Schizophrenia and Other Psychotic Disorders PDF

ST. Lideta Health Science Schizophrenia spectrum and other Psychotic disorder lecture for nursing students 1 OBJECTIVES By the end of this course the students will be able to  Define psychosis Classify schizophrenia spectrum and other psychotic...

ST. Lideta Health Science Schizophrenia spectrum and other Psychotic disorder lecture for nursing students 1 OBJECTIVES By the end of this course the students will be able to  Define psychosis Classify schizophrenia spectrum and other psychotic disorders Discuss theories of etiologies, diagnosis and treatment of schizophrenia spectrum disorder and other psychotic disorders 2 Definition of Psychosis The most generalized definition of psychosis is described as “a loss of ego boundaries or a gross impairment of reality testing Impairment of reality testing: is inability to distinguish reality from fantasy (the creation of new reality). 3 Classification of Schizophrenia spectrum and other Psychotic Disorders Schizophrenia Schizophreniform disorder Schizoaffective disorder Brief psychotic disorder Delusional disorder 4 Classification con,t… Substance/Medication-Induced Psychotic Disorder Psychotic Disorder Due to Another Medical Condition Catatonia Associated With Another Mental Disorder Catatonic Disorder Due to Another Medical Condition Other Specified Schizophrenia Spectrum and Other Psychotic disorder 5  Schizophrenia Schizophrenia is one of the most known severe psychotic disorders No clinical sign or symptom is pathognomonic for schizophrenia.  Every sign or symptom seen in schizophrenia occurs in other psychiatric and neurological disorders 6 Schizophrenia con,t…. Schizophrenia causes disturbances in: -Thought -Emotion -Behavior - reality testing Eugene Bleuler coined the term schizophrenia for the 1st time. 7  EPIDEMIOLOGY The lifetime prevalence of schizophrenia is about 1 percent Schizophrenia is equally prevalent in men and women Onset is earlier in men than in women The peak ages of onset are 15 to 25 years for men and Female (bimodal age distribution)-1st-25-35 2nd peak at 40 year (middle age) When onset occurs after age 45 years, the disorder is characterized as late-onset schizophrenia 8 EPIDEMIOLOGY Con,t…. Substance abuse is common in schizophrenia. The lifetime prevalence of any drug abuse (other than tobacco) is often greater than 50 percent Up to 90 percent of schizophrenia patients may be dependent on nicotine. Apart from smoking-associated mortality, nicotine decreases the blood concentrations of some antipsychotic drugs. 9  EPIDEMIOLOGY Con,t…. 80 percent of all schizophrenia patients have significant concurrent medical illnesses and that up to 50 percent of these conditions may be undiagnosed. About 50% have suicidal ideations and 10-15% patient with schizophrenia die of suicide Schizophrenia has been correlated with local population density in cities with populations of more than 1 million people 10 Risk factors of Schizophrenia Schizophrenia is a mental disorder with multiple etiologies(Biopsychosocial Causes) Biological factors(Genetic Factors) Family history of schizophrenia or other mental disorder Neurotransmitters e.g. too much dopaminergic activity in Mesolimbic dopamine pathway 11  Etiology Con,t…. Social factors Migration: Many studies have reported increased rates of schizophrenia in migrants Urban Birth and Upbringing Generally, studies show a twofold increase in risk of schizophrenia in urban as compared to rural settings. Psychological factors Stressful Life Events and Early Childhood Trauma 12 DSM V Diagnostic Criteria of Schizophrenia A. Two (or more) of the following, each present for a significant portion of time during a month period (or less if successfully treated). At least one of these must be (1 ), (2), or (3): 1. Delusions 2. Hallucinations 3. Disorganized speech (e.g., frequent derailment or incoherence) 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (i.e. Apathy or lack of motivation, Asociality or poor social interaction) 13 B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self care, is markedly below the level achieved C. Continuous signs of the disturbance persist for at least 6 months D. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out 14 E. The disturbance is not attributable to the physiological effects of a substance or another medical condition. F. If there is a history of autism spectrum disorder or a communication disorder of childhood onset, the additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations, in addition to the other required symptoms of schizophrenia, are also present for at least 1 month (or less if successfully treated). 