Psychotic

disorders-2

Dr. Fidia Mumtahana

 ICD 10 CLASSIFICATION OF MENTAL DISORDERS
F0: Organic, including symptomatic, F6: Disorders of personality and
mental disorders behavior in adult persons

F1: Mental and behavioral disorders due F7: Mental retardation

to use of psychoactive substances

F8: Disorders of psychological

F2: Schizophrenia, schizotypal and development
delusional disorders

F9: Behavioral and emotional disorders

F3: Mood disorders
with onset usually occurring in childhood
and adolescence
F4:Neurotic, stress-related and
somatoform disorders In addition, a group of "unspecified
mental disorders".
F5: Behavioral syndromes associated
with physiological disturbances and
physical factors
 Types of Psychotic disorders
• Schizophrenia

• Mood disorders

• Delusional Disorders

• Acute and transient psychotic disorders

• Schizoaffective disorder

• Capgras’ syndrome

• Reactive psychosis
Emotion- any of the feelings of joy, sorrow, fear, hate,
love, etc.

Affect- The outward expression of the immediate

experience of emotion at a given time.

Mood- Sustained and extensive emotional response

which colors the total experience of the person.
 Mood Disorder
 Extensive alterations in emotions that are manifested by
depression, mania (abnormally elevated arousal, affect, and energy level) or
both, and interfere with the person’s ability to live life.

 Mood disorders are best considered as syndromes (rather

than discrete disease) consisting of a cluster of signs and
symptoms sustained over a period of weeks to months, that
represent a marked deviation from a person’s habitual
functioning and tend to recur, often In cyclical fashion.
 ICD-10 classification of mood disorder

1. Manic episode

2. Depressive episode

3. Bipolar mood disorder

4. Recurrent depressive disorder

5. Persistent mood disorder

6. Other mood disorders

 ETIOLOGY

 The etiology of mood disorders is currently unknown.

 However several theories have been proposed.

These include:-
1) Biological theories
2) Psychosocial theory
Biological theories include:
1. Genetic hypotheses
2. Biochemical theory
3. Neuroendocrine theory
4. Sleep studies

Psychosocial theories include:

1. Psychoanalytic theory
2. Stress
3. Cognitive and behavioral theory.
 Genetic hypothesis
 The life time risk for the 1st degree relative of Bipolar mood
disorder patient is 25%

 Of recurrent depressive disorder patient is 20%.

 The life time risk for the children of one parent with mood disorder
is 25% and of both parents with mood disorder is 75%.

 The risk of developing bipolar disorders for monozygotic twins is

65% and for dizygotic twins is 20%.
 BIOCHEMICAL THEORY

 The monoamine hypothesis suggests abnormality in

monoamine (catecholamine and serotonin) system in
the central nervous system at one or more sites.

 So disturbance in neurotransmitter functions:

serotonin, norepinephrine or dopamine.
In depression :
Norepinephrine, dopamine and serotonin---reduces

In mania: levels become high.

 NEUROENDOCRINE THEORY
- Mood symptoms are prominently present in many
endocrine disorders, like hypothyroidism (depression),
Addison’s disease (depression), Cushing’s disease (mood
swing).

- Endocrine function is often disturbed in depression with

cortisol hypersecretion, Decreased TSH level, Decrease
growth hormone production.
 Sleep studies
 Sleep abnormalities are common in mood disorder.

Ex- Decreased need for sleep in mania

Insomnia and frequent awakenings in depression.

 Stress
 Increased number of stressful life events before the
onset or relapse in depression is observed.

 Increased stressor in the early period of development

are more important in depression.
MANIC EPISODE

• The life time risk of manic episode is 1%. This disorder

occurs in episodes, lasting usually 3-4 months, followed
by complete recovery.

• Further episodes can be manic or depressive .

• The feature of manic episode should last for at least

one week and cause disruption in occupational and
social activities.
 Manic episode
1) Elevated or expansive mood: The elevated mood can pass through four
stages:-

 A) Euphoria: (stage i)
- It is mild elevation of mood.

