Identifying Schizophrenia and Bipolar Disorder from a Sea of Mimics - Michael Sean Stanley, MD Assistant Professor OHSU Department of Psychiatry
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Identifying Schizophrenia and Bipolar
Disorder from a Sea of Mimics
Michael Sean Stanley, MD
Assistant Professor
OHSU Department of Psychiatry
Identifying Schizophrenia and Bipolar
Disorder from a Sea of Mimics
No Disclosures.
• Objectives:
– Understand the clinical presentation and approach
to treatment of Schizophrenia and Bipolar
Disorder
Psychotic disorders are: Mood Disorders are: • primarily problems of • Primarily problems of sensory processing prolonged extreme and association, not emotional tone (mood). emotion • Exhibit excessive high or • Exhibit profound low mood/motivation disconnection from from normal state sensory reality
Psychosis Schizophrenia
• a neurodevelopmental
syndrome
• associated with functional
impairments
Schizophrenia
• no single unifying cause
• emerges when environmental
accelerants act upon genetic
predisposition
• May be at the more severely
impairing end of a spectrum
of disorders.
+ - C
Positive Symptoms Negative Symptoms Cognitive Symptoms
New abnormal sx Loss of normal fxn Accompany and likely
- Hallucinations - Affective flattening precede +/- sx
(auditory most - Anhedonia - Attentional problems
commonly) - Asociality - Slower processing
- Delusions - Alogia - Difficulty with
- Significant planning/prob
disorganization of solving
thought/behavior - Memory problems
May come and go A stable loss, do not Prodromal sx?
fluctuate significantly
once lost.
May decrease to some
May be responsive to Minimally responsive to degree with tx of pos sx,
antipsychotic meds antipsychotic meds if at but rarely completely.
all.
For 6 mo or longer; Not due to medical or substance use cause.
Positive Symptoms
Most commonly during teens-20s
Neuro-Cognitive
Inappropriate Network Imbalance
Pruning or Synaptic • Lack of coordination
Changes: of neural tasks
• Decr grey matter • Lack of inhibition of
• Prefrontal neural tasks
• Parahippoca
Inappropriate salience –
mpal
hallucinations/delusions
• Temporal
• thalamic
• Decr dendritic
spines
Inflammatory Events
Damage Events
Genetics: • Pathways implicated by Genes (a selection)
• Highly heritable – 30% of offspring • Synaptic function (DRD2, GlutR, voltage-
• Many genes with small effect size dependent calcium channels)
• Some genetic overlap with other psych dx: • Synaptic plasticity
BPAD, MDD, Autism Spectrum DO • Cytoskeletal development
• Immune response/modulation
• Genes point to multiple mechanismsSchizophrenia
Onset
• One peak in men: generally adolescence to early 20s
• Two peaks in women: similar as above + over 40s
Prevalence
• Lifetime likelihood of 0.7%
Disability
• 80-90% unemployed
• Life-expectancy 10-20 years reduced
• Most likely due to cardiovascular and other health problems
• High prev of smoking
• High prev of dietary indiscretions
• Low medical care use
• Cardiometabolic effects of medication treatmentsSchizophrenia Illness Template Schizophrenia Template Present? DSM5 Stereotypic Positive Sx (Hallucinations, Delusions, Disorg) Stereotypic Negative Sx (Affective Flattening, Alogia, Apathy, Asociality) Functional Impairment Duration > 6 mo Absence of Medical/Substance Cause Research-based factors that increase probability of Schiz Age of onset during teens-20s (or ~40s if F) Family History of psychotic disorder Prodrome – cognitive, negative sx Course – subacute onset, fluc +, stable - Typical Treatment Response?
Schizophrenia Template Case • 19 yo male • CC: Presents for auditory hallucinations of his high school physics professor arguing with his parents about implanting novel “microcircuits” in his body. Feels this might be true, and has shaved parts of his body to scan the “microcircuits” • HPI (from collateral): sx began about 1 year ago, have fluctuated, and have been associated w/ performance decline at community college, last quarter his teachers expressed concern and he was on monitoring plan by student health center. Per family, throughout high school, patient displayed some thoughts of supernatural causes, but they had not caused functional problems. Gradually late in high school he became increasingly reclusive, stopped being interested in things that previously interested him, these sx have continued. • Family Hx: Paternal uncle with schizophrenia • Exam: Medical exam benign, has never used drugs other than tobacco. • Mental Status Exam: + AH and delusions, thought blocking, appeared to attend to internal stimuli, flat affect, paucity of spontaneous thought. • Course: saw psychiatrist who Rx’d Risperidone 2mg qhs, which significantly decreased AH. Stopped medication after 6 mo, when noticed gynecomastia, and AH restarted.
