1b Psychosis Flashcards
What is psychosis?
- A group of mental illnesses that features a difficulty perceiving and interpreting reality
Which type of mental illnesses are associated with psychosis (7)?
- Schizoaffective disorder
- Bipolar I
- Schizophrenia (1%)
- Delusional disorder
- Depression with psychotic features
- Substance related
- Due to other medical condition
What is the epidemiological onset of psychosis?
- Can occur at any age
- Peak incidence in adolesence / early 20s
- Peak later in women
Outline the course of psychosis.
- Often chronic & episodic
- Very variable
Outline the morbidity of psychosis (2).
- Increased risk of common health problems (e.g. heart disease)
- Significant impact on education, employment & functioning
Outline the mortality of psychosis (2).
- All - cause mortality 2.5 time higher (~15 years of life expectancy lost)
- High risk of suicide in schizophrenia ~ 28% of excess mortality
What are the genetic risk factors for psychosis & schizophrenia?
- Schizophrenia is highly heritable
- Psychosis is highly polygenic
What are the environmental risk factors for psychosis (6)?
- Cannabis and drug use
- Maternal infections
- Migrant status
- Socioeconomic deprivation
- Childhood trauma
- Prenatal / birth complications
What type of symptoms typically precede psychosis?
-
Prodromal symptoms
- Changes in social behaviour, social withdrawal and impairments in functioning
What are the 3 domains of psychosis symptoms?
- Positive symptoms
- Negative symptoms
- Disorganisation
What are the 2 main positive symptoms of psychosis?
- Hallucinations (Percepts in absence of stimulus)
- Delusions (Fixed, false believes, out of keeping with social / cultural background)
What are types of hallucinations in psychotic patients (6)?
- Auditory
- Voices commenting on you
- Voices talking to each other
- Visual
- Somatic/tactile
- Olfactory
What are types of delusions in psychotic patients (11)?
- Persecutory
- Control
- Reference
- Mind reading
- Grandiosity
- Religious
- Guilt / Sin
- Somatic
- Thought broadcasting
- Thought insertion
- Thought withdrawal
What are the 4 main negative symptoms of psychosis?
- Alogia
- Avolution / Apathy
- Anhedonia / Asociality
- Affective flattening
Define Alogia (2).
- Paucity of speech, little content
- Slow to respond
Define Avolution / Apathy (3).
- Poor self-care
- Lack of persistence at work / education
- Lack of motivation
Define Anhedonia / Asociality (3).
-
Disengaged interest and pleasure within conducting activities
- Few close friends
- Few hobbies/interests
- Impaired social functioning
Define Affective flattening (5).
- Unchanging facial expressions
- Few expressive gestures
- Poor eye contact
- Lack of vocal intonations
- Inappropriate affect
What are the 2 main forms of disorganisation symptoms?
- Bizarre behaviour
- Thought disorder
What is classified as bizarre behaviour (4)?
- Bizarre social behaviour
- Bizarre clothing / appearance
- Aggression / agitation
- Repetitive / sterotyped behaviours
What is classified as thought disorder (5)?
Lack of logical connection between thoughts
- Circumstantial thought (lots of extra irrelevant information)
- Tangential thought (goes of in a tangent)
- Flight of ideas (loosely connected train of thought/ connected by sounds, rhyming…)
- Derailment/loosening of association (string of random words)
- Word salad
How is psychosis diagnosed (2)?
- Psychiatric History
- Mental State Examination (MSE)
What is included in a psychiatric history (5)?
- History of presenting concern (HPC)
- Past psychiatric history (PPH)
- Background history (family, personal & social)
- Past medical history and medicine (PMH)
-
Corroborative history (Requires consent)
- Educational, occupational history, relationships, separation, childhood illness
What is included in a social history (4)?
- Living arrangements
- Financial issues
- Alcohol and illicit drug use
- Forensic history
What is included in a mental state examination (6)?