-Increased sense of psychological well-being and happiness not in keeping with

ongoing events

-No significant disturbance in social/occupational life

- Seen in hypomania
 B) Elation:-(Stage ii)
-It is moderate elevation of mood.
-Feeling of confidence and enjoyment along with increased
psychomotor activity.
-Seen in mania.

 C) Exaltation:-(stage iii)
-It is severe elevation of mood.
-Intense elation with delusions of grandeur; seen in severe mania.

 D) Ecstasy:- (stage iv)

-It is very severe elevation of mood.
-Intense sense of blissfulness
2) Psychomotor activity:
 There is an increased psychomotor activity ranging
from over activeness and restlessness to manic
excitement where the person is “on-the-toe-on-the-
go”.

 The activity is usually goal oriented and is based on

external environmental stimulus.
3) Speech and thought:
 The person is more talkative than usual;

 Thoughts racing in mind;

 Develops pressure of speech; uses playful language and speaks

loudly.

 Later there is flight of ideas.

 Delusion of grandiosity with markedly increase in self esteem.

 Delusion of persecution(abuse) may develop secondary to

grandiosity. (e.g. I am so great that people are against me).
• Hallucinations – both auditory and visual ( e.g. God appeared
before me and spoke to me).

• Distractibility which results in rapid changes in speech and activity.

4) Goal directed activity:-

 The person is unusually alert trying to do many things at one time.

5) Other features:-
 Sleep – usually reduced with a decreased need for sleep.

 Appetite—may increase but later there is decreased food intake

due to marked over activity.

 Insight- absent.
DEPRESSIVE EPISODE
Depression
 Depression /depressive disorders /
unipolar depression, is a mental illness
characterized by a profound and
persistent feeling of sadness.

 Psychopathological feeling of sadness.

 Symptoms of depression
• Difficulty in concentration, remembering details and making
decisions
• Fatigue and decreased energy

• Feelings of guilt, worthlessness, and/or helplessness

• Feelings of hopelessness and/or pessimism (believe that the worst will
happen)

• Insomnia, early-morning awakening (at least 2 or more hours

before the usual time of awakening), or excessive sleeping
• Irritability, restlessness
 Symptoms of depression
• Loss of interest in activities or hobbies once pleasurable,
including sexual intercourse

• Significant decrease in appetite or weight.

• Persistent aches or pains, headache, cramps, or digestive

problems that do not ease even with treatment

• Persistent sadness, anxiousness

• Thoughts of suicide, suicide attempts

 There are two main categories of
depression:
1) Major depressive disorder
2) Dysthymic disorder

Others

-Atypical depression- Depression with predominant anxiety, Phobic

anxiety, depersonalization syndrome (feeling disconnected from one’s self)

-Postpartum depression

-Bipolar depression

-Seasonal depression

-Psychotic depression
Recurrent
Major
Depressive
Episodes

Dysthymia
 Major depressive disorder
 Major Depressive Disorder (unipolar depression) is
reported to be the most common mood disorder.

 In major depression, one of the symptoms must be

present-
• depressed mood or
• loss of interest

 Also, the symptoms must be present for most of the day,

every day or nearly every day for at least two weeks.
 Major Depression-“SIGE CAPS”
• Sleep (insomnia )

• Interest (diminished)

• Guilt (feelings of worthlessness)

• Energy (loss of energy /fatigue)

• Concentration (diminished ability to think)

• Appetite (decreased or increased; unintentional weight loss)

• Psychomotor agitation

• Suicidal ideation
Unipolar depression usually lasts longer than Bipolar depression
 Major Depressive Disorder

 Lifetime prevalence

-Women: 10 - 25%

-Men: 5 - 12 %

-Pre-pubertal children: boys > girls

-Puberty to 50 yrs: women 2x men

-After 50 yrs: women=men

 Major Depression
• Onset: sudden or gradual
• Full recovery from an episode after 6 months: 50 %

• Factors that contribute to relapse:

-high number of previous episodes
-inadequate antidepressant treatment
-partial response to treatment
-discontinuation of effective treatment
-highly emotional environment.