Schizophrenia Illness Template Schizophrenia Template Present? DSM5 Stereotypic Positive Sx (Hallucinations, Delusions, Disorg) Yes Stereotypic Negative Sx (Affective Flattening, Alogia, Apathy, Asociality) Yes Functional Impairment Yes Duration > 6 mo Yes Absence of Medical/Substance Cause Yes Research-based factors that increase probability of Schiz Age of onset during teens-20s (or ~40s if F) Yes Family History of psychotic disorder Yes Prodrome – cognitive, negative sx Yes Course – subacute onset, fluc +, stable - Yes Typical Treatment Response? Yes
Differential Diagnosis of Schizophrenia
Other Psychiatric Disorders
• Schizophrenia spectrum
• Bipolar Disorder, Manic with Psychotic features
• Major Depressive Episode with Psychotic features
• Body Dysmorphic Disorder
Non-Psychiatric Disorders
• Medication-Induced Psychosis
• Substance-Induced Psychosis
• Epilepsy
• Cerebrovascular Disorders
• Neoplasm
• Dementia with Lewy bodies
• Delirium
• Autoimmune: Anti-NMDA receptor encephalitisSchizophrenia Spectrum
Del only 2+ sx 1 mo 6 mo
Normal
Cognitive or
perceptual distortions Delusions only,
or behavioral function not
eccentricities that grossly
affect social impaired Schiz +
connections, but not prominent
gross biological affective sx
function
Psychotic symptoms, such as auditory hallucinations and
paranoid thinking, occur in attenuated forms in 5–8% of the
healthy population• a disorder of emotional tone
Bipolar Disorder – Elevated = hypo/mania
– Low = major depressive episodes
• associated with functional
impairments at peaks
• emerges when environmental
accelerants act upon genetic
predispositionBipolar Disorder
!!MANIC EPISODE!! majordepressiveepisode
Epidemiology of Bipolar Disorders:
Bipolar Disorder • Lifetime prevalence of Bipolar Disorders is
1-3% worldwide
• Female:Male = 1:1
• Mean onset of Bipolar I DO is 18yo
• About 1/3 of patients with a parent with
Bipolar Disorder will go on to have Bipolar
Disorder
• Depressive Episodes are actually more
common in Bipolar Disorder than are
Manic/Hypomanic Episodes
• 10-15% of patients with Bipolar Disorder
die by suicide, which is estimated at 12-15x
greater rate than in the general populationElation, irritable mood,
MDD with
excess energy,
subsyndromal
talkativeness, racing
Mood lability, mania, cylothymia,
thoughts, decreased
subsyndromal or psychosis
need for sleep
depression or mania
symptoms
Genetic
Risk
Gestational or
Birth Stress Head Injury Life
Stressors
Substance
Early Life Stress
UseProdrome Comparison
Bipolar Prodrome Schizophrenia Prodrome
• Irritability • Strange/Unusual Ideas
• Frequent Mood Swings
• Physical Agitation • Suspiciousness
• Concentration/Attention Probs • Hallucinatory Experiences
• Difficulty • Anhedonia
Thinking/Communicating Clearly • Decreased Functioning
• Obsessions Compulsions • Social Isolation
• Depressed Mood
• Tiredness Lack of Energy
• Thinking About SuicideBipolar DO Illness Template Bipolar Disorder Template Present? DSM5 Manic Episode (Mood&Energy +3/7sx) x 1 week or hospitalition Major Depressive Episode (not needed if manic) Functional Impairment Absence of Medical/Substance Cause Research-based factors that increase probability of Bipolar DO Age of onset during teens-20s Family History of Bipolar Disorder Prodrome – isolated manic sx Course – episodic, relapsing/remitting Typical Treatment Response? Absence of other atypical features
Bipolar DO Template Case
• 20 yo male
• CC: Elevated mood, Increased energy, beliefs of God-given
mission to spread “heal broken street children” through “parkour
science”. Accompanied by agitation, decreased need for sleep,
disorganized behaviors, rapid speech.
