Psychotic Disorders
A Patient-Centered, Evidence-Based Diagnostic
and Treatment Process for Schizophrenia1,2,3
Kendall L. Stewart, MD, MBA, DLFAPA
March 21, 2014
1My
aim is to offer practical clinical insights that you can use right away in caring for patients.
let me know whether I have succeeded on your evaluation forms.
3These are complicated and exasperating patients; your gut instincts will not serve you well.
2Please
Why is this important?
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About 1 in 100 people will
develop this devastating disorder
in their lifetime.1,2
Schizophrenia is found in every
society and in every country.
It is best thought of a group of
disorders with
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Unknown cause,
Similar presentation,
Bizarre behavior,
Hallucinations,
Delusions, and
Deterioration in overall
functioning
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After listening to this
presentation, you will be able to
answer the following questions:
Why is this important?
How do these patients present?
What are the diagnostic criteria?
What is the differential
diagnosis?
– What is the treatment?
– What are some of the treatment
challenges?
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• You can view a brief
documentary here.
1
This is the cancer of mental illness.
families are the experts; you are at best a caring and knowledgeable consultant.
2The
What diagnoses are included in the Schizophrenia
Spectrum and Other Psychotic Disorders category?
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Schizotypal (Personality) Disorder
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia Associated With Another Mental Disorder
Catatonic Disorder Due to Another Medical Condition
Unspecified Catatonia
Other Specified Schizophrenia Spectrum and Other
Psychotic Disorder
Unspecified Schizophrenia Spectrum and Other Psychotic
Disorder
How do patients with schizophrenia
typically present?
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The patient is 22 years old.
He is withdrawn and hesitant to
talk.
He was brought in for evaluation
“against my will.”
The history is obtained primarily
from his parents.1,2
“During his senior year of college
he became more and more
convinced that his roommates
were making fun of him.”
“He observed that they would
cough, sneeze or look away when
he came into the room.”
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“When his girlfriend broke it off
with him, he decided that she had
been replaced with a look-alike.”
“He called the police to report her
kidnapping.”
“He stopped going to class
because he believed that the
professors were taking thoughts
out of his mind.”
“He stopping showering and
shaving.”
“He thought someone was putting
something in his food and he lost
weight.”
“We just can’t reason with him.”
families are involved, I obtain the patient’s consent and view myself as their consultant.
of my patient’s elderly mother comes in with her son every time.
What are the diagnostic criteria for
Schizophrenia?
• Two of more of the
following:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or
catatonic behavior
– Negative symptoms such as
affective flattening, alogia1,2
or absence of volition
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• Social or occupational
dysfunction
• Continuous symptoms for
6 months
1This
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is a common symptom in hospitals—and now—prisons.
mute patient suddenly told me about Rapid City, SD.
• Schizoaffective and Mood
Disorder have been ruled
out
• Substance Disorder or an
underlying General
Medical Disorder has been
ruled out.
• If there is a history of
autism or communication
disorder, prominent
delusions or hallucinations
are present.
What are some of the associated
features?
• Inappropriate affect (smiling,
giggling or weird facial
expressions)
• Loss of interest or pleasure
• Dysphoric mood
• Sleep disturbances
• Abnormal psychomotor
behavior
• Diminished concentration,
memory and attention
• 80-90% of these patients smoke
• Comorbid mental disorders
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Poor insight
Noncompliance
Somatic concerns
Motor abnormalities
Decreased life expectancy
Increased risk for suicide
Higher incidence of assault and
violence among males, younger
age, people with prior history of
violence and noncompliant
patients1,2
violence is very hard to predict in these patients.
patient nearly killed a patient who had attacked a fellow psychiatrist.
What are some of the differential
diagnoses?1,2
• Psychosis due to a General
Medical Condition
• Delirium
• Dementia
• Schizotypal, Schizoid and
Paranoid Personality
Disorders
• Substance-Induced Psychotic
Disorder
• Substance-Induced Delirium
• Substance-Induced Dementia
1At
• Substance-Related Disorders
• Mood Disorder with
Psychotic Features
• Schizoaffective Disorder
• Depressive Disorder Not
Otherwise Specified (NOS)
• Bipolar Disorder NOS
• Delusional Disorder
• Neurodevelopmental
Disorders
a moment in time, this can be a very difficult diagnosis to make.
diagnosis becomes increasingly clear over time.
2The
What interventions should be included
in the treatment plan?
