DIAGNOSIS AND MANAGEMENT OF THOUGHT DISORDERS

Ma. Victoria D. Villanueva-Briguela, MD, FPPA

OBJECTIVES
 Describe the key features that define the Psychotic Disorders
 Differentiate the different disorders in the Schizophrenia Spectrum and other Psychotic Disorders
 Discuss the treatment used for Schizophrenia and other psychotic disorders
 Describe a violent and know what to do when there is one.
SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS
1. Schizophrenia
These are included in the Schizophrenia spectrum. But Schizotypal PD will
2. Other psychotic disorders
be discussed under personality disorders.
3. Schizotypal (personality) disorder

KEY FEATURES THAT DEFINE THE PSYCHOTIC

DISORDERS
1. Hallucinations
2. Delusions
3. Disorganized thinking (speech)
4. Grossly disorganized or abnormal motor behavior
(including catatonia)
5. Negative symptoms
These features will make you say that the patient in front of
you is psychotic. Actually, these 5 are included in the criteria A
for Schizophrenia in DSM-V.

DELUSIONS HALLUCINATIONS
 Fixed beliefs that are not amenable to change in the light  Perception-like experiences that occur without an external
of conflicting evidence stimulus
 Bizarre and not understandable to same culture peers  Vivid, clear, not under voluntary control
 Variety of themes:  Most common is auditory, usually experienced as voices
o Persecutory familiar or not
o Referential DISORGANIZED THINKING (SPEECH)
o Somatic  Formal thought disorder – typically inferred from the
o Religious individual’s speech
o Grandiose a. Derailment or looseness of association – switching from
a. Persecutory one topic to another
 belief that one is going to be harassed b. Tangentiality – answers to questions are unrelated
 most common c. Incoherence or word salad – speech is
incomprehensible
Example: The patient believes that person around him is
going to kill him or has intention to hurt him. Tangentiality – example: you ask something from the patient,
the patient answers you but does not able to arrive at the
b. Referential correct answer. beats around the bush but unable to get the
answer.
 Belief that certain gestures, comments,
Circumstantiality – you ask the patient, beats around the bush
environmental cues and so forth are directed at but able to get the answer.
oneself
GROSSLY DISORGANIZED OR ABNORMAL
Transcriber’s note: Delusions of reference – patients are
MOTOR BEHAVIOR (INCLUDING CATATONIA)
convinced of “meanings” behind events and people’s
 Range from childlike “silliness” to unpredictable agitation;
actions that are directed specifically toward themselves.
probably in goal-directed behavior
c. Grandiose  Catatonia – marked decrease in reactivity to the
 One believes that she or he has exceptional abilities, environment; either negativism, stupor, mutism
wealth or fame NEGATIVE SYMPTOMS
 Diminished emotional expression; reduction in pleasure; 5As
Example: The patient believes he has the power of God or
o Avolition – reduced motivation
power to heal.
o Alogia – reduced speech output
d. Erotomanic o Anhedonia – decreased ability to experienced pleasure
 The person believes falsely that one is on love with or o Asocial – lack of interest in social interaction
him or her o Flat Affect
e. Nihilistic
Sometimes not all the 5 are not present in the patient.
 With conviction that a major catastrophe will occur Sometimes 1 or 2 can be seen in the patient. There are
f. Somatic patients who are chronically ill who have no positive
 preoccupations on health and organ function symptoms observed, mostly negative symptoms are
present.
Example: The patient believes he has worms in the stomach.

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 SCHIZOPHRENIA
 An illness in which episodes of florid disturbances, in 8. Interpersonal functioning – impaired (e.g. social
cognition, emotion, perception, thinking and behavior withdrawal, emotional detachment, aggressiveness,
(CEPT-B) sexual inappropriateness
 It is set against a background of sustained disability. No 9. Psychomotor behavior – abnormal or changed (e.g.
single symptom is pathognomonic of the disorders agitation vs withdrawal, grimacing, posturing, rituals)
10. Cognition – impaired (inattention, concreteness, or
There is a decrease in the function of the patient.
impaired information processing)
Example: The patient used to teach but with the illness, the
patient is unable to go back to teaching.  Criteria A: Patient exhibits 2 of symptoms listed as
symptom (1-5) in criterion A
 A brain disorder with structural and functional  Criterion B required the impaired functioning such as work,
abnormalities seen in neuroimaging studies and genetic interpersonal relations or self-care during the active phase
component studies of illness
 1st signs: confusing & shocking  Criterion C, symptoms must persist for at least 6 months
 Acute phase of schizophrenia – sudden onset of severe  Criterion D schizoaffective, bipolar, and depressive
psychotic symptoms of hallucination, delusion and disorders with psychosis have been ruled out.
