1. Psychotic Disorders Flashcards
Define psychosis
Out of touch with reality, they do not realise this
1) hallucinations
2) delusions
3) formal thought disorder
4) fragmentation of the boundaries of the self
What is a hallucination?
Perception without any external stimulus
Can be in any sensory modality - visual, auditory (most common in psychosis), olfactory, proprioceptive
Visual hallucination = more common in eye pathology and epilepsy than psychosis
What is a delusion?
Fixed abnormal belief, outside of cultural norms
Primary = fully formed, no experience to account for it, suggestive of schizophrenia Sec = based on current affect/preoccupations
Specific = persecution, infestation, religious, misidentification, jealousy, love, communicated
What are the causes of psychosis?
1 = EXOGENOUS (urine screen asap, stop drugs, benzo, reassure)
- Steroids
- Amphetamines (dopamine agonist)
- Cannabis, spice
2 = ENDOGENOUS (Mx underlying cause)
- Hypo/hyperthyroid (mania)
- Epilepsy (postictal)
- Dementia, delirium
- SLE
- Huntington’s
- Autoimmune encephalitis
3 = FUNCTIONAL PSYCHOSIS
- Mood disorder = predominant affective Sx, mood congruent delusions (mania + grandiose delusions, depression + -ve delusions)
- Delusional disorder = lack of hallucinations, plausibility to delusions, functional state preserved/intact self
- Schizophrenia = first rank Sx
- Schizoaffective Sx = bizarre mood incongruent psychosis, plausibility
- Psychosis not otherwise specified
List the first rank symptoms
Auditory (3):
- hear thoughts
- running commentary
- 3rd person
Thought (3):
- insertion
- withdrawal
- broadcasts
Delusion (4):
- made behaviour
- made volition
- made emotion
- somatic passivity
Delusional perception
- real perception with delusional meaning attached to it
What is schizophrenia and the types?
= disorder characterised by psychotic eps (+ve Sx) and -ve Sx
*** Paranoid Psychotic Humans Cant Supply Understandable Reasoning
1) Paranoid schizophrenia = delusions, hallucinations (+ve Sx)
2) Post-schizophrenic depression = depressive ep arising in the aftermath of a schizophrenic illness
3) Hebephrenic schizophrenia = thought disorganisation predominates, earlier (15-25y) onset
4) Catatonic schizophrenia
5) Simple schizophrenia = rare, -ve Sx without psychosis
6) Undifferentiated schizophrenia = meets general criteria but doesn’t fit any subtype
7) Residual schizophrenia = 1y chronic -ve Sx, preceded by clear-cut psychotic ep
Outline the pathophysiology of schizophrenia
Dopamine pathways – hyperactive signal transduction in the mesolimbic dopamine pathways
Brain changes = enlarged ventricles, reduced hippocampal formation, amygdala, parahippocampal gyrus and prefrontal cortex
Limbic system = brocas area can produce illogical language
What is the mesolimbic pathway
From ventral tegmental area to limbic structures
Motivation, pleasure
Overactive in schizophrenia
What is the mesocortical pathway
From ventral tegmental area to frontal cortex and cingulate cortex
Cognition, motivation, cognition response
Underactive in schizophrenia
How is schizophrenia Mx?
BIO:
ATYPICAL - 2nd gen (SGA) = 5HT2A and D2 antagonists, milder metabolic SE: weight gain, hyper glycaemia, dyslipidaemia
- 1st olanzapine (antagonist)
- risperidone
- aripiprazole (partial antagonist, low risk weight gain + pt cardiac Hx)
- clozapine (for Tx res, SE: seizure, agranulocytosis)
TYPICAL = stronger D2 antagonists, extrapyramidal SE (haloperidol, chlorpromazine)
- tend to bind more muscarinic/histaminic receptors
PSYCHO:
- CBT
- family therapy
- art therapy
SOCIAL:
- social support (housing, benefit, social skills)
- CPN, SW
*** gradual onset is a poor prognostic indicator
What are the ADRs from using antipsychotics?