15 5 dimensional symptom in schizophrenia 1. Positive symptoms of schizophrenia hallucination Delusion Disorganized speech 2. Negative symptoms schizophrenia Anhedonia(loss of interest) Apathy (lack of motivation) Asociality(poor social interaction) 16  Symptoms Con,t… 3. Cognitive symptoms of Schizophrenia Impaired attention Impaired information processing Impaired learning Impaired thought Impaired memory 17  Symptoms Con,t… 4. Aggressive/ Hostile symptoms Hostility Verbal abusiveness Physical Assault Self-injurious behavior (including suicide) Arson/property damage Impulsiveness 18 Symptoms Con,t… 5. Depressive/Anxious symptoms of Schizophrenia Depressed mood Anxious mood Guilt Tension Irritability  Depression develops in 25-50% of individuals with schizophrenia and can be associated with suicidal behaviour 19 Subtypes of Schizophrenia 1. Paranoid  Preoccupation with one or more delusion  Prominent hallucination – auditory, visual  No prominent disorganized behavior or speech  Older age of onset  Better premorbid functioning  Better outcome 20 2. Disorganized Prominent disorganized speech/behavior Delusion/hallucination – absent or fragmentary Disturbance of affect- silly, child-like behavior Early age of onset Poor premorbid functioning Poor long-term prognosis 21 3. Catatonic Motoric immobility or extreme agitation Negativism, mutism, etc. Earliest age of onset Poorest social and occupational functioning 22 4. Undifferentiated Most widely diagnosed Do not meet criteria for paranoid, disorganized, or catatonic type 5. Residual Who once met criteria for schizophrenia Negative symptoms predominate No longer prominent psychotic symptoms In DSM 5 the 5 subtypes of schizophrenia are eliminated 23 Management of Schizophrenia Hospitalization Psycho pharmacotherapy Psychological treatment(psychotherapy) Rehabilitation & social integration 24  Hospitalization Hospitalization is indicated For diagnostic purposes When there is inability to manage the patient at home For patients' safety (suicidal or homicidal ideation) If there is grossly disorganized or inappropriate behavior including the inability to take care of basic needs such as food, clothing, and shelter 25  Psychopharmacological treatment Antipsychotics Antipsychotic drugs diminish psychotic symptom expression and reduce relapse rates It can be categorized into two main groups: the older, conventional antipsychotics, which have also been called first-generation antipsychotics or dopamine receptor antagonists, and the newer drugs, which have been called second generation antipsychotics or serotonin dopamine antagonists (SDAs) 26 Conventional antipsychotics(1st generation) Block D2 receptors in all pathways mediating their therapeutic action as well as side effects Alleviate positive symptoms & aggressive behaviors Aggravate both negative & cognitive symptoms 1st generation antipsychotics can be classified as high, low and medium potent antipsychotics 27 High potent Antipsychotics Higher binding to D2 receptors Have more EPS (Extra Pyramidal Symptoms) Higher incidence of TD (Tardive Dyskinesia) less cognitive problem less cardiovascular Side effects Some examples of high potent antipsychotics Pimozide Fluphenazine Haloperidol 28 Low Potent Antipsychotics Lower binding to D2 receptors: Lower Efficacy Less EPS (Extra Pyramidal Symptoms) Lower incidence of TD (Tardive Dyskinesia) More Cognitive Problem More cardiovascular Side effects Some examples of low potent antipsychotics Chlorpromazine Thioridazine Mesoridazine 29 1st generation antipsychotics with their dosage Generic name Trade name Acute dose Maintenance dose Chlorpromazine Thorazin 100 to 1,600 50 to 400 po po/25 to 400im Trifluoperazine Stelazine 4 to 40 p.o. 4 to 10 5 to 20 p.o. IM Thioridazine Mellaril 200 to 800 p.o. 100 to 300 p.o. Haloperidol Haldol 5 to 20 p.o. 1 to 10 p.o. Haloperidol 12.5 to 25 IM 25 to 200 IM decanoate (decanoate, monthly) Fluphenazine 12.5 to 50 IM 25 to 100IM decanoate monthly 30  Side effects of typical antipsychotics 1.Neurological side effects(extra pyramidal side effect) Acute extrapyramidial syndromes Akathisia(feeling of restlessness) Acute dystonia(involntary muscle spasm) Drug-induced parkinsonism Chronic extrapyramidial syndromes Tardive dyskinesia 31 Extrapyramidial side-effects Antipsychotics, especially the high-potency agents, such as haloperidol, induce involuntary movements known as extrapyramidial side effects. These involuntary movements occur due to blockade of dopamine receptors in the Nigrostriatal pathway of the basal ganglia 32 Acute Dystonia:-Acute dystonia reactions are sustained contraction of the muscles of neck (torticollis), eyes (oculogyric crisis), tongue, jaw and other muscle groups, typically occurring within 3-5 days after initiation of the neuroleptic. Akathisia Akathisia is characterized by strong feelings of inner restlessness, which are manifest by difficulty of remaining still and excessive walking 33 pseudo parkinsonism Patients with pseudo Parkinson present with rigidity, mask-like facies,bradykinesia, and shuffling gait. Older patient are at higher risk of developing this problem Tardive Dyskinesia (TD):-Long-term blockade of dopamine 2 receptors by dopamine 2 antagonists in the Nigrostriatal dopamine pathway may cause these receptors to up-regulate. A clinical consequence of this may be the hyperkinetic movement disorder known as tardive dyskinesia. 