1. Psychosis Flashcards
Describe: Psychosis (4)
- Psychosis is an interruption from reality that may affect thought process, thought content, behaviors, and/or perceptions.
- It is manifested by delusions, hallucinations, disorganized thoughts and behaviors, or failed reality testing.
- Delusions are fixed, false beliefs that fall outside of cultural norms.
- Psychosis is a symptom and not a Dx.
Schizophrenia is characterized by what? (3)
- positive symptoms (delusions, hallucinations)
- negative symptoms (affective blunting, anhedonia, avolition, alogia)
- and cognitive impairment (attention, concentration, processing speed, learning, memory, executive function).
The lifetime prevalence of schizophrenia is what? (1)
1% .
Age of onset of psychosis in schizophrenia is when?
late teens to mid-30s, and is earlier for men.
A prodrome is often noted in adolescence when? (3)
- when nonspecific symptoms such as social withdrawal, irritability, antagonistic thoughts, and functional decline become noticeable by others
- Attenuated psychotic signs present during this time such as suspiciousness and perceptual distortions are thought to have a high positive predictive value for schizophrenia.
- This is an area of active clinical interest as it is thought that a long duration of untreated psychosis is related to adverse outcomes.
The genetic risk for schizophrenia is ___% when both parents are affected, and ___% with a monozygotic twin.
The genetic risk for schizophrenia is 50% when both parents are affected, and 60% to 84% with a monozygotic twin.
Name psychosis environmental factors (3)
- perinatal events
- obstetric complications
- social stressors.
What produces positive symptoms? (1)
Hyperdopaminergic state in the D2 striatal system
What leads to cognitive deficits? (2)
- hypodopaminergic state in the prefrontal D1 system
- Glutamate and GABA have also been investigated, and activity at the glutamater- gic and GABA receptors produces some of the behavioral and cognitive symptoms of schizophrenia.
What explains negative symptoms? (1)
However, the dopamine theory does not adequately explain negative systems, and it is thought that other monoamine receptors (serotoninergic, histaminergic, muscarinic, a-adrenergic) are contributory.
What explains the high use of tobacco among patients with schizophrenia? (1)
the involvement of acetylcholine is thought to explain
Name changes in imageries in psychosis (4)
- The most common anatomical finding is enlargement of the ventricles.
- PET studies show reduced frontal lobe activation.
- Functional MRI studies demonstrate functional circuit disruption rather than localized dysfunction.
- Diffusion tensor imaging looks at the structural integrity of white matter, and decreased coherence has been shown in the prefrontal cortex and in frontotemporal and frontoparietal tracts
Describe HX of psychosis (17)
- Important notes before beginning the interview:
- The patient who is psychotic will not be reliable and he or she may have no insight. Collateral information gathered from family, caregivers, ambulance, or available police reports is needed to corroborate information.
- Make sure that you are safe during the interview. Patients with psychosis may act erratically if they are paranoid, attending to internal stimuli (e.g., command hallucinations).
- Patient identifiers: name, age, occupation
- Social and contextual information: relationship status, living arrangement, work or source of income, children, caregivers of children besides the patient
- Who is looking after the patient’s children? Does social work have to be involved?
- Ask about the DSM-5 criteria for psychotic disorders
- Recent and current stressors: personal losses that have occurred or anticipated (e.g., death in family, loss of work, property), role transitions, financial difficulties, interpersonal conflict, isolation
- Social supports available
- Suicide
- Screen for symptoms of depression, mania/hypomania, and anxiety
- Substance use: Comorbid substance use is common.
- Forensic history
- Psychiatric history
- For the multiepisode patient, it is crucial to know what medications have been tried, which ones worked, the side effects that occurred, and what doses have been tried and for how long.
- Family psychiatric history: Particularly important in patients with first-break psychosis
- Medical history
- Medications
- Allergies
- Personal history: childhood relationships, performance in school at different stages, highest level of education, occupations held, relationships in adolescence and adulthood, history of abuse at any stage in life
- Look for signs of attenuated psychosis in the prodromal period in the first break patient
Name DDx of psychosis (Figure)
- Psychiatric
- Psychotic disorders
- Schizophrenia
- Schizophreniform
- Brief psychotic disorder
- Delusional disorder
- Schizoaffective disorder
- Bipolar I disorder with psychotic features
- Major depression with psychotic features
- OCD
- Mental retardation
- Autism spectrum disorder
- Personality disorders
- Schizotypal, Schizoid, Borderline, Paranoid
- Malingering, factitious
- Psychotic disorders
- Substance/Medications
- Substance of abuse
- Alcohol, sedative withdrawal
- Cannabis
- Stimulants, hallucinogens, ketamine
- Anxiolytics
- Prescription medications
- Anesthetics, analgesics, anticonvulsants
- Anticholinergics
- Antihistamines
- CV medications
- Steroids
- Dopamine agonists, MAOIs
- Digitalis toxicity
- Toxins
- Organophosphates
- CO, CO2
- Volatiles, fumes, paint
- Substance of abuse
- General medical conditions
- CNS
- Lesions
- Infections: HIV, Neurosyphilis
- Seizures*
- Strokes
- Systemic illness
- Autoimmune diseases
- Metabolic abnormalities*
- Endocrine abnormalities*
- Vitamin deficiencies
- Sepsis
- CNS
Describe A simplified Dx tree of psychotic psychiatric disorders. (Figure)