• HPI: sx started ~10 days ago, after returned from study abroad in
Europe, increased gradually over 2-3 days.
• Collateral noted the following:
• Cousin with Bipolar I Disorder on Lithium
• Successfully recently completed 6 mo study abroad
program in global finance in Switzerland.
• Has a girlfriend and 2 friends who accompanied him to ED,
and who are very worried about him, as this is very
different behavior for him, as he has not been spiritual.
• Girlfriend noted that he had had sporadic periods of
decreased need for sleep in past, but never like this.
• Med hx/Psych hx: no med probs, no psych dx, has never used
drugs other than remote brief cannabis trial in high school
• Exam: agitation, talking mildly rapidly, focuses on spiritual
mission, requires interruption, denies AH/VH, denies SI/HI.
• Course: Risperidone 2mg qhs, responded well, tapered off 12 mo
later, did not have recurrence of delusions immediately, although
2 years later had beginning of similar sx.Bipolar DO Illness Template Bipolar Disorder Template Present in this case? DSM5 Manic Episode (Mood&Energy +3/7sx) Yes x 1 week or hospitalition Major Depressive Episode (not needed if manic) N/A Functional Impairment Yes Absence of Medical/Substance Cause Yes Research-based factors that increase probability of Bipolar DO Age of onset during teens-20s Yes Family History of Bipolar Disorder Yes Prodrome – isolated manic sx Yes Course – episodic, relapsing/remitting Yes Typical Treatment Response? Yes Absence of other atypical features Yes
Differential Diagnosis of Bipolar DO
Other Psychiatric Disorders
Bipolar Disorder • Schizophrenia & spectrum
• Major Depressive Disorder
• Premenstrual Dysphoric Disorder
• Borderline Personality Disorder
• Attention-deficit Hyperactivity Disorder
Non-Psychiatric Disorders
• Medication-Induced Mania
– Corticosteroids, Isoniazid, Levodopa
• Substance-Induced Mania
– Cocaine, Stimulants, Cannabis
• Hyperthyroidism
• Seizures/Strokes/Neoplasm
• Multiple Sclerosis
• EncephalitisIdentifying whether a primary psychiatric or secondary disorder:
• there are no pathognomonic signs to differentiate primary from secondary disorders.
• Early differentiation is observational, based on
• The known epidemiology and course of primary disorders
• The known presentations of primary disorders:
• History
• physical exam
• mental status exam
• Any confounding features
• Follow-up over long-term watching for symptoms or signs that increase or decrease
probability of primary psychiatric diagnosisCases
Case: “I’ve killed them all” • 80 yo female • CC: New onset fixed false beliefs in the last few days that she has caused the death of multiple friends, and the only way to atone is to starve herself. No hallucinations. Affect flattened. • HPI: Adult daughter noted that her sx started 3 weeks ago, slowly becoming more encompassing; that she had stopped going to church, was isolating more over last month, staying in bedroom sleeping a lot, eating little. • Past Med/Psych hx: mild vascular dz, a few episodes of major depression, but never tolerated medications long- term. Rare glass of red wine, no other substances. • Fam Hx: depression, no psychosis. • Exam: psychomotor slowing, slowed responses, seems distracted, flattened or sad affect, repeatedly comes back to thought that she must have caused deaths of friends. • Course: Receives visits from members of church who have missed her leadership of their benevolent services committee. Referred to Electroconvulsive therapy (ECT) under daughter as POA, improves within a few weeks.
Case: “I’ve killed them all”
Schizophrenia Template Present in this case?
DSM5
Stereotypic Positive Sx Yes
Stereotypic Negative Sx Yes
Functional Impairment Yes
Duration > 6 mo No
Absence of Medical/Substance Cause Yes
Research-based factors that increase
probability of Schiz
Age of onset during teens-20s (or ~40s if F) No
Family History of psychotic disorder No
Prodrome – cognitive, negative sx No
Course – subacute onset, fluc +, stable - No
Typical Treatment Response? ?