disorganized thinking  Criterion E, disturbance is not attributable to the
 Psychosis – state of mental impairment marked by physiologic effects of a substance or another medical
hallucination and delusion. Less obvious symptoms are condition
social isolation or withdrawal, unusual speech and thinking  Criterion F, additional diagnosis of schizophrenia is made if
Psychosis vs. Neurosis with prominent delusions and hallucinations diagnosis of
Psychosis – derailment or disturbance in reality testing autism is made only If
Neurotic – patient has contact with reality; alam nila yung
nangyayari sa paligid but the patient experiences severe In MSE, hallucinations are part of
anxiety, phobia, trauma/PTSD, OCD. They do not experience perceptual disturbances IT IS NOT A
delusions or hallucinations which can be found in psychosis. THOUGHT DISTURBANCE.
Hallucinations = perceptual
You need to delineate who is psychotic and who is neurotic disturbance
because the treatment is different. Delusion = thought content
disturbance
PSYCHOTIC PATIENT
 Grossly impaired sense of reality
 Emotional and cognitive disabilities POSITIVE SYMPTOMS
 Talk and act bizarre fashion  Reflects the presence of an abnormal mental process and
 Delusions and hallucinations relatively transient
 May be confused or disoriented 1. Delusion - false, unshakeable personal ideas or beliefs
DIAGNOSIS OF SCHIZOPHRENIA that are out of keeping with the patients educational,
 History and mental status examination (based on cultural and social background, held with conviction and
observation and description of the patient) subjective certainty, contrary to the face of evidence.
 In the DSM-V: 2. Hallucination - are false perceptions in the absence of
A. At least 2 or more of the following five (5) symptoms real external stimulus, and are perceived as having the
should be present for at least a month (or less if same quality as real perceptions, are not subject to
successfully treated): conscious manipulation, can occur in any modality, most
a. Hallucinations prevalent are auditory hallucinations
b. Delusions 3. Formal thought disorder - is a disorder of conceptual
c. Disorganized speech thinking often reflected in the difficult to understand
d. Disorganized behavior speech of people with schizophrenia (ex. Loose of
e. Negative symptoms association)
Note: only one criterion A symptom is required if delusions are bizarre Positive Symptoms are:
or hallucinations consist of a voice keeping up a running commentary  Delusions
on the person’s behavior or thoughts or two or more voices
 Hallucinations
commenting with each other.
 Distortions or exaggerations in language and
 Other diagnostic features of schizophrenia are:
communication
1. Overall functioning – decline in level of functions or fails
 Disorganized speech
to achieve expected level
2. Thought content – abnormal (ex. Ideas of reference or  Disorganized behavior
poverty of content)  Catatonic behavior
3. Form of thought – illogical (e.g. derailment, looseness of  Agitation
association, circumstantiality, tangentiality, neologism, NEGATIVE SYMPTOMS
overinclusiveness, blocking)  Alogia (poverty of speech)
4. Perception – distorted (ex. Hallucinations visual,  Flat affect
olfactory, tactile and most frequently auditory)  Anhedonia
5. Affect – abnormal (ex. Flat, blunted, silly, labile,  Asocial (social withdrawal)
inappropriate)  Avolition (lack of initiative)
6. Sense of self – impaired – loss of ego boundaries, gender  Inattention
confusion, inability to distinguish internal from external COGNITIVE SYMPTOMS
reality  Impaired attention and memory
7. Volition – altered (e.g. inadequate drive or motivation or  Problems in executive function
marked ambivalence)

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 OTHER PSYCHOTIC DISORDERS
SCHIZOPHRENIFORM DISORDER
 Symptoms more than 1 month but less than 6 months,
distinguished by its difference in duration, the total
duration including prodromal, active, and residual phase
 Criterion A of DSM 5 is same as in schizophrenia
BRIEF PSYCHOTIC DISORDER
A. Presence of one or more of the following:
1. Delusion
2. Hallucination
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
B. An acute psychotic episode lasting at least 1 day but less
than 1 month w/ eventual full return to function.
