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Year 2 - BRS > 4.3 - Psychosis > Flashcards

4.3 - Psychosis Flashcards

1
Q

What is psychosis?

A
  • 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
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2
Q

What are some examples of psychotic disorders? (7)

A
  • schizophrenia
  • schizoaffective disorder
  • bipolar I
  • depression with psychotic symptoms
  • delusional disorder
  • drug induced
  • due to other medical condition
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3
Q

What are the three symptom domains in psychosis?

A
  • positive symptoms
  • negative symptoms
  • disorganisation
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4
Q

What are the two types of positive symptoms of psychosis?

A
  • hallucinations
  • delusions
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5
Q

What are hallucinations (and give examples)?

A
  • perception in absence of a stimulus
  • can occur in any sensory modality:
    • auditory - 1st (thought echo), 2nd, 3rd / running commentary / command hallucinations
    • visual (consider organic cause)
    • somatic/tactile/formication
    • olfactory
    • gustatory
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6
Q

What are delusions (disorder of thought content)?

A

Fixed, false beliefs not in keeping with social/cultural norms. Delusions have a theme/flavour

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7
Q

What are some examples of delusions? (9)

A
  • persecutory / paranoid
  • reference
  • grandiosity
  • religious
  • pathological jealousy
  • nihilistic / guilt
  • somatic
  • erotomanic
  • passivity experiences (1st rank symptoms) - thought broadcasting, insertion, withdrawal
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8
Q

What are the four types of negative symptoms of psychosis?

A
  • alogia (speech paucity/poverty)
  • anhedonia / asociality
  • avolition / apathy (reduced drive/motivation)
  • affective flattening
  • (think AAAA)
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9
Q

What is alogia?

(Negative symptom of psychosis)

A
  • paucity / poverty of speech (little content)
  • slow to respond to questioning
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10
Q

What is anhedonia / asociality?

(Negative symptom of psychosis)

A
  • lack of enjoyment/pleasure
  • few close friends
  • few hobbies/interests
  • impaired social functioning
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11
Q

What is avolition / apathy?

(Negative symptom of psychosis)

A
  • poor self-care
  • lack of drive/persistence at work/education
  • lack of motivation
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12
Q

What is affective flattening?

(Negative symptom of psychosis)

A
  • unchanging facial expressions
  • few expressive gestures
  • poor eye contact
  • lack of vocal intonations
  • inappropriate affect
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13
Q

What are the two types of disorganisation symptoms in psychosis?

A
  • bizarre behaviour
  • formal thought disorder (disorder of thought form)
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14
Q

What are some examples of bizarre behaviour?

A
  • inappropriate social behaviour
  • bizarre clothing/appearance
  • aggression/agitation
  • repetitive/stereotyped behaviours
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15
Q

What is formal thought disorder?

A

Lack of logical connection between thoughts

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16
Q

What is the order of increasing severity of formal thought disorder?

A
  • circumstantial thought
  • tangential thought
  • flight of ideas
  • derailment/loosening of association
  • word salad
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17
Q

What is the onset of psychosis like?

A
  • can occur at any age
  • peak incidence in adolescence/early 20s
  • peak later in women
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18
Q

What is the course of psychosis like?

A
  • often chronic and episodic
  • variable prognosis
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19
Q

What is the morbidity of psychosis like?

A
  • substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
  • significant impact on education, employment and functioning
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20
Q

What is the mortality of psychosis like?

A
  • all-cause mortality 2.5x higher
  • around 15% years life expectancy lost
  • high risk of suicide in schizophrenia - 28% of excess mortality
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21
Q

What is psychosis often preceded by?

A
  • prodromal symptoms (often misdiagnosed as depression)
  • 6-18 months before florid psychotic symptoms emerge
  • increasing isolation
  • poor self-care
  • social withdrawal
  • declining academic performance
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22
Q

What kind of disorders earlier in life can make people at high-risk of developing psychosis?

