Psych Review I Alyssa Norman, MS4 - PowerPoint Presentation

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Psych Review I

Alyssa Norman, MS4

aherman@buffalo.edu

Slide2

Goals

Brief

o

verview of material covered thus far

Highlight important, exam-relevant material

Provide a space for questions and discussion

These reviews should help guide your studying!

Slide3

Topics

Mental Status Exam

Psychosis and Psychotic Disorders

Schizophrenia

Antipsychotics

Intoxication/Withdrawal

Slide4

Mental Status Exam

Appearance

– age, hygiene, physical characteristics, dress

Attitude

/Activity

–

cooperativity

, eye contact, calm

/irritable, behaviors

Mood

– predominant internal emotional state, quoted from the patient

Affect

– expression of that emotional state, as observed by the

clinician

Speech

– volume, rate, spontaneity, articulation,

semantics

Thought

Form

– thought

organization

Thought

Content

– thought

substance

Perception

– illusions, hallucinations, depersonalization,

autoscopy

, déjà vu,

jamais

vu

Cognition

– AOx3, concentration, registration, short/long-term memory, construction

, abstraction

Insight

– patient’s understanding of their illness, behavior, and benefits of

treatment

Judgment

– consideration before action

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Mental Status Exam

Affect

– emotional expression as

observed by the

clinician

Congruency

with stated mood

Appropriateness

with conversation content

Intensity

– level of expression

Blunted

= minimal

expression

Flat = no expression

Range

– emotional spectrum displayed by the patient

Full

or

restricted

Mobility

– fluidity/ease of movement through that spectrum

Labile

> Mobile >

Fixed

Reactivity

– responds appropriately to shifts in conversation content

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Mental Status Exam

Thought Form

(Organization)

Organized

Circumstantial

Tangential

Flight

of Ideas

Loosening of Associations

Word Salad

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Mental Status Exam

Other abnormalities of thought form

Neologisms

Clanging

Echolalia

Thought blocking

Perseveration

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Mental Status Exam

Thought Content

–

types of ideas expressed by patient

Delusions

: fixed false beliefs not shared by peer group

Bizarre

Non-bizarre

Overvalued ideas

–

“delusions” that you can reason with

Suicidal/Homicidal ideations

Obsessions

–

persistent, intrusive, ego-dystonic thoughtsPreoccupations

Magical thinking- “superstitious” thinking Ideas of reference – insignificant events or remarks have some special personal meaning to the patientPoverty of speech

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Psychosis

Psychosis describes a distorted perception of reality characterized by:

Hallucinations

Delusions

Disorganized Thought/Speech

Disorganized behavior

REMEMBER: Psychosis is a

symptom

,

not a diagnosis

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Schizophrenia

Chronic or recurrent disorder characterized by:

Sustained

periods of psychosis,

“

positive symptoms” (

~1 month

)

Negative

symptoms

Long

-term deterioration in functional

ability

Symptom duration of at least 6 months

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Schizophrenia

Positive Symptoms

Delusions

Hallucinations

Thought/speech disorganization

Disorganized behavior

Catatonia

Negative Symptoms

Blunted affect

Anhedonia

/

Asociality

Alogia

Inattention

Avolition

/Apathy

Dopamine in mesolimbic tractOccurs late, waxing/waningHospitalizationResponds well to antipsychoticsDopamine in mesocortical tractOccurs early (

prodrome), progressiveImpairs functionDoes not respond as well to antipsychotics

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Schizophrenia:

DSM-V

A. 2

+ of the following symptoms for at least 1 month:

Delusions

Hallucinations

Disorganized

speech

Grossly

disorganized or catatonic behavior

Negative

symptoms

B

. Social/Occupational Dysfunction

C. Overall duration of at least 6 months D. Not attributable to schizoaffective or mood disorder, substance use, general medical condition, pervasive developmental disorder