Absence of other atypical features No
Diagnosis: Major Depression with PsychosisCase: “they’re telling me to kill myself” • 16 yo female • CC: New onset auditory hallucinations telling her to end her life, tactile hallucinations of worms under her skin. • HPI: Started 1 week ago per friend, one day she was good the next hallucinating. Per community health case worker who brought her to the ED, pt was recently homeless, has hx of DV trauma and parents with significant substance use disorders. Case worker had never seen her like this. • Med/Psych Hx: no known medical conditions, hx of substance use, but no prior psychosis known. • Exam: somewhat cooperative with exam, scratching at skin, asked if ED staff could see the worms, disorganized speech at times, agitation, teary at times. • Labs: UDS +methamphetamines, no other abnormalities. • Course: Started on quetiapine 50mg BID and 100mg QHS, kept in ED obs, calms over 24 hours to cooperative with nursing staff, very congenial and thankful upon discharge. Sees outpatient psychiatrist who quickly tapers her quetiapine, offers hydroxyzine and trazodone PRN as she enters treatment program.
Case: “they’re telling me to kill myself”
Schizophrenia Template Present in this case?
DSM5
Stereotypic Positive Sx Yes
Stereotypic Negative Sx No
Functional Impairment Yes
Duration > 6 mo No
Absence of Medical/Substance Cause No
Research-based factors that increase
probability of Schiz
Age of onset during teens-20s (or ~40s if F) Yes
Family History of psychotic disorder No
Prodrome – cognitive, negative sx No
Course – subacute onset, fluc +, stable - No
Typical Treatment Response? No
Absence of other atypical features? No
Diagnosis: Psychosis due to Methamphetamine UseCase “I’m so tired of this!”
• 24 yo female
• CC: Mood lability, irritability. Wants referral for Bipolar DO.
• HPI: mood sx + easily tearing, attention/memory problems,
lethargy, low motivation, quick temper flares, seem to come and
go from one week to next. Most recently over last 7 days, but
has happened previously many times. She is a junior manager at
a local IT firm, and has had to take days off recently because of
her symptoms, and worries that because of some irritable
outbursts she may be on the verge of being fired. No history of
mania or prolonged periods of depression lasting 2 weeks.
• Medical hx: No medical problems, uses alcohol intermittently in
evening only
• Exam: physical exam nl, labs nl; mental status exam: patient
tearing often, complains that she wishes she could communicate
what is happening better, and does lose train of thought a couple
times, is mildly irritable, but displays no agitation, rapid speech,
or psychotic sx. She reports her sleep is good.
• Course: PCP refers to psychiatrist, but patient calls 2 days later to
state she feels so much better and just started menstruation. PCP
has patient track mood symptoms over 2 menstrual cycles.Case “I’m so tired of this!”
Bipolar Disorder Template Present in this case?
DSM5
Manic Episode (Mood&Energy +3/7sx) No
x 1 week or hospitalition
Major Depressive Episode (not needed if manic) No
Functional Impairment Yes
Absence of Medical/Substance Cause Yes
Research-based factors that increase probability
of Bipolar DO
Age of onset during teens-20s Yes
Family History of Bipolar Disorder No
Prodrome – isolated manic sx No
Course – episodic, relapsing/remitting Yes
Typical Treatment Response? -
Free of confounding features No – rapid remittance,
Diagnosis: Premenstrual Dysphoric DisorderCase: “we’re surrounded” • 48 yo male • CC: new onset auditory hallucinations of people outside house, paranoid – checking locks, agitation, insomnia • HPI: Started rapidly 3 days ago; brought to ED by brother, wife and teenage daughter who note he has never had sx like this; was recently working as middle school science teacher for last 22 years, assistant coaches school basketball team; recently treated for severe asthma for first time with high-dose prednisone • Medical hx: severe asthma from childhood, moderate alcohol use, but no hx of use disorder or withdrawal. No prior psychiatric hx. • Family Hx: cousin with schizophrenia • Exam: Well-groomed male with mild agitation, restlessness, tremor, exhibiting paranoid thoughts, appears distracted at time, but accepts reassurance from brother, no SI/HI, accepting of help. • Course: Started on olanzapine 2.5mg for duration of prednisone treatment, then decreased slowly 1 week after prednisone treatment completed, psychotic sx do not recur.
