Psychosis in Women The Hidden Challenge in Primary Care

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Slide 1 : Psychosis in Women: The Hidden Challenge in Primary Care National Nursing Centers Consortium 6th Annual Conference Carla J. Groh, PhD, APRN, BC
Slide 2 : October 8, 2007 C. Groh, PhD, APRN, BC 2 Prevalence of Psychotic Symptoms Schizophrenia & related disorders 0.4% - 1.0% in primary care Psychotic symptoms may be far more common 2-3% respondents in ECA study reported auditory hallucinations; more frequent among women and increased with age (N = 18,572). 75-90% psychiatric illnesses treated in PC More than 25% PCP regularly prescribe antipsychotics
Slide 3 : October 8, 2007 C. Groh, PhD, APRN, BC 3 Prevalence of Psychotic Symptoms Occur in a variety of psychiatric disorders: Schizophrenia Bipolar disorder (manic phase) Major depression with psychotic features Substance-induced psychosis Occur in general medical conditions: Neurological disorders Endocrine disorders Metabolic disorders Autoimmune disorders
Slide 4 : October 8, 2007 C. Groh, PhD, APRN, BC 4 Prevalence of Psychotic Symptoms Studies results vary from 3.7% (sample of middle-class patients to 20.9% (sample of poor, little formal education, Hispanic patients) of primary care patients reporting 1 or more psychotic symptoms. Prevalence of voice hearing found to be 32.8% in sample of cognitively intact but hearing impaired adults >65 years of age Major concern are persons who present with sub-threshold psychotic symptoms and first episode of psychosis
Slide 5 : October 8, 2007 C. Groh, PhD, APRN, BC 5 Common Psychotic Symptoms Auditory hallucinations Paranoia (being spied on or followed by others) Visual hallucinations Belief that people are plotting to poison them Able to hear other people’s thoughts Thought insertion
Slide 6 : October 8, 2007 C. Groh, PhD, APRN, BC 6 Comorbidities with Psychosis Panic disorders Generalized Anxiety Disorder Major Depressive Disorder Alcohol use disorder Borderline personality Suicidal ideation**
Slide 7 : October 8, 2007 C. Groh, PhD, APRN, BC 7 Sequelae of Psychotic Symptoms Low self esteem React to voices with suspicion Work (either not working or missing work) Family (marital discord, parent/child problems) Social (isolative, fearful)
Slide 8 : October 8, 2007 C. Groh, PhD, APRN, BC 8 Schemata Content: Verbal Auditory Hallucinations Ego dystonic: Aggression Dependency Indecision Self-punishment Sexual identity or character
Slide 9 : October 8, 2007 C. Groh, PhD, APRN, BC 9 Schemata Content: Verbal Auditory Hallucinations Ego syntonic: Companionship Entertainment Evaluation Role identity & self care Self-importance Attenuation of distress Source: Larkin, A.R. (1979). The form and content of schizophrenia hallucations. American Journal of Psychiatry, 136(7), 940-943.
Slide 10 : October 8, 2007 C. Groh, PhD, APRN, BC 10 Assessment of Psychosis: Neurological Disorders Epilepsy Neoplasm Cerebral trauma Multiple sclerosis Huntington’s disease Infections, especially viral Cerebrovascular disease Other space occupying lesions
Slide 11 : October 8, 2007 C. Groh, PhD, APRN, BC 11 Assessment of Psychosis: Endocrine, Metabolic, Autoimmune Disorders Porphyria Systematic lupus Wilson’s disease Hyperparathyroidism Vitamin B12 deficiency Cushing’s syndrome (20%) Hyperthyroidism and hypothyroidism
Slide 12 : October 8, 2007 C. Groh, PhD, APRN, BC 12 Assessment of Psychosis: Screening Tests First psychotic episode: Electrolytes Erythrocyte sedimentation rate Thyroid function tests Live function tests Full blood examination Iron studies Vitamin B12 and folate levels Syphilis serology EKG
Slide 13 : October 8, 2007 C. Groh, PhD, APRN, BC 13 Assessment of Psychosis: Prodromal Symptoms Suspiciousness Anxiety Depression Irritability Restlessness Change in appetite Sense of change in self Social isolation Marked impairment: role functioning personal hygiene Peculiar behavior Blunted, flat affect Odd or bizarre ideation Lack of initiative, interests or energy
Slide 14 : October 8, 2007 C. Groh, PhD, APRN, BC 14 Assessment of Psychosis: Psychiatric Evaluation Comprehensive history, including (goal is to differentiate between primary versus secondary psychosis: Family history Prodromal symptoms Past medications Substance use/abuse/misuse Description of the voices, content, degree to which voices distress patient
Slide 15 : October 8, 2007 C. Groh, PhD, APRN, BC 15 Treatment Options Treatment based on diagnosis Pharmacological management Atypical antipsychotics Mood stabilizers, antidepressants, ECT
Slide 16 : October 8, 2007 C. Groh, PhD, APRN, BC 16 Treatment Options Non-pharmacological management: Cognitive behavioral therapy In 20 RCT, CBT found to be superior in short-term but not over the long-term
Slide 17 : October 8, 2007 C. Groh, PhD, APRN, BC 17 When to Refer First time psychotic episode Suicidal or homicidal Person refractory to treatment Non-adherent to treatment Complicated psychiatric and medical picture
Slide 18 : October 8, 2007 C. Groh, PhD, APRN, BC 18 Case Study

 


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