Need at least one of these

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Schizophrenia

Cognitive Symptoms

Memory

Language

Attention

Executive

Function

Mood Symptoms

Depression

Dysphoria

Involves all domains

Progressive

Highly correlated with functional impairment

Poor response to antipsychotics

Disabling/distressingContributes to suicidality Suicide in Schizophrenia

20-50% attempt 5-6% succeed

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Schizophrenia

Positive Prognostic Factors

Acute and/or late onset

Positive

symptoms

Family

Hx

of affective disorder

Supportive

family

Good

premorbid functioning

N

egative Prognostic Factors

Insidious and/or early onset

Negative symptoms Family Hx of schizophrenia

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Schizophrenia

Epidemiology

~1%

prevalance

1.4 men

:

1 woman

Starts in 20s

Concordance

Rate

Twins/both parents: 50%

Siblings/one parent: ~10%

Risk Factors

Family

hx

Obstetric complicationsInfectionWinter Birth

Immune factorsNutritional DeficienciesCannabis/drug useImmigrationAdvanced paternal age

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Schizophrenia

Etiology

Dopamine Hypothesis

:

+

symptoms due to over activity of dopamine in mesolimbic tract; psychotic symptoms can be induced by dopamine agonists

Neurodevelopmental Hypothesis

Genetic + Environmental risk

Neurodegenerative Hypothesis

Functional and structural brain abnormalities

Cognitive disturbances

Progressive nature of disease

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Differential Diagnosis: Psychosis

Delusional Disorder

1+ delusions for

at least 1 month

Functioning not impaired

Disorganized speech, negative

sxs

not present

Tx

= can use any antipsychotic, but poor response to antipsychotics, SSRIs may be beneficial

Brief Psychotic

Disorder

Psychotic symptoms

>

1

day but <1 month with gradual recovery to baseline

Tx = brief hospitalization, self-limited, antipsychotics can be helpful with agitation/distress; f/u with psychotherapy/supportive therapy after

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Differential Diagnosis: Psychosis

Schizophreniform

Disorder

Symptoms similar to Schizophrenia

Duration

> 1 month, but < 6 months

Tx

= hospitalization, antipsychotics

Most go on to diagnosis of Schizophrenia, mood disorder, or Schizoaffective

Schizophrenia

Symptom duration

> 6 months

Tx

: Antipsychotics (1

st

or 2nd gen), ECT, hospitalization, outpatient therapy,

mutli-faceted approach

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Differential Diagnosis: Psychosis

Schizoaffective Disorder

Major mood

episode

+ Schizophrenia

sxs

Mood

sxs

predominate

Must have at least 2 weeks of delusions or hallucinations

in absence of mood disorder

(differentiates from mood disorder w/ psychotic features

)

Tx = 2nd gen antipsychotics, additional mood stabilizer or antidepressant possible, ECT for medication-resistant forms

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Differential Diagnosis: Psychosis

Substance/Medication

–

Induced Psychotic Disorder

Mood Disorders

Neurocognitive Disorders

Psychosis secondary to general medical conditions

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Antipsychotics

Four Dopamine (DA) Pathways

Mesolimbic



DA

 Positive symptoms

Mesocortical



DA

 Negative symptoms

Nigrostriatial

DA competes with Ach in basal ganglia

Tuberoinfundibular

DA inhibits prolactin release

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Antipsychotics

-

Typicals

Typical Antipsychotics

(Conventional, First Generation)

Mechanism of Action

Dopamine

(D2) blockade

– therapeutic action (as well as side effects

)

Muscarinic

(M1) blockade

– anticholinergic effects Alpha1 blockade

– orthostatic hypotension/dizziness/drowsinessHistamine (H1) blockade – drowsiness, weight gain

Slide23

Antipsychotics -

Typicals

Four Dopamine (DA) Pathways

Mesolimbic



DA

 Positive

symptoms

Mesocortical



DA

 Negative

symptoms

Nigrostriatial

DA competes with Ach in basal gangliaTuberoinfundibularDA inhibits prolactin release

