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PsychReviewIAlyssaNorman,[email protected]
Goals• Briefoverviewofmaterialcoveredthusfar• Highlightimportant,exam-relevantmaterial• Provideaspaceforquestionsanddiscussion
• Thesereviewsshouldhelpguideyourstudying!
Topics² MentalStatusExam² PsychosisandPsychoticDisorders² Schizophrenia² Antipsychotics² Intoxication/Withdrawal
MentalStatusExam• Appearance–age,hygiene,physicalcharacteristics,dress• Attitude/Activity–cooperativity,eyecontact,calm/irritable,behaviors• Mood–predominantinternalemotionalstate,quotedfromthepatient• Affect–expressionofthatemotionalstate,asobservedbytheclinician• Speech–volume,rate,spontaneity,articulation,semantics• ThoughtForm–thoughtorganization• ThoughtContent–thoughtsubstance• Perception–illusions,hallucinations,depersonalization,autoscopy,déjà
vu,jamaisvu• Cognition–AOx3,concentration,registration,short/long-termmemory,
construction,abstraction• Insight–patient’sunderstandingoftheirillness,behavior,andbenefits
oftreatment• Judgment–considerationbeforeaction
MentalStatusExam
• Affect–emotionalexpressionasobservedbytheclinician• Congruencywithstatedmood• Appropriatenesswithconversationcontent• Intensity–levelofexpression
• Blunted=minimalexpression• Flat=noexpression
• Range–emotionalspectrumdisplayedbythepatient• Fullorrestricted
• Mobility–fluidity/easeofmovementthroughthatspectrum• Labile>Mobile>Fixed
• Reactivity–respondsappropriatelytoshiftsinconversationcontent
MentalStatusExam• ThoughtForm(Organization)
MentalStatusExam• Otherabnormalitiesofthoughtform
• Neologisms• Clanging• Echolalia• Thoughtblocking• Perseveration
MentalStatusExam• ThoughtContent–typesofideasexpressedbypatient
• Delusions:fixedfalsebeliefsnotsharedbypeergroup• Bizarre• Non-bizarre
• Overvaluedideas–“delusions”thatyoucanreasonwith• Suicidal/Homicidalideations• Obsessions–persistent,intrusive,ego-dystonicthoughts• Preoccupations• Magicalthinking-“superstitious”thinking• Ideasofreference–insignificanteventsorremarkshavesome
specialpersonalmeaningtothepatient• Povertyofspeech
MentalStatusExam
• Affect–emotionalexpressionasobservedbytheclinician• Congruencywithstatedmood• Appropriatenesswithconversationcontent• Intensity–levelofexpression
• Blunted=minimalexpression• Flat=noexpression
• Range–emotionalspectrumdisplayedbythepatient• Fullorrestricted
• Mobility–fluidity/easeofmovementthroughthatspectrum• Labile>Mobile>Fixed
• Reactivity–respondsappropriatelytoshiftsinconversationcontent
Psychosis• Psychosisdescribesadistortedperceptionofrealitycharacterizedby:• Hallucinations• Delusions• DisorganizedThought/Speech• Disorganizedbehavior
REMEMBER:Psychosisisasymptom,notadiagnosis
Schizophrenia• Chronicorrecurrentdisordercharacterizedby:• Sustainedperiodsofpsychosis,• “positivesymptoms”(~1month)
• Negativesymptoms• Long-termdeteriorationinfunctionalability• Symptomdurationofatleast6months
SchizophreniaPositiveSymptoms
DelusionsHallucinations
Thought/speechdisorganizationDisorganizedbehavior
Catatonia
NegativeSymptomsBluntedaffect
Anhedonia/AsocialityAlogia
InattentionAvolition/Apathy
éDopamineinmesolimbictractOccurslate,waxing/waning
HospitalizationRespondswelltoantipsychotics
