Schizophrenia and Other Psychotic Disorders - 2nd Edition

Educational Objectives

Upon completing this educational activity, participants will be able to:
1. Utilize knowledge of recent developments in genetics and neuroscience to more effectively diagnose and manage psychiatric disorders.
2. Discuss optimal diagnosis, treatment, and clinical understanding of bipolar disorder.
3. Identify and overcome barriers to the effective management of personality disorders.
4. Identify and manage key factors that may affect a patient's risk for violent behavior.
5. Recognize common causes of treatment failures in patients suffering with anxiety and depression.
6. Implement therapy techniques for managing patients with somatic disorders.

Summary

Schizophrenia and Other Psychotic Disorders

Joseph F. Goldberg, MD, Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York

Overview: review clinical phenomenology, epidemiology, neurobiology, associated characteristics of primary psychotic disorders (schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, brief psychotic disorder); diagnosis and treatment issues

Schizophrenia: dementia praecox (Dr. Emil Kraepelin); persistent psychotic disorder; dementing process adolescent and young adulthood onset; different from chronic dementia (Alzheimer disease); schizophrenic cognitive elements identified early; term first used by Dr. Paul E. Bleuler; dissociation of patterns of thinking, split fibers of thought; AAAA (association [cognitive], affect [blunted, flat, poorly related], autism [internal preoccupation, poor relatedness], ambivalence [inability to exercise executive functions]); cognitive elements central feature; incidence 1% of population; higher in poor urban areas; equal between men and women; onset later for women; 90% of men onset before age 30; 25% women before age 30; prodromal phases (social withdrawal, isolation, poor hygiene, inattentiveness to appearance, impaired work or school functioning, interpersonal problems, odd ideas) may be evident in early to mid-adolescence; prodromes may help identify risk for schizophrenia; no data for treatment with antipsychotic medications

Positive and negative symptoms: negative — absence of phenomena (alogia, impoverishment of thinking, affective blunting, avolition, apathy, anhedonia); harder to treat; positive — presence of phenomena (delusions, hallucinations, disorganized behavior, formal thought disorder); pharmacology more efficacious for positive symptoms; negative symptoms more persistent

Cognitive symptoms: not part of Diagnostic and Statistical Manual of Mental Disorders criteria; cognitive deficits (pervasive attention deficits, coding, verbal fluency, verbal and visual spatial memory, executive functioning [working memory], speed of processing); no cognitive symptom treatment

Heritability: heritable condition; concordance rate (monozygotic twins 50%, dizygotic twins 10% to 15%); parent or sibling with schizophrenia proband 10% to 12% likelihood of schizophrenia; 2 parents with schizophrenia 40% likelihood; interaction with environment important; complex trait; non-Mendelian phenomenon; multiple genes; linkage studies; robust chromosomal regions in replication studies (6p, 6q, 8p, 1q, 5q, 10p, 13q) may have signal in schizophrenia; velo-cardio-facial syndrome (22q11 microdeletion) associated with psychosis, schizophrenia, bipolar disorder; first-degree relative with schizophrenia risk factor

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: A criterion — delusions (false, fixed beliefs), hallucinations (false perceptions of sensory system), disorganized speech, disorganized behavior, negative or deficit symptoms; only 1 A criterion needed (bizarre delusions [not plausible], voices); B criterion — social or occupational dysfunction; C criterion — must persist at least 6 months; D criterion — exclusionary; no diagnosis of schizoaffective disorder and schizophrenia (cannot be comorbid with both); mood disorder duration must be brief compared with illness

Schizophreniform disorder: duration 1 to <6 months; provisional diagnosis; may resolve within 6 months; includes Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, specifiers with or without good prognostic features (abrupt acute onset, sense of confusion, perplexity by symptoms, good premorbid functioning, absence of flat affect); Schneiderian first rank symptoms (audible thoughts, voices [argue, discuss, comment]), somatic passivity, thought withdrawal or insertion, locus of control (external), delusional perception, volitional made acts (actions not own); motor symptoms (odd movements, stereotypical movements [basal ganglia, cerebellar involvement]); includes motor functions as part of composite picture