TYPICAL
- EPSE = shuffling gait, tremor, slurred speech, acute dystonia (head stuck to one side, cant talk or swallow), tardive dyskinesia (chewing, pouting)
- ** switch to procyclidine
- Hyperprolactinaemia (haloperidol)
ATYPICAL
- Weight gain
- Hyperglycaemia (DM)
- Hyperprolactinaemia (risperidone)
- Stroke/VTE in elderly
Sexual dysfunction = ED, decreased libido, anorgasmia
Sedation
CVD = stroke, postural hypotension, QT prolongation
Akathisia = sense of inner restlessness and inability to keep still - due to long Hx of anti-psychotic use
Outline a nigrostriatal pathway
From substantia nigra to striatum
Less dopamine = less MOVEMENT
Outline clozapine
Antagonists at 5HT-2A (serotonin) receptors
- atypical
- should be used after 2 other antipsychotics have not been effective
- titrate dose over 2w
- smoking cessation = rise in clozapine levels
SE:
- agranulocytosis (monitor FBC)
- GI: constipation, bowel obstruction
- weight gain
- excessive salivation
- neutropenia
- myocarditis
- arrhythmia
What are the SEs of clozapine
Agranulocytosis = need FBC monitoring
Metabolic = weight gain, hyperglycaemia/DM
GI = severe constipation, GORD, nausea
Sedation, hypersalivation, changes in BP, tachy, fever, seizures, nocturnal enuresis
What are the S+S of schizophrenia?
Positive Sx = (Delusions Held Firmly Think Psychosis)
- Delusions
- Hallucinations
- Formal thought disorder
- Thought interference = insertion
- Passivity phenomenon (activity, feeling, emotions being controlled by external force)
Negative Sx = (the A factor)
- Avolition (decreased motivation)
- Asocial behaviour
- Anhedonia
- Alogia (quan/qual decrease in speech)
- Affect blunted
- Attention decreased (cognitive)
How is schizophrenia diagnosed?
1 - thought insertion 2 - delusions 3 - hallucinatory voices 4 - persistent delusions 5 - persistent hallucinations 6 - breaks in train of thought 7 - catatonic behaviour 8 - -ve Sx
1 very clear Sx in groups 1-4
OR
Sx from at least 2 of the groups 5-8.
For >6m, present for most of the time for 1m, impairment in work/home functioning
What advice and monitoring should be carried out before/during the use of antipsychotics?
Personal/FH - DM, HTN, CVD
Advice - diet, weight control, exercise
Baseline - BP/pulse, weight, LFTs, lipid profile, HbA1c, FBC
- ECG if on clozapine
Weekly - weight
3mly - FBC, lipids, LFT, U+E, prolactin, weight, HbA1c, ECG, BP
All again yearly
What is formal thought disorder?
Problem of speech and the flow of thought, which means that each sentence (phrase or word) does not follow on from the next
How should schizophrenia be Ix
Bloods: FBC (anaemia), TFTs, glucose/HbA1c, Ca, U+Es, LFTs, cholesterol, vit B12/folate
Urine drug test
ECG (antipsychotics cause prolonged QT interval)
CT (rule out SOL)
EEG (rule out temporal lobe epilepsy as cause)
Briefly outline puerperal psychosis
Acute onset of a manic or psychotic ep usually in the first 2w following birth
Affects 0.2% of women
Mother and baby unit (MBU) = antidepressants, antipsychotics, mood stabilisers, CBT, ECT
Outline neuroleptic malignant syndrome
Pts taking antipsychotic meds
It has been proposed that blockade of D2-like (D2, D3 and D4) receptors induce massive glutamate release, generating catatonia, neurotoxicity and myotoxicity.
S+S = fever, muscle rigidity, delirium, autonomic instability (tachy, fluctuating BP), confusion
***death usually to rhabdomyolysis, renal failure, seizures
Ix = markedly raised serum CK, raised WCC, deranged LFTs
Mx = stop causative factor, lorazepam (for acute behavioural disturbance + muscle relaxant), fluids, cooling blankets, O2, Na bicarb (rhabdomyolysis), haemodialysis if renal failure from rhabdo
Comp = PE, renal failure, shock
How are EPSE treated?
Anticholinergics
- Too much Ach to dopamine (Ach:D) in nigrostrial pathway, so reduce Ach
- Procyclidine
**not effective for/may exacerbate tardive dyskinesia
Outline the use of depot injections to manage psychosis
Slow-release, slow-acting antipsychotic
Types =
- FGA: haloperidol decanoate
- SGA: aripiprazole, olanzapine, risperidone (or its metabolite: paliperidone)
Indication = been on meds a while and working well, expect to be taking a while, can be used for pt refusing PO