A

People at high-risk of developing psychosis often have/had another mental disorder like affective disorders earlier in life

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23
Q

What are the genetics behind schizophrenia?

A
  • highly heritable - 46% concordance in MZ twins
  • highly polygenic - lots of genes of small effect sizes, but ones found so far account for 20% of known genetic risk
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24
Q

What are the environmental risk factors for psychosis? (6)

A
  • drug use (especially cannabis)
  • prenatal/birth complications
  • maternal infections
  • migrant status
  • socioeconomic deprivation
  • childhood trauma
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25
Q

What is the psychiatric history? (5)

A
  • history of presenting concern (PC)
  • past psychiatric history
  • background history (family, personal, social)
  • past medical history and medicines
  • corroborative history
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26
Q

What is history of the presenting concern?

A
  • patient’s description of the presenting problem - nature, severity, onset, course, worsening factors, treatment received
  • circumstances leading to arrival at hospital - why now?
27
Q

What is gathered from past psychiatric history?

A
  • any known diagnosis?
  • any treatment?
  • known to a community team?
  • any previous admissions to hospital?
28
Q

What do we look for in family history (background history)?

A
  • age of parents, siblings, relationship with them
  • atmosphere at home
  • mental disorder in family, abuse, alcohol/drug misuse, suicide
29
Q

What do we look for in personal history (background history)?

A
  • mother’s pregnancy and birth
  • early development, separation, childhood illness
  • educational and occupational history
  • intimate relationships
30
Q

What do we look for in social history (background history)?

A
  • living arrangements
  • financial issues
  • alcohol and illicit drug use
  • forensic history
31
Q

What do we ask in past medical history?

A
  • regular medications?
  • compliance?
  • over the counter medications?
  • interactions?
32
Q

Who do we take a corroborative history from?

A
  • informants - relatives, friends, authority
  • maintain confidentiality
  • need patient consent if you want to inform relatives
33
Q

What does a mental state examination consist of? (7)

A
  • appearance and behaviour
  • speech
  • mood
  • thoughts
  • perceptions
  • cognition
  • insight
34
Q

What does appearance and behaviour include?

A
  • general appearance
  • facial expression
  • posture
  • movements
  • social behaviour
35
Q

What does neglect imply?

A
  • alcoholism
  • drug addiction
  • dementia
  • depression
  • schizophrenia
36
Q

What does weight loss imply?

A
  • anorexia nervosa
  • depression
  • cancer
  • hyperthyroidism
  • financial issues/homelessness
37
Q

What do we look for in posture?

A
  • depressive - hunched shoulders, downcast head and eyes
  • anxious - sitting upright, head erect, hands gripping chair
38
Q

What do we look for in movement?

A
  • manic - overactive, restlessness
  • depressive - inactive, slow
  • stupor - immobile, mute
  • tremors, tics, choreiform movements
  • dystonia (spasms)
  • tardive dyskinesia (face and jaw spasm)
  • mannerism, stereotypes
39
Q

What would you look for in appearance and behaviour in psychosis patients specifically?

A
  • bizarre or inappropriate clothing e.g. no shoes
  • agitation/aggression
  • poor personal hygiene or neglect of self care (negative symptoms)
  • injuries - more likely to be victims of violence, self-harm
  • psychomotor retardation/agitation
  • abnormal movements
  • echophenomena (echopraxia, echolalia)
  • stupor and mutism (catatonia)
40
Q

What do we assess in speech in MSE? (4)

A
  • quantity - less/more/mutism
  • rate - slow/fast/pressure
  • spontaneity - e.g. latency
  • volume
41
Q

How do we assess mood?

A
  • subjective - directly ask how mood is
  • objective - how you perceive their mood to be without asking
  • predominant mood
  • constancy - emotional incontinence, reduced reactivity/blunting/flattening, irritability
  • congruity - cheerful when describing sad events
42
Q

Why is it important to assess for mood in people with psychosis?

A
  • some affective disorders can cause psychosis (e.g. bipolar, depression) with implications for treatment
  • depression is comorbid with schizophrenia in 30% of cases
  • people at high risk of psychosis often have another mental disorder
43
Q

What do we look for in thoughts?

