2 - Psychosis and Schizophrenia Flashcards

1
Q

What is the definition of psychosis?

A

‘Lost touch with reality’

Someone who is perceiving, believing or interpreting a different reality to the rest of us

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2
Q

What are some causes of psychosis?

A
  • Schizophrenia (Most common, non affective)
  • Affective (Bipolar and Depression)
  • Drug induced (Transient)
  • Head injury
  • Brain tumour
  • Puerperal
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3
Q

How can we prevent psychosis?

A

Referral to specialist services in patients who are distressed with declining social function and:

  • Transient or attenuated psychotic symptoms or
  • Other experiences or behaviour suggestive of possible psychosis or
  • A first-degree relative with psychosis or schizophrenia

Trained in CBT, family interventions and can treat any anxiety and depression

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4
Q

What are some symptoms of psychosis?

A
  • Hallucinations
  • Delusions
  • Thought and Speech disorder
  • Disorders of the self (Jed changing shape)
  • Lack of insight!!!!!
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5
Q

What is Schizophrenia?

A

Chronic relapsing condition that is a form of psychosis with distortion to thinking and perception and inappropriate or blunted affect

Psychotic Symptoms and Negative Symptoms

Usually acute episodes of psychosis and presents in early life (age 15-35)

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6
Q

What is the incidence and prevalence of Schizophrenia?

A

Incidence: 14.5 per 1000 people/year

Prevalence: 0.5-1% background risk

Same prevalence in men and women but women present later!

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7
Q

What are people with Schizophrenia at an increased risk of?

A
  • Cardiovascular disease
  • Suicide
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8
Q

What are some changes in the brain anatomy of a person with schizophrenia?

A
  • Increased size of ventricles
  • Decreased brain volume
  • Increased activity of dopamine in the mesolimbic region (psychosis)
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9
Q

What are some risk factors associated with Schizophrenia?

A
  • Family history
  • Cannabis use (especially in childhood)
  • Illicit substances
  • Traumatic events in childhood (e.g. poor maternal affection and bonding, poverty, exposure to natural disasters)
  • Maternal poor health (including malnutrition and infections such as rubella and cytomegalovirus)
  • Birth trauma (hypoxia and blood loss in particular)
  • Living in the city
  • Living in/emigrating to more developed countries
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10
Q

What are some symptoms of schizophrenia?

A
  • Hallucinations
  • Delusions
  • Thought insertion/withdrawal/broadcast
  • Catatonic behaviour
  • Negative symptoms (apathy, blunting)
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11
Q

What are some prodromal symptoms for schizophrenia?

A

Usually occur up to 18 months before first episode of psychosis

Gradual deterioration in function

Changes: Transient psychotic symptoms, odd thoughts/beliefs/behaviours, concentration problems, altered affect, social withdrawal, reduced interest in daily activities

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12
Q

What is the ICD-10 diagnostic criteria for Schizophrenia?

A

Psychotic episode lasting for at least one month, schizophrenia may be diagnosed if one (or more) of the following is present:

  • Thought echo, insertion, withdrawal, or thought broadcasting.
  • Delusions that thoughts, feelings, impulses or actions are being controlled by external forces
  • Hallucinatory voices giving a running commentary on the patient’s behaviour, or discussing him between themselves
  • Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather).

Or psychotic episode lasting for at least one month if two (or more) of the following are present:

  • Persistent hallucinations in any modality, when occurring every day for at least one month
  • Breaks or interpolations in the train of thought, resulting in incoherence or irrelevant speech (Knight’s move thoughts)
  • Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.
  • “Negative” symptoms such as marked apathy, paucity of speech, and blunting or incongruity of emotional responses

The episode should not be attributable to organic brain conditions (e.g. encephalitis), or to substance misuse, intoxication, dependence or withdrawal

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13
Q

What are the first rank symptoms of Schizophrenia?

A
  • Delusional Perception
  • Auditory Hallucinations
  • Somatic Hallucinations
  • Thought interference
  • Passivity Phenomena/Control Delusions
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14
Q

What are some examples of negative symptoms in Schizophrenia?

A
  • Alogia (poverty of speech)
  • Anhedonia (inability to derive pleasure)
  • Incongruity/blunting of affect
  • Avolition (poor motivation)
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15
Q

What are the different subtypes of schizophrenia?

A
  • Paranoid: most common, hallucinations and/or delusions are prominent. Usually no abnormal affect or catatonia
  • Hebephrenic: Onset 15-25 years, poor prognosis, affective symptoms are prominent with abnormal behaviour. Negative symptoms are significant and social isolation may result
  • Catatonic schizophrenia: Predominant symptoms are those of psychomotor disturbance e.g stupor, posturing, waxy flexibility
  • Undifferentiated schizophrenia: Those that meet the diagnostic threshold but do not fit into one of the above categories
  • Simple and Residual: negative symptoms predominate
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16
Q

What is the definition of the following:

  • Schizoaffective disorder
  • Schizotypal disorder
  • Schizophreniform
A
  • Schizoaffective disorder: When patient has both symptoms of a mood disorder (mania or depression) and schizophrenia at the same time and of the same intensity. Need to give anti-psychotic and mood stabiliser
  • Schizotypal disorder: Personality disorder which has partial expression of schizophrenia, treated without medication
  • Schizophreniform: Disorders that fail to meet threshold for schizophrenia (usually duration of psychosis) but still have symptoms and deterioration in functioning. Treated with antipsychotics
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17
Q

What investigations should you do if you suspect Schizophrenia?

