5.1 Psychosis

Question 1

What is the phenomenological definition of psychosis?

Answer 1

Mental condition where signs and symptoms are not understandable (in ordinary sense of thought, word, deed), out of touch with reality (cultural context of mores, norms) & loss of insight (anosognosia)

Question 2

What is the sociocultural definition of psychosis?

Answer 2

Mental condition where there is a breakdown in cultural conformity (referencing the communal context), communication, and control over one’s own behaviour

Question 3

What is the clinical definition of psychosis?

Answer 3

Clinical condition characterised by presence of ≥ 1 of the following psychopathologies (picked up only after clinical assessment):
• Perception: hallucinations, delusions, passivity experience
• Cognition: thought disorder, loss of insight
• Emotion: abnormal mood
• Behaviour: anomalous behaviour

Question 4

What is the medicolegal definition of legal insanity?

Answer 4

insanity refers to unsoundness of mind (≠ clinical psychosis):
• Assessed via a very specific set of criteria

Question 5

What is the definition of delusion (persecutory, referential, grandiose, infidelity, sin, poverty, hypochondriacal, nihilistic ) ?

Answer 5

False belief based on incorrect inference about external reality that is firmly held despite evidence to the contrary and despite the fact that other members of the same culture do not share belief.

Question 6

What is the definition of hallucination (auditory, visual, tactile, olfactory, gustatory ) ?

Answer 6

False sensory perception occurring in the absence of any relevant external stimulation of the sensory modality

Question 7

What is the definition of catatonia?

Answer 7

Commonly manifests as various types of motor abnormalities

Question 8

What is the definition of mutism?

Answer 8

paucity or absence of speech whereas

Question 9

What is the definition of negavism?

Answer 9

opposition of resistance to outside suggestions or advice

Question 10

What does catatonic stupor refer to?

Answer 10

absence of all relational activities such as movement, social speech and response to external stimuli as in catatonic stupor. A person with catatonic stupor although fully conscious is mute, immobile and unresponsive to external stimuli,

Question 11

What is disorganised behaviour?

Answer 11

Bizarre, or gross socially inappropriate behaviou

Question 12

What is disorganised speech?

Answer 12

Inability to think sequentially in a goal directed manner such that the speech lacks a logical flow (derailment) and appears difficult to follow to other people.

Question 13

What is expressed emotion?

Answer 13

emotional over involvement, hostility, and critical attitude of the family members towards the patient.

Question 14

Psychosis is a type of mental illness characterised by loss of contact with reality. It is a type of major mental illness.

• The hallmark of psychosis is ______________ which refers to an ability to distinguish internal fantasy from external reality
• -> Example: A person suffering from psychosis may believe that people around him are conspiring against him while the truth is that this is his own fantasy thinking.
• In addition, there may be an ______________. This refers to the patient’s inability to distinguish what is outside the body from what is inside.
• -> Example: attributing own bodily sensations as being imposed upon the body by an external agency or person as seen in phenomenon of somatic passivity which is a first rank symptom of schizophrenia.
• -> Another example is the phenomenon of depersonalization which can be found in other mental disorders of altered mental states as well.
• Impaired a_________________: they find it difficult to adjust to their circumstances effectively leading to impaired social and occupational functioning

Answer 14

impaired reality testing ;

impairment of sense of reality;

daptation to reality

Question 15

What kind of hallucinations do schizophrenic patients hear?

Answer 15

• Third person auditory hallucinations: voices discussing the patient in third person
• Running commentary auditory hallucinations: voices commenting upon the patient’s thoughts or actions
• Thought echo: hearing one’s own thoughts being spoken aloud . The voices may repeat his thoughts out loud as they are being thought (gedanken laut-werden), just after they have been thought (echo de la pensee), or just before they have been thought

Question 16

What kind of thought alienation do schizophrenic patients hear?

Answer 16

• Thought broadcast: patient believes that his thoughts are being read by others as if they were being broadcasted
• Thought withdrawal: the experience of one’s own thoughts being removed from one’s mind by an external agency
• Thought insertion: External (alien) thoughts are being inserted into his mind by an external agency

Question 17

How does a schizophrenic patient fee; that his free will has been removed?

Answer 17

• Made act: experiencing one’s actions as being controlled by an external agent
• Made emotion: one’s emotions being experienced as not one’s own but imposed by an external agent
• Made impulse; experiencing impulse for an action as being imposed by an external agent

Question 18

what is somatic passivity?

Answer 18

the belief that sensations are being imposed upon one’s body by an external agent

Question 19

What is delusional perception?

Answer 19

a primary delusion in which a normal perception in infused with a unique and idiosyncratic delusional meaning which does not have any apparent link between the perceived object and the delusion

Question 20

What is waxy flexibility?

Answer 20

in which patient’s limbs can be moulded into a position and remained fixed for a long period of time

Question 21

What is posturing?

Answer 21

patient adopts an inappropriate or a bizarre bodily posture continuously for a substantial period of time

Question 22

What is avolition?

Answer 22

Lack of wilful activity resulting from loss of drive or initiative

Question 23

What is anhedonia?

Answer 23

Difficulty in experiencing interest or pleasure. It may express itself as a lost of interest in pleasurable activities or lack of involvement in social relationships of various kinds

Question 24

What is flattening of affect?

Answer 24

Impoverishment of emotional expression, reactivity or feeling

Question 25

What is alogia?

