1B psychosis Flashcards
Give examples of psychotic disorders
- Schizophrenia
- Schizoaffective disorder
- Bipolar I
- Depression with psychotic features
- Delusional disorder
- Drug induced
- Due to other medical condition
How heritable and polygenic is schizophrenia?
- Highly heritable- 46% concordance in MZ twins
- Highly polygenic- lots of genes of small effect sizes, but ones found so far account for 20% of known genetic risk
What are the symptom domains in psychosis?
- Positive symptoms
- Negative symptoms
- Disorganisation
Define psychosis
- Psychosis is the difficulty perceiving and interpreting reality
- It is caused many disorders with focus in research often in schizophrenia
Explain and give examples of hallucinations
This is the presence of sensory phenomenon in absence of external stimulus.
These can occur in any sensory modality:
- Auditory
- 1st (thought echo), 2nd and 3rd person
- Running commentary
- Command hallucinations
- Visual (consider organic cause)
- Somatic/tactile/formication
- Olfactory (rare)
- Gustatory
Explain and give examples of delusions (disorder of thought content)
These are fixed, false beliefs not in keeping with social/cultural norms.
Have a theme/flavour:
- Persecutory/Paranoid
- Reference
- Grandiosity
- Religious
- Pathological jealousy
- Nihilistic/Guilt
- Somatic
- Erotomanic
- Thought:
- broadcasting
- insertion
- withdrawal
What are the four types of negative symptoms of delusion?
- Alogia
- Anhedonia/asociality
- Avolition/apathy
- Affective flattening
What are the two types of positive symptoms?
- Hallucinations
- Delusions
What is anhedonia/asociality?
Lack of pleasure
- Few close friends
- Few close hobbies
- Impaired social functioning
What is avolition/apathy?
Complete lack of motivation and self care
- Lack of persistence at work/education
- Lack of motivation
What is alogia?
Poverty of speech
- Paucity of speech, little content
- Slow to respond
What is affective flattening?
- Unchanging facial expressions
- Few expressive gestures
- Poor eye contact
- Lack of vocal intonations
- Inappropriate affect
What two types of disorganisation symptoms are there?
- Bizarre behaviour
- Formal thought disorder
What are some examples of bizarre behaviour?
- Bizarre social behaviour
- Bizarre clothing/appearance
- Aggression/agitation
- Repetitive/stereotyped behaviour
What are examples of thought disorder?
- Circumstantial thought
- Tangential thought
- Flight of ideas
- Derailment/loosening of association
- Word salad
What is psychosis often preceded by?
- Prodromal symptoms often misdiagnosed as depression:
- 6-18 months before florid psychotic symptoms emerge
- Increasing isolation
- Poor self-care
- Social withdrawal
- Declining academic performance
- People at high risk of developing psychosis often have/had another mental disorder like affective disorders earlier in life
What environmental risk factors are there for psychosis?
- Drug use, esp cannabis
- Prenatal/birth complications
- Maternal infections
- Migrant status
- Socioeconomic deprivation
- Childhood trauma
At what age can psychosis occur?
- Can occur at any age
- Peak incidence = early 20s
- Peak later in women
Describe the course of psychosis
- Often chronic & episodic
- Very variable
Why is the morbidity of psychosis substantial?
- Substantial because:
- disorder itself increases morbidity
- disorder can increase risk of common health problems, and therefore increase morbidity indirectly
- Significant impact on education, employment & functioning
Why is the mortality of psychosis substantial?
- All-cause mortality 2.5x higher, ~15 years life expectancy lost
- High risk of suicide among schizophrenia- 28% of excess mortality
What is the prognosis of psychosis?
Some completely recover after an episode, most follow an episodic course with periods of wellness and relapses
What is the long-term management for psychosis?
- Community follow up
- Managing antipsychotic side effects e.g. weight, diabetes
- Health promotion- reducing risk factors e.g. smoking, diet
- All-cause mortality 2.5x higher in schizophrenia -14 years old
What is the Mental State Examination?
MSE is a snapshot of patient current mental state
What does MSE consist of?
- Appearance and behaviour
- Speech
- Mood and affect
- Thought content/form
- Perceptions
- Cognition
- Insight
(IMPACTS)
What things would you look for in appearance and behaviour in psychosis patients specifically?
- Bizarre or inappropriate clothing e.g. no shoes
- Psychomotor retardation/agitation
- Self-neglect
- Self-harm injuries
- Echophenomena (echopraxia, echolalia)
- Stupor and mutism (catatonia)
What do we assess in speech?
- Quantity (less/more/medium)
- Rate (slow, fast, pressure of speech)
- Rhythm
- Volume
What is circumstantial thought disorder?
Longwinded responses but the asked question is eventually answered
What do we assess in mood?
- Subjective: directly ask how mood is
- Objective: perceive their mood without asking
Why is it important to assess for mood in people with psychosis?
