detecting psychosis in the primary care setting presented by: jonathan betlinski, md date:...

Detecting Psychosisin the Primary Care Setting

Presented by: Jonathan Betlinski, MDDate: 03/05/2015

Disclosures and Learning Objectives

Learning Objectives:•Know the prevalence of psychotic symptoms in primary care•Know the 6 common symptom clusters for schizophrenia•Be able to list at least 5 reasons why an individual might be psychotic

Disclosures: Dr. Jonathan Betlinski has nothing to disclose.

Psychosis in Primary Care

• Review the epidemiology of psychosis

• Review common causes of psychosis

• Review diagnostic criteria for psychosis

• Discuss screening questions for psychosis

• Review the basic first steps of managing psychosis

• Reveal next week’s topic

Psychosis: Epidemiology

• 3.7% of primary care patients report at least one psychotic symptom

• Most common symptom is believing that others are spying on or following the individual

http://www.researchgate.net/publication/14290258_Psychotic_symptoms_in_primary_care

• 50-90% of those with a serious mental illness (SMI) have at least one chronic medical illness

• Individuals with SMI die 25 years earlier http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-care-providers-am-j-m-2012.pdf

• Up to 30% of individuals with psychotic symptoms rely solely on primary care

https://books.google.com/books?id=Jxfm86wOR8UC&pg=PA237&lpg=PA237&dq=psychosis+in+the+primary+care+setting&source=bl&ots=ffP64uxT4T&sig=Mrhy-v51_bw_LsP4WMWfDSY6t8A&hl=en&sa=X&ei=wJz3VKjsIYHxoASGyYGYCw&ved=0CFUQ6AEwCTgK#v=onepage&q=psychosis%20in%20the%20primary%20care%20setting&f=false

Psychosis – Epidemiology for schizophrenia

• 0.7% lifetime risk for schizophrenia• Mortality rate is 2-3x higher

• 3.4x Infectious disease• 3.2x Respiratory disease• 2.7x Endocrine• 2.5x Gastrointestinal• 2.3x Cardiovascular (50-60% of premature death)

• Smoking, obesity, DM, HTN, Hyperlipidemia and Metabolic Syndrome are all 1.5-5x more present

• 5% lifetime risk of suicide (13x greater)http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-care-providers-am-j-m-2012.pdf

Psychosis

Psychosis is characterized by a loss of contact with reality

• Delusions (fixed false beliefs)

• Hallucinations (false sensory perceptions)

• Disorganized speech

• Disorganized behavior

These problems cause lead to social or occupational dysfunction

http://www.nmji.in/archives/Volume_19_6_Nov_Dec_2006/Everyday_Practice_new/every_day_practice_19_6.htm

Psychosis – Psychological Causes

• Schizophrenia

• Schizoaffective Disorder

• Brief Psychotic Disorder

• Major Depressive Disorder

• Bipolar I Disorder

• Psychotic Disorder, NOS

• Delusional Disorder

• Personality Disorders

• Narcolepsyhttp://www.nhs.uk/Conditions/Psychosis/Pages/Causes.aspx;

http://pro.psychcentral.com/dsm-5-changes-schizophrenia-psychotic-disorders/004336.html

Psychosis – Substance-induced Causes

• Alcohol

• Cannabis

• Cocaine

• Amphetamine

• Methamphetamine

• Mephedrone (MCAT)

• MDMA (ecstasy)

• LSD (acid)

• Psilocybins

• Ketamine

• Jimson Weedhttp://www.nhs.uk/Conditions/Psychosis/Pages/Causes.aspx

http://www.psychiatrictimes.com/sites/default/files/pt/00846.png

Psychosis – Medical Causes

• Epilepsy

• Head injury

• Brain tumors

• Infections• Malaria

• Syphilis

• Lyme Disease

• HIV and AIDS

• Autoimmune Disorders• Lupus

• Multiple sclerosishttp://www.psychiatrictimes.com/forensic-psychiatry/differential-diagnosis-psychotic-symptoms-medical-%

E2%80%9Cmimics%E2%80%9D

• Endocrine Disorders• Thyroid disorders

• Hypoglycemia

• Cushing’s Disease

• Dementias• Alzheimer’s Disease

• Parkinson's disease

• Lewy Body Dementia

• Metabolic Disorders• Acute Intermittent

Porphyria

Schizophrenia – Diagnostic Criteria A

Two (or more) of the following for 1 month (over 6m), one of which must be from the first 3

• Delusions

• Hallucinations

• Disorganized speech

• Grossly disorganized or catatonic behavior

• Negative Symptoms (i.e. Affective flattening, Alogia, Avolition, etc)

http://dnalc.org/view/899-DSM-IV-Criteria-for-Schizophrenia.html

http://pro.psychcentral.com/dsm-5-changes-schizophrenia-psychotic-disorders/004336.html

Schizophrenia – Diagnostic Criteria BCDEF

B. Social/Occupational Dysfunction

C. Duration- Continuous signs for 6 months

- Active symptoms for 1 month

- Prodromal or residual periods may have only negative symptoms or 2+ attenuated positive symptoms

D.It’s not SAD or a mood disorder

E.It’s not due to a substance or medical condition

F.If AD or PDD exists, delusions or hallucinations must be prominent for at least 1 monthhttp://dnalc.org/view/899-DSM-IV-Criteria-for-Schizophrenia.html

