33. Hallucinations/disordered thinking

Question 1

Differentials for hallucinations/delusional thinking

Answer 1

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

Question 2

History taking hallucinations/visual disturbance

Answer 2

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? “

Question 3

bizzare vs non-bizzare delusion

Answer 3

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.

Question 4

features of psychosis

Answer 4

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

Question 5

Good prognosis predictors psychosis

Answer 5

high IQ

Question 6

bad prognosis predictors psychosis

Answer 6

Gradual onset
History of social withdrawal
Strong family history
Lack of obvious precipitant eg trauma

Question 7

what invetsigation should you always do if acute pscyhosis

Answer 7

Urinary toxicology (short history of psychotic symptoms)

Question 8

management of psychosis

Answer 8

atypical antipsychotic

Question 9

what are schneiders frist rank symptoms of Sz

Answer 9

Acronym WASBID

Withdrawal (thought)
Auditory hallucinations
Somatic passivity + made act
Broadcasting (thought)
Insertion (thought)
Delusional perception

Question 10

negative symptoms of sz

Answer 10

affective flattening
apathy
avolition
anergy
anhedonia
alogia
asociality
attentional impairment

Question 11

disorganised symptoms of sz

Answer 11

Disordered thinking/speech
Disorganised behaviour
Inappropriate affect

Question 12

features of paranoid sz

Answer 12

Relatively stable, often paranoid, delusions, usually accompanied by hallucinations and perceptual disturbances

Uncommon : disturbances of affect, volition, speech, catatonia

can be episodic or chronic

Question 13

most common type of sz

Answer 13

Paranoid Sz

Question 14

features of hebephrenic sz

Answer 14

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

Question 15

DSM criteria for a diagnosis of schizophrenia

Answer 15

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

Question 16

features of prodromal phase Sz

Answer 16

Social withdrawal
Self-neglect

Question 17

risk factors Sz

Answer 17

Cannabis use, especially in adolescence
Family history
Black Caribbean ethnicity

Question 18

what factors are associated with poor prognosis of Sz

Answer 18

strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant

Question 19

Management of Sz

Answer 19

1. Atypical antipsychotic 1
   + cognitive behavioural therapy should be offered to all patients
2. Antipsychotic 2
3. Clozapine (Sz that does not respond to two consecutive trials of antipsychotics (TRSz) should be given clozapine)

Question 20

onset of peurperal psychosis

Answer 20

Within the first 2-3 weeks following birth

Question 21

features of peurperal psychosis

Answer 21

severe swings in mood (similar to bipolar disorder)

and disordered perception (e.g. auditory hallucinations)

Question 22

management peuperal psychosis

Answer 22

Admission to hospital is usually required, ideally in a Mother & Baby Unit

Question 23

risk of recurrence peurperal psychosis

Answer 23

25-50% risk of recurrence following future pregnancies

Question 24

what is schizoaffective disorder

Answer 24

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.

Question 25

genetic associated narcolepsy

Answer 25

HLA-DR2

Question 26

pathophysiology narcolepsy

Answer 26

low levels of orexin (hypocretin), a protein which is responsible for controlling appetite and sleep patterns

Question 27

features narcolepsy

Answer 27

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

Question 28

invetsigation of choice narcolepsy

Answer 28

multiple sleep latency EEG

Question 29

management of narcolepsy

Answer 29

daytime stimulants (e.g. modafinil)

PLUS

nighttime sodium oxybate