Psychopharm of supporting people with psychosis to have their optimal life.

1. S
Psychopharmacology
Lecture 10 – Treating psychotic spectrum
dissorders in primary care psychology

2. TIME FRAME OF RISKS
Across the Lifespan
S In utero
S Childhood
S Young adult
S Adult
S Senior

3. Medication of the
Week Presentation
S Describe a medication briefly,
S Describe what it is used to treat
S Describe its side effects
S Describe other relevant information.

4. Elyn Saks
Orrin B. Evans Professor of Law, Psychology, and
Psychiatry and the Behavioral Sciences
Elyn R. Saks specializes in mental health law, criminal law, and children and
the law. Her recent research focused on ethical dimensions of psychiatric
research and forced treatment of the mentally ill. She teaches Mental Health
Law, Mental Health Law and the Criminal Justice System, and Advanced
Family Law: The Rights and Interests of Children. She served as USC Law's
associate dean for research from 2005-2010 and also teaches at the Institute
of Psychiatry and the Law at the Keck School of Medicine at USC and is an
adjunct professor of psychiatry at the University of California, San Diego.

5. “The schizophrenic mind is
not so much split as shattered.
I like to say schizophrenia is
like a waking nightmare”
- Elyn Saks
Some people say I'm unique,
that there aren't other people
with schizophrenia like me.
Well, there are people like me
out there, but the stigma is so
great that they don't come
forward.
- Elyn Saks

6. “Pride comes from
resistance, courage, creativity
and collective action.”
Mad Pride emerged out of many historical
movements for self-determination and
dignity… “Mad liberation”, anti-psychiatry,
ex-psychiatric patient, self-reliance, anti-
poverty, consumer survivor, service user and
other movements.

7. Types of Psychotic Disorder:
Schizophrenia: People with this illness have changes in behavior and
other symptoms -- such as delusions and hallucinations -- that last longer
than six months, usually with a decline in work, school, and social
functioning.
Schizoaffective disorder: People with this illness have symptoms of
both schizophrenia and a mood disorder, such as depression or bipolar
disorder.
Schizophreniform disorder: People with this illness have symptoms of
schizophrenia, but the symptoms last between one and six months.
Brief psychotic disorder: People with this illness have sudden, short
periods of psychotic behavior, often in response to a very stressful event,
such as a death in the family. Recovery is often quick -- usually less than
a month.

8. Types of Psychotic Disorder:
Delusional disorder: People with this illness have a delusion (a false, fixed
belief) involving real-life situations that could be true, such as being followed,
being conspired against, or having a disease. These delusions persist for at least
one month.
Shared psychotic disorder: This illness occurs when a person develops
delusions in the context of a relationship with another person who already has
his or her own delusion(s).
Substance-induced psychotic disorder: This condition is caused by the use of
or withdrawal from some substances, such as alcohol and crack cocaine, that
may cause hallucinations, delusions, or confused speech.
Psychotic disorder due to a medical condition: Hallucinations, delusions, or
other symptoms may be the result of another illness that affects brain function,
such as a head injury or brain tumor.
Paraphrenia: This is a type of schizophrenia that starts late in life and occurs
in the elderly population.

11. Symptoms
of
Psychosis

14. Negative Symptoms of
Schizophrenia

15. Negative Symptoms of
Schizophrenia
Cariprazine
Was the first medication
found to significantly reduce
both positive and negative
symptoms of schizophrenia in
a phase 3 randomized control
trial of 2700 and is approved
by the FDA.

16. • Mesolimbic Pathway: Is responsible for positive symptoms in
psychotic spectrum disorders.
• Mesolimbic Pathway: Uses Primarily the D2 Transmitter
and Has too much Dopamine in individuals with psychotic
spectrum disorders.
• Antipsychotic Medications: Antipsychotic Medications are
D2 Antagonists turning down dopamine.
Mesolimbic = Positive Symptoms of Psychotic Spectrum

17. • Mesocortical Pathway: Is responsible for negative symptoms in
psychotic spectrum disorders.
• Mesocortical Pathway: Uses Primarily the D1 Transmitter and
Has too much Dopamine in individuals with psychotic spectrum
disorders.
• Antipsychotic Medications: Antipsychotic Medications are D2
Antagonists turning down dopamine. And at times reduce D1
Mesocortical = Negative Symptoms of Psychotic Spectrum

20. National Institute of Care Excellence (NICE)
Guidelines for Treating Schizophrenia:
Recommends that the first line treatment for a person
post first psychotic episode is a combination of CBT
and Antipsychotic Medications.

