4.3 - Psychosis Flashcards
What is psychosis?
- 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
What are some examples of psychotic disorders? (7)
- schizophrenia
- schizoaffective disorder
- bipolar I
- depression with psychotic symptoms
- delusional disorder
- drug induced
- due to other medical condition
What are the three symptom domains in psychosis?
- positive symptoms
- negative symptoms
- disorganisation
What are the two types of positive symptoms of psychosis?
- hallucinations
- delusions
What are hallucinations (and give examples)?
- 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
What are delusions (disorder of thought content)?
Fixed, false beliefs not in keeping with social/cultural norms. Delusions have a theme/flavour
What are some examples of delusions? (9)
- persecutory / paranoid
- reference
- grandiosity
- religious
- pathological jealousy
- nihilistic / guilt
- somatic
- erotomanic
- passivity experiences (1st rank symptoms) - thought broadcasting, insertion, withdrawal
What are the four types of negative symptoms of psychosis?
- alogia (speech paucity/poverty)
- anhedonia / asociality
- avolition / apathy (reduced drive/motivation)
- affective flattening
- (think AAAA)
What is alogia?
(Negative symptom of psychosis)
- paucity / poverty of speech (little content)
- slow to respond to questioning
What is anhedonia / asociality?
(Negative symptom of psychosis)
- lack of enjoyment/pleasure
- few close friends
- few hobbies/interests
- impaired social functioning
What is avolition / apathy?
(Negative symptom of psychosis)
- poor self-care
- lack of drive/persistence at work/education
- lack of motivation
What is affective flattening?
(Negative symptom of psychosis)
- unchanging facial expressions
- few expressive gestures
- poor eye contact
- lack of vocal intonations
- inappropriate affect
What are the two types of disorganisation symptoms in psychosis?
- bizarre behaviour
- formal thought disorder (disorder of thought form)
What are some examples of bizarre behaviour?
- inappropriate social behaviour
- bizarre clothing/appearance
- aggression/agitation
- repetitive/stereotyped behaviours
What is formal thought disorder?
Lack of logical connection between thoughts
What is the order of increasing severity of formal thought disorder?
- circumstantial thought
- tangential thought
- flight of ideas
- derailment/loosening of association
- word salad
What is the onset of psychosis like?
- can occur at any age
- peak incidence in adolescence/early 20s
- peak later in women
What is the course of psychosis like?
- often chronic and episodic
- variable prognosis
What is the morbidity of psychosis like?
- substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
- significant impact on education, employment and functioning
What is the mortality of psychosis like?
- all-cause mortality 2.5x higher
- around 15% years life expectancy lost
- high risk of suicide in schizophrenia - 28% of excess mortality
What is psychosis often preceded by?
- prodromal symptoms (often misdiagnosed as depression)
- 6-18 months before florid psychotic symptoms emerge
- increasing isolation
- poor self-care
- social withdrawal
- declining academic performance
What kind of disorders earlier in life can make people at high-risk of developing psychosis?
People at high-risk of developing psychosis often have/had another mental disorder like affective disorders earlier in life
What are the genetics behind schizophrenia?
- 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
What are the environmental risk factors for psychosis? (6)
- drug use (especially cannabis)
- prenatal/birth complications
- maternal infections
- migrant status
- socioeconomic deprivation
- childhood trauma
What is the psychiatric history? (5)
- history of presenting concern (PC)
- past psychiatric history
- background history (family, personal, social)
- past medical history and medicines
- corroborative history
What is history of the presenting concern?
- patient’s description of the presenting problem - nature, severity, onset, course, worsening factors, treatment received
- circumstances leading to arrival at hospital - why now?
What is gathered from past psychiatric history?
- any known diagnosis?
- any treatment?
- known to a community team?
- any previous admissions to hospital?
What do we look for in family history (background history)?
- age of parents, siblings, relationship with them
- atmosphere at home
- mental disorder in family, abuse, alcohol/drug misuse, suicide
What do we look for in personal history (background history)?
- mother’s pregnancy and birth
- early development, separation, childhood illness
- educational and occupational history
- intimate relationships
What do we look for in social history (background history)?
- living arrangements
- financial issues
- alcohol and illicit drug use
- forensic history
What do we ask in past medical history?
- regular medications?
- compliance?
- over the counter medications?
- interactions?
Who do we take a corroborative history from?
- informants - relatives, friends, authority
- maintain confidentiality
- need patient consent if you want to inform relatives
What does a mental state examination consist of? (7)
- appearance and behaviour
- speech
- mood
- thoughts
- perceptions
- cognition
- insight
What does appearance and behaviour include?
- general appearance
- facial expression
- posture
- movements
- social behaviour
What does neglect imply?
- alcoholism
- drug addiction
- dementia
- depression
- schizophrenia
What does weight loss imply?
- anorexia nervosa
- depression
- cancer
- hyperthyroidism
- financial issues/homelessness
What do we look for in posture?
- depressive - hunched shoulders, downcast head and eyes
- anxious - sitting upright, head erect, hands gripping chair
What do we look for in movement?
- manic - overactive, restlessness
- depressive - inactive, slow
- stupor - immobile, mute
- tremors, tics, choreiform movements
- dystonia (spasms)
- tardive dyskinesia (face and jaw spasm)
- mannerism, stereotypes
What would you look for in appearance and behaviour in psychosis patients specifically?
- 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)
What do we assess in speech in MSE? (4)
- quantity - less/more/mutism
- rate - slow/fast/pressure
- spontaneity - e.g. latency
- volume
How do we assess mood?
- 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
Why is it important to assess for mood in people with psychosis?
- 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
What do we look for in thoughts?
- stream - spontaneous thought production
- form - how you are thinking
- content - what you are thinking
What does thought content consist of?
- preoccupations - thoughts constantly on mind
- morbid thoughts - e.g. suicidality
- delusions, overvalued ideas
- obsessional symptoms
- compulsions
What are the three types of delusions?
- 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
What are three types of perceptions?
- illusions
- hallucinations
- distortions
What are illusions?
Misperception of a real external stimulus
What are hallucinations?
- 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
What is distortion?
Thoughts that distort one’s perception of reality
What do we assess in cognition?
- consciousness
- orientation
- memory
- language
- attention and concentration
- visuospatial functioning
What do we test for in insight?
- 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
What are the three different types of treatment options available for psychosis?
- pharmacological
- psychological
- social support
What are some examples of pharmacological management of psychosis?
- antipsychotic medications
- often mainstay of treatment
What are some examples of psychological management of psychosis?
- CBT for psychosis
- newer therapies like avatar therapy
What are some examples of social support for psychosis?
- supportive environment, structures and routines
- housing, benefits
- support with budgeting/employment
What neurotransmitter system is most implicated in the mechanism of antipsychotics?
Dopamine - but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine
What is increased dopamine activity associated with in psychosis?
- increased dopamine activity in mesolimbic dopamine system implicated in causing positive symptoms of psychosis
- evidence from imaging, drug models, post-mortem studies
What kind of drugs are most antipsychotics?
- dopamine antagonists
- newer agents e.g. aripiprazole are partial agonists
- dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms
What side effects can certain antipsychotics cause?
- 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)
What are some examples of extra-pyramidal side effects? (4)
- parkinsonism
- acute dystonic reactions (spasms)
- tardive dyskinesia (spasms face and jaw)
- akathisia (cannot stay still)
What are the symptoms of parkinsonism? (7)
- 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
What is the difference between typical and atypical antipsychotics?
- 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)
What are the management principles of EPSEs? (5)
- 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)
What are some other side effects of antipsychotics?
- 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
