Psychotic Disorders | Psychiatry | OnlineMedEd

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a dog psychotic disorders are going to

be primarily schizophrenia and it's

variants so we're gonna spend a lot of

time in this lesson about schizophrenia

a little bit about its treatment and

then how you modify the name based on

the duration of symptoms and whether or

not mood disorder is present psychosis

is a thought disorder so it's more than

delusions but what you're gonna see is

predominantly the delusion so a delusion

is a fixed false belief a bizarre

delusion is a fixed false belief they

couldn't possibly be true the problem is

that bizarre is going to depend under

culture if you live in the United States

and believe that physics is truth then

you may look up in the stars at night

and believe that there are balls of gas

emitting light from light years away and

we're seeing light from ten million

years ago which if you told that to

somebody who didn't believe your physics

would sound pretty bizarre but he

considered that truth so someone else

may have a cultural difference that

believes that those same stars that you

believe are light are simply fairies

they're communicating to us so it's not

enough anymore to say that a delusion is

bizarre that diagnostic criteria is out

you must have sufficient diagnostic

criteria to make it fit schizophrenia

otherwise it may not be a disorder at

all delusions fix false beliefs bizarre

delusions can't possibly be true but

that can't possibly be true because it's

a variable and culture is no longer

heavily relied on so what I want to do

is start off with schizophrenia learn a

lot about that modify it and round off

the lesson with some of the highlights

of treatment knowing that we're gonna

get into the path Oh fizz in the farm in

the farm psych lecture it's not of us

gets afraid I promise it won't be that


we know that schizophrenia

is a thought disorder and we also know

that it is a genetic component you don't

exactly know what the gene is we do know

that those who are identical twins have

significantly increased risk of

developing schizophrenia usually it is

the disorder of a mind that is

predisposed to schizophrenia following a

sufficient stressor so how that becomes

relevant in the middle of the lesson

with schizophrenia is consists of both

positive symptoms those things that are

there that shouldn't delusions

hallucinations and we believe that this

is caused by an excess amount of

dopamine you can see psychotic features

like hallucinations

if you treat someone with Parkinson's

with dopamine agonists you're trying to

restore the movement portion of the

brain but you're giving dopamine

everywhere and you may precipitate

hallucinations or delusions there's also

negative symptoms these are the things

that should be there but aren't and we

believe that these are caused by an

increase in serotonin now I'm not

getting down to the subtype or the

location we will do that in the psych

farm lesson I just want you to see not

where I want you to lock in one-to-one

positive symptoms dopamine negative

symptoms serotonin and it may not be

wholeheartedly truthful just happens to

be that's how the medications have

turned out typicals cover dopamine focus

on positive atypicals work on both

doesn't mean answer tone and end up

treating positive and negative symptoms

alright enough a warm up let's talk

about the diagnostic criteria

schizophrenia you must have at least two

of the five about the list and one must

be from 1 to 3 see hip why that makes

sense in just a second and I'm going to

break them down into positive symptoms

and negative symptoms

you have to have two of the five and any

one must come from one two three number

one or the delusions the delusions may

be bizarre or otherwise which are

looking for in these delusions there's

going to be two major ones that are

going to predominate that is persecution

or grandiosity someone's out to get them

or they're bigger than they appear

number two is hallucinations and

schizophrenia a psychotic disorder is

unlike those that are induced by

medication or illness are generally

going to be auditory and you may

actually see this in a patient

responding to internal stimuli they're

looking off into the corner

they're having a full conversation

they're pausing at appropriate time then

responding to questions that are being

asked but you only hear one side of the

conversation because the person they're

talking to isn't there

they see them talking to them they hear

the whole conversation much like someone

wearing a cell phone you're not sure if

they're talking to their cell phone

mother talking to themselves

schizophrenia patient has no cell phone

they're talking to someone on the other

side but that person really isn't there

which can be very frustrating for

patients might have you ever tried to

have a conversation with somebody when a

