5. Psychosis Flashcards
Psychosis
Abnormal condition of the mind that results in difficulties determining what is real and what is not.
Two domains of psychosis:
• Perception. • Cognition
Hallucinations division
Physiological, Physical, Psychiatric
Delusion:
Disorder of thought content. Usually, false belief that is out of keeping with patient’s social and cultural background.
Primary delusions
Not understandable, not occurring in response to psychopathology
Primary delusions entail:
Delusional perception and Wahnstimmung/delusional mood
Delusional perception
true perception to which a patient attributes a false meaning; eg. Traffic light turning red interpreted as martians are about to land
Wahnstimmung
change of mood preceding a delusion, patient senses an mysterious change in the environment
Autochthonous delusion
morbid origin, not a transformation of real perception (ghosts), suggestive of schizophrenia
Secondary delusions and systematization
Where brain formulates and establishes delusions secondary to another psychopathological state, delusions induced by morbid psychopathology
Capgras syndrome:
Believe a close acquittance has been replaced by a pretender/imposter
Fregoli syndrome:
Two or more people are the same person changing disguises in order to mislead
Othello syndrome:
One believes their partner is being unfaithful
Cotard syndrome:
Nihilistic delusion (severe depression) you believe your body is rotting away/ you are dead
Couvade syndrome:
Pregnant women’s partner experiences symptoms mimicking pregnancy.
De Clerembault’s syndrome or erotomania:
Excessive sexual desire, often believing a VIP is in love with them
Ekbom’s syndrome:
Belief that one is infested with parasites
Factitious disorder/Munchausen:
Consciously pretending to have a medical illness as they have satisfaction in taking a sick role
VS. Hypochondriasis:
Unconsciously pretending they have a medical illness
Folie a deux:
Shared delusions, hallucinations between people
Formal Thought Disorder
Illogical or muddled thinking, experiences of struggling to think clearly.
Three features of healthy thinking (Schneider):
- Constancy
- Organization
- Continuity
Tangentiality:
Wandering from a topic without returning to it
Entgleisen
Jumping between topics that are not connected
Word salad:
Completely incoherent speech where real words are strung together into nonsense sentences
The Kraepelinian continuum
Affective disorder – schizoaffective disorder – schizophrenia/psychotic disorder
First Rank Symptoms
Used to distinguish affective psychosis from schizophrenia and related ‘purely psychotic’ disorders.
First rank formula
n = 11 = (3x3+2)
3 auditory hallucinations, 3 passivity phenomena, 3 thought phenomena +2 (delusional perception and somatic hallucinations)
Positive symptoms of schizophrenia
Caused by excess of dopamine in mesolimbic pathway, symptoms include hallucinations and delusion – decreasing dopamine in the pathway would be therapeutic
Negative and cognitive symptoms in schizophrenia
shortage of dopamine in mesocortical pathway - increasing dopamine in this pathway would be therapeutic
Mesocortical pathway
Cognition and executive function
Mesocortical, hypodopaminergic symptoms:
Alogia, affective flattening, avolition
Mesolimbic pathway
Regulation of emotional behaviour
Mesolimbic, hyperdopaminergic symptoms:
Delusions, hallucinations, disorganised speech, behaviour, thought
Nigrostriatal pathway
Motor control
Tuberoinfundibular pathway
Regulation of prolactin secretion
Schizophrenia pathophysiology
Dopamine increased in mesolimbic pathway (Causes positive symptoms) and dopamine levels in mesocortical pathway decreased (causing negative and cognitive symptoms)
Schizophrenia treated with Dopamine 2 antagonist
Reduces dopamine signalling in mesolimbic pathway – reduce positive symptoms, Negative symptoms are not addressed
Schizophrenia treated with atypical dopamine 2 partial agonist
Reduced excess dopamine in mesolimbic pathway, and enhances dopamine signalling in mesocortical pathway (improving both positive and negative symptoms)
Schizophrenia definition
Severe mental illness characterised by disintegration of the thinking process, of contact with reality, and of emotional responsiveness (hallucinations and delusions)
Schizophrenia diagnosis (Schneiders 1st rank)
At least 1 for >1 month
- Delusions (false and fixed beliefs)
- Passivity (delusions of control)
- Thought disorders (thought insertion, withdrawal, broadcasting)
- Auditory hallucinations (thought echo, 3rd person voice, running commentary)
Schizophrenia diagnosis
> =2 of the following for >=1 month
• Paranoid: persistent hallucinations in any modality
• Hebephrenic: incoherent or irrelevant speech (neologisms)
• Catatonic: excitement, posturing, waxy flexibility, negativism, negativism, mutism, stupor
• Simple Schizophrenia: negative symptoms – apathy
Residual schizophrenia:
previous schizophrenia -> now just negative signs and symptoms
1st line treatment for Schizophrenia
Low dose Aripiprazole/ Quetiapine or high dose Olamzapine/Risperidone
Aripiprazole side effects
Initial akathisia
Quetiapine side effects
Sedation and weight gain
Olanzapine side effects
Weight gain
Risperidone
Hyperprolactinaemia, EPSEs, sedation
Augmentation
Diazepam or lithium
Non compliance 1st line treatment for schizophrenia
1x monthly IM depot injection, Clopixol
2nd line treatment for Schizophrenia
6 weeks, typical antipsychotics
3rd line treatment for Schizophrenia/resistance
Clozapine
Clozapine side effects
Neutropenia or agranulocytosis
Mood congruent
‘in agreement’: manic person believes they are a powerful god
Mood incongruent
‘conflicting’: laughing when your dog dies
Schizoaffective disorder
A group of disorders in which both affective and schizophrenic (psychotic) symptoms are prominent equally but do not justify a full diagnosis of either of those.
Manic type schizoaffective disorder
Both schizophrenic and manic symptoms prominent, develop at the same time; Single episode or recurrent disorder (majority manic episodes)
Depressive Type schizoaffective disorder
Both schizophrenic and depressive symptoms prominent, develop at the same time; Single episode, or recurrent disorder (majority depressive episodes)
Schizoaffective disorder diagnosing criteria
Psychotic (schizophrenic) states to persist for >=2 weeks without concurrent affective symptoms
Requires 2 episodes of psychosis:
• 1 episode lasting >2 weeks without mood disorder symptoms
• 1 episode requires obvious overlap of mood and psychotic symptoms
Schizoaffective disorder treatment
As per schizophrenia
BPAD treatment (mania+depression)
1st line: Fluoxetine (SSRI) + Olanzapine (antipsychotic)
2nd line: Lamotrigine