*associated feature is an emotional turmoil or
overwhelming function
SCHIZOAFFECTIVE DISORDER
A. An uninterrupted period of illness during which there is a
major mood disorder (manic/depressive) concurrent
with criterion A of schizophrenia
B. Delusions or hallucinations for 2 or more weeks in the
absence of a major mood episode (depressive/manic)
during the lifetime prevalence of the illness.
PSYCHOTIC DISORDER DUE TO ANOTHER
MEDICAL CONDITION
A. Prominent hallucinations or delusions
B. There is evidence from the history, physical
examinations, laboratory findings that disturbance is
direct pathophysiologic consequence of another medical
condition
C. Disturbance is not better explained by another mental
condition
CATATONIA
A. The clinical picture is dominated by 3 or more of the
following:
1. Stupor (no psychomotor activity)
2. Catalepsy (passive induction of a posture held against
gravity)
3. Waxy flexibility (resistance to positioning by examiner)
4. Mutism (no verbal response)
5. Negativism (opposition)
6. Posturing (spontaneous or maintenance of a posture
against gravity)
7. Mannerism (odd, circumferential)
8. Stereotypy (repetitive, abnormally frequent non-goal-
directed movement)
9. Agitation (not influence by external stimuli)
10. Grimacing
11. Echolalia
12. Echopraxia
SCHIZOPHRENIA (cont.)
 most common psychotic disorder
TYPES
1. Catatonic
2. Paranoid
3. Disorganized
4. Undifferentiated
5. Residual
SUBTYPES
1. Paranoid
 Characterized mainly by presence of delusion or
persecution/grandeur
 Frequent auditory hallucinations usually persecutory
 Patients are typically tense, suspicious, guarded,
reserved, hostile or aggressive.
D. It does not occur exclusively during the course of a
delirium
E. It causes significant distress of impairment in social,
occupational and other areas of functioning.
SUBSTANCE/MEDICATION-INDUCED
PSYCHOTIC DISORDER
A. Presence of one or both of the following symptoms:
1. Delusions
2. Hallucinations
B. Presence in the history, physical examination, laboratory
findings of both:
1. Signs in criteria A developed during or soon after
substance intoxication or withdrawal or after
exposure to a medication
2. Involved substance or medication is capable of
producing the substance in criteria A.
3. It is not better explained by a psychotic disorder
that is not substance-medication induced.
 Such evidence of an independent psychotic disorder
could include the following:
o The symptoms preceded the onset of the
substance/medication use; the symptoms persist
for a substantial period of time or severe
intoxication or there is other evidence of an
independent non-substance/medication induced
psychotic disorder
Use of methamphetamine or use of illegal substances – can
mimic the symptoms of schizophrenia; presentation can be
paranoia, persecutory delusions, that you can see in a
schizophrenic patient, the only difference is these patients
are positive for methamphetamine/other
substances/medication.
Echolalia – patient repeats the statement of the examiner
Echopraxia – patient repeats/follows the movement of the
examiner
Perseveration vs Verbigeration
Perseveration – patient responds with the same answer to
every question
Example:
Examiner: What’s your name?
Patient: Flordeluna
Examiner: Where do you live?
Patient: Flordeluna
Verbigeration – patient gives answers/responses repetitively
even without a stimulus
Example:
Patient: Sasakay ako sa bus, sasakay ako sa bus, sasakay ako
sa bus
2. Disorganized (formerly Hebephrenic)
 Marked regression to primitive, disinhibited or
unorganized behavior
 Absence of symptoms that meet criteria for catatonic
 Occur before age 25
 Signs observed: incongruous grim/grimacing, behavior
is silly
 Incoherence marked looseness of association, and
pronounce though disorder
3. Catatonic
 Classic feature is marked disturbance in motor function,
involves stupor, negativism, rigidity, excitement or
posturing
 Rapid alteration between extremes of excitement and
stupor
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 4. Undifferentiated
 Pronounced delusion, hallucination, incoherence or
grossly disturbed behavior
 Cannot fit into one type or another
5. Residual
 Continuing evidence of schizophrenia, disturbance
in absence of complete set of active symptoms or of
sufficient symptom to meet the diagnosis of
another type of schizophrenia
POST-PSYCHOTIC DEPRESSIVE DISORDER OF
SCHIZOPHRENIA
 Following the acute schizophrenic episode, some patients
become depressed
 It closely resemble the symptoms of the residual phase of
schizophrenia and the adverse effects of commonly used
antipsychotics
EARLY-ONSET SCHIZOPHRENIA
 Patients who manifest schizophrenia in childhood, onset is
insidious, chronic and prognosis is unfavorable
LATE-ONSET SCHIZOPHRENIA
 Onset of schizophrenia is after age 45, tends to
appear more frequently in women, prognosis if
favorable.