Subtypes: paranoid, disorganized, catatonic, undifferentiated; paranoid — better prognosis; older patient; rapid onset; organized theme; preservation of cognitive function; affect more intact; disorganized — (formally hebephrenia); disorganized speech; disorganized behavior; flat affect; form of thinking profoundly disturbed (clang associations, neologisms, word play, word salad [cannot make sense of words]); nonpurposeful behavior; residual or undifferentiated — 1 episode in past; no current symptoms; ongoing negative symptoms (attenuated positive symptoms [idiosyncratic ideas, odd beliefs, peculiarities, eccentricities]); catatonic — not specific to schizophrenia; motoric immobility (catalepsy, waxy flexibility; excitement; extreme negativism, rigid posturing; immobility; resistance to passive movement); mutism; echolalia or echopraxia (speech mimic)

Risks and risk factors: ninth leading cause of disability; World Health Organization Global Burden of Disease Study; 8-fold increased risk for mortality; life expectancy loss 12 to 15 years; high comorbidity with medical conditions (cardiovascular disease, diabetes); paternal age >50 may be high risk factor; season of birth; viral infections

Course of illness: no uniform outcome; 10% experience full recovery; 20% overall good outcome; 20% to 30% relapse during first year; 20% to 30% poor outcome; 20% attempt suicide; completion rates 5%; good prognosis signs (good premorbid function, acute onset, precipitating events [loss, separation], female, older age at onset, family history of mood disorder, no family history of schizophrenia); 30% to 50% have comorbid alcohol or substance use disorders (cannabis, cocaine); nicotine addiction (three-quarters of patients smoke)

Neurobiology: positive symptoms (mesolimbic high dopamine); negative symptoms (low dopamine mesocortical); measured through plasma, cerebrospinal fluid levels; homovanillic acid; correlates with severity of psychosis; glutamate dysfunction important; excitatory neurotransmitter; glutamate transmission synapses onto dopaminergic pathways; corticolimbic glutamate tract; gamma-aminobutyric acid interneuron (inhibitory); faulty glutamate signaling; N-methyl-D-aspartate receptor deficits; hypofunction of receptor; fundamental aspect of disease; no treatment to address glutamate dysfunction; enlarged lateral ventricles

Other neurologic brain structural deficits: small temporal gyri; decreased hippocampal volume (endophenotype); disorganized structure of pyramidal cells in hippocampus; increased basal ganglia volume (motor features); overall decreased cerebral size; loss of gray matter during adolescence; large ventricles imply neuronal loss; decreased prefrontal brain functioning (decreased glucose uptake, decreased cerebral blood flow); sensory gating (evoked potentials); auditory event related potentials; suppression of P50 waveform; impaired filtering of auditory input; suppression of event-related potential; P50 and P300 waveforms associated with abnormalities; smooth or saccadic eye movements; not specific to schizophrenia

Schizoaffective disorder: controversial diagnosis; concept described in 1930s; full mood episode, major depressive, manic, mixed episode, A criterion must coexist and co-occur in same time period; psychosis elements occur for ≥2 weeks in absence of prominent mood symptoms; mood symptoms constitute substantial portion of entire period; mood-incongruent symptoms negative prognostic features; polarity of mood state specifier of subtype (schizoaffective depression [major depressive episodes superimposed with psychosis symptoms], schizoaffective bipolar [manic or mixed episodes superimposed with psychosis]); cannot have psychotic mania; better prognosis than schizophrenia; worse prognosis than mood disorders

Delusional disorder: must have nonbizarre delusions; singular or plural; persist at ≥1 month; may involve ideas of reference; may have prominent tactile and olfactory hallucinations (related to delusional theme); auditory or visual hallucinations (must be less prominent); tactile consistent with nonbizarre delusion; patients intact (cognitively, affectively, perceptually, no formal thought disorder); later age at onset (middle or late adult); rare (0.03% lifetime prevalence); no familial pattern; depressive symptoms can occur (mild or brief); differential diagnosis (delirium, dementia, substance-induced psychosis, psychosis secondary to general medical condition); schizophrenia, schizoaffective disorder, psychotic mood disorders (major depression or mania with psychosis); psychosis remits with mood symptoms; no persistence of psychosis; subtypes (erotomania delusions, grandiose delusions, persecutory delusions [most common], jealous delusions [better prognosis], somatic delusional disorder); features may be mixed

Brief psychotic disorder: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, category; sudden onset of ≥1 A criterion for schizophrenia; features last ≤1 month; 2 specifiers (with or without marked stressors, with or without postpartum onset); usual onset typically late 20s or early 30s; evolves; longitudinal course important element in affirmation of diagnosis

Readings

Disclosures

Acknowledgements

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Lecture ID:

PSBR160121

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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