• Combination treatment
– Biological
– Psychological
– Social
• Biological
– Typical antipsychotics
• Phenothiazines
• Haloperidol
– Atypical antipsychotics1
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Clozapine
Risperidone
Olanzapine
Quetiapine
• Psychological
– Prevent harm
– Minimize stress
– Minimize risk of relapse
• Social
– Social support
– Good alliance with patient
and the family
1These
are now usually the psychiatrist’s initial choices.
What prescription guidelines1 should
you consider?
• Stage 1 - Olanzapine, quetiapine or resperidone
• Stage 2 - Switch to another atypical agent; for
noncompliant patients use decanoate preparations
• Stage 3 - Switch to a third atypical antipsychotic
• Stage 4 - Switch to a typical antipsychotic
• Stage 5 - Use clozapine
• Stage 5a - Augment clozapine
• Stage 6 - Augment with additional drugs and or
ECT
1Chiles,
et. Al., “The Texas Medication Algorithm Project: Development and Implementation of the Schizophrenia Algorithm,”
Psychiatric Services, January 1999, Vol. 40 No. 1
What treatment challenges can you
expect?
• These patients have a hard
time building and
sustaining a therapeutic
relationship.
• Families often burn out
and opt out.
• Noncompliance is a
constant challenge.
• Maintaining hope is not
always easy.
1One
• Setting realistic
expectations is difficult.
• These patients are often
desperately poor.1
• The medications often
seem to cause more harm
than benefit.
of my patients brought one card from his collection to each visit as a gift to my sons.
How should you behave1,2 while
treating these patients?
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Adopt a quiet, calm demeanor.
Isolate your own emotional arousal.
Avoid perceived intrusion.
Observe carefully.
Listen intently.
Know the diagnostic criteria.
Ask brief clarifying questions.
Avoid painful exploration.
Review available records.
Engage the patient’s family and
social support network.
Consider the differential diagnoses.
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Convey understanding, confidence
and intent to help.
Recommend the most appropriate
medications.
Explain most common side effects
briefly.
Explain treatment plan briefly.
Invite questions.
Begin educating the family about
what to expect.
Arrange for social support.
Communicate with stakeholders.
Arrange for follow up.
with the result you want—this patient to receive the best possible care—then focus on those behaviors necessary.
only behaviors you can really control are your own!
What have you learned?
• The first descriptions of schizophrenia date back to 1400 BC.
• Schizophrenia is currently viewed as a devastating group of disorders
that involve
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Deterioration from a previous level of functioning,
Characteristic symptoms involving multiple mental processes,
Typical psychotic symptoms during the active phases of the illness, and
A demoralizing, chronic course.
• Onset usually is in the patient’s teens and 20s.
• The treatment challenges are daunting.
• Antipsychotic medications are helpful but not dramatically so, and side
effects are real problems in themselves.
• Only clozapine stands out;1 the rest differ only in expense and side
effects.
• Multi-modal intervention is the key to maximizing recovery and
preventing relapse.
1Lieberman,
et. al., “Effectiveness of Antipsychotic Drugs in Patients with Chronic Schizophrenia,” The New England
Journal of Medicine, September 22, 2005, Volume 353;1209-1223 (CATIE)
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Treatment Process
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Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of my problems and
concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
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Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment plan
while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
How can you access the OU-HCOM
psychiatry flash cards online?
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Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, 2013
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts General Hospital Handbook of
Neurology, 2011
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Third Edition, 2011
Klamen, D, and Pan, P, Psychiatry PreTest Self-Assessment and Review,
Thirteenth Edition, 2012
Blitzstein, Sean, Lange Q&A Psychiatry, 2011
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, 2010
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where
evidence-based medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the
specialties of your choice here.
Subscribe to Evidence-Based Mental Health and search a
database at the National Registry of Evidence-Based Programs
and Practices maintained by the Substance Abuse and Mental
Health Services Administration here.
Explore a limited but useful database of mental health
practices that have been "blessed" as evidence-based by
various academic, administrative and advocacy groups
collected by the Iowa Consortium for Mental Health here.
How can you contact me?
Kendall L. Stewart, MD, MBA, DLFAPA
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
Clinical Professor of Psychiatry
Ohio University Heritage College of Osteopathic Medicine
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
Are there other questions?1,2
Justin Greenlee, DO
Director
Family Medicine
Residency
 Safety  Quality  Service  Relationships Performance 
Thomas Carter, DO
Director
Emergency Medicine
Residency
1Learn
2Learn
more about Southern Ohio Medical Center.
more about our Family Medicine and Emergency Medicine Residencies.