Day # 4: Clinical Pearls for Psychotic Disorders

Welcome to day four of our introduction to psychotic disorders. We are going to spend most of the time discussing clinical pearls to include tips on the clinical interview and techniques to better understand the patients perspective.


Today's Content Level: Beginner; Intermediate


Clinical Interview / Evaluation


•Clarify onset/duration of symptoms with patient and family

•Identify any history of “prodromal” period - patients with schizophrenia may have a period of decline prior to onset of psychotic symptoms which may include school/work/social difficulties, poor self care, and depression

Substance use - determine if this is substance/medication induced

Medical and family history

•Carefully document amount of episodes - this is important b/c if it is only one episode up to 70% of first episode can achieve full remission and can remain stable. With more episodes the prognosis changes drastically.

Risk assessment for suicide and aggression - will cover risk/safety assessments in significant detail in later lessons, but remember that patients with schizophrenia have a 20x greater risk of suicide than the general population.

Optional rating scales: Positive and Negative Syndrome Scale (PANSS); Scale for the Assessment of Positive Symptoms (SAPS); Scale for the Assessment of Negative Symptoms (SANS); Brief Psychiatric Rating Scale (BPRS)


Patients perspective


As mental health professionals we have our own lingo and way of characterizing symptoms. Here are some tips to use patient friendly concepts to attempt to better understand their reality.

•Are you having intrusive significant thoughts? (Thought interference)

•Do you find yourself having frequent repetition of insignificant thoughts or images? (Thought perseveration)

•Are your thoughts at times confusing or chaotic? (Chaos of thoughts)

•Do you suddenly lose your train/thread of thinking? (Thought blocking)

•Have you had difficulties understanding what others are saying? (Disturbance of receptive language)

•Do you have difficulty finding the right words to say? (Expressive speech)


A quick word on cognition. Patients with schizophrenia experience high rates of cognitive deficits and this is not explicitly laid out in the DSM criteria. Here is a memory aid to help remember some of these deficits.

Speed of Processing

Memory (visual, verbal, working)

Attention

Reasoning

Tact / Social cognition (emotional processing, social cues, mentalizing)


A quick word on delusions. As discussed during yesterdays lesson, delusions are firmly held false beliefs despite incontrovertible evidence. Delusions can be a major cause of distress, anxiety, and paranoia for patients. As promised, here are some common delusions experienced by psychotic patients.

Persecutory: believes a person, group, or organization is mistreating, attacking, harming, or conspiring against them despite contradictory evidence

Erotomania: believes another is in love with them, despite no evidence. This other person is often a celebrity or person in power.

Somatic: believes they have an illness or their body is affected by a strange condition, despite contradictory evidence.

Grandiosity: believes they have superior abilities or qualities (i.e. talent, fame, wealth) or special relationship to diety or famous person despite no evidence.

Being controlled: feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than under their own control

Bizarre: involving a phenomenon that the person’s culture would regard as impossible

Thought broadcasting: one’s thoughts are being broadcast out loud so that they can be perceived by others

Thought insertion: some of one’s thoughts are not one’s own, but rather are inserted into one’s mind

Thought withdrawal: thoughts have been “taken out” of a person’s mind without permission


Conclusion


Nice work! You are building a strong foundation of knowledge about psychotic disorders. I want these lessons to have enough detail to provide significant value while at the same time keeping them brief enough that they can easily be read in less than five minutes a day. Tomorrow we will take a one day detour from our current them and discuss the mental status exam, which, as you will see, is essential to cover early on in our material. Next week we will continue our theme of psychotic disorders and will cover topics ranging from relevant pointers on the mental status exam, diagnostic work-up for "first break psychosis", antipsychotic medications, and supportive psychotherapy. Resources for this post include Psychiatric Interviewing: The Art of Understanding and Pocket Psychiatry.












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