Acute psychiatric disorders

doc. MUDr. Pavel Pavlovský, CSc.doc. MUDr. Pavel Pavlovský, CSc.Department of Psychiatry, First Faculty of Department of Psychiatry, First Faculty of Medicine, Charles University and General Medicine, Charles University and General

University Hospital in PragueUniversity Hospital in Prague

Acute and transient psychotic disorders ICD-10: F23.xICD-10: F23.x DSM-IV: Brief psychotic disorder 298.8 DSM-IV: Brief psychotic disorder 298.8

Basic schizophrenic symptoms

Thought echo, thought insertion or withdrawal, Thought echo, thought insertion or withdrawal, thought broadcasting=intrapsychic hallucinationsthought broadcasting=intrapsychic hallucinations

Delusions of control, influence or passivity, Delusions of control, influence or passivity, delusional perceptiondelusional perception

Hallucinatory voices giving a running Hallucinatory voices giving a running commentary on the patient´s behaviour, voices commentary on the patient´s behaviour, voices coming from some part of the bodycoming from some part of the body

Persistent delusions culturally inappropriate Persistent delusions culturally inappropriate (religious or political identity, superhuman (religious or political identity, superhuman powers, in communications with another world)powers, in communications with another world)

Basic schizophrenic symptoms-cont. Persistent hallucinations [accompanied by Persistent hallucinations [accompanied by

delusions]delusions] Breaks or interpolations in the train of thought, Breaks or interpolations in the train of thought,

incoherent speech, neologismsincoherent speech, neologisms Catatonic behavior [excitement, posturing, Catatonic behavior [excitement, posturing,

negativism, stupor….]negativism, stupor….] Negative symptoms [apathy, blunting of Negative symptoms [apathy, blunting of

emotional responses, social withdrawal, lowering emotional responses, social withdrawal, lowering of social performance]of social performance]

A significant change in the overall quality of A significant change in the overall quality of personal behaviorpersonal behavior

Key features of acute and transient psychotic disorders an acute onset within 2 weeksan acute onset within 2 weeks the presence of typical syndromesthe presence of typical syndromes the presence of associated stressthe presence of associated stress

Key features

acute onset - a change from a state without acute onset - a change from a state without psychotic features to a clearly abnormal psychotic psychotic features to a clearly abnormal psychotic statestate within less than 2 weeks within less than 2 weeks

abrupt onset within 48 hoursabrupt onset within 48 hours typical syndromes – rapidly changing and variable typical syndromes – rapidly changing and variable

state – polymorphicstate – polymorphic associated acute stress – within about 2 weeks of associated acute stress – within about 2 weeks of

an event regarded as stressful [bereavement, an event regarded as stressful [bereavement, unexpected loss of partner or job, psychological unexpected loss of partner or job, psychological trauma of combat, terrorism, torture] trauma of combat, terrorism, torture]

Clinical types of dg F23.x

Acute polymorphic psychotic disorder Acute polymorphic psychotic disorder without symptoms of schizophreniawithout symptoms of schizophrenia

Acute polymorphic psychotic disorder with Acute polymorphic psychotic disorder with symptoms of schizophreniasymptoms of schizophrenia

Acute schizophrenia-like psychotic disorderAcute schizophrenia-like psychotic disorder Other acute predominantly delusional Other acute predominantly delusional

psychotic disorderspsychotic disorders

Brief psychotic disorder – DSM IV. Presence of one or more of the following Presence of one or more of the following

symptoms: delusions, hallucinations, disorganized symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behaviorspeech, grossly disorganized or catatonic behavior

Duration 1 day – 1 monthDuration 1 day – 1 month Excluded: mood disorder, schizophrenia, Excluded: mood disorder, schizophrenia,

substance or general medical conditionsubstance or general medical condition With /without marked stressor, with postpartum With /without marked stressor, with postpartum

onsetonset

Treatment of acute psychotic states Antipsychotics 1st generation:Antipsychotics 1st generation:

Phenothiazines [chlorpromazine 50-100mgs Phenothiazines [chlorpromazine 50-100mgs i.m., levomepromazine 25-50mgs i.m.]i.m., levomepromazine 25-50mgs i.m.]

Butyrophenons [haloperidol 5mgs i.m., Butyrophenons [haloperidol 5mgs i.m., melperonmelperon-Buronil p.o.-Buronil p.o.]]