DIAGNOSTICS
 CBC
 Basic electrolytes (NA, K)
 Serum Ca
 Thyroid function (TSH, T3 and T4)
 Serology (HIV, Syphilis)
 EEG
 CT Scan
 MRI
 Psychological Test
COURSE OF SCHIZOPHRENIA AND
TREATMENT EFFECTS
 Classic course – deterioration overtime with acute
exacerbation superimposed on a chronic course
 Prodromal symptoms - anxiety, perplexity, terror or
depression precede onset of schizophrenia
 Precipitating events – separations, use of drugs,
emotional trauma
 Relapse - occurs in 40% of patients on medications and
80% of patients if not on meds
PROGNOSIS
 Rule of third
 1/3 of patients lead a somewhat normal lives
 1/3 continue to experience significant symptoms but can
function in society and
 1/3 are markedly impaired and require frequent
hospitalization (10% of these need institutionalization)
LIVES OF SCHIZOPHRENIC
 vary from inactivity and in urban setting
 homelessness and poverty
COURSE OF SCHIZOPHRENIA AND PROGNOSIS
(5-10 years after 1st hospitalization)
 10-20% of patients can be described with good outcome
 >50% have poor outcome with repeated exacerbations of
symptoms
 40-60% remain significantly impaired for their entire lives
COURSE AND TREATMENT
 Research has found that psychosocial interventions can
augment the clinical improvement
 Supportive psychotherapy (music, art, vocational therapy
ex. Sheltered workshops)
 An unpleasant reaction by the patient to the first dose
correlates strongly with future response and non-
compliance
 Noncompliance with antipsychotic medication is a major
reason for relapse
TREATMENT
 Hospitalization: indications are for
1. Diagnostic purposes
2. Stabilization of medication
3. Patient’s safety
4. Grossly disorganized or inappropriate behavior as
inability to take care of basic needs
I. Pharmacotherapy
II. Psychosocial
III. ECT
I. PHASES OF TREATMENT IN SCHIZOPHRENIA
TREATMENT OF ACUTE PSYCHOSIS
 acute psychotic symptoms require immediate
attention
 Focus: alleviating the most severe psychotic
symptoms
 Duration: 4 to 8 weeks.
 Acute Phase signs:
o Severe agitations
o Frightening delusion
o Hallucinations
o Suspicious
GOALS OF TREATMENT (FOR ACUTE PHASE)
1. Prevent harm
2. Control disturbed behavior
3. Reduced severity of psychosis and associated signs
4. Effect a rapid return to the best level of functioning
5. Develop alliance with patients and family
6. Formulate short and long term treatment plans
GOALS OF ACUTE PHASE ASSESSMENT
1. Evaluate the reason for recurrence or exacerbation of
signs (e.g. medication nonadherence)
2. Determine or verify patient’s diagnosis
3. Identify any comorbid psychiatric or medical condition
like substance use disorder
4. Evaluate general medical health
5. Undertake a thorough initial work up – complete medical
and psychiatric examination, physical and MSE
6. Routinely interview family members or other individuals
knowledgeable about the patient
 In emergency situation, it maybe necessary to speak with
others without patient’s consent
 Assess risk factors for suicide (previous attempts,
depressed mood, hallucinations, hopelessness, anxiety,
eps)
DIFFERENTIATE AKATHISIA VS SEVERE AGITATION
a. If 1st generation AP used, patient is given trial w/
anticholinergic/anti-Parkinson agent or benzodiazepine
or propranolol;
b. To manage – agitation for psychosis:
o AP and BZP rapid calming of patient
o Highly agitated patient may give AP IM for more
rapid effect
From Kaplan: An advantage of an AP is that a single IM
injection of haloperidol, fluphenazine, olanzapine or
ziprasidone will often result in calming effect without excessive
sedation.
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ANTIPSYCHOTICS  Recommendation: multi-episode patients – give
 Low potency APs are associated sedation and postural maintenance treatment for 5 years or indefinitely
hypotension particularly when administered
Encourage patient kahit no more active symptoms, no more
intramuscularly hallucination or delusion, you still continue the medications of
Example: Chlorpromazine the patient. This is the stabilization and maintenance phase. Do
Remember: Chlorpromazine = low potency ChLOWpromazine not stop intake of medication. Example, if the patient stops the
Haloperidol = high potency HIGHloperidol medication, after two weeks, he becomes psychotic again. To
prevent relapse of the symptoms, the medications should be
 Haloperidol can cause frightening dystonia or akathisia continued.