Case: “we’re surrounded”
Schizophrenia Template Present in this case?
DSM5
Stereotypic Positive Sx Yes
Stereotypic Negative Sx No
Functional Impairment Yes
Duration > 6 mo No
Absence of Medical/Substance Cause No
Research-based factors that increase
probability of Schiz
Age of onset during teens-20s (or ~40s if F) No
Family History of psychotic disorder Yes
Prodrome – cognitive, negative sx No
Course – subacute onset, fluc +, stable - No
Typical Treatment Response? No
Absence of other atypical features No
Diagnosis: Psychosis due to Steroid TreatmentCase “people piss me off”
• 30 yo male
• CC: Irritability, rapid anger, impulsive behaviors
• HPI: Was recently seen in ED for multiple cuts to wrists which
required minor bandaging, cuts occurred in context of his
girlfriend breaking up with him. Was not hospitalized for SI, was
told to get referral to psychiatry from PCP. Works as truck driver
to avoid people. Similar symptoms, including quick anger, chronic
feelings of emptiness, suicidal ideation, impulsive self-harm,
spending, substance use - have been around since teens. Was
diagnosed in teens with “Bipolar Disorder” and started on
multiple medications while at a home for teen boys. Denied hx of
mania or prolonged depressions with severe veg sx.
• Med/Psych hx: HTN, chronic pain, hx of opioid pain medication
overuse.
• Family Hx: depression and various substance use disorders,
including heroin. No Bipolar or Psychotic Disorders.
• Exam: No agitation, no psychotic sx, no pressured speech, no
flight of ideas, cognition normal, but irritability, chronic SI
• Course: With psychiatrist, discusses fear of abandonment,
cutting to “feel something” and to get girlfriend back. Feels good
when “on the same page” as others, black/white thinking.
Psychiatrist refers patient to Dialectical Behavioral Therapy. Over
time works to reduce medications when patient expresses
openness to it.Case “people piss me off”
Bipolar Disorder Template Present in this case?
DSM5
Manic Episode (Mood&Energy +3/7sx) No
x 1 week or hospitalition
Major Depressive Episode (not needed if manic) Yes
Functional Impairment Yes
Absence of Medical/Substance Cause Yes
Research-based factors that increase probability
of Bipolar DO
Age of onset during teens-20s Yes
Family History of Bipolar Disorder No
Prodrome – isolated manic sx No
Course – episodic, relapsing/remitting Yes
Typical Treatment Response? Yes/No
Free of confounding features No: fears of abandonment,
sx peak in interpersonal
situations, cutting
Diagnosis: Borderline Personality DisorderCase: “they’re putting it in my food.” • 75 yo female • CC: New onset visual hallucinations, tactile hallucinations, paranoia that staff are poisoning her; • HPI: Brought to ED by assisted living care staff, for rapid onset over last 1 week of hallucinations/paranoid delusions; found searching halls for lost dog which she doesn’t have, then locking herself in her room. Is former executive assistant, mother of 3, grandmo of 6, was cooperative 1 week prior • Med/Psych Hx: osteoporosis, osteoarthritis on low-dose nortriptyline for chronic pain, hypothyroidism, mild neurocognitive disorder. No prior Psych hx. • Family Psych Hx: none • Exam: fluctuating sensorium and disorientation - she thought date was 1985 and that the ED physician was her son. At times she would lose track of the conversation or become upset and hit out at staff. Bladder distention, tachycardia. • Labs: hyponatremia • Course: Was given 0.25mg haldol, and she calmed and cleared for 6 h, but then disorientation, VH came back.
Case: “they’re putting it in my food.”
Schizophrenia Template Present in this case?