34 Neuroleptic Malignant Syndrome -A potentially fatal side effect of 1st generation antipsychotic treatment - It can occur at any time during the course of the treatment Symptoms include: extreme hyperthermia, severe muscular rigidity mutism, confusion, agitation, increased pulse rate and blood pressure (BP) leading to cardiovascular collapse. 35 2. Seizure Threshold Lower the seizure threshold. Low-potency drugs are more epileptogenic than high potency drugs Chlorpromazine, Thioridazine, and other low-potency drugs are thought to be more epileptogenic than are high- potency drugs. 3. Anticholinergic side effecs:dry mouth, constipation, urinary retention Low potent antipsychotic drugs are responsible for this side effects 36 4. Sedation Blockade of histamine H1 receptors is the usual cause of sedation Chlorpromazine is the most sedating typical antipsychotic. Giving the entire daily dose at bedtime usually eliminates any problems 5. Cardiac Effects Low-potency DRAs are more cardio toxic than are high potency drugs. Chlorpromazine and Thioridazine mainly-are indicated 37  Atypical Antipsychotics(SDAs) The serotonin-dopamine antagonists (SDAs) are also known as second-generation or atypical antipsychotic drugs. These drugs include 1. Clozapine : 300-500mg 2. Risperidone : 4-8 mg. 3. Olanzapine : 15-25mg 4. Quetiapine : 150-600mg. 5. Ziprasidone : 80-160mg 38  They are called SDAs because they have a higher ratio of serotonin type 2 (5-HT2) to D2 dopamine receptor blockades than the typical, or conventional The SDAs also appear to be more specific for the Mesolimbic than Nigrostriatal dopamine system 39 All of the SDAs share the following characteristics: 1. Low D2 receptor blocking effects when compared with DRAs, which have high D2 receptor blockades; 2. A reduced risk of extrapyramidial side effects compared with older agents, a reduced risk that probably extends to the occurrence of tardive dyskinesia as well; 3. Proved efficacy as treatments for schizophrenia; and 4. proved efficacy as treatments for acute mania 40  Side effects of SDAs Weight gain :-e.g olanzapine Erectile dysfunction, orgasmic dysfunction, are associated with Resiperidone use Agranulocytosis:-caused by clozapine treatment Seizure :-caused by clozapine treatment 41 Phases of Treatment in schizophrenia Acute phase Goal- immediate control of psychosis 4 -8wks. Stabilization phase Goal:To decrease the rate of relapse. -Same agents as in the acute phase. -As long as 6 months 42 Maintenance phase - starts when the patient is in relative remission Goals - 1. prevention of psychotic relapse. 2. assist patients in improving their level of functioning Duration of maintenance treatment 1 to 2 years - after the first psychotic episode. 5 years - after a second psychotic episode Lifetime maintenance - after the third psychotic episode 43 Electroconvulsive therapy ( ECT) For acute and sub acute forms of schizophrenia Patients not responding to antipsychotic medications Severe catatonic symptoms – stupor, extreme agitation Severe depressive symptoms secondary to schizophrenia 44 Psychological treatment  It Includes a variety of methods to increase: Social abilities, self sufficiency, practical skills, and Interpersonal communication in schizophrenia patients.  Goal: is to enable persons who are severely ill to develop social and vocational skills for independent living.  Treatment carried out at many sites, including: hospitals, outpatient clinics, mental health centres, day hospitals, and home or social clubs. 45 Psychological treatment con,t…. Social Skills Training (behavioral skills therapy) Family-Oriented Therapies Group Therapy focuses on real-life plans, problems, and relationships. Effective in: Reducing social isolation, increasing sense of cohesiveness Improving reality testing for patients with schizophrenia Cognitive Behavioural Therapy (CBT) to improve cognitive distortions, reduce distractibility, and correct errors in judgment 46 Psychological treatment con,t…. Psychiatric rehabilitation, including:  Supported employment or education  Community supports—preferably natural-which can Provide basic necessities: Finances Housing Personal support network Other forms of individual treatment: Play therapy Combination of the above options is best treatments 47 Other psychotic disorders 48 Schizophreniform Disorder The symptoms of Schizophreniform are similar to those of schizophrenia; however, with Schizophreniform disorder, the symptoms last for at least 1 month but less than 6 months Patients with Schizophreniform disorder return to their baseline level of functioning after the disorder has resolved. They are unlikely to report a progressive decline in social and occupational functioning. 