• 5-10 % of individuals with a single episode of major depression will

eventually develop bipolar disorder.
 Dysthymia depression
 Dysthymia :
• It is referred to as chronic depression. It is a less
severe form of depression.

• In dysthymia, the depression symptoms can persists

for a long period of time, perhaps two years or longer

• Those who suffer from dysthymia are usually able to

function adequately but might seem consistently
unhappy.
 Warning signs of suicide with depression
• A sudden switch from being very sad to being very calm
or appearing to be happy

• Always talking or thinking about death

• Clinical depression (deep sadness, loss of interest,

trouble sleeping and eating) that gets worse

• Having a "death wish"

• Taking risks that could lead to death- like driving

through red lights
 Warning signs of suicide with depression
• Losing interest in things one used to care about

• Making comments about being hopeless, helpless, or

worthless again & again suddenly

• Saying things like "It would be better if I wasn't here" or "I

want out”

• Talking about suicide

• Visiting or calling people he/she cares about.

 Suicidal risk
 High suicidal risk in the presence of :

• Marked hopelessness

• Male, >40 yrs, single, divorced/widowed

• Written or verbal communication of suicidal plan

• Early stage of depression

Depression-suicide rate
Organic Illnesses Associated with Depression

• Rheumatologic - rheumatoid arthritis, SLE

• Cardiac - myocardial infarction, hypertension

• Endocrine - hypothyroidism, Addison’s disease,

diabetes mellitus, postpartum state
• Gastrointestinal - cirrhosis, inflammatory bowel
disease, pancreatitis
• Hematologic - sickle cell anemia
Organic Illnesses Associated with Depression
• Nutritional deficiencies - B12, Folate, iron, thiamine, niacin

• Infectious - encephalitis, hepatitis, tuberculosis

• Renal - renal transplant, uremia

• Neoplastic - Leukemia

• Neurologic - subdural hematoma, multiple sclerosis, CVA,

Parkinson’s,
• Miscellaneous – psoriasis..
 Drugs Commonly Associated with Depression
• Amphetamines, other CNS stimulants
• Barbituates
• Benzodiazepines
• Cimetidine
• Clonidine
• Beta-blockers
• Corticosteriods
• Indomethacin
• Alpha-methyldopa
• Oral contraceptives, estrogens
• Reserpine, guanethidine
• Sulfonamides
Depression in Children & Adolescents
Presenting symptoms may include:
-Sad or irritable mood

-Loss of interest/pleasure in usual activities

-School difficulties

-School-refusal

-Somatic complaints

-Aggressive/antisocial behavior patterns

-Weight change or sleep pattern disruption

 Depression in Geriatric Population

• Often overlooked due to geriatric population have

already impaired cognition, sadness and confusion

• Medical and neurological complications and side

effects of medications can obscure the diagnosis

• Higher suicide rates

• 30% of patients with dementia also have major

depression.
BIPOLAR DISORDER
 Bipolar disorder is characterized by recurrent episodes of
Mania and Depression in the same patient at different time.

 The mood swings alternate from clinical depression to mania.

 The mood swings can range from very mild to extreme and
they can happen gradually or suddenly within a timeframe of
minutes to hours.

 When mood swings happen frequently, the process is called

rapid cycling.
 Causes
• Strong genetic component
• Stressful life events
• Antidepressant drugs or street drug use
 Bipolar mood Disorder
• The first episode may occur at any age from childhood to old
age.

• The frequency of episodes and the pattern of remissions and

relapses all are very variable.

• The lifetime prevalence is between 0.5 an 1 %.

