1b// Psychosis Flashcards
What is psychosis?
difficulty perceiving and interpreting reality (I.e., failure of reality testing)
A clinical syndrome that can be caused by many disorders- focus in research is often schizophrenia
What are some psychotic disorders? (7)
Bipolar I
Schizoaffective disorder
Schizophrenia
Depression with psychotic symptoms
Delusional disorder
Drug Induced
Due to other medical conditions
Is psychosis a diagnosis?
No, it is a clinical term- something leads to psychosis, loss of touch w/ reality
What is hallucination?
appreciation of a sensory input without there being any sensory input (i.e., hearing, seeing, smelling, etc.) has to be very realistic (symptom of psychosis)
What is thought disorder?
(symptom of psychosis)
Thought disorder is a disorganized way of thinking that leads to unusual speech and writing. People with thought disorder have trouble communicating with others and may have trouble recognizing that they have an issue.
What is delusion?
Fixed, false belief not in keeping with social/cultural norms. Delusions have a theme/flavour;
What are the symptom domains in psychosis?
Positive symptoms= gains a functions
negative symptom= loss of function
disorganisation= everything else
What are the 2 types of positive symptoms?
Hallucinations
Delusions (disorder of thought content)
What are the types of positive symptoms of hallucinations?
Perception in absence of a stimulus
Can occur in any sensory modality:
1. Auditory
- 1st (thought echo), 2nd, 3rd person
- Running commentary
- Command hallucinations
2. Visual (consider organic cause)
3. Somatic/tactile/formication
4. Olfactory
5. Gustatory
What are the types of positive symptoms of delusions?
Persecutory/Paranoid Reference Grandiosity
Religious
Pathological jealously
Nihilistic/Guilt
Somatic
Erotomanic (believe people are in love w/ u)
passivity experiences:
- 1st rank symptoms
Thought broadcasting
Thought insertion
Thought withdrawal
What is thought broadcasting?
believe that people can read your mind
What is thought insertion?
believe people are putting thoughts into your mind
What is thought withdrawal?
their thoughts just stop, it might show as them stop talking midway through a sentence
What hallucination is a red flag for organic hallucination?
visual e.g., drug induced
What are the negative symptoms of of delusions?
Alogia
Anhedonia/ asociality
Avolition/ apathy
Affective flattening
What is alogia?
paucity/ poverty of speech (little content)
slow to respond to questioning
What is anhedonia/ asociality?
few close friends
few hobbies/ interests
impaired social functioning
What is avolition/ apathy?
poor self-care
lack of drive/ persistence at work/ education
lack of motivation
What is affective flattening?
- Unchanging facial expressions
- Few expressive gestures
- Poor eye contact
- Lack of vocal intonations
- Limited emotional range
What are the negative symptoms of delusions often misdiagnosed for?
depression
but for these people their mood is fine
What are the disorganisation symptoms of delusion?
Bizarre behaviour
Formal thought disorder (disorder of thought form)
What is bizarre behaviour?
- Inappropriate social behaviour
- Bizarre clothing/appearance
- Aggression/agitation
- Repetitive/stereotyped behaviours
What is formal thought disorder?
lack of logical connection between thoughts
How would you describe the increasing severity of formal thought disorder?
(going down is increasing severity)
o Circumstantial thought
o Tangential thought
o Flight of ideas
o Derailment/loosening of association
o Word salad
What is the epidemiology of psychosis? (onset)
can occur at any age
peak incidence in adolescence/ early 20s
peak later in women
What is the epidemiology of psychosis? (course)
often chronic and episodic
variable and prognosis
What is the epidemiology of psychosis? (morbidity)
Substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
Significant impact on education, employment and functioning
What is the epidemiology of psychosis? (mortality)
All-cause mortality 2.5x higher, ~15 years life expectancy lost
High risk of suicide in schizophrenia - 28% of excess mortality
What is an MSE exam and what is involved in it?
mental state examination (MSE):
o Appearance and behaviour
o Speech
o Mood and Affect
o Thoughts
o Perceptions
o Cognition
o Insight
When do you start psychological therapies for psychotic disorders?
when they are more stabilised
What are the treatment options for psychotic disorders?
Pharmacological
Psychological
Social Support
What is involved with the pharmacological treatment for psychotic disorders?
antipsychotic medications
often mainstay of treatment
What is involved with the psychological treatment for psychotic disorders?
CBT for psychosis
newer therapies like avatar therapy
What is involved with the social support treatment for psychotic disorders?
Supportive environments, structures and routines
Housing, benefits
Support with budgeting /employment
What neurotransmitter system is most implicated in the mechanism of antipsychotics?
Dopamine - but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine
Increased dopamine activity in mesolimbic dopamine system implicated in causing positive symptoms of psychosis.
Evidence from imaging + drug models + post-mortem studies
Which drug actions on dopamine receptors would be most likely to improve psychotic symptoms?
Antagonists
Most antipsychotics are dopamine antagonists. Newer agents (e.g. aripiprazole) are partial agonists
Dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms
What does EPSEs stand for?
Extrapyramidal side effects
What are extrapyramidal side effects?
Umbrella term for side effects outside the traditional pyramidal movement pathway
Caused by dopamine blockade in the nigrostriatal (extrapyramidal) dopamine system (parts of the brain that enable us to maintain posture and tone)
What are examples of extrapyramidal side effects?
parkinsonism
acute dystonic reactions
tardive dyskinesia
akathisia (restlessness, restless legs)
What is parkinsonism?
- Bradykinesia
- Postural instability
- Rigidity - characteristic ‘cog-wheeling’
- Slow and shuffling gait
- Festination (chasing centre of gravity)
- Lack of arm swing in gait – early sign
- ‘pill-rolling’ tremor - slow (4-6Hz) movement of the thumb across the other fingers:
What are the management principles of 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)
How are antipsychotics divided?
Antipsychotics divided into older typical drugs and newer atypical drugs:
o Also referred to as first and second generation
Atypical antipsychotics associated with a lower risk of EPSE
Why are atypical antipsychotics less likely to cause ESPEs?
Less likely to cause EPSEs due to 5HT-2A antagonism
What are other side effects of antipsychotics?
CNS:
- EPSEs
- sedation
Haematological:
- agranulocytosis
- neutropenia
Metabolic:
- increased appetite
- weight gain
- diabetes
Gastrointestinal:
- constipation
Pituitary;
- increased prolactin
Cardiac:
- dysrhythmia
- long QTC
Why is increased prolactin a symptom of antipsychotics?
because prolactin is suppressed by dopamine
less dopamine= more prolactin
Describe the 2 main components of a psychiatric history assessment.
- psychiatric history
- mental state examination
What are the main components of the psychiatric history?
What is hypnagogia?
transitional state of consciousness between wakefulness and sleep
What is hypnopompic?
hallucinations in people with deteriorating vision
What is Charles Bonnet syndrome?
hallucinations in people with deteriorating vision
What often precedes psychosis?
prodromal symptoms
Describe some risk factors for psychosis.
What might you look out for in appearance and behaviour of someone with psychosis?
What cognitive impairments are associated with schizophrenia?
Working memory impairments
Lower scores of cognitive testing (from childhood)
Poorer educational attainment (from childhood)
Cognitive impairments are stable over time and independent of psychotic symptoms
Cognitive impairments are difficult to treat and cause morbidity
What difficulties might you have treating someone with very poor insight into their psychosis>
concordance with treatment
Attendance at follow-up
Would not stay in hospital
What are the advantages and disadvantages of being given a diagnosis?
What are the differentials of psychosis?
What is dystonia?
What is tardive dyskinesia?
Do you understand this infographic of psychosis?