49  DSM- V Diagnostic Criteria of Schizophreniform Disorder A. Two (or more) of the following, each present for a significant portion of time during a1-month period (or less if successfully treated). At least one of these must be (1), (2),or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 5. Negative symptoms (i.e., diminished emotional expression or avolition). 50 B. An episode of the disorder lasts at least 1 month but less than 6 months C. Schizoaffective disorder and depressive or bipolar disorder with psychotic features have been ruled out because either 1 D.The disturbance is not attributable to the physiological effects of a substance 51  Specify if With good prognostic features: This specifier requires the presence of at least two of the following features: 1. Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; 2. Confusion or perplexity: 3.Good premorbid social and occupational functioning; and 4. Absence of blunted or flat affect. Without good prognostic features: This specifier is applied if two or more of the above features have not been present. With catatonia if the patient has 3 catatonic symptoms 52  EPIDEMIOLOGY A fivefold greater rate in men than in women. Is a very Rare disorder (0.11% LTP) 60%-80% progressed to schizophrenia 53  Treatment Antipsychotics – 3-6 months course Rapid response – 80% within 8 days Trial of mood stabilizers if recurrent episodes Psychotherapy – helps the patients to integrate the psychotic experience into their understanding 54 BRIEF PSYCHOTIC DISORDER Brief psychotic disorder is defined as a psychotic condition that involves the sudden onset of psychotic symptoms, which lasts 1 day or more but less than 1 month. Brief psychotic disorder is an acute and transient psychotic syndrome. Remission is full, and the individual returns to the premorbid level of functioning. 55 DSM -V Diagnostic Criteria of Brief psychotic Disorder A. Presence of one (or more) of the following symptoms. At least one of these must be (1), (2), or (3): 1. Delusions. 2. Hallucinations. 3. Disorganized speech (e.g., frequent derailment or incoherence). 4. Grossly disorganized or catatonic behavior. 56 B. Duration of an episode of the disturbance is at least 1 day but less than 1 month, with eventual full return to premorbid level of functioning. C. The disturbance is not better explained by major depressive or bipolar disorder with psychotic features or another psychotic disorder 57 Specify if: A. With marked stressor(s) B. Without marked stressor(s) C. With postpartum onset: If onset is during pregnancy or within 4 weeks postpartum. D. With catatonia 58  Etiology Usually precipitated by extreme stress or trauma like: the death of a love one, accident/assault/natural disaster. Major predisposing factor is a personality disorders as: Paranoid, Borderline, schizoid, Schizotypal Course tends to be characterized by rapid onset and rapid resolution with no residual Considered as non re-occurring Frequency was 2-fold higher in women than in men. 59 Treatment of Brief Psychotic Disorder A. Brief hospitalization may be necessary, especially if suicidal or homicidal ideation is present. Patients can also be very confused and impulsive. B. A brief course of a neuroleptic, such as haloperidol 2-10 mg per day, is usually indicated. Adjunctive benzodiazepines can speed the resolution of symptoms. C. Supportive psychotherapy is indicated if precipitating stressors are present. Supportive psychotherapy is initiated after psychosis has resolved. 60  Schizoaffective Disorder Schizoaffective disorder has features of both schizophrenia and mood disorders. prevalence for schizoaffective disorder is less than schizophrenia The lifetime prevalence is under one percent, possibly in the range of 0.5 to 0.8 percent 61 DSM –V Diagnostic Criteria of schizoaffective disorder A. An uninterrupted period of illness during which there is a major mood episode (major depressive or manic) concurrent with Criterion A of schizophrenia. Note: The major depressive episode must include Criterion A1 : Depressed mood. B. Delusions or hallucinations for 2 or more weeks in the absence of a major mood episode (depressive or manic) during the lifetime duration of the illness 62 Symptoms that meet criteria for a major mood episode are present for the majority of the total duration of the active and residual portions of the illness D. The disturbance is not attributable to the effects of a substance (e.g., a drug of abuse, a medication) or another medical condition 63 Specify If: Bipolar type: This subtype