ABC PTSD
- Appearance and behaviour
- Cognition
- Perceptions
- Thoughts
- Speech
- Disposition (Mood)
What additional sources of information are available to support a diagnosis of psychosis (2)?
- Collateral history from family, friends and work
- Healthcare records: GP, Mental health services
What is insight in terms of assessing a patient’s mental state (4)?
- Awareness of onself as presenting phenomena that other people consider abnormal
- Recognition that these phenomena are abnormal
- Acceptance that these abnormal phenomena are caused by mental illness
- Awareness that treatment is required
What difficulties are encountered when treating someone with very poor insight into their psychosis (3)?
- Concordance with treatment
- Attendance at follow-up
- Would not stay in hospital
What are the differentials for psychosis (6)?
- Delirium
- Schizophrenia
- Personality disorder
- Dementia
- Drugs
- Encephalitis (behavioural changes)
What are the 3 types of psychosis management?
- Pharmacological
- Psychological (CBT and avatar therapy)
- Social support
What is the pharmacological management of psychosis (1)?
- Antipsychotic medications
Depends on patient
What is the psychological management of psychosis (2)?
- CBT for psychosis
- Newer therapies also available (i.e. avatar therapy)
What is the social support management of psychosis (3)?
- Supportive environments, structures and routines
- Housing, benefits
- Support (i.e. budgeting / employment)
What are some of the causes of psychosis?
Genetics - Genes predisposing to SCZ must also confer significant advantage
Developmental adversity/abuse - Biased cognitive schemas, sensitised striatal dopaminergic system, high expressed emotion - “double-bind” family dynamic
Neurodevelopmental - Prematurity, hypoxia, infection, winter/spring births
Life stressors - Stress-vulnerability model
Relationship with recreational drugs - Around 25% of psychosis
In PET scans and post-mortem studies of someone with schizophrenia, what is there an excess of?
Striatal presynaptic dopamine
What type of drugs usually are antipsychotics?
dopamine antagonists (but aripriprazole is a partial antagonist)
Give the three dopamine pathways in neuroanatomy
- Cerebrum- cortic and limbic
- Striatum
- Pituitary
What is the effect of dopamine agonists like those used in parkinsons?
psychotic symptoms
What is one of the main issues with dopiminergic drugs?
many side effects
(act on many neurotransmitters including serotonin, acetylcholine, histamine)
what are the side effects of antipsychotics?
- constipation
- parkinsonism
- akathisia
- tardive dyskinesia
- agranulocytosis, neutropenia
- increased appetite, weight gain, diabetes
- dysrhythmia, long QTc
- hyperprolactinaemia
Extrapyramidal side effects of antipsychotics
post-synaptic dopamine blockade in the extrapyramidal system (parts of the brain that enable us to maintain posture and tone)
Causes:
• Parkinsonism
• Acute Dystonia
• Tardive Dyskinesia
• Akathisia
What is Parkinsonism?
• rigidity
• slow and shuffling gait
• Lack of arm swing in gait (early sign)
• ‘pill-rolling’ tremor
What is dystonia?
• Increased motor tone -> sustained
abnormal posture
What is Tardive dyskinesia?
• repeated oral/ facial/ buccal/ lingual
movements
What is Akathisia?
• Inner restlessness
• Feel compelled to move, but does
little to alleviate
Do Typical or Atypical antipsychotics cause extreme pyramidal side effects?
‘Typical’ antipsychotics commonly
cause extrapyramidal side effects
First line medical treatment for
psychosis
• Avoid typical antipsychotics in the first place: atypical antipsychotics usually first-line
• Change medication
• Anticholinergic medications can help e.g. procyclidine
What is Neuroleptic malignant syndrome?
How is it treated?
A medical emergency that typically occurs shortly after starting a new antipsychotic medication - stop medication and give dantrolene and benzodiazepines with IV fluids and dialysis.