Thioxanthens [zuclopenthixol {Cisordinol Thioxanthens [zuclopenthixol {Cisordinol Acutard} 50-150mgs i.m., chlorprothixen]Acutard} 50-150mgs i.m., chlorprothixen]

Treatment of acute psychotic states – cont. Antipsychotics 2nd generation:Antipsychotics 2nd generation:

Selective antagonists of dopamine receptors [D2, Selective antagonists of dopamine receptors [D2, D3] – sulpiride {Dogmatil}, amisulprid {Solian}D3] – sulpiride {Dogmatil}, amisulprid {Solian}

SDA [antagonists of serotonine and dopamine SDA [antagonists of serotonine and dopamine receptors] – risperidon {Risperdal, Rispen}, receptors] – risperidon {Risperdal, Rispen}, ziprasidon {Zeldox}ziprasidon {Zeldox}

MARTA [multireceptors antagonists] – clozapin MARTA [multireceptors antagonists] – clozapin {Leponex}, olanzapin {Zyprexa}, quetiapin {Leponex}, olanzapin {Zyprexa}, quetiapin {Seroquel}, zotepin {Zoleptil}{Seroquel}, zotepin {Zoleptil}

Aripiprazol {Abilify}Aripiprazol {Abilify}

Treatment of acute psychotic states-cont. Antipsychotics 2nd generationAntipsychotics 2nd generation

olanzapin (Zyprexa) – inj.i.m. 10mgsolanzapin (Zyprexa) – inj.i.m. 10mgs

Zyprexa Velotab 5-10mgs p.o.Zyprexa Velotab 5-10mgs p.o. risperidon sol. 1ml=1mg (Risperdal)risperidon sol. 1ml=1mg (Risperdal)

quicklet 1 tab.=2mgquicklet 1 tab.=2mg ziprasidon (Zeldox) – 10-40mg i.m.ziprasidon (Zeldox) – 10-40mg i.m.

Treatment of acute psychotic states – cont. BenzodiazepinesBenzodiazepines

diazepam {Apaurin,Valium, diazepam {Apaurin,Valium, Seduxen…}– 10-20mgs i.m. or i.v. [very Seduxen…}– 10-20mgs i.m. or i.v. [very slowly]slowly]

clonazepam {Rivotril} – 1mg i.v.clonazepam {Rivotril} – 1mg i.v.

Delirium- F05.x

An etiologically nonspecific syndromeAn etiologically nonspecific syndrome Qualitative change of consciousnessQualitative change of consciousness Disturbance of perception (illusions, Disturbance of perception (illusions,

hallucinations), thinking (transient delusions, hallucinations), thinking (transient delusions, some degree of incoherence), memory (immediate some degree of incoherence), memory (immediate recall and recent memory), anxiety, fears, recall and recent memory), anxiety, fears, disorientation, reversal of the sleep-wake cycle disorientation, reversal of the sleep-wake cycle (sundown sy).(sundown sy).

Delirium-neurological signs

TremorTremor NystagmusNystagmus MyoclonusMyoclonus HyperreflexiaHyperreflexia EEG changes (slow waves, low voltage, EEG changes (slow waves, low voltage,

disorganized graph)disorganized graph)

Delirium – cont.

Delirium not superimposed on dementia Delirium not superimposed on dementia Delirium superimposed on dementia Delirium superimposed on dementia

(vascular d., m. Alzheimer,…)(vascular d., m. Alzheimer,…)

Delirium - etiology

Hypoxia of brain, dehydration, metabolic changes,Hypoxia of brain, dehydration, metabolic changes, Arteriosclerosis, infectious diseases, tumorsArteriosclerosis, infectious diseases, tumors Liver disordersLiver disorders IntoxicationIntoxication Withdrawal statesWithdrawal states Brain injury, postoperative statesBrain injury, postoperative states Severe stressSevere stress

Delirium- treatment

Treatment of the underyling physical disorder Treatment of the underyling physical disorder (hydration, antibiotics, antiinflammatory agents, (hydration, antibiotics, antiinflammatory agents, vitamines B,…)vitamines B,…)

Antipsychotics : tiaprid 100-200mgs i.m., max. Antipsychotics : tiaprid 100-200mgs i.m., max. daily dose up to 1.400mgs i.m. olanzapin, daily dose up to 1.400mgs i.m. olanzapin, risperidon, melperon, haloperidolrisperidon, melperon, haloperidol

Clomethiazol (Heminevrin) in delirium tremensClomethiazol (Heminevrin) in delirium tremens Psychological approachPsychological approach

Acute mental disorders due to a severe stress Acute stress disorder (F43.0) – natural Acute stress disorder (F43.0) – natural

catastrophe, accident, battle, criminal catastrophe, accident, battle, criminal assault, rape,.. – symptoms disappear within assault, rape,.. – symptoms disappear within 2-3 days2-3 days

Dissociative (conversion) disorders (F44.x): Dissociative (conversion) disorders (F44.x): dissoc. amnesia, fugue, stupor, trance, of dissoc. amnesia, fugue, stupor, trance, of movement and sensation, convulsions, movement and sensation, convulsions, anaesthesia and sensory lossanaesthesia and sensory loss