PSYCHOSES
PSYCHOSES
Jon Lehrmann MD
Assistant Professor of Psychiatry
Medical College of WI
VAMC 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 surgeryeven 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