DSM5
Stereotypic Positive Sx Yes
Stereotypic Negative Sx No
Functional Impairment Yes
Duration > 6 mo No
Absence of Medical/Substance Cause No
Research-based factors that increase
probability of Schiz
Age of onset during teens-20s (or ~40s if F) No
Family History of psychotic disorder No
Prodrome – cognitive, negative sx No
Course – subacute onset, fluc +, stable - No
Typical Treatment Response? Yes
Absence of other atypical features No – fluctuating
consciousness, VH,
disorientation
Diagnosis: Delirium from multiple potential causesCase: “can you see them?” • 79 yo male • CC: New onset visual hallucinations of children outside room at assisted living facility where lives with wife • HPI: last 3 weeks has had VH, are distracting, but don’t strike fear, and have led him to wander outside to look for the children. Also has had severe sleep probs, mild cognitive problems. Worked in healthcare for 40 years, with ~20 years as hospital administrator for single local children’s hospital. Was seen in ED 1 weeks ago where UA showed equivocal UTI, and superimposed delirium was considered, was given haldol once – had severe medication-induced parkinsonism, and flattening. • Medical hx: Hx hip replacement, no prior psych hx, no alcohol or substance use. • Fam hx: grandson with Autism, father had Parkinsons, no other mental health disorders. • Exam: fluctuating vitals, parkinsonism (now off haldol), mild cognitive impairments, fleeting VH.
Case: “can you see them?”
Schizophrenia Template Present in this case?
DSM5
Stereotypic Positive Sx Yes/No
Stereotypic Negative Sx No
Functional Impairment Yes
Duration > 6 mo No
Absence of Medical/Substance Cause ??
Research-based factors that increase
probability of Schiz
Age of onset during teens-20s (or ~40s if F) No
Family History of psychotic disorder No
Prodrome – cognitive, negative sx No
Course – subacute onset, fluc +, stable - No
Typical Treatment Response? No
Absence of other atypical features No - VH only, fluct vitals,
sleep probs, Parkinsonism
Diagnosis: Lewy-Body DementiaCase “I get bored”
• 15 yo male
• CC: Anger, Agitation, Poor Sleep, Impulsive behaviors. Brought to
PCP by parents for worry about risky behaviors.
• HPI: Recently got caught for stealing a neighbors car and going
for a joyride with a friend in the middle of the night on a
weeknight. Has court date coming up. Father notes he is “up at
all hours”, “can’t finish anything at school or home” and “won’t
listen to anything we say”. With father in room, sulks with arms
folded, doesn’t speak. With father gone talks about hating
school, not knowing if its worth continuing to go, he doesn’t feel
good about himself there, just wishing he could leave home or
die, but doesn’t have active SI. He says he gets to sleep at 1-2am
most nights because it is hard to shut his body down, barely
wakes in time for school at 7am feeling exhausted, and on
weekends sleeps until noon. Chronically impulsive, attention
problems, no grandiosity, likes to sleep, no psychosis.
• Med/Psych Hx: ADHD since age 8, multiple broken bones; Has
tried many substances, but nothing repeatedly.
• Social hx: High school sophomore in IEP for ADHD, performing
poorly, and missing classes. Enjoys skateboarding and rock
climbing. Has girlfriend and multiple friends.
• Family Hx: ADHD
• Exam: phys exam normal, mental status exam: exhibits mild
hyperactivity, overtalks at times, but shows no severe agitation,
no flight of ideas or loose associations, no psychosis sx. UDS neg.Case “I get bored”
Bipolar Disorder Template Present in this case?
DSM5
Manic Episode (Mood&Energy +3/7sx) No
x 1 week or hospitalition
Major Depressive Episode (not needed if manic) No
Functional Impairment Yes
Absence of Medical/Substance Cause Yes
Research-based factors that increase probability
of Bipolar DO
Age of onset during teens-20s No - before
Family History of Bipolar Disorder No
Prodrome – isolated manic sx No
Course – episodic, relapsing/remitting No
Typical Treatment Response? -
Free of confounding features No: chronic hyperactivity,
impulsivity, not decreased
need for sleep
Diagnosis: ADHD +/- Oppositional Defiant/conduct DO and Substance Use
DisorderCase: “tell them to stop shouting at me”
• 17 yo female
• CC: Auditory hallucinations, paranoia, possible seizure, mutism
• HPI: last 2 weeks experienced fairly fast onset of above sx.
Brought to parents who are very concerned because this was a
very sudden change for her, and she has never had such
symptoms prior, has had to stay home from school. She is an A
student and vice president of her class at high school, who
recently helped lead organization of the high school dance.
