“It’s almost as if a demon has passed from one host to another.” – John Forbes Nash, Jr., 1994 Nobel Prize Winner in Economics
Changes from DSM IV to DSM V
- Schizoaffective disorder: A major mood episode (MDD) must be present for the majority of the disorder’s duration once the patient has satisfied the psychotic criteria
- Delusional disorder: Delusions no longer have to be non-bizzare. It’s difficult to distinguish between what is bizarre and non-bizzare. Bizarre type specifiers for delusional disorders have been introduced. In order to diagnose delusional disorder the patient must not fit the diagnostic criteria for schizophrenia, schizoaffective disorder. Delusional disorder is no longer separated from shared delusional disorder (folie a deux)
Overview
In general, men have an earlier onset than women (15-25y vs 25-35y) for psychotic disorders. Several drugs can cause hallucinations or delusions, so their use should be ruled out with urine toxicology screen. Organic conditions to rule out include epilepsy, stroke/TIA, encephalitis, and SOLs (tumour and trauma). It is important to assess safety and hospitalize the patient if they pose a risk to themselves and others. .
All patients with psychosis are at an INCREASED RISK OF SUICIDE
- Psychotic disorders
- Schizophrenia (>6mos)
- Schizophreniform disorder (1-6mos)
- Brief psychotic event (1day – 1mo)
- Schizoaffective disorder
- Delusional disorders
- Substance-induced psychotic disorder
Hallucinations
A hallucination is a a sensory perception that is not real (in the absence of a real stimulus). It can be something the patient hears, feels, smells etc. that isn’t heard, felt, or smelt by others. The most common type of hallucinations in psychosis are auditory hallucinations
- Causes of hallucination
- In healthy people: Sensory deprivation, Sleep deprivation, Religion. Isolation
- Organic brain disorders: Epilepsy (Temporal lobe epilepsy), Charles Bonnet syndrome (with vision loss), Neurocognitive disorders (delirium, dementia). Brain tumours
- Drug use:
- Psychedelics: LSD, Psilocybin (shrooms), Mescalin (peyote), DMT (ayahuasca)
- Dissociatives: ketamine, PCP, dextromethorphan
- Deliriants: diphenhydramine, benztropine, atropine
- Stimulants: cocaine, methamphetamine
- Mental illness e.g. schizophrenia, depression, mania
Delusions
Delusions are interpretations of real stimuli that contradict what is generally heald to be reality. They are fixed false beliefs that usually go against the patients culture. They are typical and can be diagnostic on their own for Schizophrenia. Delusions can also be seen in bipolar disorder, MDD, Substance use and major neurocognitive disorders.
- Types of delusions
- Systematized delusions: delusions organized around a common theme (typical of delusional disorder and paranoid schizophrenia)
- Bizzare and non-bizarre delusions
- Bizarre delusion: something that is totally impossible…
- Non-bizarre delusion: something that is possible but is contradictory to reality
- Delusion of guilt
- Delusions of grandiosity
- Delusions of jealousy (eg. Othello syndrome)
- Persecutory delusion
- Delusions of reference
- Nihilistic delusion
- Delusions of infestation/parasistosis
Eponymous/named delusion
| Eponymous delusion | Description |
|---|---|
| Capgras syndrome | Delusion that a close family member, spouse, relative, friend or pet etc. has been replaced by a double (misidentification syndrome) |
| Othello syndrome | Morbid jealousy (delusion of infidelity) |
| De Fregoli syndrome | Belief that different people are in fact a single person who changes appearance or is in disguise |
| Folie a deux | Shared delusional disorder (”Folly of two”) |
| Cotard syndrome | Delusional belief that the individual is dead, does not exist, is putrefying, has lost blood, or has lost internal organs. |
| De Clerambault syndrome | Erotomania |
| Ekbom syndrome | Delusions of parasitosis |
Antipsychotic drugs
The mainstay of treating psychotic disorders is atypical antipsychotics. Typical antipsychotics are used for acute agitation. Antipsychotics antagonize dopamine. Chlorpromazine (Largactil, Thorazine), the first antipsychotic, was developed for WWII and introduced in 1952.
- Typical (classical, older) antipsychotics
- Haloperidol*, procholrperazine, chlorpomazine*, pimozide
- They have major side effects
- Can cause extrapyramidal symptoms, and neuroleptic malignant syndrome (fever, muscle rigidity)
- Atypical (newer) antipsychotics
- Ziprasidone, Olanzapine, Quetiapine, Aripiprazole, Clozapine
- Clozapine is used as a last resort since it is associated with Agranulocytosis
- Ziprasidone is notorious for causing weight gain
