1.

1 Management of Psychotic Disorders (09/06/2023)

Dr. Hannah Lois Tarroja-Trinidad
Objectives: - Prodromal Phase: beginning: change of
- To review the different types of psychotic disorders interest but no symptoms in DSM 5
- To discuss general principles of care for psychotic - Active Phase: lose in contact with reality;
disorders psychosis
- To discuss treatment strategies for common - Residual Phase: in touch with reality but
psychotic disorders negative symptom appears; intact memory
Psychosis
➢ Prognosis
- Heterogenous etiologies, clinical presentations,
treatment response, and course of illness Good Prognosis Poor Prognosis
- Person loses contact with reality
- Obvious precipitating - No precipitating factors
- Changes in perception, emotion, cognition,
factors - Insidious onset, young
thinking, and behavior (signs and symptoms are - Acute onset onset
variable) - Good premorbid - Poor premorbid social,
➢ Positive symptoms social, sexual, and sexual, and work
o Additional to expected behavior work histories histories
o Hallucinations (5 senses: Visual, Auditory, - Mood disorder - Withdrawn, autistic
Tactile, Olfactory, Gustatory), delusions symptoms behavior
(make believe that their culture cannot (especially - Single, divorced, or
depressive widowed
explain), agitations (usually as a response disorders) - Family history of
to hallucination and delusion) - Married schizophrenia
➢ Negative symptoms - Family history of - Poor support systems
o Missing from expected behavior mood disorders - Negative symptoms
o Social withdrawal, lack of motivation, flat - Good support - Neurological signs and
affect systems symptoms
- Positive symptoms - History of perinatal
Psychotic Disorders
trauma
➢ Schizophrenia - No remissions in 3
➢ Schizophreniform Disorder years
➢ Brief Psychotic Disorder - Many relapses
➢ Schizoaffective Disorder - History of
➢ Delusional Disorder assaultiveness
➢ Catatonic Disorder
➢ Treatment
Schizophrenia o Pharmacotherapy + Psychosocial
Interventions
➢ 2 or more in 1 month period, disturbance
o Antipsychotic medication is the mainstay
continuous for 6 months
treatment but studies shows that
o Delusion (core)
Psychotherapy can augment the treatment
o Hallucination (core)
➢ Hospitalization
o Disorganized Speech (core) o Patient’s safety (may be suicidal)
o Disorganized Behavior o Diagnostic purposes
o Negative Symptoms o Stabilization of medications
➢ Etiology o Grossly disorganized or inappropriate
Biological Social Others behavior (includes inability to take care of
basic needs like food and shelter)
- Dopamine (most - No social or - Season of o Establishing an effective association
common NT environmental birth: cold between patients and community support
involved), factors weather
systems
Serotonin, - Downward months
norepinephrine, drift (low o Oriented towards practical issues to self-
GABA economic care, quality of life, employment, and
- Genetics status) social relationships
- Excessive ➢ Pharmacotherapy
pruning Dopamine Receptor Serotonin Dopamine
➢ Course Antagonists (1st gen) Antagonists (2nd gen)
- Chlorpromazine - Risperidone
- Haloperidol - Olanzapine
- Fluphenazine - Aripiprazole
- Clozapine
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1.1 Management of Psychotic Disorders (09/06/2023)
Dr. Hannah Lois Tarroja-Trinidad
• Clozapine – tx for
➢ Phases of treatment psychosis with suicidal
ideation but can cause
Acute Psychosis → Stabilization & maintenance
agranulocytosis
o Acute Psychosis o Side Effects
▪ Require immediate attention ▪ May begin almost immediately
▪ Focus: alleviate most severe (side effects may occur first before
psychotic symptoms the therapeutic effect)
▪ Last for 4-8 weeks ▪ Low potency drugs: sedation,
▪ typically associated with severe postural hypotension,
agitation or harm to others due to anticholinergic effects
delusion that someone wants to ▪ High potency drugs:
hurt them or hallucination → extrapyramidal side (EPS) effects
behaviors are usually associated (tremors etc.)
as a response to their psychosis • Reduce dose of
▪ Antipsychotics: antipsychotic
• Intramuscular: more rapid • add antiparkinson drug
without excessive (biperiden)
sedation (haloperidol: 15
• change to SDA with less
– 20 mins to exhibit
EPS
calming effect)
▪ Tardive dyskinesia: 20-30% on
▪ Benzodiazepines
long-term treatment with
o Stabilization & Treatment
conventional DRA
▪ Goals: Prevent psychotic relapse
• Lowest effective dose
and assist patients in improving
• Prescribing cautiously
level of functioning
• Examining patients on a
▪ no to minimal psychotic episode/
regular basis
symptoms
▪ Maintained of antipsychotics: • Considering alternatives to
lower relapse the antipsychotic &
▪ Multiepisode: maintenance considering dosage reduction
treatment for at least 5 years • Discontinuing the
▪ 1-2 years medication is not antipsychotic or switching to a
enough; usually lifetime different drug
o Noncompliance • Clozapine – very effective in
▪ 40-50% noncompliant within 1 to 2 reducing Tardive dyskinesia
years ▪ Other Treatments:
▪ Long-acting medications • ECT
(Fluphenazine) increase • Psychosocial Therapies
compliance o Social skills training
▪ Advantages: (how to relate to others,
• Clinicians know facial expression, etc)
immediately when o Family-oriented
noncompliance occurs therapies (aim to resolve
• less day-to-day variability family situation)
in blood levels o Case management
• many patients prefer it o assertive community
o Poor Responders treatment
▪ 60% improve, 40 % with variable o group therapy
levels of symptoms o CBT
▪ Important to assure that they o Individual
received an adequate trial of the Psychotherapy (done
medication: 4–6-week trial with therapist, deal with
▪ If responding poorly: emotions)
• Increase dose above o Personal Therapy
usual therapeutic level o Dialectical Behavioral
• Change to another drug Therapy
• Change to an SDA