 Typical AP cause:  Long-acting depot AP:
o Extrapyramidal symptoms (EPS);
o Increases compliance
o Raised prolactin (causes sexual dysfunction and o Clinicians know if medicine effect dissipates
galactorrhea) at therapeutic doses;
o Less day to day variability in bld levels
o With more anticholinergic (dry mouth,
o Easy to establish minimal effective dose
tachycardia, urinary obstruction) and o Preferred than daily dose scheduling
antiadrenergic (postural hypotension,
impotence) effects. TYPICAL ANTIPSYCHOTICS: Chlorpromazine, fluphenazine,
 Antipsychotics: haloperidol
1. All AP cause sedation at varying degrees, lowers ATYPICAL ANTIPSYCHOTICS: Clozapine, Aripiprazole,
seizure threshold, especially clozapine Olanzapine, Quetiapine, Risperidone
2. All AP cause weight gain except for aripiprazole and
ziprasidone and impaired glucose tolerance Drugs Recommended Dose Half-life
3. AP probably increase risk for thromboembolic Chlorpromazine 300-1000 6
disease equally Fluphenazine 5-20 mg 33
Haloperidol 5-20 21
4. For acutely psychotic patient – use short acting
Clozapine 150-600 12
parenteral formulation of 1st/2nd generation AP
Aripiprazole 10-30 75
agent.
Olanzapine 10-30 33
Quetiapine 300-800 6
METABOLIC SYNDROME
Risperidone 2-8 24
 3 or more of the following (the first 3 are most common)
1. Abdominal obesity II. PSYCHOSOCIAL THERAPY
 Waist circumference  Methods use to increase social abilities, self-sufficiency,
 >102 cm in men practical skills and interpersonal communication
 >88 cm in women 1. Social Skills Training uses video tape, role playing and
2. Hypertension homework assignments
 BP >130/85 mmHg 2. Cognitive Behavior Therapy – improve cognitive
3. Serum Triglycerides distortions, reduce distractibility, and correct errors
 >1.69 mmol/l in judgement
4. Serum HDL 3. Individual Psychotherapy – patients develop good
 <1.04 mmol/l in men treatment alliance
 <1.29 mmol/l in women 4. Personal Therapy – uses social skills, relaxation
exercise, psychoeducation, self-education, self-
 Patients with chronic psychoses – unhealthy lifestyle, awareness and exploration of individual vulnerability
often seen in metabolic syndrome, mostly among to stress
those patients using atypical AP 5. Vocational Therapy – enable patients to be gainfully
 Choice of AP drug is best made in consultation with employed mean towards a sign of recovery
patients in the context of psychosocial intervention 6. Art Therapy – art helps patients communicate with
promoting recovery. others and share their inner frightening world with
others
With the advent of atypical anti-psychotics, patients can have
7. Integrating Pharma and Psychosocial Treatment –
metabolic syndrome. Sometimes, unavoidable but you still need
to give the medication  So give precautions to the patient and single most effecting treatment
to consult internist for metabolic abnormalities. Monitor the lipid
There should be a combination of pharmacotherapy and
and blood sugar of the patient. Encourage patient to improve the
psychotherapy to have an effective treatment.
lifestyle because they have less activities. Advise to have exercise
or eat proper meal.