A

Need to rule out other causes e.g infections, metabolic abnormalities and organic brain disease

Bedside

  • Blood sugar
  • Urine dipstick (+/- MSU)
  • ECG (evaluate for long QT if considering antipsychotics)

Bloods

  • FBC
  • LFT
  • Thyroid function tests
  • Syphilis serology
  • Bloodborne virus screen
  • Autoimmune screen (e.g. ANA, anti-DS DNA for Lupus)

Illicit drugs and alcohol screen

Those presenting with acute psychosis of unknown cause

Additional investigations

CT, MRI head or EEG may be ordered. Serum markers of autoimmune encephalitis (anti-NMDA receptors) can be sent as well as lumbar puncture and CSF sampling if indicated

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18
Q

What are some differentials for Schizophrenia?

A
  • Substance induced psychosis (commonly drugs of abuse, but can be iatrogenic e.g. steroids)
  • Organic psychosis: infection, brain injury, Wilson’s disease
  • Metabolic disorder: hyperthyroidism and hyperparathyroidism
  • Dementia and depression can also co-occur with psychosis
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19
Q

When a patient has a first episode of psychosis, what is the management plan?

A
  1. Assess risk: Suicide, Self-harm, Harm to others
  2. Early intervention in psychosis (EIP): Team dedicated to reducing duration of untreated psychosis, reducing loss of life trajectory, increase the likelihood of return to employment or education. Work with the individual and their support network for up to 3 years. Teams consist of psychiatrists, psychologists, community psychiatric nurses, social workers and support workers

3. Assessment and Care Planning for Psychological Interventions: Full mental health history and MSE. Look at DHx for any organic causes of psychosis. Address any history of drug abuse and trauma. Tackle support mechanisms. Come up with care plan, crisis plan, advanced statement (from the patient on how they want to be treated when acutely unwell) and key contacts

  1. Antipsychotics: Start as soon as possible as longer left untreated the more negative symptoms there are. Can have depot if concordance is issue
20
Q

What investigations need to be done before a patient can be started on an antipsychotic?

A
  • Weight
  • Height
  • Waist circumference
  • Pulse and blood pressure
  • ECG (if clozapine)
  • Blood tests: Fasting blood glucose, HbA1c, Blood lipid profile, Prolactin levels

The following assessments should be recorded:

  • Assessment of any movement disorders
  • Assessment of nutritional status, diet and level of physical activity
21
Q

What are the different types of antipsychotics, give a few examples of each and what is their mechanism of action?

A

Typical (First-Generation)

  • D2 Antagonists
  • Haloperidol, Chlorpromazine

Atypical antipsychotics (Second generation)

  • D2 and Serotonin (5HT2A) antagonist
  • Clozapine, Olanazpine, Quetiapine, Risperidone, Zotepine

Third Generation

  • D2 partial agonist
  • Aripiprazole
22
Q

What are some general side effects of typical and atypical antipsychotics?

A

Typical

  • Extrapyramidal side effects e.g dystonia and tremor
  • Tardive dyskinesia (uncontrollable repetitive movements)
  • Bone marrow suppression
  • Agranulocytosis

Atypical

  • Weight gain
  • Insuline resistance
  • Dyslipidaemia
  • Bone marrow suppression
  • Agranulocytosis
23
Q

What are some specific side effects with atypical antipsychotics?

A
  • Hyperprolactinaemia: usually olanzapine
  • Sexual Dysfunction: ED, low libido, anorgasmia, retrograde ejaculation (risperidone)
  • Weight gain
  • Diabetes
  • Long QT, Fatal Myocarditis, Cardiomyopathy: clozapine
  • Daytime drowsiness: clozapine
  • Seizure threshold: lowered
24
Q

How are side effects avoided with antipsychotics?

A

Start low increase slow

25
Q

If a patient on typical antipsychotics develops extra pyramidal side effects, how can these be treated?

A

Reach lowest tolerable dose of antipsychotic

Parkinsonism: change to SGA or try procyclidine

Acute Dystonia: Procyclidine IM/IV

Akathisia: propanolol and cyproheptadine

Tardive Dyskinesia: may be irreversible but try tetrabenazine

26
Q

How do you choose what antipsychotic to give a schizophrenic patient?