movies play but you like that movie

you're distracted from the conversation

rather the movie or maybe you're

instructed from the movie by the

conversation you can't attend both

that's what's happening to a

schizophrenic all the time there's full

conversation this hallucination is

talking at them trying to have a

conversation while you're interviewing

them you don't know what's going on but

they're trying to shut that person up or

tune them out but it's really hard

because if their own brain doing it is

it also can lead to the disorganization

in 3 & 4

or about disorganization while you can

also have catatonia I'm going to leave

it off the board because I want you to

link catatonia with mood disorders that

was one of the big changes in dsm-5

there's no more subtypes paranoid

catatonic disorganized schizophrenia are

gone they're simply diagnostic criteria

disorganization can occur in the way of

speech or behavior disorganization is

fairly difficult to explain but it's

pretty easy to spot just organization

means you just don't do things the right

way right you've lost touch with reality

you're doing something that's completely

off the wall the way this manifests is

in appearance people stop grooming it's

not bathing such changing their clothes

and they stop believing the house if you

can imagine JFK in the king of Spain

normally they're talking to a college

kid telling him not to go to class but

to where it's in the file on their head

to protect them from the aliens but

don't go outside because if you go

outside the satellites will get you and

US government's coming after you you can

imagine that that kid who's listening at

JFK in the king of Spain it's probably

gonna have a tough time making good

decisions and so it's when if that

full-blown it's obvious and so this is

there but it's very difficult to

punctate what disorganization means and

one lone v is all the negative symptoms

so any one negative symptom counts but

you're generally gonna see these

combined they're gonna see things like

flat effect poverty of speech or

movement anhedonia well you might even

see cognitive impairment or cognitive

delay they weren't born this way and

when they're active give me impressive

you're talking at them but they don't

even engage that you're there it was

blank stare on their face well if they

finally turned to you they can only

respond in one or two words sounds

that's not because they're gravely

disabled because mental retardation

cognitive impairment it's because their

disease is active if you treat the

disease they go back to normal and

that's the thing though when you see

someone who's active the presentation is

almost always going to be a psychotic

break there's like otic breaks occur

when medications are stopped for the

first time I first identify the disease

and they may even have breaks

medications every time they have a break

it'll be left with more cognitive

impairment than they had previously so

in a stepwise fashion as they get older

it's because her findings lose function

faster will end up being demented way

sooner than non schizophrenics the

classic board question of a first

psychotic break is going to occur and

someone who's a teenager or in their

early 20s usually after a major stressor

and the major stressor that most kids go

through is adulthood a teen you leave

the house get a job where you go to

college and if you see a kid with a

change in behavior hallucinations and

delusions may not yet be apparent but

they're acting weird

they're not showing up to class and when

you find knock on their door they've got

feces all over the wall and haven't paid

in seven days that's abnormal I have to

change the behavior and change in thaw

that may not be overt at first when you

see that in a college-age kid role of

drugs particularly cooking we do have

the utox make sure it's not intoxication

or thrall and when you've ruled that out

well then what you want to do is

determine the duration of symptoms and

whether or not there's mood because

that's gonna name the disorder and tell

you what you're gonna use to treat and

when the treatment is going to be with

antipsychotics talk more about that in a


what I want to focus first is on how do

you name the disease how long do you

treat it schizophrenia positive symptoms

negative symptoms dopamine serotonin you

need two of the five and one of the five

needs to be hooked delusions

hallucinations or disorganized speech

look primarily for persecution

grandiosity and auditory hallucinations

to separate from drug-induced or

metabolic induced hallucinations that

are usually visual so to talk about the

spectrum of schizophrenia we're gonna

find schizophrenia here in the very

middle of the board if you have

schizophrenia the duration will have

been greater than six months and the

treatment is lifelong

as you move up the board between me