applies if a manic episode is part of the presentation. Major depressive episodes may also occur. Depressive type: This subtype applies if only major depressive episodes are part of the presentation. With catatonia 64  Epidemiology It is less than 1%, possibly in the range of 0.5- 0.8%. Bipolar subtype: M:F=1:1  Young adults than in older adults Depressed subtype: twofold female to male older persons than in younger The age of onset for women is later than that for men Associated with social and occupational dysfunction, but not a diagnostic criterion (as it is for schizophrenia) 65 Treatment of Schizoaffective Disorder A. Psychotic symptoms are treated with antipsychotic agents ( newer antipsychotics preferred) B. The depressed phase of schizoaffective disorder is treated with antidepressant medications (SSRI prefer especially, if pt is not insomniac or agitated) C. For bipolar type, mood stabilizers (e.g., lithium, vaporate or carbamazepine) are used alone or in combination with antipsychotics D. Electroconvulsive therapy may be necessary for severe depression or mania. 66 Delusional Disorder Delusion - is a false, unshakeable belief that is out of keeping with the patient’s social and cultural background They are of particular diagnostic importance in psychotic disorders and particularly in schizophrenia, manic episode and psychotic depression. The belief is not ordinarily accepted by other members of the person’s culture or subculture and religion Mean age of onset is 40years 67 Classification of delusional disorder Non-bizarre delusions Persecutory-paranoid, Delusion of reference Grandiose delusion, Somatic delusion Delusion of love (erotomania) Delusion of jealousy 68 Bizarre delusions Thought insertion, thought withdrawal Nihilistic delusion  thought broadcasting, thought reading delusion of control 69  Mood congruent delusion :- the delusion is in harmony with the mood of the patient Mood incongruent:-the delusion is not in harmony with the mood of the patient Patients with mood disorder with mood-congruent psychoses have a psychotic type of mood disorder; however, patients with mood disorder with mood- incongruent psychotic symptoms may have schizoaffective disorder or schizophrenia 70  Non-bizarre delusions means that the delusions are about situations that can occur in real life Persecutory delusion A delusion in which the central theme is that one is being attacked, harassed, cheated, persecuted, or conspired against. Delusion of jealousy(Delusion of infidelity) A delusion that one's sexual partner is unfaithful Persecutory-type and jealousy-type delusions are probably the forms seen most frequently by psychiatrists 71 Delusion of reference False belief that ordinary, insignificant comments, objects, or events refer to or have special meaning for the patient. for example, belief that people on television or radio are talking or about the patient. Grandiose delusion- A delusion of inflated worth, power, knowledge, identity, or special relationship to a deity or famous person. Somatic delusion - A delusion whose main content pertains to the appearance or functioning of one's body. 72 Delusion of love (Erotomania): A delusion that another person, usually of higher status, is in love with the individual More common in women than in men Mixed type: Involves delusions of at least two of the above without a predominate theme. 73 2). Bizarre delusions A delusion that involves a phenomenon that the person's culture would regard as totally implausible Nihilistic delusion: false feeling that self, others, or the world is nonexistent or ending. Thought insertion A delusion that certain of one's thought are not one's own, but rather are inserted into one's mind. 74  Thought withdrawal A delusion that ones thought is taken up by other without their will and utilized by them Delusion of control A delusion in which feelings, impulses, thoughts, or actions are experienced as being under the control of some external force rather than being under one's own control. Thought reading: delusional belief that people can read one’s mind or know one’s thought. 75 DSM V Diagnostic Criteria of Delusional disorder A. The presence of one (or more) delusions with a duration of 1 month or longer. B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation). 76 C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired, and behavior is not obviously bizarre or odd. D. If manic or major depressive episodes have occurred, these have been brief relative to the duration of the delusional periods. E. The disturbance is not attributable to the physiological effects of a substance or another medical condition and is not better explained by another mental disorder 77 Epidemiology of Delusional Disorder The prevalence of delusional disorder is less than 1% The mean age of onset is 40 and ranges from 18-90 years. There are no major gender differences in the overall frequency of delusional disorder. But Men are more likely to develop paranoid delusions than women Women are more likely than men to develop delusions of erotomania. 