Psychotic Disorders

Psychotic Disorders Source of answers, unless otherwise noted are DSM-IV-TR or APA Practice Guideline on schizophrenia, Supplement to AJP, February, 2004. As of 10July2012

Dx criteria Q. What are the dx criteria for schizophrenia?

Dx criteria Ans. Two or more of five: 1] delusions 2] hallucinations 3] disorganized speech 4] disorganized behavior or catatonia 5] deficit signs of flat affect, apathy, alogia, and so on [“negative” signs].

Delusions - exception Q. Under what circumstances can you give a person a dx of schizophrenia when delusions is the only one of the five supra that the pt has?

Delusions -exception Ans. When the delusions are “bizarre.” By bizarre, DSM means that the idea could not be true. It could be true, for example, that someone is poisoned, but it could not be true that the pt’s father lives on the planet Jupiter. [Thus, one does not need to dx psychotic disorder NOS when faced with a six month illness that only has bizarre delusions, but can dx “schizophrenia.”]

Hallucinations - exception Q. What characteristics of hallucination allows one to dx a person with schizophrenia even when the individual lacks any of the other four signs of schizophrenia listed supra?

Hallucinations -- exceptions Ans. Two exceptions: 1] “Hearing” a voice constantly reflecting on the pt’s behavior or thoughts. 2] “Hearing two voices conversing with each other.

Catatonia v. paranoid Q. Your pt has the signs of catatonic type and has the signs of the paranoid type, what is the dx?

Catatonic v. paranoid Ans. Catatonic Type. The catatonic type trumps all the other types. Disorganized type also trumps paranoid type.

Deficit signs • Q. Your pt has developed deficit [negative] signs. Besides being part of schizophrenia, what are two other possibilities common in psychiatric practice? [These slides avoid the terms “positive” and “negative” and instead use “psychotic” and “deficit.”]

Deficit signs Ans. While the list could be long, two will probably reach the exam question: • -- Parkinsonian signs from the meds. • -- Depression

Schizoaffective Disorder • Q. Criteria for schizoaffective disorder?

Schizoaffective Disorder Ans. Someone who has: • -- signs of a mood disorder • AND • -- delusions or hallucinations for at least two weeks when mood disorder is not present. [note, not “schizophrenia,” but “delusions or hallucinations.”]

Structural Neuroimaging studies Q. Most consistent structural neuro-imaging finding of these pts with schizophrenia in comparison to general population?

Structural Neuroimaging studies Ans. Enlargement of lateral ventricles.

Functional neuroimaging studies Q. What has been the most consistent finding as to functional neuroimaging studies in pts with schizophrenia?

Functional neuroimaging studies Ans. Hypofrontality.

Schizophrenia - death • Q. People with schizophrenia death rate compared with the general population is?

Schizophrenia - death Ans. Die a decade or more earlier. [since 2007, “25 years” has become a common figure.]

Death rate - why Q. List the three reasons why the death rate is higher.

Death rate - why • Suicide rate is much higher • Accidents are much more common • Medical care is more inadequate. • [Side effects of meds that are used to treat the mentally ill may become the fourth.]

Suicide Q. What is rate of suicides?

Suicides Ans. DSM-IV says 10%. More recent studies say 5%.

Suicide risks • Q. What five suicide risk factors DIFFER from the suicide risk factors of the general populations? That is, if you are doing a risk assessment on a pt with schizophrenia, what findings would increase the suicide risk chances with pt with schizophrenia, findings that would not increase the suicide risk in the general population.

Suicide – risk factors Ans. Risk factors that are different from the general population include: • 1. Young • 2. High socioeconomic status • 3. High IQ • 4. Good scholastic record • 5. High aspirations • [This is a pretty common question on Boards, consistent with the focus on passing a safe psychiatrist.]

Proven to reduce suicide in people with schizophrenia • Q. Med/meds proven to reduce suicide rate?

Proven to reduce suicide rate Ans. Clozapine • [Lithium’s use might be an acceptable answer too, but clozapine has a specific FDA approval for suicidal risk in pts with schizophrenia. Li does not.]

Suicide - prediction • Q. Status of clinicians ability to predict suicide?

Suicide - prediction Ans. Not able to predict. [This will be correct answer to almost any question as to ability to predict suicide, not just the psychotic disorders.]

Aggressive behavior • Q. List three co-morbid disorders that increase risk of aggressive behavior in pts with schizophrenia.

Aggressive behavior Ans. • 1. Substance abuse/dependence [especially PCP, but alcohol, cocaine, and sedatives] • 2. Neurological disorders • 3. Antisocial personality

Prognosis – family hx • Q. Does a hx of mood disorders in the family hx suggest a poorer prognosis for your pt with schizophrenia?

Prognosis – family hx Ans. A family hx that has a mood disorder has a better prognosis.

Prognosis - gender • Q. Does gender make a difference as to prognosis?

Gender Ans. Women have a better prognosis.

Prognosis – age of onset • Q. What about prognosis and age of onset?

Prognosis - age Ans. The later the onset of the illness, the better the prognosis.

Prognosis – Mental Status • Q. What two mental status findings have a good prognosis?

Prognosis – mental status • A. Good prognostic signs are: • -- Lack of anosognosia • -- Signs of mood disorder [If neither of the above two are among the choices, seems confused may be the correct answer.]

Prognosis – Course of illness • Q. What course of illness suggests a good prognosis? List two as to onset. List one as inter-episode functioning.

Prognosis - course Ans. The following suggest a relatively good prognosis: • -- acute onset • -- precipitating, traumatic, event • -- good prior-episode or good inter-episode functioning

Stages • Q. APA Practice Guideline has what stages for schizophrenia?

Schizophrenia - stages • Ans. • -- Acute • -- Stabilization • -- Stable [“maintenance” also used]

Acute phase • Q. Definition of acute phase?

Acute phase Ans. Beginning with the onset of the episode until the pt reaches what the clinician believes is to be the pt’s baseline.

Course • Q. You are treating a pt during his first break, age 21. What are the chances he will never have another schizophrenic episode?

Course Ans. 10-20%

Maintenance • Q. Indefinite maintenance of antipsychotic meds is recommended when?

Maintenance • Ans. If the pt has had two psychotic episodes within five years.

Stable phase – relapse rate • Q. Within one year, in a pt who responds adequately to meds in the acute phase, what percentage will relapse if continued on meds? What percentage if meds are discontinued?

Psychotic Disorders