êDopamineinmesocorticaltractOccursearly(prodrome),progressive
ImpairsfunctionDoesnotrespondaswelltoantipsychotics
Schizophrenia:DSM-VA.2+ofthefollowingsymptomsforatleast1month:• Delusions• Hallucinations• Disorganizedspeech• Grosslydisorganizedorcatatonicbehavior• Negativesymptoms
B.Social/OccupationalDysfunctionC.Overalldurationofatleast6monthsD.Notattributabletoschizoaffectiveormooddisorder,substanceuse,generalmedicalcondition,pervasivedevelopmentaldisorder
Needatleastoneofthese
Schizophrenia• CognitiveSymptoms
• Memory• Language• Attention• ExecutiveFunction
• MoodSymptoms• Depression• Dysphoria
InvolvesalldomainsProgressive
Highlycorrelatedwithfunctionalimpairment
Poorresponsetoantipsychotics
Disabling/distressingContributestosuicidality
SuicideinSchizophrenia
20-50%attempt5-6%succeed
SchizophreniaPositivePrognosticFactors
Acuteand/orlateonsetPositivesymptoms
FamilyHxofaffectivedisorderSupportivefamily
Goodpremorbidfunctioning
NegativePrognosticFactorsInsidiousand/orearlyonset
NegativesymptomsFamilyHxofschizophrenia
SchizophreniaEpidemiology• ~1%prevalance• 1.4men:1woman• Startsin20s
ConcordanceRate• Twins/bothparents:50%• Siblings/oneparent:~10%
RiskFactors• Familyhx• Obstetriccomplications• Infection• WinterBirth• Immunefactors• NutritionalDeficiencies• Cannabis/druguse• Immigration• Advancedpaternalage
SchizophreniaEtiology
1. DopamineHypothesis:+symptomsduetooveractivityofdopamineinmesolimbictract;psychoticsymptomscanbeinducedbydopamineagonists
2. NeurodevelopmentalHypothesis1. Genetic+Environmentalrisk
3. NeurodegenerativeHypothesis1. Functionalandstructuralbrainabnormalities2. Cognitivedisturbances3. Progressivenatureofdisease
DifferentialDiagnosis:PsychosisDelusionalDisorder
• 1+delusionsforatleast1month• Functioningnotimpaired• Disorganizedspeech,negativesxsnotpresent• Tx=canuseanyantipsychotic,butpoorresponsetoantipsychotics,
SSRIsmaybebeneficial
BriefPsychoticDisorder• Psychoticsymptoms<1daybut>1monthwithgradualrecoveryto
baseline• Tx=briefhospitalization,self-limited,antipsychoticscanbehelpful
withagitation/distress;f/uwithpsychotherapy/supportivetherapyafter
DifferentialDiagnosis:Psychosis
SchizophreniformDisorder• SymptomssimilartoSchizophrenia• Duration>1month,but<6months• Tx=hospitalization,antipsychotics• MostgoontodiagnosisofSchizophrenia,mooddisorder,orSchizoaffective
Schizophrenia• Symptomduration>6months• Tx:Antipsychotics(1stor2ndgen),ECT,hospitalization,outpatienttherapy,mutli-facetedapproach
DifferentialDiagnosis:PsychosisSchizoaffectiveDisorder• Majormoodepisode+Schizophreniasxs• Moodsxspredominate• Musthaveatleast2weeksofdelusionsorhallucinationsinabsenceofmooddisorder(differentiatesfrommooddisorderw/psychoticfeatures)
• Tx=2ndgenantipsychotics,additionalmoodstabilizerorantidepressantpossible,ECTformedication-resistantforms
DifferentialDiagnosis:Psychosis
• Substance/Medication–InducedPsychoticDisorder
• MoodDisorders• NeurocognitiveDisorders• Psychosissecondarytogeneralmedicalconditions
AntipsychoticsFourDopamine(DA)Pathways1. Mesolimbic
• éDAàPositivesymptoms
2. Mesocortical• êDAàNegativesymptoms
3. Nigrostriatial• DAcompeteswithAchinbasalganglia
4. Tuberoinfundibular• DAinhibitsprolactinrelease