based on duration of symptoms as you

move down the board maybe about the

presence or absence of mood disorder

schizophrenia symptoms for more than six

months it's not gonna turn off on its

own lifelong antipsychotics at the top

of the board is going to be brief

psychotic disorder of which postpartum

psychosis counts stressor was pregnancy

we talked about this in mood 2 and the

response was psychosis brief psychotic

disorders have a duration of more than

one day but less than one month in the

treatment should be only for a month and

then once you've stopped the medications

the psychosis should go away and there

won't be at risk for developing more

symptoms if it persists chances are it's

gonna be schizophrenia but you go

through another disorder first which is

schizophrenic form here the duration is

greater than a month but less than six

months the treatment is three to six

months usually six months the idea here

there's nothing that happens at six

months no the pathology doesn't change

the point is that if they still have

symptoms after being adequately treated

for more than six months the response is

going to be you're not gonna get control

spontaneously you're gonna needs to

medicate that's the idea a need to

medicate is is based on the name of the

disorder which is based on the duration

of symptoms it's not that at six months

it becomes a new disease that it's not

like PTSD where if you intervene sooner

you can prevent schizophrenia from

happening if there's a stressor and

someone's going to get schizophrenia

because their brain is predisposed

they're gonna get it you don't know that

they have it until you try them on

medications stop the medication and see

what happens as we go down we're gonna

get into mood disorder so schizo

affective disorder is schizophrenia

duration greater than six months but

there's also mood and it's get so


the psychosis predominates and there's a

little bit of mood here you treat the

mood first if you have mostly mood

you'll have mood disorder with psychotic

features just around it out

you could have mood disorder without

psychotic features - and it's not

relevant for this lesson and mood

disorder with psychotic features you got

a lot of mood maybe - predominates and

you got a little bit of psychosis maybe

hallucination or - treatment still move

first and - treat mood disorders with of

course mood medications what's not on

this list are the personality disorders

which have the letters skits in them

which confuse people schizoid or the

loners or happy to be alone generally

you don't see them because they don't

seek attention schizotypal have bizarre

thoughts and dress and magical thinking

but they're not really disorganized and

they're not delusions and so that

becomes very hard as you push somebody

has who's very benign schizophrenic

against someone who's a really severe

schizotypal making the judgment of do

you need to be medicated schizophrenia

or not it's a tie Pole and it comes

challenging you want have to make that

decision they're gonna be non-bizarre

delusions and they're gonna be fairly


where did schizophrenic is going to be

homeless disheveled talking to himself

delusions hallucinations it's going to

be overt on the test in real life it may

be a little harder to tease them apart

all right so this is schizophrenia and

it's modifiers moving the different

names by the duration and the presence

or absence of mood I do want to touch on

delusional disorder because much likes

it's a title it's hard to tell in real

life a delusional disorder will be a non

bizarre delusion and there's no

impairment and specifically what it

means is someone who has a delusion but

doesn't have one through three it

illusion is a fixed false belief and it

may be something as simple or innocuous

as the cashier who falls in love with a

doctor and he thinks the doctors in love

with him

even though all he's ever said to her is

3:17 do you want a receipt it's

reasonable for two people to fall in

love in a workplace but to the doctor

she doesn't know who he is

that's weird another example would be a

gentleman from Maine who believes that

Jamie Lynn Spears and he are destined to

be together

star-crossed lovers keeps showing up at

Jamie Lynn's house well he keeps getting

sent back to Maine he's not violent it's

not where he's not just organized the

fact he's got a lot of money so every

time the police send him back to Maine

he ends up back in Louisiana trying to

get into Jamie Lynn's house yen more

bizarre but now not really impaired

doesn't meet one through three that same

guys got into a dream disease and won't

call it analysis because he believes

that he's gonna live to the same age as

Jesus Christ age 33 even if he doesn't

go to dialysis more towards it's a

friend yet but if it doesn't have one

through three he's not schizophrenic the

point is a delusional disorder it's