• Past Medical Hx: No medical problems, had tried cannabis once
in last month
• Family Hx: Schizoaffective Disorder and Borderline Personality
Disorder
• Exam: patient had some insight to abnormality of thinking, some
attention-problems, headache, autonomic instability, odd
posturing, periods of mutism, fluctuating paranoia and
hallucinations. Mother sat with her to calm her.
• Course: Low dose olanzapine given, but did not help much. Head
MRI showed mesiotemporal hyperintensities, EEG showed
generalized slowing, LP showed oligoclonal bands, and ovarian
teratoma discovered. Removal of ovarian teratoma and
immunosuppression led to symptom remission.Case: “tell them to stop shouting at me”
Schizophrenia Template Present in this case?
DSM5
Stereotypic Positive Sx Yes
Stereotypic Negative Sx No
Functional Impairment Yes
Duration > 6 mo No
Absence of Medical/Substance Cause No
Research-based factors that increase
probability of Schiz
Age of onset during teens-20s (or ~40s if F) Yes
Family History of psychotic disorder Yes
Prodrome – cognitive, negative sx No
Course – subacute onset, fluc +, stable - No
Typical Treatment Response? No
Absence of other atypical features No – some insight,
headache, autonomic
instability, MRI findings
Diagnosis: Anti-NMDA receptor encephalitisCase “I don’t know what’s
happening to me”
• 37 yo female
• CC: Rapid onset over a week of agitation, mood irritability and
lability, increased energy, decreased ability to sleep, “because I
can’t stop my brain”, rapid speech, agitation.
• HPI: Had some recent viral infection, was just getting over it,
when she began to feel less herself, have harder time sleeping,
more moody, difficulty controlling thoughts and attention, lost
track of what she was doing several times during the day.
• Med/Psych Hx: Depression stable on escitalopram for many
years. No other problems. Not pregnant.
• Social hx: Works in mayor’s office on regional planning team.
• Family Hx: Depression
• Physical exam: double vision, mild ataxia
• Mental Status Exam: well-groomed female appearing stated age,
mild agitation, but not requiring redirection, no tremor, speech
mildly pressured, some challenges with attention, seems to lose
track of course of conversation, memory poor for short term, but
can remember things from a few weeks ago, problem finding
words at times, mood/affect labile and irritable, insight fair to
“something being wrong”, judgment fair.
• Course: Received Olanzapine 2.5mg which helped her sleep and
improved mood. Referred for urgent MRI brain, which showed a
few scattered T2 white matter hyperintensities. Referred to
neurology.Case “I don’t know what’s
happening to me”
Bipolar Disorder Template Present in this case?
DSM5
Manic Episode (Mood&Energy +3/7sx) Yes
x 1 week or hospitalition
Major Depressive Episode (not needed if manic) Yes
Functional Impairment Yes
Absence of Medical/Substance Cause ??
Research-based factors that increase probability
of Bipolar DO
Age of onset during teens-20s No
Family History of Bipolar Disorder No
Prodrome – isolated manic sx No
Course – episodic, relapsing/remitting No
Typical Treatment Response? Yes
Free of confounding features? No: Sudden onset outside
typical years, with MRI
hyperintensities
Diagnosis: Bipolar Disorder due to Multiple SclerosisCase “We’re connected”
• 17 yo female
• CC: Referred to Psychiatry for bizarre thoughts
• HPI: Over course of last year has begun to voice that she feels
she is directing the actions of a K-pop band from afar, and they
communicate to each other through a special “radio-force-
channel” that others do not experience.
• Collateral: parents note she has become more isolative, spends
much of her time drawing pictures of K-pop stars and collating
memorabilia, and school engagement and performance has
declined over last year, does not complete much school work.
Denies significant mood sx or clear hallucinations. Reported
delusion does not go away, but intensity fluctuates.
• Past Med Hx/Psych Hx: no medical conditions, has been
diagnosed with cognitive processing disorder, on IEP in school
for last 3 years.
• Family Hx: unknown, patient adopted at age 12 months
• Exam/Labs: normal
• Mental Status Exam: Speech normal, thought content
+delusions, thought process mildly slowed, cognition mild
attention probs, orientation good, memory fair, affect is flat,
insight poor to delusional process, judgment fair to care.