- Some affective disorders can cause psychosis (e.g. bipolar, depression) with implications for treatment
- Depression is comorbid with schizophrenia in 30% of cases
- People at high risk of psychosis often have another mental disorder
- Lifetime risk of suicide 5% in schizophrenia
What do we look for in thought?
- Form: how you are thinking, flight of ideas
- Content: what you are thinking of- thought disorder manifests as disordered speech
What do we look for when assessing pereceptions?
Objectively responding to hallucinations
What is used to assess cognition?
Addenbrooke’s Cognitive Examination
- (ACE III) - A 100 item cognitive assessment that looks at multiple areas of cognition.
- Administration takes 20-25 mins
How is cognitive impairment related to schizophrenia?
- Schizophrenia originally described as dementia praecox (dementia of the young)
- Commonly affects working memory and executive function
- Poorer educational attainment (from childhood)
- Cognitive impairment is stable over time and independent of psychotic symptoms
- Cognitive impairments are difficult to treat and cause morbidity
What neurotransmitter system is most implicated in the mechanism of antipsychotics?
Dopamine
Also serotonin, acetylcholine, histamine
What is increased dopamine activity associated with in psychosis?
- Increased dopamine activity in mesolimbic dopamine system implicated in causing positive symptoms in psychosis
- Evidence from imaging, drug models and post mortem studies show elevated presynaptic dopamine in striatum
What kind of drugs are most antipsychotics?
- Dopamine antagonists
- Aripiprazole is a partial agonist
- Dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms
What side effect can certain antipsychotics cause?
Extra Pyramidal Side Effects (EPSEs)
- This is caused by dopamine blockage in the nigrostriatal (extra pyramidal system) dopamine system (parts of brain that enable us to maintain posture and tone)
What examples of EPSEs are there?
- Parkinsonism
- Acute dystonia reactions
- Tardive Dyskinesia
- Akathisia
What are the features of Parkinsonism?
- Bradykinesia
- Postural instability
- Rigidity
- Slow and shuffling gait
- Festination
- Lack of arm swing in gait: early sign
- ‘Pill-rolling’ tremor (4-6Hz)
What makes a ‘typical’ vs ‘atypical’ antipsychotic?
- Typical cause EPSE
- Atypical e.g. olanzapine are less likely to cause EPSE
- due to 5HT-2A antagonism
How do we manage EPSEs?
- Counsel about risk
- Use lowest therapeutic dose
- Use atypical as first line
- Change medication to a more movement sparing agent
- Anticholinergic medications can help (e.g. procyclidine)
What are other side effects of antipsychotics?
- CNS → EPSEs, sedation
- Haematological → agranulocytosis, neutropenia
- Metabolic → increased appetite, weight gain, diabetes
- GI → constipation
- Pituitary → more prolactin (release suppressed by dopamine)
- Cardiac → dysrhythmia, long QTc (can cause palpitations, fainting, seizures)
What is tangential thought disorder?
Train of thought goes off on tangents/ Tangents are logically connected but the question asked isn’t answered.
What is flight of ideas in thought disorder?
Trains of thought loosely connected. May be connected by meaning semantics, sounds, rhyming or puns (clanging/clang associations).
‘I’m a smoker, but not a joker. I take a toke whilst drinking coke’
What is derailment in thought disorder?
Train of thought has ‘gone off track’. Unrelated and unconnected trains of thought.
What is word salad?
Complete breakdown of logical connection between thoughts. String of random words.
What are perceptions?
Objectively responding to hallucinations
What are the types of hallucinations?
- Tactile
- Auditory
What are pseudohallucinations?
- True hallucinations must be phenomenologically indistinguishable from a true perception (e.g. voices must be perceived as originating from outside, not inside, a person’s head)
- Insight typically preserved in pseudohallucinosis
i.e. Pseudohallucinations are sensory experiences vivid enough to be considered hallucination but considered by person unreal
What is insight?
The awareness into your own mental state, symptoms and need for treatment.
What difficulties might you have treating someone with poor insight into their psychosis?
- Concordance with treatment
- Attendance at follow-up
- Willingness to be admitted to hospital
- Impact on ability to have capacity to consent to treatment
How are psychotic disorders diagnosed?
- Heterogeneity within disorder categories and episodes of illness
- Many people who have a first episode psychosis will not have another
- Follow up for 3 years under Early Intervention in Psychosis Services
What does biopsychosocial management consist of?
- Pharmacological
- Psychological
- Social support
What is involved in pharmacological management for psychosis?
- Antipsychotic medications
- Often mainstay of treatment
What is involved in psychological management for psychosis?
- CBT
- Newer therapies like avatar therapy
What social support is involved in psychosis management?
- Supportive environments, structures and routines
- Housing, benefits
- Support with budgeting/employment