gonna be pretty obvious and again on

your test it's going to be a non bizarre

delusion that is completely reasonable

and you're not gonna be shorter if it's

true or not my wife's trying to kill me

for my money

I don't know a she maybe she is maybe

she's not but you're gonna have to

figure out is it a true delusion is it a

fixed false belief it's something that's

reasonable you need to investigate if

you make the decision that it is a

delusional disorder you're going to need

to do gentle confrontation you need to

show them that what they're thinking is

wrong generally because their delusion

is going to impair someone else

not that the delusion is going to impair

them I'm going to close this lesson with

what you need to know about medications

choosing the right man in the situation

in which you're going to pick a

medication in order to get the test

answer right we're gonna cover a lot of

detail about psyche farm in the site

forum lesson so I want you to see four

different scenarios someone who is

normal see it's a phrenic they want to

take their meds they don't want to have

symptoms I got to be compliant someone

who is combative in eating someone who

is non-compliant won't take their meds

when they do well when they're on their

knives they just don't want to take them

to the end them not and what happens

when everything fails typical and

atypical antipsychotics are called that

because typicals were made first

typicals happen to work on the dopamine

receptors and most they are prevent the

positive symptoms and they have a very

dirty side-effect profile the more

potent the more severe the

extrapyramidal symptoms can be there's

also medical energy properties a typical

means second generation second

generations generally have a cleaner

side-effect profile aren't quite as

potent but work on both dopamine and

serotonin so work on both positive and

negative symptoms if you have your

choice what you should do for a normal

patient is use a typicals the second

generation that's going to be things

like quetiapine olanzapine and risperdal

oral medications people want to take

them no big deal a combative patient in

the ER is going to need typicals we're

gonna need that potency and you're gonna

need access to I am or IV that's going

to be found with hella pair at all on

the medicine service inpatient you might

find an atypical is used

olanzapine dissolving capsule under the

top this is the wrong answer and I want

you to learn I want you to know about it

because that's used all the time but if

someone's combative you need to put them

down and use haloperidol the

non-compliant patient it's gonna need a

form that lasts rather than once or

twice a day pills only view once a week

or once a month injection to do that you

need the depo forms and we're coming up

with a typical depots but the depo form

I want you to learn about it as

haloperidol I'm trying to do is keep

your selection limited atypicals for

normal haloperidol for everything else


all else fails in which case used

clozapine clozapine was the first of the

attempt evils and it was by far the best

drug we had it fixes positive symptoms

negative symptoms and almost always

works the problem is that it can cause a

granule cytosis in patients die so in

order to get it you have to have tried

everything health and get on the

registry tried everything else means

starting medication your choice increase

the dose daily until the symptoms go

away or you reach a max dose doesn't

work stop that try something else you

keep going until you find something that

controls the symptoms and be on the

lookout we talked about this during the

extrapyramidal lesson anti psychotics

can cause neuroleptic malignant syndrome

which needs to be treated at dantrolene

if you see somebody who's got fever

rigidity elevated CK and is on a typical

or atypical antipsychotic think NMS give

dantrolene this lesson mostly focused on

schizophrenia causes symptoms negative

symptoms to lose and so this ination

disorganisation don't forget about the

negative symptoms identify that kid

who's going to college who has their

first break after a major stressor roll

out drugs you're gonna treat for the

duration based on the duration of

symptoms and always visit antipsychotic

unless you get into the presence of mood

disorder in which case you're going to

treat the mood first delusional disorder

is someone who has a delusion but is not

really impaired and the only reason you

confront them is if it bothers someone

else and then in terms of choosing the

right medication go taia penal and zippy

and risperdal essentially equivalent to

each other use in routine cases

haloperidol IV I am using the combative

patient in the ER haloperidol depo using

non-compliant patients and clozapine if

all else fails you identify NMS use

dantrolene that is the psychotic


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