Antipsychotics-TypicalsTypicalAntipsychotics(Conventional,FirstGeneration)• MechanismofAction
• Dopamine(D2)blockade–therapeuticaction(aswellassideeffects)
• Muscarinic(M1)blockade–anticholinergiceffects• Alpha1blockade–orthostatichypotension/dizziness/drowsiness• Histamine(H1)blockade–drowsiness,weightgain
Antipsychotics-TypicalsFourDopamine(DA)Pathways1. Mesolimbic
• éDAàPositivesymptoms
2. Mesocortical• êDAàNegativesymptoms
3. Nigrostriatial• DAcompeteswithAchinbasalganglia
4. Tuberoinfundibular• DAinhibitsprolactinrelease
UniversalD2Blockadeê DAàêpositivesxsê DAàénegativesxs
ê DAàéAchàEPS
êDAàéProlactinàgalactorrhea/amenorrhea
ExtrapyramidalSymptoms(EPS)
• Parkinsonism– bradykinesia,masklikefacies,cogwheeling,pill-rollingtremor• Tx=anticholinergics(benztropine,trihexyphenidyl,
diphenhydramine)• Akathisia– unpleasanturgetomove
• Tx=propranolol• Dystonia–painful,involuntarymusclespasms(usuallyof
headorneck)• Tx=anticholinergics(benztropine,diphenhydramine)
• TardiveDyskinesia– involuntarymovementsofface/neck/extremities(chewing,tongueprotrusion,grimacing)• Prolongedantipsychoticuse• Oftenirreversible;switchtolowerriskantipsychotic
NeurolepticMalignantSyndrome(NMS)• Musclerigidity,fever,autonomicinstability,↑CPK• ImmediatelySTOPantipsychotic(potentiallyfatal)• Tx=supportive(cooling),dantrolene(inhibitscalciumreleasefromSRandallowsmusclestorelax),dopamineagnoists
Antipsychotics
LowPotencyTypicals(lowerD2affinity)– Chlopromazine• édoseneededàéanticholingericeffectsàêAchàêEPS• Predominatesideeffects:anticholinergic,drowsiness,orthostatic
hypotension
HighPotencyTypicals(higherD2affinity)– Haloperidol,Fluphenazine,Trifluoperazine
• êdoseneededàéanticholinergiceffectsàéAchàéEPS• EPSsymptomspredominate,hyperprolactinemia
Overall:improvepositivesxs,worsennegativesxs,causeEPS,anticholinergic,drowsiness,orthostasis
Antipsychotics-AtypicalsAtypicalAntipsychotics(2ndGeneration)• Mechanismofaction
• Dopamine(D2)blockade• Serotonin(5-HT2A)blockade
• SerotonininhibitsDA• ê5-HT2AàéDA(essentiallycounteractingtheDAblockade)• 5-HT2Areceptorlevelsveryindifferentbrainregions
• Mesolimbic–lowlevels• Mesocortical,Nigrostriatial,Tuberoinfundibular–highlevels
• Whatdoesthismean?ThereisaselectiveD2blockadeinthemesolimbictract
Antipsychotics-AtypicalsFourDopamine(DA)Pathways1. Mesolimbic(few5-HT2Areceptors)
• éDAàPositivesymptoms
2. Mesocortical(many5-HT2Areceptors)
• êDAàNegativesymptoms
3. Nigrostriatial(many5-HT2Areceptors)• DAcompeteswithAchinbasalganglia
4. Tuberoinfundibular(many5-HT2Areceptors)• DAinhibitsprolactinrelease
5-HT2AandD2Blockadeê DAàêpositivesxsê 5-HTàéDAàênegativesxs
ê 5-HTàéDAàêAchàêEPS
ê5-HTàéDAàêProlactinàêgalactorrhea/amenorrhea
Antipsychotics-Atypicals• Risperidone-hyperprolactinemia(mostsimilartotypicals)• Olanzapine-weightgain• Quetiapine-sedation• Ziprasidone-êweightgain,éQTc• Aripiprazole(D2partialagonist)-akathisia
• Clozapine– agranulocytosis(needsfrequentbloodwork)• Onlyantipsychoticwithéefficacy• Reducesriskofsuicide• NoEPS,TDorprolactinemia• Useincasesof2xfailedtx
AntipsychoticsAllAtypicals• éweight• Metabolicsyndromerisk• Varyingdegreeofanticholingergicsymptoms,sedation,orthostasis
AllAntipsychotics• êseizurethreshold
