, chronic interpersonal
difficulties and most cannot maintain employment
A 20th-century artist, Louis
Wain, who was fascinated by
cats, painted these pictures over
a period of time in which he
developed schizophrenia. The
pictures mark progressive
stages in the illness and
exemplify what it does to the
victim's perception. Slide
courtesy of Dr. Sharon Romm
Treatment
Positive symptoms respond better than negative
Antipsychotics are mainstay of treatment.
Atypical antipsychotics: used first to reduced risk
of Tardive Dyskinesia (TD) but can have weight
gain, metabolic syndrome including elevated
lipids and type 2 diabetes
Risk of TD approximately 3-5% per year for typical
antipsychotics. Highest in older women with
affective disorders
Risk of dystonic reaction highest in young males
Schizoaffective disorder
Uninterrupted period: either major depressive,
episode or mixed episode while criterion for
schizophrenia met
Periods where delusions or hallucinations present
for >2 weeks without prominent mood symptoms
Symptoms that meet criteria for a mood disorder
are present for a substantial portion of the illness
Lifetime prevalence rates is 0.7%
Schizoaffective disorder treatment
Antipsychotics are mainstay
If depressed type: add antidepressant
If Bipolar type: mood stabilizers as well
Substance induced psychotic
disorder
Substances associated with psychosis include:
Alcohol The lifetime prevalence was 0.5%
Cocaine
Amphetamines
Cannabis
LSD, PCP, NMDA, Ketamine
Substance induced
psychotic disorder
Substance-induced
psychotic disorder (SIMD)
A. Prominent hallucinations or delusions.
B. There is evidence from the history,
physical examination, or laboratory
findings of either (1) or (2):
(1) the symptoms in Criterion A developed
during, or within a month of
Substance Intoxication or Withdrawal
(2) substance use is etiologically related to the
disturbance
The diagnosis cannot be made if the
symptoms occurred before the substance
or medication was ingested, or are more
severe than could be reasonably caused by
the amount of substance involved.
If the disorder persists for more than a
month after the withdrawal of the
substance, the diagnosis is less likely with
the exception of methamphetamines.
Substances associated
with inducing psychosis:
Alcohol
Cocaine
Amphetamines
Cannabis
LSD, PCP
NMDA, Ketamine
Inhalants
Opiods
Treatment
Stop the drug use
Chemical dependence treatment if indicated
Consider antipsychotics depending on how
psychotic the patient is and how long the
symptoms have been present
Psychotic disorders due to a General
Medical Condition (GMC)
Brain tumors
Seizure disorders
Delirium
Huntingtons disease
Multiple Sclerosis
Cushings syndrome
Vitamin deficiencies
Electrolyte
abnormalities
Thyroid disorders
Uremia
SLE
HIV
Wellbutrin
Anabolic steroids
Corticosteroids
Antimalarial drugs
Delusional disorder
Nonbizarre delusions (i.e. involving situations that
occur in real life such as being poisoned, loved at
a distance, deceived by a spouse) of at least one
months duration.
Criterion A for Schizophrenia never met
Apart from impact of delusions functioning not
markedly impaired
Not due to mood disorder or substance
Lifetime prevalence = 0.03%
Mean age of onset is ~40 years
Slightly higher in females compared to males
Delusional disorder
subtypes
Erotomanic
Grandiose
Persecutory
Jealous
Somatic
Mixed
See erotomanic
delusions more often
in women
See persecutory
delusions more often
in men
Brief psychotic disorder
Presence of one or more of the following
delusions
Hallucinations
Disorganized speech
Disorganized or catatonic behavior
Duration of episode is <1 month with eventual
return to premorbid level of functioning
Psychosis NOS
If pt has psychotic sx
but does not meet
criteria for any
diagnosis they get
the Psychosis NOS
diagnosis
Getting back to our case
29 yo woman was brought to the emergency
room by the police after she started
screaming at Starbucks then threw coffee at
the barista. In the emergency room she stated
I need to be taken to jail. I think I
contaminated someone with a virus and I
need to go to jail. Dont get near meI will
make you sick too.
PE, VS, lab work all unremarkable
Mental status exam
Appearance: disheveled, anxious
Behavior: mild PMR, poor eye contact
Speech: soft, constricted prosody
Mood: beyond terrible
Affect: mood congruent, depressed
Thought process: perseverative on belief she
must go to jail because of perceived wrong doing
Thought content: +delusions she has harmed
someone, +paranoia, -AH, passive SI stating she
deserves to die without plan, -HI, -TI, -TB, -IOR
Cognition: fully oriented
Insight/judgement: poor
Lets get back to our differential
diagnoses for Psychotic disorders
Mood Disorders with Psychotic Features
Schizophrenia and Schizophreniform Disorder
Substance-Induced Psychotic Disorder
Delusional Disorder
Psychotic Disorder due to General Medical
Condition
Shared Psychotic disorder (Folie a Deux)
Psychotic Disorder NOS
Look alikes: BPD, OCD, PPD, schizotypal pd
Given just what you know what is
the most likely dx?
Annunciation door- Rome
MDD with psychotic
features
Leading diagnosis
given depressive
themes to psychosis,
depressed mood,
negative utox, no
abnormalities in labs,
normal PE and lack
of negative sx
To rule in the DX
Pt needs to currently meet criteria for a major
depressive episode and not have other
reasons for psychosis for example
What information would you need
to r/o other dx?
No history of manic episodes- r/o BAD
No drug/ETOH use in recent past- r/o SIPD
No medical issues such as hypothryoidism- r/o
psychotic disorder due to a GMC
Does not meet criteria for schizophrenia
Clinical pearls
How to approach a
psychotic pt
Acknowledge you believe they are
experiencing what they are reporting
Try not to collude with the pt
Try to establish rapport before confronting
psychotic beliefs
Dont be overly friendly or it can feed into the
paranoia
Take home points
Psychotic disorders can be primary or
secondary
Cornerstone of treatment is antipsychotics if
primary psychotic illness
If secondary psychotic illness treat underlying
cause and often will also need to use
antipsychotics
There are approaches as outlined earlier that
can make interactions with patients more
effective
