Common Presentations in Primary Care:

Schizophrenia

Y Pritham Raj, MD

Medical Director, Emotional Wellness Center

Adventist Health Portland (an OHSU Partner)

Clinical Associate Professor

Departments of Internal Medicine & Psychiatry

Oregon Health & Science University

Consulting Associate

Department of Psychiatry & Behavioral Sciences

Duke University Medical Center

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Clinical Case: I Need a Dog

• A 43 yo AA man presents to his first primary care

visit with you. He is agitated, clearly paranoid,

and ramped up. You immediately consider a

substance use disorder but he won’t provide you

with a urine sample – saying he doesn’t have time

for that. He repeatedly asks you to just help him

get a dog. He feels having a dog will cure all his

ills. What do you do next?

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Diagnostic Pearl

• Resist the temptation to jump to ANY psychiatric

diagnosis (especially a psychotic disorder)

without first completing a full organic workup.

• My suggestion: UDS, CMP, RPR, HIV,

ESR, TSH. And in some cases: ANA,

lumbar puncture, cortisol*

• In any “first break” scenario of psychosis always

get an MRI of the brain!

Screening:

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What is Psychosis?

• 1845: A state of disordered thoughts or

impairment in reality testing, as manifested by

perceptual disturbances (e.g., hallucinations) and

disorganized speech and behavior.

• Affects 3-5% of the population at some point.

• When people are in psychotic states, they are at

high risk for aggression, agitation, suicide, and

impulsive behavior in general.

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What is the difference between delusions

and hallucinations?

• Delusions are defined as fixed false beliefs despite

obvious evidence to the contrary.

– HARDEST to treat.

• Hallucinations are problems of perception

(hearing or seeing things that are not present).

• Pearl: the “standard of care” for a non-psychiatrist

when screening for psychosis is to ask about A/V

hallucinations.

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Clinical Case: Palpitations

• A 51 yo Korean national experiencing palpitations

and near-syncope was sent by his PCP to

cardiology clinic for evaluation. While there, he

endorsed longstanding auditory hallucinations and

was sent to the ED for further assessment.OHSU

Quick Audience Poll

• Does this patient need hospital admission or can his

psychosis be handled in the outpatient setting

(provided there is a plan for a Holter monitor, etc.)?OHSU

Case 2 continued…

• He was eventually admitted to our inpatient

psychiatry service for a constellation of symptoms

including: AH, palpitations, and delusions

including feeling as though people were

“spraying” him with noxious substances which

would then lead to emesis. He wore a protective

mask to guard him from the sprays a la…

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The Plot Thickens...

• Again, the AH were not new. But historically, he described the ability to abolish the AH for a year at a time using electricity: either touching both car battery terminals or putting butter knives into electrical outlets.OHSU

The Plot Thickens...

• Again, the AH were not new. But historically, he described the ability to abolish the AH for a year at a time using electricity: either touching both car battery terminals or putting butter knives into electrical outlets.

• Same principle as

ECT

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Bonus Material: TMS

Transcranial Magnetic Stimulation

• TMS (transcranial magnetic

stimulation) is a more favored

approach by some experts

(including this one).

• Typically an 18 minute

outpatient procedure done

daily for 4-6 weeks approved

by the FDA in October ‘08 for

Treatment Resistant

Depression - NOT psychosis

at this time

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Epidemiology: Psychosis

• The lifetime prevalence of psychotic disorders in U.S. residents is about 3-5%.

• In one study involving over one thousand urban and academic centered primary care patients, roughly 20% reported some type of psychotic symptom, most commonly auditory hallucinations.

• Those who have psychotic symptoms are much more likely to experience comorbid depression, anxiety, suicidal thinking and alcohol abuse.

• Olfson M, Lewis-Fernandez R, Weissman M, et al. Psychotic symptoms in an urban general medicine practice.

Am J Psychiatry. 2002;159:1412–1419.

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Primary Psychiatric Causes

of Psychosis

• brief psychotic disorder

• schizophrenia and schizophreniform disorder

• delusional disorder

• schizoaffective disorder

• mood disorders (bipolar disorder or unipolar

depression) with psychotic features

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Schizophrenia

As Defined by Bleuler

• Autism (preoccupation with internal stimuli)

• Inappropriate Affect (external manifestations of mood

– often flat)

• Associational Disturbances (loose associations) -

Illogical or fragmented thought processes

• Ambivalence (simultaneous, contradictory thinking)

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Signs/Symptoms Not to Miss

• Cognitive Screen: Consider a formal cognitive

tests such as the SLUMS, MoCA, or Folstein

MMSE to evaluate for Delirium/Dementia.