• Course: Referred to Early Assessment and Support Alliance,
started in activities, and started on Asenapine 5mg twice daily,
responds well.Case “We’re connected”
Schizophrenia Template Present in this case?
DSM5
Stereotypic Positive Sx Yes
Stereotypic Negative Sx Yes
Functional Impairment Yes
Duration > 6 mo Yes
Absence of Medical/Substance Cause Yes
Research-based factors that increase
probability of Schiz
Age of onset during teens-20s (or ~40s if F) Yes
Family History of psychotic disorder unknown
Prodrome – cognitive, negative sx Yes
Course – subacute onset, fluc +, stable - Yes
Typical Treatment Response? Yes
Absence of other atypical features Yes
Diagnosis: SchizophreniaCase “Ommmmm”
• 23 yo female
• CC: Brought to ED by police
• HPI: Very little history, she is speaking rapidly, has difficulty
sitting down at times, writes copious notes on every piece of
paper she is given, disrobes and lays on the ground of her room
repeating “Om” on repeat for over an hour, is irritable when
others try to ask her to stop. While in ED, does not sleep.
• Police match to missing persons report, calls point of contact,
mother, who notes:
• Patient went missing a week prior after displaying some
bizarre behaviors at her academic lab job.
• Police had contacted her lab PI who noted increasingly
pressured speech, some bizarre associations and ideas
about the research, and attending work disheveled, and a
few times in the same clothes she wore the previous day.
He said this was very uncharacteristic of her, and denied
any known in-lab toxic exposures.
• Exam: phys exam and labs are normal, UDS negative.
• Family Hx: father has Bipolar Disorder w/ mult hospitalizations.
• Course: She is admitted and started on olanzapine 20mg at
bedtime, eventually started on lithium. Her mood normalizes
over 10 days. Transfers to intensive outpatient program for 3
weeks. Back to work part time after 2 montha.Case “Ommmmm”
Bipolar Disorder Template Present in this case?
DSM5
Manic Episode (Mood&Energy +3/7sx) Yes
x 1 week or hospitalition
Major Depressive Episode (not needed if N/A
manic)
Functional Impairment Yes
Absence of Medical/Substance Cause Yes
Research-based factors that increase
probability of Bipolar DO
Age of onset during teens-20s Yes
Family History of Bipolar Disorder Yes
Prodrome – isolated manic sx Unknown
Course – episodic, relapsing/remitting Too early to tell
Typical Treatment Response? Yes
Free of confounding features? Yes
Diagnosis: Bipolar I Disorder, most recent episode manicTreatments – Schizophrenia Am Fam Physician. 2014;90(11):775-782
Antipsychotic • Most of effect comes from effect at Dopamine Receptor 2 (D2)
Medications – Some medications very potent – haldol
– Some less potent – quetiapine
– A few have very minimal effects at D2 – clozapine
• effective when the levels occupy approximately 70% of D2
receptors.
• Persons with schizophrenia vary in response to antipsychotics:
– 10-30% of pts with schiz get no benefit
– up to 30% may get partial benefit
– 50%+ get strong positive response
• In patients with schizophrenia recommendation is to
continue antipsychotic treatment life long.
– 4-30% of patients with schizophrenia will have another during their
lifetime – and no way to predict who will or won’t.
– In studies of continuation, 64% of patients randomized to placebo had
relapse within 1 year, 23% of patients randomized to continuation of
antipsychotic had relapse with 1 year.N Engl J Med. 2019;381:1753-61. Antipsychotic Medications
Antipsychotic Am Fam Physician. 2014;90(11):775-782 Medications
Treatments – Bipolar Disorder Am Fam Physician. 2014;90(11):775-782
Medications to treat Bipolar Disorder Lancet 2016; 387: 1561–72
Extras Medical Causes of psychosis
Extras Medical Causes of psychosis
Extras Medical Causes of mania
N Engl J Med. 2019;381:1753-61. N Engl J Med. 2004; 351:476-486. Am Fam Physician. 2014;90(11):775-782 Am Fam Physician. 2014;90(11):775-782 Lancet. 2016; 388: 86–97 Lancet 2016; 387: 1561–72
Schizophrenia Bulletin. 2010;
36 (1) pp 94-103
Bipolar Disorders.
2018; 20 (2):97-170.You can also read
