33. Hallucinations/disordered thinking Flashcards
Differentials for hallucinations/delusional thinking
Organic:
- visual loss –> charles bonnet
- lewy body dementia
- Migraine aura
- Focal seizure affecting the temporal lobe
- narcolepsy
- metabolic encephalopathy
- autoimmune encephalitis
- CNS infection
- delirium
- parkinsons
- tumour
substance related:
- acute intoxication
- drug induced psychosis eg steroids
- alcohol withdrawal
Psychiatric:
- acute psychosis
- schizophrenia
- schizoaffective disorder
- depression with psychotic symptoms
-grief reaction
- delusional disorder
History taking hallucinations/visual disturbance
self
“Do you feel like you have any special abilities compared with others?”
“Do you feel in control of your body and your actions?”
“Do you feel like anyone is removing your thoughts or adding thoughts?”
others
“How are you getting on with other people?”
world
“Do things around you have a special meaning to you?”
hallucinations
“do you ever feel that your imagination plays tricks on you. Have you heard or seen things that are unusual? Or seen and heard anything other people can’t?”
delusions
“do you have any new beliefs or things you’ve been thinking a lot about recently? “
bizzare vs non-bizzare delusion
Bizarre delusion: Delusions are deemed bizarre if they are clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences
Non-bizarre delusion: A delusion that, though false, is at least technically possible, e.g., the affected person mistakenly believes that they are under constant police surveillance.
features of psychosis
hallucinations (e.g. auditory)
delusions
thought disorganisation
alogia: little information conveyed by speech
tangentiality: answers diverge from topic
clanging
word salad: linking real words incoherently → nonsensical content
Associated features:
agitation/aggression
neurocognitive impairment (e.g. in memory, attention or executive function)
depression
thoughts of self-harm
Good prognosis predictors psychosis
high IQ
bad prognosis predictors psychosis
Gradual onset
History of social withdrawal
Strong family history
Lack of obvious precipitant eg trauma
what invetsigation should you always do if acute pscyhosis
Urinary toxicology (short history of psychotic symptoms)
management of psychosis
atypical antipsychotic
what are schneiders frist rank symptoms of Sz
Acronym WASBID
Withdrawal (thought)
Auditory hallucinations
Somatic passivity + made act
Broadcasting (thought)
Insertion (thought)
Delusional perception
negative symptoms of sz
affective flattening
apathy
avolition
anergy
anhedonia
alogia
asociality
attentional impairment
disorganised symptoms of sz
Disordered thinking/speech
Disorganised behaviour
Inappropriate affect
features of paranoid sz
Relatively stable, often paranoid, delusions, usually accompanied by hallucinations and perceptual disturbances
Uncommon : disturbances of affect, volition, speech, catatonia
can be episodic or chronic
most common type of sz
Paranoid Sz
features of hebephrenic sz
Prominent affective changes
Mood inappropriate and accompanied by: giggling or self-satisfied, self-absorbed smiling, grimaces, mannerisms, pranks, hypochondriac complaints and reiterated phrases
Disorganised thought and speech
Delusions and hallucinations are fleeting and fragmentary
Adolescence/young adult onset
Poor prognosis due to rapid development of negative symptoms
DSM criteria for a diagnosis of schizophrenia
2 of 5 main symptoms present for a significant number of time in 1 month
Delusions
Hallucinations
Disorganised speech
Movement
Negative symptoms
Present for 6 months
features of prodromal phase Sz
Social withdrawal
Self-neglect
risk factors Sz
Cannabis use, especially in adolescence
Family history
Black Caribbean ethnicity
what factors are associated with poor prognosis of Sz
strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant
Management of Sz
- Atypical antipsychotic 1
+ cognitive behavioural therapy should be offered to all patients - Antipsychotic 2
- Clozapine (Sz that does not respond to two consecutive trials of antipsychotics (TRSz) should be given clozapine)
onset of peurperal psychosis
Within the first 2-3 weeks following birth
features of peurperal psychosis
severe swings in mood (similar to bipolar disorder)
and disordered perception (e.g. auditory hallucinations)
management peuperal psychosis
Admission to hospital is usually required, ideally in a Mother & Baby Unit
risk of recurrence peurperal psychosis
25-50% risk of recurrence following future pregnancies
what is schizoaffective disorder
Schizoaffective disorder is characterised by abnormal thought processes and an unstable mood. This diagnosis is made when the person has symptoms of both schizophrenia (usually psychosis) and a mood disorder: either bipolar disorder or depression.
genetic associated narcolepsy
HLA-DR2
pathophysiology narcolepsy
low levels of orexin (hypocretin), a protein which is responsible for controlling appetite and sleep patterns
features narcolepsy
typical onset in teenage years
hypersomnolence
cataplexy (sudden loss of muscle tone often triggered by emotion)
sleep paralysis
vivid hallucinations on going to sleep or waking up
invetsigation of choice narcolepsy
multiple sleep latency EEG
management of narcolepsy
daytime stimulants (e.g. modafinil)
PLUS
nighttime sodium oxybate