• Suicidal tendencies – about 20%.
• Co morbidity with alcohol and drug abuse

• Rapid-cycling includes those patients who have had at least 4

episodes of a major depressive, manic, hypomanic or mixed
episode during the past 12 months.
 The clinical depression symptoms seen with bipolar disorder
include:-

• Decreased appetite and/or weight loss or overeating and weight

gain

• Difficulty concentrating, remembering, and making decisions

• Fatigue, decreased energy, being "slowed down"

• Feelings of guilt, worthlessness, helplessness

• Feelings of hopelessness, pessimism

 The clinical depression symptoms seen with bipolar
disorder include:
• Insomnia, early-morning awakening, or oversleeping

• Loss of interest or pleasure in hobbies and activities that were

once enjoyed
• Persistent physical symptoms that do not respond to treatment,
such as headaches, digestive disorders, and chronic pain
• Restlessness, irritability

• Persistently sad, anxious, thoughts of death or suicide

 The signs of mania with bipolar disorder include:-

• Disconnected and racing thoughts

• Grandiose idea

• Inappropriate elation

• Inappropriate irritability & social behavior

• Increased sexual desire

• Increased talking speed and/or volume

• Markedly increased energy

• Poor judgment

• Severe insomnia
 SUBTYPE OF BIPOLAR DISORDER
1) Bipolar I:-
Characterized by episodes of
severe mania and severe
depression.

2) Bipolar II:-
Characterized by episodes of
hypomania and severe
depression.
depression hypomania
Bipolar disorder I

mania
depression

Bipolar disorder II
 RECURRENT DEPRESSIVE DISORDER

This disorder is characterized by recurrent (at

least two) depressive episodes (unipolar
depression).
 Persistent mood disorder
 This disorder is characterized by persistent mood
symptoms which are not severe enough to be labeled as
even hypomania or mild depressive episode.

 Lasting more than 2 years.

 The symptoms can turn towards-

 Cyclothymia: Persistent instability of mood between
mild depression and mild elation.
or
 Dysthymia: If the symptoms of consists of persistent
mild depression.
 Prognostic factors in mood disorders
• Good: • Poor:
 Co-morbid medical
 Acute or abrupt onset
disorders, personality
 Typical clinical feature disorder or alcohol
dependence.
 Severe depression
 Dysthymic depression
 Good premorbid personality  Stress
 Good response to  Marked hypochondriacal
features
treatment.
 Poor drug compliance
 Pre-medication investigations:

- Blood picture

-Renal Function test (RFT)

-Thyroid Function Test (TFT)

-Liver Function Test (LFT)

-ECG.
 Management of Mood Disorder
• Antidepressants
 Monoamine Reuptake Inhibitor
 Monoamine Oxidase Inhibitors (MAOIs)
 Selective Serotonin Reuptake Inhibitors

• Mood stabilizers

• Antipsychotics

• Electroconvulsive Therapy

• Interpersonal Psychotherapy

• Cognitive-Behavioral Therapy
 A. Drug Treatment
• 1.Monoamine Reuptake Inhibitor (MARI):
I. Non-selective: TCAs- Amitriptyline, Nortriptyline, Imipramine …..
II.Selective: a) Noradrenaline – Maprotiline, desipramine, reboxetine
(NARI)
b) 5-HT- Fluoxetine, sertraline, cetalopram….

• 2. Monoamine Oxidase Inhibitors ( MAOIs):

I. Reversible- Moclobemide, caroxazone
II. Irreversible- Phenelzine, Selegiline….

• 3. Noradrenergic and Specific Seretonergic (NaSSAs): Mirtazapine

 A. Drug Treatment
4. Mood stabilizers: to control manic or hypomanic episodes.
 Lithium
 Valproic acid
 Carbamazepine
 Lamotrigine
 Divalproex sodium

5 . Antipsychotics: If symptoms of depression or mania persist in spite of

treatment with other medications, adding an antipsychotic drug may be
helpful, such as -
Olanzapine, Clozapine, Risperidone,
Quetiapine, Aripiprazole, Haloperidol
Ziprasidone…
 Tricyclics (TCAs)
• Imipramine 100-250 mg/day
• Amitriptyline 100-250 mg/day
• Nortriptyline 75-150 mg/day