Universal D2 BlockadeDA   positive sxsDA

negative sxs

DA   Ach 

EPS



DA 



Prolactin

galactorrhea

/amenorrhea

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Extrapyramidal Symptoms (EPS)

Parkinsonism

–

bradykinesia

, masklike

facies

,

cogwheeling

, pill-rolling tremor

Tx

=

anticholinergics

(benztropine, trihexyphenidyl, diphenhydramine)Akathisia –

unpleasant urge to moveTx = propranolol Dystonia – painful, involuntary muscle spasms (usually of head or neck)

Tx = anticholinergics (benztropine, diphenhydramine)Tardive Dyskinesia – involuntary movements of face/neck/extremities (chewing, tongue protrusion, grimacing)Prolonged antipsychotic useOften irreversible; switch to lower risk antipsychotic

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Neuroleptic Malignant Syndrome (NMS)

Muscle

rigidity, fever, autonomic instability, ↑ CPK

Immediately STOP antipsychotic (

potentially fatal

)

Tx

=

supportive (cooling),

dantrolene

(inhibits calcium release from SR and allows muscles

to relax), dopamine agonists

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Antipsychotics

Low Potency

Typicals

(lower D2 affinity)

–

Chlopromazine



dose needed





anticholingeric

effects 

Ach  EPS

Predominate side effects: anticholinergic, drowsiness, orthostatic hypotensionHigh Potency Typicals (higher D2 affinity) – Haloperidol, Fluphenazine, Trifluoperazine dose needed

  anticholinergic effects   Ach 

EPSEPS symptoms predominate, hyperprolactinemia

Overall

: improve positive

sxs

, worsen negative

sxs

, cause EPS, anticholinergic, drowsiness,

orthostasis

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Antipsychotics -

Atypicals

Atypical Antipsychotics

(2

nd

Generation)

Mechanism of action

Dopamine (D2) blockade

Serotonin (5-HT2A) blockade

Serotonin inhibits DA



5-HT2A





DA (essentially counteracting the DA blockade)5-HT2A receptor levels very in different brain regions

Mesolimbic – low levelsMesocortical, Nigrostriatial, Tuberoinfundibular – high levelsWhat does this mean? There is a selective D2 blockade in the mesolimbic tract

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Antipsychotics -

Atypicals

Four Dopamine (DA) Pathways

Mesolimbic

(few 5-HT2A receptors)



DA

 Positive

symptoms

Mesocortical

(many 5-HT2A receptors)



DA

 Negative

symptomsNigrostriatial (many 5-HT2A receptors)DA competes with Ach in basal

gangliaTuberoinfundibular (many 5-HT2A receptors)DA inhibits prolactin release5-HT2A and D2 BlockadeDA 

 positive sxs

5-HT  DA 

negative

sxs

5-HT





DA





Ach 



EPS



5-HT 



DA 



Prolactin



galactorrhea

/amenorrhea

Slide29

Antipsychotics -

Atypicals

Risperidone

-

hyperprolactinemia

(most similar to

typicals

)

Olanzapine

- weight gain

Quetiapine

- sedation

Ziprasidone

-

 weight gain,  QTc Aripiprazole

(D2 partial agonist) - akathisiaClozapine – agranulocytosis (needs frequent blood work)Only antipsychotic with  efficacyReduces risk of suicide

No EPS, TD or prolactinemiaUse in cases of 2x failed tx

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Antipsychotics

All

Atypicals



weight

Metabolic syndrome risk

Varying degree of

anticholingergic

symptoms, sedation,

orthostasis

All Antipsychotics



seizure threshold

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Intoxication & Withdrawal

Substance Use Disorder

– problematic pattern of substance use leading to significant impairment or distress over 12 month period involving

:

Impaired

Control – can’t cut down, taking more than

intended

Social

Impairment – not fulfilling obligations, giving up important

activities

Risky

Use – ignoring hazardous purchasing conditions or physical

effects

Pharmacologic Dependence – tolerance, withdrawal if stop using

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Intoxication & Withdrawal

Stimulants

Sedatives

Hallucinogens

Dissociative Anesthetics

Cannabinoids

Cocaine

Alcohol

LSD

PCP

Marijuana

Amphetamines

Benzodiazepines

Psilocybin

Ketamine

K2

Crystal

MethBarbituatesMescaline

MDMA(Ecstasy)Opioids

Bath Salts

Slide33

Stimulants

Mechanisms of Action:

Cocaine

–



reuptake of DA, NE, 5HT

Smoking and injection = most

addictive

Also block nerve impulses causing local anesthetic effect

Amphetamines

– 

reuptake,  release,

 degradation of NE and DAEcstasy – amphetamine MoA +  release of 5HTCrystal Meth –

fat solubility  BBB penetration  more addictive

Bath Salts – effect is similar to amphetamiens

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Stimulants

Intoxication

–

sympathomimetic (



HR,



BP,



RR),

mydriasis

, euphoria

Cocaine overdose  formications

, delirium, seizure, stroke, MIEcstasy  emotional openness, euphoria, “afterglow”Withdrawal

– malaise, fatigue, depression, SI, hypersomnia, miosisSymptomatic treatmentEcstasy – long-term use can deplete 5HT  depression

Slide35

Dissociative

Anesthetics

PCP

MoA

: blocks NMDA glutamate receptors, activates DA receptors

Intoxication

: hallucinations,

nystagmus

, violence, anesthesia

Overdose

: fever,

rhabdo

, renal failure, seizure, respiratory depression, death

Treatment

: isolate,

benzos, urine acidification (NOT antipsychotics – can worsen psychosis)KetamineHallucinations, dissociation, profound respiratory depression

Slide36

Hallucinogens

LSD, Psilocybin, Mescaline

MoA

–

5HT receptor agonist

Intoxication

–

visual distortions, intense emotions,

mydriasis

,

tachycardia, altered sense of time/space

Hallucinogen Persisting Perception

(“Bad Trip”) –

acute anxiety reactionTx – reassurance and wait, +/- benzos, antipsychotics last resort

Flashbacks can occur in times of fatigue/stress or while using other drugsDurationLSD, mescaline: 6-10 hrsPsilocybin – 2-4 hrs

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Cannabinoids

Marijuana (Cannabis)

MoA

–

THC binds endogenous cannabinoid receptors

Intoxication

–

euphoria, relaxation,

conjunctival

injection, paranoia, increased appetite

Withdrawal

– irritability, restlessness, anxiety, depressed mood, abdominal pain

K2 (Spice)Synthetic cannabinoid, 10x more affinity for receptor than THCMore severe

sxs – hallucinations, thought disorganization, aggression

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Sedatives

Alcohol, Benzodiazepines,

Barbituates

MoA

–

potentiates the effects of GABA (CNS depressant)

Intoxication

–

incoordination, slurred speech,

nystagmus

, coma

Benzo

overdose

 flumazenilWithdrawal

– LIFE THREATENING!!!!Autonomic hyperactivity, tremor, seizures, DTs (day 2-3)Tx

– frequent vitals, benzo taper, carbamazepine

Slide39

Sedatives

Opioids

–

Heroin, Methadone, Buprenorphine, Naloxone, Naltrexone

MoA

–

bind opioid receptors (full and partial agonists, antagonists), most importantly the Mu receptors

Intoxication

–

euphoria, analgesia, respiratory depression,

miosis

, constipation

Overdose can be

fatal  treat with naloxone (antagonist)Withdrawal –

dysphoria, nausea/vomting, diarrhea, lacrimation, rhinorrhea, yawing, mydriasisTreatments for dependenceMethadone, Suboxone (buprenorphine/naloxone) – detox and maintenanceNaltrexone – maintenance only