III. ELECTROCONVULSIVE THERAPY
TREATMENT ON STABILIZATION AND  Effective for acute psychosis and catatonic type; with
MAINTENANCE PHASE synergistic efficacy with antipsychotics
 illness is in stage of remission
 Goal: to prevent relapse and to assist patients in
improving their level of functioning
o Minimize stress on patients and provide support
o Minimal psychosis
o Much lower relapse rate if patient is still on
medication than if their meds are discontinued

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 SCHIZOPHRENIFORM DISORDER
 This is similar to schizophrenia except that the symptoms
last at least one months but less than 6 months DIFFERENTIAL DIAGNOSIS
 They return to their baseline level of functioning once the 1. Psychosis secondary from medical condition
disorder has resolved 2. Psychosis induced by substances
 An acute psychotic disorder with rapid onset and lacks a 3. Schizophrenia
long prodromal phase 4. Mood disorders
 Symptom profile is same as in schizophrenia in that only 2 TREATMENT
or more psychotic symptoms must be present.  Hospitalization
DSM IV-TR DIAGNOSTIC CRITERIA FOR  Treatment with anti-psychotics for 3-6 months
SCHIZOPHRENIFORM DISORDER  Psychotherapy to integrate their psychotic experience
 Criteria A, same as in schizophrenia into themselves
Hallucinations, delusions, disorganized speech, grossly
disorganized/catatonic behavior, negative symptoms
 Criterion B should be at least 1 month but less than 6
months
 Criterion C schizoaffective disorders must have been
ruled out
SCHIZOAFFECTIVE DISORDER
 In ICD-10, schizoaffective disorder is a distinct entity and  Treatment: mood stabilizers, antipsychotics, use of ECT
patients who have co-occurring mood symptoms and and psychosocial therapy
schizophrenic-like mood incongruent psychosis
 Nondeteriorating course and respond better to Li
DELUSIONAL DISORDER
 Criterion A: presence of nonbizarre delusion of one month 4. Somatic – delusion that the person has some physical
duration defect or GMC
 Non-bizarre delusions – is about situations that occur in 5. Jealous – delusion that the individual’s sexual partner is
real life as being followed, infected and loved at a distance unfaithful
have to do with phenomena that although not real are 6. Mixed type delusions characteristic of more than one of
possible the above types but no one theme predominates
 Rare that schizophrenia, onset is 40 y/o 7. Unspecified type
 Criterion C: apart from impact of delusions, function is not DIFFERENTIAL DIAGNOSES
impaired, behavior is not bizarre  Psychotic disorder due to GMC w/ Delusion - medical
 Criterion D: if mood episode has occurred concurrently conditions that may mimic delusional d/o
with delusions, total duration has been brief relative to the hypothyroidism or hyperthyroidism, parkinson’s disease,
duration of mood symptoms. multiple sclerosis, Alzheimer’s disease and trauma to the
 Criterion E: disturbance is not attributable to physiologic basal ganglia
effects of a substance or other medical condition and not  Substance Induced Psychotic disorder – intoxication with
better explained by another mental disorder sympathomimetics (ex. Amphetamine, marijuana o
TYPES levodopa) is likely to result in delusional symptom.
1. Persecutory delusions that someone (to whom the  Paranoid personality disorder – patients are predisposed
person is close) is being malevolently treated in someway to delusions. No true delusions occur though patients
2. Grandiose – delusions of inflated worth, power, and have overvalued ideas that verge to being delusional
knowledge, identity or special relation to a deity or TREATMENT
person  Psychotherapy
3. Erotomania – delusion that another person, usually of  Hospitalization, pharmacotherapy
higher status or is in love with someone
BRIEF PSYCHOTIC DISORDER
 A psychotic condition that involves sudden onset of  Clinical features: emotional volatility, strange or bizarre
psychotic symptoms, which lasts 1 day or more but less behavior, screaming or muteness and impaired memory
than 1 month. for recent events
 Remission is full and the person returns to premorbid  Following symptoms can occur- delusions, hallucinations,
level of functioning. disorganized speech and grossly disorganized behavior
 Acute and transient  Treatment: hospitalization – pharmacotherapy and
 3 subtypes: psychotherapy
o Presence of stressors
o Absence of stressors and
o Postpartum onset
CHOICE OF MEDICINE IN ACUTE PHASE TREATMENT
 First episode: Grp 2 ROQZA  Repeated nonadherence to pharmacologic treatment –
 Persistent hostility and aggressive behavior – Grp 3 – Grp 4 long acting AP injectable
Clozapine
 Tardive Dyskinesia – Grp 2

If patient has tardive dyskinesia, choice here is atypical

antipsychotic since they have less EPS.