• Dementia should be considered as a causative

factor for psychotic symptoms as about 30% of

patients with dementia have comorbid psychosis.OHSU

Why is it Important NOT

to Miss Dementia?

• Elderly patients with dementia-related psychosis

treated with atypical or second-generation

antipsychotic drugs are at increased risk (1.6 to 1.7

times) of death, compared to placebo (4.5% to

2.6%, respectively).OHSU

Suicide rates in Psychosis

• Mortality in those with schizophrenia is about three times that of the general population.

• Approximately 30% of those with schizophrenia attempt suicide and 1/3 of all deaths are from suicide

» Auquier P, Lancon C, Rouillon F, et al. Mortality in schizophrenia. Pharamcoepidemiol Drug Saf. 2007;16(12):1308–1312.

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Cardiovascular Disease (CVD)

Drives 25-Year Loss in Life Expectancy Among the Mentally Ill

• 50% to 80% of patients with diagnosable mental illness are smokers, as compared with approximately 25% of the US population as a whole

• The mentally ill are less likely to undergo revascularization procedures and are more likely to die following an MI

• People with severe mental illness are up to two times more likely to have diabetes, dyslipidemia, hypertension, obesity, and/or metabolic syndrome

» Newcomer JW, Hennekens CH. Severe mental illness and risk of cardiovascular disease. JAMA 2007; 298:1794-1796.

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Pharmacotherapy

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Raging Debate In Psychiatry

Neuronal Viability/Toxicity of Haloperidol

Maldonado JR

• Scheduled IV haloperidol

use in treating

delirium/psychosis reduces

length of stay (15 vs 11

days), total duration of

delirium (13 vs 6 days),

and percentage time being

delirious

– Maldonado JR, Crit Care Clin

24(2008):657-722.

Nasrallah HA

• Haloperidol exerts

measurable neurotoxic

effects at all doses via

many molecular

mechanisms that lead to

neuronal death…but the

effect in SGAs was smaller

and mainly at high doses.

– Nasrallah HA. Ann Clin Psychiatry

29(3) 2017:195-202.

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Pharmacotherapy

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Asenapine (Saphris)

• Starting Dose: 5-10mg (sublingual) bid

• Target Dose in schizophrenia is the same as

starting dose: 5mg bid. No added benefit with

10mg bid dose in clinical trials (more akathisia).

• Side Effects (incidence ≥5% and at least twice that

for placebo): akathisia, oral hypoesthesia, and

somnolence.

» Psychopharmacology Bulletin. 2007;40(2):22-37.

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Lurasidone (Latuda)

• Starting Dose: 40mg qd taken with a meal (at

least 350 calories)

• Target Dose: 40-80mg qd

• Side Effects: some somnolence, akathisia, nausea,

and parkinsonism, especially early in treatment.

» Kane JM. J Clin Psychiatry 2011;72(suppl 1)

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Are SGAs Equal in Terms of Extra-

Pyramidal Side Effects?

• Cochrane Review suggests NO.• Risperidone was associated with more use of antiparkinson

medication than clozapine, olanzapine, quetiapine, and

ziprasidone.

• Ziprasidone showed more use of antiparkinson medication

than olanzapine and quetiapine.

• Quetiapine showed significantly less use of antiparkinson

medication than the 3 other SGAs it was compared with

(olanzapine, risperidone, and ziprasidone).

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How Long to Treat?

• The American Psychiatric Association (APA)

recommends indefinite antipsychotic medication

treatment against recurring psychosis in patients

with primary psychotic disorders, if two or more

episodes occur within 5 years.OHSU

CATIE Trial –NEJM 2005;353:1209-23

• 1493 pts with schizophrenia randomized to: olanzapine, perphenazine, quetiapine, or risperidone (later ziprasidone). TD patients were excluded from perphenazine arm.

• Primary aim: differences in effectiveness – judged by discontinuation of tx for any cause

• 1061/1432 = 74% patients discontinued meds prior to 18 months

• Olanzapine most effective in terms of rates of discontinuation but more weight gain/lipid & glucose issues and not significantly different from perphenazine group.

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Thank You

Fortune Favors the Prepared Mind

- Louis Pasteur

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