Intoxication&WithdrawalSubstanceUseDisorder–problematicpatternofsubstanceuseleadingtosignificantimpairmentordistressover12monthperiodinvolving:• ImpairedControl–can’tcutdown,takingmorethanintended
• SocialImpairment–notfulfillingobligations,givingupimportantactivities
• RiskyUse–ignoringhazardouspurchasingconditionsorphysicaleffects
• PharmacologicDependence–tolerance,withdrawalifstopusing
Intoxication&WithdrawalStimulants Sedatives Hallucinogens Dissociative
Anesthetics Cannabinoids
Cocaine Alcohol LSD PCP Marijuana
Amphetamines Benzodiazepines Psilocybin Ketamine K2
CrystalMeth Barbituates Mescaline
MDMA(Ecstasy) Opioids
BathSalts
StimulantsMechanismsofAction:Cocaine– êreuptakeofDA,NE,5HT
• Smokingandinjection=mostaddivtive• Alsoblocknerveimpulsescausinglocalanestheticeffect
Amphetamines– êreuptake,érelease,êdegradationofNEandDAEcstasy– amphetamineMoA+éreleaseof5HTCrystalMeth– éfatsolubilityàéBBBpenetrationàmoreaddictiveBathSalts–effectissimilartoamphetamiens
StimulantsIntoxication– sympathomimetic(éHR,éBP,éRR),mydriasis,euphoria• Cocaineoverdoseàformications,delirium,seizure,stroke,MI
• Ecstasyàemotionalopenness,euphoria,“afterglow”
Withdrawal– malaise,fatigue,depression,SI,hypersomnia,miosis• Symptomatictreatment• Ecstasy–long-termusecandeplete5HTàdepression
DissociativeAnestheticsPCP• MoA:blocksNMDAglutamatereceptors,activatesDAreceptors
• Intoxication:hallucinations,nytagmus,violence,anesthesia
• Overdose:fever,rhabdo,renalfailure,seizure,respiratorydepression,death
• Treatment:isolate,benzos,urineacidification(NOTantipsychotics–canworsenpsychosis)
Ketamine• Hallucinations,dissociation,profoundrespiratorydepression
HallucinogensLSD,Psilocybin,Mescaline• MoA–5HTreceptoragonist• Intoxication–visualdistortions,intenseemotions,mydriasistachycardia,alteredsenseoftime/space• HallucinogenPersistingPerception(“BadTrip”)–acuteanxietyreaction• Tx–reassuranceandwait,+/-benzos,antipsychoticslastresort
• Flashbackscanoccurintimesoffatigue/stressorwhileusingotherdrugs
• Duration• LSD,mescaline:6-10hrs• Psilocybin–2-4hrs
CannabinoidsMarijuana(Cannabis)• MoA–THCbindsendogenouscannabinoidreceptors• Intoxication–euphoria,relaxation,conjunctivalinjection,paranoia,increasedappetite
• Withdrawal–irritability,restlessness,anxiety,depressedmood,abdominalpain
K2(Spice)• Syntheticcannabinoid,10xmoreaffinityforreceptorthanTHC
• Moreseveresxs–hallucinations,thoughtdisorganization,aggression
SedativesAlcohol,Benzodiazepines,Barbituates• MoA–potentiatestheeffectsofGABA(CNSdepressant)
• Intoxication–incoordination,slurredspeech,nystagmus,coma• Benzooverdoseàflumazenil
• Withdrawal– LIFETHREATENING!!!!• Autonomichyperactivity,tremor,seizures,DTs(day2-3)• Tx–frequentvitals,benzotaper,carbamazepine
SedativesOpioids–Heroin,Methadone,Buprenorphine,Naloxone,Naltrexone
• MoA–bindopioidreceptors(fullandpartialagonists,antagonists),mostimportantlytheMureceptors
• Intoxication–euphoria,analgesia,respiratorydepression,miosis,constipation• Overdosecanbefatalàtreatwithnaloxone(antagonist)
• Withdrawal– dysphoria,nausea/vomting,diarrhea,lacrimation,rhinorrhea,yawing,mydriasis
• Treatmentsfordependence• Methadone,Suboxone(buprenorphine/naloxone)–detoxandmaintenance• Naltrexone–maintenanceonly