Schizophrenia: DSM 5 Diagnostic Criteria

Symptoms must be present for 6 months, active for 1 month, and cause dysfunction

• Negative symptoms: amotivation, decreased emotional expression, limited social interaction and poor speech

• Cognitive dysfunction: may affect memory, processing speed and executive function

• Disorganization of speech

• Delusions and hallucinations

• Motor system abnormalities: tremor, bradykinesia, catatonia, akathisia, abnormal involuntary movements

• Affective symptoms: demoralization, major depression, manic behaviors (energy, excitement, irritability, disinhibition)

http://www.jpshealthnet.org/sites/default/files/schizophrenia_e-resource_-_february_2014.pdf

Screening for Psychosis

Normalize the experience• Sometimes when people are [under stress or feeling

anxious/depressed], they can have strange experiences such as trouble with thinking or seeing or hearing things that others don’t.

• The next questions are about unusual things, like seeing visions or hearing voices that some people may not believe in. In fact these things may be quite common in certain situations.

http://santabarbarastreetmedicine.org/wordpress/wp-content/uploads/2011/04/Schizophrenia-for-primary-care-providers-am-j-m-2012.pdf

http://ocfp.on.ca/docs/collaborative-mental-health-care-network/15-minute-psych-assessment-presentation.pdf


• Have your eyes or ears (or brain) ever played tricks on you?

• Have there ever been times when you heard or saw things that other people could not?

• Have you ever heard voices that other people could not hear? I don't mean having good hearing, but rather…voices coming from inside your head talking to you or about you, or voices coming out of the air when there was no one around. Did you ever hear voices in this way?




• Have you had any strange or odd experiences lately that are difficult to explain or that others would find hard to believe?

• Have you felt people are watching or following you?

• Does anyone in particular seem intent on harassing or hurting you?

• Have you felt like others can hear your thoughts or that you can hear another person’s thoughts?




• Have you ever felt that some mysterious force was inserting thoughts—that were that were definitely not your own thoughts—directly into your head?

• Have you ever felt that your thoughts were being read by other people or were being stolen out of your mind?

• Did you ever have a time when you felt that that your mind was being taken over by others?

• Have you ever felt that someone or something was trying to communicate directly with you by sending special signs or signals?


http://www.hcp.med.harvard.edu/wmhcidi/about.php


• Has a doctor ever told you that you have schizophrenia?

• Who in your family has had problems with psychosis or schizophrenia?

• Do you have any special powers that most people lack?


http://www.hcp.med.harvard.edu/wmhcidi/about.php

Psychosis – Initial Workup

• Medical and family history

• Physical exam

• Focused Neuro exam

• Labs• CBC, CMP, Thyroid

• Vit B12, HIV,UDS

• RPR vs. FTAAT?

If Clinically Indicated

•Head Imaging• MRI preferred

• Low Yield

•EEG

•Ceruloplasmin

•CXR

•Lumbar Puncture


Psychosis – Initial Management

• Evaluate for safety• Refer for psychiatric evaluation

• EASA referral for first psychosis

• If no safety concerns exist and there is no timely referral available, consider starting an antipsychotic• Go with what’s worked best in the past• Risperidone or Perphenazine if no prior


Psychosis – Initial PCP Treatment (NICE)

• Do not start AP for 1st psychosis without consultation

• Collect the following baseline information• Weight, girth• BP, pulse• Fasting glucose, HbA1c, Lipid profile, prolactin• assessment of any movement disorders• assessment of nutritional status, diet and level of

physical activityhttp://www.guidelines.co.uk/central_nervous_system_nice_psychosis_schizophrenia_feb14#.VPedV-85CW8

Psychosis – Treatment Considerations

APA Treatment Guidelineshttp://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf

http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia-watch.pdf

http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia-guide.pdf

NICE Treatment Guidelineshttp://www.guidelines.co.uk/central_nervous_system_nice_psychosis_schizophrenia_feb14#.VPedV-85CW8

http://www.nice.org.uk/guidance/cg120/chapter/guidance

National Medical Journal of Indiahttp://www.nmji.in/archives/Volume_19_6_Nov_Dec_2006/Everyday_Practice_new/every_day_practice_19_6.htm

Australian Guidelineshttp://www.ycentral.com.au/wp-content/uploads/2014/11/Aust-Clinical-Guidelines-for-Early-Psychosis.pdf

https://www.ranzcp.org/Files/Resources/Publications/CPG/Clinician/APY535-pdf.aspx

http://www.guideline.gov/content.aspx?id=43862

Summary

• Nearly 4% of primary care patients have psychotic symptoms

• Less than 1% will have schizophrenia

• Psychosis can arise for psychological, medical and substance-induced reasons

• Those with psychotic symptoms tend to have worse medical outcomes

• Treatment of psychosis includes medical assessment, routine monitoring and targeted interventions

The End!

Pharmacologic Interventions for Psychosis

03/12/15

http://earthobservatory.nasa.gov/IOTD/view.php?id=84560

detecting psychosis in the primary care setting presented by: jonathan betlinski, md date:...

Documents

psychosis psychosis

psychosis epidemiology

false slide

primary care settingf

individual http

primary care https

primary care patients

greater http