PSYCHOSES

PSYCHOSES

Jon Lehrmann MDAssistant Professor of PsychiatryMedical College of WIVAMC 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 ship…Where 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 sx’s 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 sx’s 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 20’s

• Runs strongly in families

• Positive Sx’s- depending on type of Schizophrenia- Thought disorg, AH’s , Paranoia, Complicated and fixed delusions

• Negative Sx’s

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 sx’s

• Mood congruent psychotic sx’s

Bipolar Disorder

• Manic sx’s

• 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 surgery- even 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, CVA’s etc.)

Etiologies cont’d

• 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 dz’s

Etiologies cont’d

• 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: LHERMITTE’S 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 PATIENT’S 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