78 Treatment Delusional disorder is challenging to treat  Patients' frequent denial  Difficulties in developing a therapeutic alliance, and  Social/interpersonal conflicts.  Antipsychotics are the treatment of choice for delusional patients 79  CATATONIC DISORDER Catatonia is defined by the presence of three or more of 12 psychomotor features in the diagnostic criteria for catatonia associated with another mental disorder and catatonic disorder due to another medical condition. 80  DSM-5 Diagnostic Criteria for Catatonia Associated with Another Mental Disorder A. The clinical picture is dominated by three (or more) of the following symptoms: 1. Stupor (i.e., no psychomotor activity; not actively relating to environment). 2. Catalepsy (i.e., passive induction of a posture held against gravity).It is a general term for an immobile position that is constantly maintained 3. Waxy flexibility (i.e., slight, even resistance to positioning by examiner 81 4. Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]). 5. Negativism (i.e., opposition or no response to instructions or external stimuli). 6. Posturing (i.e., spontaneous and active maintenance of a posture against gravity). is the adoption of unusual bodily postures continuously for a long time 7. Mannerism (i.e., odd, circumstantial caricature of normal actions). 82 8. Stereotypy (i.e., repetitive, abnormally frequent, non- goal-directed movements). 9. Agitation, not influenced by external stimuli. 10. Grimacing:-a facial expression usually of disgust, disproval or pain 11. Echolalia (i.e., mimicking another’s speech). 12. Echopraxia (i.e., mimicking another’s movements). 83 Postpartum psychosis Postpartum psychosis is a reversible but severe mental health condition that affects women after they give birth. Most women with postpartum psychosis show symptoms within 4 weeks of giving birth 84 Postpartum Psychosis No DSM V diagnostic criteria but it is specifier of Brief psychotic disorder Mood disorder →Initially  Fatigue, insomnia  Restlessness, tearfulness & emotional Lability → Later  Suspiciousness, confusion, incoherent irrelevant statement  Obsessive concern about the baby’s health & welfare 85 Delusions Dead or deformed baby, Denial of birth or marriage, persecution  Hallucinations Voice telling to kill the baby  Feelings of Not wanting to care for the baby Wanting to do harm to the baby or to themselves 86 Treatment 1. Pharmacological :- Antidepressants , antianxity agents, lithium and antipsychotic medication. 2. Psychological:- individual and marital therapy. 3. Hospitalization 87  Psychotic Disorder Due to a General Medical Condition The diagnosis of psychotic disorder due to a general medical condition is defined by specifying the predominant symptoms. When the diagnosis is used, the medical condition, along with the predominant symptoms pattern, should be included in the diagnosis (e.g., psychotic disorder due to a brain tumor, with delusions) 88 DSM V Criteria Psychotic Disorder due to Another Medical Condition A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct path physiological consequence of another medical condition. C.The disturbance is not better explained by another mental disorder. D. The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 89 Specify whether With delusions: If delusions are the predominant symptom. With hallucinations: If hallucinations are the predominant symptom. 90  DSM V Criteria Substance- or Medication- Induced Psychotic Disorder A. Presence of one or both of the following symptoms: 1. Delusions. 2. Hallucinations. B. There is evidence from the history, physical examination, or laboratory findings of both (1)and (2): 1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. 2. The involved substance/medication is capable of producing the symptoms in Criterion A. 91 C.The disturbance is not better explained by a psychotic disorder that is not substance/medication-induced D.The disturbance does not occur exclusively during the course of a delirium. E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 92 Specify whether With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication. With onset during withdrawal: If the criteria are met for withdrawal from the substance and the symptoms develop during or shortly after withdrawal 93  Treatment Treatment involves identifying the general medical condition or the particular substance involved. At that point, treatment is directed toward the underlying condition and the patient’s immediate behavioral control Hospitalization may be necessary to evaluate patients completely and to ensure their safety 94