 Side effects:

• A. Anticholinergic: dry mouth, blurred vision, constipation, urinary

retention, delirium
• B. CVS: Postural hypotension, tachycardia, arrhythmias…

• C. Neuropsychiatry: Sedation, confusion

• D. Sexual: Diminished libido

• E. Weight gain
 Selective Serotonin Reuptake Inhibiters (SSRI)
• Name Dose (mg/day)
• Cap. Fluoxetine 20-60
• Tab. Sertraline 50-150
• Tab. Paroxetine 20-80
• Tab. Citalopram 20-50
• Tab. Escitalopram 10-40

S/E:
• General: G.I upset, irritation, diarrhea, nausea, Anxiety, restlessness,
sleep disturbances, Hypoglycemia

• Sexual dysfunction- Erectile dysfunction.

There are 3 phases of treatment:

1.Acute treatment (till remission occurs)

2.Continuation treatment (from remission till end of

treatment)

3.Maintenance treatment (to prevent further

recurrences)
• Maintenance treatment may be indicated in the
following patients:
-Partial response to acute treatment

-Poor symptom control during the continuation treatment.

-More than 3 episodes (90% chances of recurrence)

-More than 2 episodes with early age of onset

-Recurrence within 2 years of stopping antidepressants

-Life threatening depression

-Family history of mood disorder

-Dysthymic depression
 General principles of Depression Treatment
• Most antidepressants take 7-21 days to come to antidepressant action.

• Initial dose is built gradually

• Therapeutic trial should last at least 6 weeks

• Discontinuation should be gradual

• Sedative antidepressant improves sleep immediately.

• Older people and children need one-half to one-third of adult dose.

• Select antidepressant according to clinical profile

• Inform about side effects.

• About 20-30% of depressed patients are
resistant to antidepressant medication.

• These patient may require –

- A change of antidepressant.

- Combination of several types of antidepressants.

- Augmentation with lithium (maintenance therapy)

- ECT
 PSYCHOSOCIAL TREATMENT
A) COGNITIVE BEHAVOUR THERAPY
 The focus is identifying unhealthy, negative beliefs and behaviors
and replacing them with healthy, positive ones.

 Teaching of effective strategies to manage stress and to cope with

upsetting situations.

B) INTERPERSONAL THERAPY
This therapy attempts to recognize and explore interpersonal
stressors, social isolation, or social skill deficits which act as
precipitants for depression.
C) FAMILY THERAPY: Family support and communication
can help to stick with treatment plan and help
everyone to recognize and manage warning signs of
mood swings

D)GROUP THERAPY
 ECT (Electroconvulsive therapy)
 The indication of ECT in depression are:
a) Severe depression with suicidal risk

b)Severe depression with stupor, severe psychomotor retardation

c) Refractory depression

d) Delusional depression

e)Presence of significant antidepressant side-effects or intolerance to drugs.

f)Acute manic excitement if it is not responding to antipsychotics and

lithium.
 ECT
 Relative Contraindications to Electroconvulsive Therapy   

• Conditions with increased intracranial pressure   

• Intracerebral hemorrhage   

• Pheochromocytoma

• Recent myocardial infarction   

• Space-occupying intracerebral lesions

• Unstable vascular aneurysms or malformations.

 The response is rapid, resulting in marked
improvement.
 Usually 6-8 ECTs are needed
 MOOD STABILIZING DRUGS
Lithium carbonate
• Oldest and most frequently prescribed drug.
• Acute phase of mania
• Prevention of further episodes in bipolar mood
disorder
• Takes 4-7days to reach a therapeutic level
• SODIUM VALPROATE
-For acute treatment in mania and prevention of bipolar mood
disorder.

-particularly useful in those patient who are refractory to

lithium.

• CARBAMAZEPINE
-For acute treatment of mania and prevention of bipolar mood
disorder.

-particularly in those patient who are refractory to lithium and

valproate.