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1.1 Management of Psychotic Disorders (09/06/2023)
Dr. Hannah Lois Tarroja-Trinidad
o Vocational Therapy (eg. o Delusion (core)
TESDA: px can go back to o Criterion for Schizophrenia not met
work) o No marked impairment
o Art Therapy o May have brief mood episode (related to
o Cognitive Training delusion)
o No hallucination in the criteria but patient
may have hallucination related to the
Schizophreniform Disorder delusion.
➢ Etiology: Unknown ➢ Types
➢ 2 or more in a 1-month period, last at least 1 month o Erotomanic type (de Cleramabault
but less than 6 months (similar to schizophrenia but Syndrome)
different duration) o Grandiose type (Megalomania)
o Delusion (core) o Jealous type (Othello syndrome)
o Hallucination (core) o Persecutory type
o Disorganized Speech (core) o Somatic type
o Disorganized Behavior ▪ Parasitosis
o Negative Symptoms ▪ Delusion of Dysmorphopobia
➢ Treatment ▪ Bromosis of halitosis
o Hospitalization (allows effective, o Mixed type
assessment, treatment, management) o Unspecified type
o Antipsychotic: 3- to 6-month course ▪ Capgras syndrome (familiar
(respond faster to antipsychotic drugs than person replaced by impostor)
schizophrenia) ▪ Fregoli’s phenomenon (stranger
o Psychotherapy (help the patient recognize seen as a familiar person)
the psychosis) ▪ Intermetamorphosis (shape
o ECT (for catatonic) shifter)
o Progression to Schizophrenia (despite tx): ▪ Cotard syndrome (lost body parts)
course of management for chronic illness ➢ Treatment
(if recurrent →it can progress to o Hospitalization: evaluation, assessment of
schizophrenia) impulses, stabilization of relationships
o Antipsychotic: IM for severely agitated
o Psychotherapy: individual therapy
Brief Psychotic Disorder ▪ Establish alliance and rapport to
➢ Etiology: Unknown the patient
➢ 1 or more symptom/s, last at least 1 day but less ▪ Do not agree or challenge the
than 1 month delusion in the 1st therapy
o Delusion (core)
o Hallucination (core)
o Disorganized Speech (core) Schizoaffective disorder
o Disorganized Behavior ➢ Etiology: Unknown
➢ Treatment ➢ Criteria
o Hospitalization: acutely psychotic for o Major Mood Episode (Depressive or
evaluation and protection Manic)
▪ Close monitoring of symptoms o Criterion A of schizophrenia
▪ Hospital is quiet so it helps them o Absent Mood episode + Hallucinations or
quiet down delusions (>2 more weeks)
o Antipsychotic and Benzodiazepine (used ➢ Treatment:
for psychosis – short-term) o Mood stabilizer/Antidepressant +
o Psychotherapy: exploration and Antipsychotic
development of coping strategies ▪ Mood stabilizer: mainstay for
▪ Identify the stressors and coping bipolar
mechanisms. Is it adaptive or ▪ Antidepressant: for depressive
maladaptive? type; it can worsen mania
▪ Help the patient deal with stress o ECT
o Family therapy + social skills training +
cognitive rehabilitation
Delusional Disorder
➢ Etiology: Unknown
➢ 1 or more delusion/s, 1 month or longer

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1.1 Management of Psychotic Disorders (09/06/2023)
Dr. Hannah Lois Tarroja-Trinidad
Catatonic Disorder Summary
➢ Etiology ➢ Hospitalization (prioritize safety)
General Medical - Stratus epilepticus, o Evaluation
Conditions head trauma, infection, o Protection
metabolic disturbances ➢ Antipsychotic
Medications - Corticosteroids o Efficacy
- Immunosuppressants o Side effects (for DM, and other metabolic
- Antipsychotics problems)
➢ Psychosocial treatment
o Individual needs (basis of treatment)
➢ 3 or more symptoms with evidence that it is caused
o Relationships (with family and other
by GMC
people)
Stupor ** - No psychomotor activity
- Not actively relating to
environment
Catalepsy - Passive induction of a posture Reference:
held against gravity Lec & PPT ni Doc
Waxy flexibility - Slight, even resistance to
positioning by examiner
Mutism ** - No or very little verbal
response to instructions or
external stimuli
Negativism - Opposition or no response to
instructions or external stimuli
Posturing - Spontaneous and active
** maintenance of a posture
against gravity
Mannerism - Odd, circumstantial caricature
of normal actions
Stereotypy - Repetitive, abnormally
frequent, non-goal-directed
movements
Agitation ** - Not influenced by external
stimuli
Grimacing
Echolalia - Mimic speech
Echopraxia - Mimic movement
**commonly seen symptoms
➢ Treatment
o Correct underlying medical condition or
pharmacological cause
o Benzodiazepine: temporary improvement
o ECT: life threatening catatonia