21. http://www.cibhs.org/sites/main/files/file-attachments/tues_10_30_placer_cbt_for_psychosis_hardy.pdf

23. Catecholamine Synthesis Pathway

24. First Generation
Antipsychotics

25. Second Generation Antipsychotics
< D2 &
<
5HT2A
Are Known as Dopamine and Serotonin
Antagonist

26. Higher Risk of
Extrapyramidal &
Cognitive Impacts
Higher Risk of
Hyperlipidemia,
Diabetes, Weight
Gain
Second Generation
Antipsychotics
First Generation
Antipsychotics
= tx outcomes

30. High
When endogenous dopamine is LOW
Cariprazine acts like a partial
dopamine agonist increasing dopamine
levels…
––
When endogenous dopamine is HIGH
Cariprazine acts like a partial
dopamine antagonist decreasing
dopamine levels…

31. Rates of
Poly-Pharmacy
in the treatment
of symptoms of
psychosis in
Australian
Sample

32. Side Effects
of
Neuroleptic
Medications

34. Trauma From
Psychosis
S The experience of a psychotic episode can lead to symptoms
of PTSD.
S Reporting childhood trauma (27X increase) and other social
risk factors leads to increased risk of a traumatic response to
psychotic episodes. doi: 10.1177/0004867411430877
S Experience of childhood trauma can lead to affective,
cognitive and coping challenges that increase the chance of
PTSD from psychotic experiences.
doi: 10.1177/0004867411430877

35. Rational for CBT
Tx of Psychosis
Symptoms
S Many people experience continued symptoms of psychosis despite
medication.
S Many individuals have a fluctuating level of symptoms even with
medication having multiple life time episodes.
S Stress and coping with stress is a vital part of treatment.
S People can learn to reappraise the impact of their symptoms.
S There is a large emotional and affective impact of psychosis along with
comorbidity of mood challenges.
S The social disability people face from this illness can impact both the course
of treatment and quality of life.
S Psychotic experiences are deeply scary for people and people can build
acceptance of their symptoms.

37. CBT Tx for Psychosis
Symptoms
S Randomized controlled trial: 21% Large levels of
improvement and 29% meaningful improvement.
S Gains were maintained at 18 mo follow up for 65% of PT.
S CBT was found to be superior then “supportive
relationship” control.
S Studies have been focused on treating specific aspects of
psychosis: delusions, hallucinations and social skills.

38. CBT Tx for Psychosis
Symptoms
S Increase understanding about psychotic experiences.
S Improved coping with residual symptoms.
S Reduction of distress due to auditory hallucinations.
S Reduction of conviction in delusional beliefs.
S Maintenance of gains and relapse prevention.

39. Non-Psychotic
Hallucinations
S Many hallucinations are non-psychotic.
S Hypnogogic hallucinations: Occur with the onset of sleep.
S Release Hallucinations: Occur when an individual has had a
loss of sensory input or brain area that regulates or inhibits
hallucination. Musical, Auditory, Visual
S The Charles Bonnet syndrome refers to symptoms of visual
hallucinations that occur in patients with visual acuity loss
or visual field loss.
S Blips and spots… Perceptual abnormalities…

40. PTSD and Psychosis
S People with psychosis are more likely to have experienced child hood
trauma.
S One study compared 17 married individuals with psychosis to 52
matched controls and found 43% of individuals with psychosis had
Childhood sexual abuse (CSA) compared to 6% of controls.
S 61 children who had 5+ years of documented maltreatment were
compared to non-maltreated controls. It was found that 9% of maltreated
children had psychosis and none in the control group.
S 4045 person study measured for MH symptoms and childhood abuse. At
three year follow up those who had not initially reported symptoms of
psychosis but had reported child hood trauma were 7X more likely to
have symptoms of psychosis.

41. Date of download:
1/30/2013
Copyright © American Psychiatric Association.
All rights reserved.
From: Psychotic Symptoms in Posttraumatic
Stress Disorder
Focus. 2011;9(3):278-285.
Proposed Operational Criteria for PTSD with Secondary Psychotic
Features (PTSD-SP)
Figure Legend:

42. S
CasCase Consultation

43. Closing Questions
???