 History of sensitivity to EPS/Prolactin elevation – Grp 2

except higher doses of risperidone

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 Memorize this table
THE VIOLENT PATIENT
 Violence – behavior used by the individual that intentionally  Best predictor of future violence: history of violence
threat or attempt to actually inflict harm to others TEN SAFETY DOS
PRINCIPLES IN ASSESSMENT 1. Search for patient contraband and remove dangerous
1. Check the airway, breathing, circulation objects
2. Check for head/neck trauma/ infections 2. Keep door open when interviewing patient
3. Consider your safety as well as safety of staff and the 3. Make sure your environment is uncluttered and safe
patient 4. Make sure personal belongings are tucked away
4. Do vital signs – include temperature and O2 saturation, 5. Position yourself with rapid means of egress
blood glucose 6. Know how to get help
PROMOTING SAFETY 7. Know where your panic buttons
1. Make sure position yourself in examination room such 8. Trust your gut feeling about patients
that you have rapid accessible means of escape. 9. Ask patient about suicidal/homicidal plans
2. Make sure exit is cleared of any obstruction. 10. Ask patient about access to weapon and remove it
3. If at any point you feel in danger, leave the room immediately
immediately. TREATMENT GOALS
4. Know where security staff is located and how to get  To calm the patient so you get informed consent; and
help/immediate assistance. develop patient-doctor relation
5. Any objects that may be used as weapon should be  Do not trivialize threats of violence and do not be
removed by hospital staff. embarrassed to ask for help.
FOR MEDICAL STUDENTS  Speak to patient in calm, emphatic, controlled voice and
 It is important to communicate with your supervising non-confrontational approach
physician that you will be evaluating potentially  Avoid threatening stance like crossing your arms
dangerous patient  Acknowledge a patient discomfort
PRIORITIES IN MANAGING AGITATION  Verbal de-escalation conveys professional concern for
1. Identify and treat life threatening diagnoses well-being of patient → calms the patient
presenting as violent/agitated patient 1. Verbal de-escalation
2. Get complete history, PE, and MSE 2. Physical restraint – any device that restrict freedom
3. Get collateral data from family members, etc. of movement of one’s body
4. Give information on factors that precipitate violent - Soft restraint – wrist and ankles
behavior. - Vest restraint – on torso (body)
DIFFERENTIATE AS TO ETIOLOGY 3. Chemical restraint – use of medication to confine
Differentiate psychosis that can have psychiatric bodily movement
problem/organic problem - Punishment and staff inconveniences are
Psychiatric Organic not indicated for restraints
Oriented Disoriented MEDICATIONS USED
Alert Decreased level of BENZODIAZEPINE
consciousness
 2-4 mg IV/IM/PO
Gradual Onset Sudden onset
 onset action is 5-30 mins
Normal vital signs Abnormal vital signs Lorazepam
 respiratory depression
Normal PE Abnormal PR (pulse rate)
 sedation
DIFFERENTIAL DIAGNOSIS
 5 mg IV/IM/PO
 Genetic/Metabolic – Sanfilipo’s or Vogt Syndrome or Midazolam
 onset action 10-30 min
phenylketonuria; XXX, XYY, XXY respectively ANTIPSYCHOTICS
 Hormonal disease – Cushing’s; thyroid storm
 2.5-10mg PO/IM/IV
 Neurologic – brain lesion, tumor, seizures- complex partial Haloperidol
 onset 30-60 mins
seizure  10mg q2hr or 20 mg q4hrs
 Mental disorders – personality disorders (antisocial,  PO/IM
borderline), mental retardation, schizophrenia, paranoid, Ziprasidone
 onset 15-20 mins
delirium, dementia, oppositional defiant disorder  QTC prolongation
TREATMENT  5-10 mg 2-4 hrs
 The rule should be ACT FAST:  PO/IM
Olanzapine
o Acting out behavior  onset 15-45 mins for IM 3-6 hrs PO
o Combative posture and stance  QTC prolongation, hypotension
o Threatening remarks  2mg q2hrs PO onset <90 mins
o Pacing Risperidone  QTC prolongation
o Psychomotor agitation  hypotension
 Violent outcome - screaming, yelling, biting, throwing
objectives There is no health without mental health.
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 PAST E (2017)
END OF TRANSCRIPTION 1. Disorders of the form of thought are objective observable
in patients spoken and written language. What are they?
a. Disorders of the form of thought
b. Perceptual disturbances
Transcription Team 2019 c. Disorders of thought content
Transcribed by: Jogylle Lanzar d. Disorders in thought process
References: Ppt, recording, Kaplan 2. Verbigeration, work salad and mutism are examples of:
Remarks: a. Disorders in thought process
b. Disorders of form of thought
PAST E (2018) c. Perceptual disturbances
52. True for schizophrenia: d. Disorders of thought content
a. increased concentration of FSH is correlated with the length of the 3. These are the most difficult symptoms for many clinicians
illness and students to understand, they maybe the core
b. findings of decrease in the release of thyrotropin releasing symptoms of schizophrenia.