A
  • stream - spontaneous thought production
  • form - how you are thinking
  • content - what you are thinking
44
Q

What does thought content consist of?

A
  • preoccupations - thoughts constantly on mind
  • morbid thoughts - e.g. suicidality
  • delusions, overvalued ideas
  • obsessional symptoms
  • compulsions
45
Q

What are the three types of delusions?

A
  • primary - occurs suddenly
  • secondary - arises from previous abnormal idea/experience (i.e. hallucinations, delusions)
  • shared delusion (folie a deux) - same delusion shared by two individuals, solution is to separate them
46
Q

What are three types of perceptions?

A
  • illusions
  • hallucinations
  • distortions
47
Q

What are illusions?

A

Misperception of a real external stimulus

48
Q

What are hallucinations?

A
  • perception in the absence of external stimulus
  • true perception
  • pseudohallucination (coming from outside the head)
  • hypnagogic - awake –> asleep transition state
  • hypnopompic - sleep –> awake transition state
  • auditory
  • visual - Charles Bonnet syndrome
  • gustatory
  • tactile/deep sensation
49
Q

What is distortion?

A

Thoughts that distort one’s perception of reality

50
Q

What do we assess in cognition?

A
  • consciousness
  • orientation
  • memory
  • language
  • attention and concentration
  • visuospatial functioning
51
Q

What do we test for in insight?

A
  • awareness of oneself 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
  • acceptance of treatment
52
Q

What are the three different types of treatment options available for psychosis?

A
  • pharmacological
  • psychological
  • social support
53
Q

What are some examples of pharmacological management of psychosis?

A
  • antipsychotic medications
  • often mainstay of treatment
54
Q

What are some examples of psychological management of psychosis?

A
  • CBT for psychosis
  • newer therapies like avatar therapy
55
Q

What are some examples of social support for psychosis?

A
  • supportive environment, structures and routines
  • housing, benefits
  • support with budgeting/employment
56
Q

What neurotransmitter system is most implicated in the mechanism of antipsychotics?

A

Dopamine - but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine

57
Q

What is increased dopamine activity associated with in psychosis?

A
  • increased dopamine activity in mesolimbic dopamine system implicated in causing positive symptoms of psychosis
  • evidence from imaging, drug models, post-mortem studies
58
Q

What kind of drugs are most antipsychotics?

A
  • dopamine antagonists
  • newer agents e.g. aripiprazole are partial agonists
  • dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms
59
Q

What side effects can certain antipsychotics cause?

A
  • dopamine antagonist antipsychotics may cause extrapyramidal side effects (EPSEs)
  • umbrella term for side effects outside the traditional pyramidal movement pathway
  • caused by dopamine blockade in nigrostriatal (extrapyramidal) dopamine system (parts of brain that enable us to maintain posture and tone)
60
Q

What are some examples of extra-pyramidal side effects? (4)

A
  • parkinsonism
  • acute dystonic reactions (spasms)
  • tardive dyskinesia (spasms face and jaw)
  • akathisia (cannot stay still)
61
Q

What are the symptoms of parkinsonism? (7)

A
  • 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 thumb across other fingers
62
Q

What is the difference between typical and atypical antipsychotics?

A
  • antipsychotics divided into older typical drugs and newer atypical drugs
  • also referred to as first and second generation
  • atypical antipsychotics are associated with a lower risk of EPSE (due to 5HT-2A antagonism)
63
Q

What are the management principles of EPSEs? (5)

A
  • 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)
64
Q

What are some other side effects of antipsychotics?

A
  • CNS - EPSEs, sedation
  • haematological - agranulocytosis, neutropenia
  • metabolic - increased appetite, weight gain, diabetes
  • GI - constipation
  • pituitary - increased prolactin release (suppressed by dopamine)
  • cardiac - dysrhythmia, long QTc

Year 2 - BRS (84 decks)

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