A

Discuss side effects with patient and come to an agreed decision

Atypicals like Risperidone usually favoured as less EPSE

If patient has failed to respond to two antipsychotics (one being atypical) then they need CLOZAPINE!!! High risk of agranulocytosis/neutropenia so need to monitor FBCs

27
Q

What monitoring is done on antipsychotics?

A
  • Weight: every week for 6 weeks, then every 12 weeks, then at 1 year, then annually (plot on graph)
  • Waist circumference: measure yearly (plot on graph)
  • Pulse and blood pressure: measure at twelve weeks, then at 1 year, then annually
  • Fasting glucose, HbA1c, blood lipids: at 12 weeks, then at 1 year, then annually
28
Q

How are antipsychotics usually given?

A

Depot or Long acting injectable

29
Q

When can someone stop taking antipsychotics?

A

Not recommended as high rate of relapse

If wants to stop need to slowly taper down and have close monitoring for 2 years as very high risk of relapse

30
Q

What is some lifestyle advice to give to patients starting on antipsychotics?

A
  • Smoking cessation advice as induces metabolism and lowers amount of antipsychotic in blood. If stop lower dose of drug
  • Take at bedtime as can make you hungry 3 hours after taking
  • Increased thirst so drink water or sugar free drinks
31
Q

What advice can be given to the following groups of people starting on antibiotics:

  • Elderly
  • Children
  • Breastfeeding and Pregnant Mothers
A

Elderly and Children more prone to side effects

Do not use in breastfeeding. Weigh up benefits against harm to mother when pregnant

32
Q

Psychological Interventions are a key part of the care plan in Psychosis as well as antipsychotics. What are the different interventions that can be used to promote a quick recovery and prevent relapse?

A
  • CBT: general or targeted on auditory hallucinations. 16 one to one sessions starting in acute phase
  • Family Sessions: all families who live near or are in close contact. 10 sessions over 3 months to 1 year. Can help address carer issues like embarrassment, self blame and shame
  • Referral to Early Intervention Service
33
Q

What are some predictors of a better prognosis in Schizophrenia?

A
  • Sudden onset
  • No negative symptoms/Positive symptoms predominant
  • Supportive home
  • Female sex
  • Later onset of illness
  • No family history
  • High IQ/Education
34
Q

What is the typical prognosis with Schizophrenia?

A

Chronic Disease

Rule of quarters: 25% never have another episode, 25% improve substantially on treatment, 25% have some improvement and 25% are resistant to treatment

-Following treatment significant improvement in positive symptoms but negative difficult to treat

-The majority of patients will have further acute psychotic episodes, though treatment can reduce the frequency

-Around 10-15% have persistent psychotic features following on from an acute episode.

35
Q

What are some predictors of a poor prognosis with Schizophrenia?

A
  • Substance abuse
  • Early-onset
  • Poor treatment adherence
  • Poor cognitive skills
  • Genetics
36
Q

What is the suicide risk in patients with Schizophrenia?

A

Lifetime: 5%

Acute Phase is 10% and Chronic Phase is 4%

37
Q

People with Schizophrenia die 9-15 years earlier than the general population. Why?

A
  • Suicide
  • Smoking
  • T2DM
  • CVD
38
Q

After a patient has had a psychotic episode what aftercare are they given?

A

Care Programme Approach (CPA)

Given a key worker and a MDT

39
Q

What hallucinations are most common in psychosis?

A

AUDITORY (2ND OR 3RD PERSON)

‘I’m hearing voices in my head’ is Pseudohallucination. The noises are perceived as out in the external world if a real hallucination

40
Q

What hallucinations are most common in delirium?

A

Visual

41
Q

There are lots of organic causes of psychosis e.g drug induced. What are the functional causes?

A
  • Schizophrenia
  • Manic
  • Depressive
42
Q

What model should you use for treatment of Schizophrenia?

A

Biopsychosocial Model

Bio: Rule out organic causes

Psycho: MSE and Collateral Hx

Social: Social assessment

43
Q

Which section/form would the consultant complete to initiate emergency ECT?

A

Section 62:

  • C6 Form
  • Allows two sessions of emergency ECT. A second opinion approved doctor (SOAD) should be applied for at this time in order to provide the required legal framework for ongoing ECT
44
Q

What are the side effects of ECT?

A
  • Short-term memory loss – this resolves completely in most cases, although memory tests should be performed throughout treatment to monitor for significant memory loss
  • Headache – use simple analgesia if needed.
  • Temporary confusion.
  • Muscle aches - due to seizures
  • Nausea/vomiting
  • Risks of general anaesthetic
45
Q

Mrs B has completed a course of ECT and is stabilised on Venlafaxine. She is much better, eating and drinking well, and has no thoughts of self-harm or suicide. She is keen to go home and happy to continue her medication and recovery at home. What other components of the management plan might you consider for her discharge?

A
  • Referral for a CPN
  • Referral to the Crisis Team for initial support on discharge – especially whilst awaiting allocation of a CPN
  • CBT
  • Advice on lifestyle measures e.g. the importance of sleep and routine and the risks of