hormone is noted. a. Disorders of mood
c. it is likely to parallel the disease of the other organs like b. Disorders of cognition
myocardial infarction. c. Disorders of thought
d. results of dexamethasone suppression test have been reported d. Disorders of affect
unaffected in patients with schizophrenia 4. This is the single leading cause of premature death among
people with schizophrenia
53.Which of the following statements is True regarding mental illness a. Violence
and its treatment b. Suicide
A. The mentally ill should not be given responsibility c. Homicide
B. The mentally ill are violent and should be kept in mental institutions d. Impulsiveness
C. Mental illness are primarily treated by psychosocial treatment.
D. Mental illness like psychosis are treated by atypical 5. Among the following personality disorders which has the
antipsychotics and psychotherapy most similar symptoms of Schizophrenia:
a. Obsessive-compulsive
54. Which among the following is the preferred antipsychotic for b. Schizoid
Agitated patients? c. Histrionic
A. Haloperidol d. Borderline
B. Chlorpromazine 6. Which among the following is a positive symptom in
C. Quetiapine schizophrenia?
D. Aripiprazole a. Affective flattening
b. Auditory hallucinations
55. Of the first generation antipsychotic the low potency agents are c. Avolition
causing d. Anhedonia
A. Hypertension 7. Most schizophrenic patients have:
B. Sedation a. Increase theta activity
C. Agitation b. Increase theta and delta activity
D. Weight gain c. Decreased alpha activity
d. Normal EEG
56. Schizotypal patients show disturbances akin to those seen in : 8. A type of schizophrenia characterized by marked regression
A. Manic patients to primitive and chaotic behavior.
B. Schizophrenic patients a. Paranoid
C. Suicidal patients b. Disorganized
D. Histrionic patients c. Undifferentiated
d. Catatonic
57. The classic symptom in delusional disorder is : 9. Leoren, 42 y/o, presents with 2 days o hearing voices of
A. Flat affect relatives abroad saying, “pangit ka, tamad” followed by
B. Delusion of persecution sleeplessness. History revealed he used metamphetamine
C. Auditory hallucination 3 days prior to consult. Your initial assessment is.
D. Disorganized speech a. Delusional disorders
b. Schizophreniform
58. Among the following items which is NOT a risk factor associated c. Brief psychotic disorder
with Delusional Disorder? d. Substance induced psychotic disorder
A. Sensory impairment in isolation 10. Joseph 23 years old was presented by his mother for
B. (+) Family history confinement due to the following as walking
C. Young and active. inappropriately “pabali or paatras maglakad”, suspicious to
D. Social isolate on neighbors that he is talked about, and strongly believed that
the neighbor will kill him. This behavior has been present
59. A sudden onset of benign course associated with mood symptoms for more than 6 months. What is your assessment:
and clouding of consciousness occuring at least 1 month to less than a. Schizophreniform
6 months. b. Schizophrenia
A. Delusional disorder c. Brief psychotic disorders
B. Postpartum Psychosis d. Delusional disorder
C. Brief Psychotic Disorder 11. For your differential diagnosis that is least likely considered:
D. Schizophreniform disorder a. Brief psychotic disorder
b. Delusional disorder
60. This is a negative symptom in schizophrenia c. Schizoaffective
A. Hallucinations d. Postpartum psychosis
B. Ideas of reference 12. In delusional disorder, men are more likely to develop
C. Affective flattening paranoid delusions while women are more likely to have
D. Grandiose delusion ______ delusions
a. Persecutory delusions
b. Somatic delusion
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 c. Erotomanic delusion
d. Religious delusion
13. If psychotherapy is given to patient with delusional
disorder, this should be avoided:
a. Respond to patient that delusion is disturbing
b. Be straightforward
c. You should argue or challenge the patient’s delusion
d. Listen to patients concern about the delusion
14. For patients diagnosed to have schizophrenia, best
treatment is:
a. Anti-anxiety
b. Antipsychotic
c. Antiparkinsonism
d. Anticonvulsant
15. Male, 25 y/o, with symptoms of auditory hallucinations,
paranoid delusion. He became markedly restless and
agitated. He admitted having used “tsongki” (marijuana),
“shabu” (metamphetamine) and occasional alcohol used
since he was in grade 6 which he continued to take on and
off. His last intake of the substances was December 2013.
What is your assessment?
a. Schizophrenia
b. Schizophreniform
c. Substance induced psychotic disorder
d. Delirium

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