PSYCHOSES

PSYCHOSES

Jon Lehrmann MD Assistant Professor of Psychiatry Medical College of WI VAMC Milwaukee, WI

Symptoms
Delusions Hallucinations- Auditory, Visual, Olfactory, and Tactile Losing Sense of Reality Disorganization of Thought Thought Blocking

Bob! Wake up! Bob! A ship! I think I see a shipWhere are your glasses?

Causes of Psychosis
Functional vs Organic? Primary vs Secondary? Secondary/ Organic= psychoses secondary to medical conditions, substance intox or w/d, or focal brain lesions Functional/Primary= psychoses originating from psychiatric illness (Schizophrenia, Major Depression, Bipolar Dis or Schizoaffective Disorder)

Neurochemistry of Psychosis- the Dopamine Hypothesis:

Excess of Dopamine activity in Mesolimbic region of the brain This is supported by 2 major findings- first neuroleptics block D2 receptors and improve sxs of psychosis, and second, amphetamines which increase DA transmission can provoke psychotic states.

A Psychosis is a Psychosis
You cannot clearly make a diagnosis of the underlying causative illness based upon the psychotic sxs alone- but there are clues. Look at the course of the illness. Look for Family Hx.

Primary Psychoses:
Schizophrenia Major Depression Bipolar Disorder Schizoaffective disorder

Schizophrenia
Occurs in 1% of population Onset usually in Teens and 20s Runs strongly in families Positive Sxs- depending on type of Schizophrenia- Thought disorg, AHs , Paranoia, Complicated and fixed delusions Negative Sxs

Major Depression w/ Psychosis

Lifetime Prevalence 15% 2X more common for women Family Hx? Mean age is 40, but can occur at any age Depressive sxs Mood congruent psychotic sxs

Bipolar Disorder
Manic sxs Course of illness Family hx Rare after age of 50 for onset of illness

Schizoaffective Disorder
Evidence of mood disorder and Evidence of psychotic episodes at times without the mood component.

Biological Treatment of Primary Psychoses

Schizophrenia: antipsychotic Bipolar- manic psychosis: antipsychotic, mood stabilizer, benzodiazepine Major Depression w/ psychosis: antidepressant and antipsychotic Schizoaffective disorder: Antipsychotic, Mood stabilizer, ? Antidepressant.

Secondary Psychoses:
Delirium Brief Reactive Psychosis Dementias Others...

Axis II Disorders associated w/ Psychosis

Stress + Predisposition
Borderline Schizotypal

Treatment includes antipsychotic and psychotherapy

Delirium 15-25% of patients on general medical wards experience delirium, S/P surgeryeven higher percentages. Advanced age and underlying dementia are risk factors. 1 yr mortality rate for those w/ episode of delirium= up to 50%! Recognizing and Treating Delirium is a medical urgency.

Etiologies:
Intracranial Causes: Seizures and Postictal states, Brain Trauma Neoplasms Infections Vascular Disorders (Vasculitis, CVAs etc.)

Etiologies contd
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 dzs

Etiologies contd
Systemic Infections Electrolyte abnormalities Postoperative states Trauma

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

Antipsychotics
Atypical vs Typical
High vs Low Potency

Wait a minute Mr Crumbly. This may not be kidney stones after all!

Secondary Psychoses
NOT PSYCHIATRIC ORGANICALLY BASED VARIANTS
PEDUNCULAR HALLUCINOSIS CLASSIC CHARLES BONNET SYNDROME RELEASE HALLUCINATIONS

Kathleen Patterson, Ph.D. VAMC

PEDUNCULAR HALLUCINOSIS: LHERMITTES SYNDROME (1922)

VIVID VISUAL, CHROMATIC, DETAILED, OFTEN MOVING (LILLIPUTIAN) FIGURES AND/OR OBJECTS IN THE WHOLE VISUAL FIELD INTACT VISUAL ACUITY AND VISUAL FIELDS DREAMLIKE STATES WITH LUCID MENTATION LESIONS IN THE THALAMUS, BRAINSTEM (TUMORS COMPRESSING THE BRAINSTEM), AND SUBSTANTIA NIGRA PARS RETICULATA AURA OF BASILAR MIGRAINE LOCALIZABLE TO THE BRAINSTEM; AFTER VETEBRAL ANGIOGRAPHY; MANIFESTATION OF VERTEBROBASILAR INSUFFICIENCY D/T SEVERE HYPOPLASIA OF A VETEBRAL ARTERY

CLASSIC CHARLES BONNET SYNDROME

FORMED PLEASANT OR NEUTRAL, NONTHREATENING VISUAL HALLUCINATIONS IN OLDER PERSONS WITH NORMAL COGNITION AND INSIGHT: 1769
? NO MRI OR COMPLEX COGNITIVE TESTING TO R/O SUBTLE COGNITIVE DECLINE IMPAIRED VISUAL ACUITY
MORE RECENTLY ALSO DIAGNOSED IN PATIENTS WITH MS, FRONTAL AND OCCIPITAL LOBE CHANGES, TEMPORAL ARTERITIS, AND PITUITARY TUMORS WHY? BRAIN COMPENSATES FOR SENSORY DEPRIVATION

RELEASE HALLUCINATIONS
ANY MODALITY BUT VISUAL MOST COMMON: DEPENDS ON END ORGAN AFFECTED NONTHREATENING: RECOGNITION THAT THEY ARE NOT REAL: MAY PROGRESS FROM SIMPLE TO COMPLEX ABNORMAL FUNCTIONING OF A LARGE SCALE NEURONAL NETWORK

THESE ARE MUCH MORE COMMON THAN THOUGHT AND UNDERREPORTED BECAUSE PEOPLE DO NOT WANT TO BE CONSIDERED CRAZY.

VISUAL RELEASE HALLUCINATIONS

VISUAL IMPAIRMENT: GLAUCOMA, CATARACTS, MACULAR DEGENERATION
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

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 PATIENTS 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