Answer 25

impoverishment of thinking leading to either paucity or output of speech or content of speech or both

Question 26

The clinical picture is dominated by the presence of symptoms, such as
- Delusions of persecution, such as the patient believing that others are plotting against him
- Delusions of reference such as believing that strangers or the television, radio or newspapers are referring to the patient in particular; when such thoughts do not reach delusional intensity they are known as ideas of reference.
- Delusions of exalted birth, or having a special mission; for example, the belief that one has been born with a messiianic role
- Delusions of boldly change
- Delusions of jealousy
Hallucinatory pisces of a threatening nature or that issue commands to the patient
- Non verbal auditory hallucinations, such as laughing, whistling or humming
- Hallucinations in other modalities, such as smell, taste, vision or of sexual or other somatic sensations

What is this type of schizophrenia?

Answer 26

Paranoid schizophrenia

Question 27

The following features are typical of this form of schizophrenia

• Irresponsible and unpredictable behaviour, with the patient often exhibiting mannerisms and playing pranks
• Rambling and incoherent speech
• Affective changers, including an incongruous affect and shallow mood, often with giggling and fatuousness
• Poorly organized delusions
• Fleeting and fragmentary hallucinations.

Answer 27

Hebephrenic schizophrenia

Question 28

In this form there is insidious onset of functional decline. Negative symptoms develop without the prior occurrence of positive symptoms. For this reason the diagnosis is often made confidently only in retrospect.

What is this form of schizophrenia?

Answer 28

Simple schizophrenia

Question 29

What is this form of schizophrenia?

- Catatonic symptoms are predominant

Answer 29

Catatonic schizophrenia

Question 30

What kind of delusions do schizophrenic patients have?

Answer 30

persecutory, referential, grandiose, infidelity, sin, poverty, hypochondriacal, nihilistic, bizarre delusions

Question 31

what is this syndromic classification of schizophrenia called + where is the loss of maximal activation in the brain?
- characterized by poverty of speech, flatness of affect and decreased spontaneous movement

Answer 31

• Psychomotor poverty syndrome

- Prefrontal cortex

Question 32

what is this syndromic classification of schizophrenia called + where is the loss of maximal activation in the brain?
- characterized by disorders of the form of thought and inappropriate affect

Answer 32

• Disorganization syndrome

- Anterior cingulate cortex

Question 33

what is this syndromic classification of schizophrenia called + where is the loss of maximal activation in the brain?
- characterized by the occurrence of delusions and hallucinations,.

Answer 33

• Reality distortion syndrome\

- Parahippocampal gyrus

Question 34

What are the investigations required for schizophrenia?

Answer 34

• Further emotion
• Urea and electrolytes, fbc, thyroid function tests, lfts
• Screen for illicit drugs, if psychoactive substance use is suspected a cause
• Vitamin B12 and folate levels
• Syphilitic serology
• Electroencephalography (EEG: the symptoms may be caused by complex partial seizures of the temporal lobe)
• Computed tomography (CT) or magnetic resonance imaging (MRI) scan (if clinically indicated).
  In the case of 1st presentation in elderly, i,.e. When the the diagnosis being considered in paraphrenia, tests of hearing and vision should be carried out in early stage, as sensory deprivation is an important cause in this age group

Question 35

What are the ddx of schizophrenia?

Answer 35

• Organic disorders and psychoactive substance use disorders, should be excluded before making a diagnosis of schizophrenia
• Mood disorders may present with symptoms similar to schizophrenia. Negative symptoms and early stages of early schizophrenia may be difficult to distinguish for depression. In such cases care should be taken to look for other symptoms of schizophrenia, both in the acute phase and following an episode of schizophrenic illness (post schizophrenic depression). Schneider’s first rank symptoms can occur in mania. Therefore, one should look for other features of mania, particularly if there is not previous history of schizophrenia.
• The onset of schizophrenia can lead to personality deterioration, which may stimulate a personality disorder.

Question 36

what are predisposing factors, precipitating factors and maintaining factors in the stress diathesis model?

Answer 36

• Predisposing factors: Genetic predisposition, birth complications, effects of early infections
• Precipitating factors: stressful life events, illicit drug use
• Maintaining factors: high expressed emotion in the family, illicit drug use

Question 37

Brain abnormalities in Schizophrenia

Hypofrontality demonstrable on brain imaging

• ________________ is present in a proportion of patients with schizophrenia
• Diffuse reduction in the volume of cortical grey matter has been found in schizophrenic patients by MRI (also been associated with poor premorbid function).

Changes in regional blood flow demonstrable on functional imaging
- Neuropathological changes on post mortem examination- hippocampal cell loss and disarray
- Compared with control brains, the brains of patients with schizophrenia have been found to be a little lighter and to have a reduced hippocampal size and fewer neurones in the hippocampus, with these changes being particularly marked on the left side.
- Abnormalities have also been found in the _______________, which forms the anterior part of the parahippocampal gyrus and lies superficial to the amygdala and to the uncal and most anterior parts of the body of the hippocampal formation. These abnormalities include invaginations of the cortical surface and heterotopic displacements of the neurons. They are likely to be caused by abnormal neuronal migration. As neuronal migration is usually almost complete by the time of birth, such abnormalities probably represent neurodevelopmental pathology.
The hippocampus and entorhinal cortex are interconnected and are involved jointly in the functions of memory and reality testing so that the abnormalities in their cytoarchitecture may be responsible for some of the symptoms of schizophrenia.

Neurocognitive deficits

Answer 37

Cerebral ventricular enlargement;

entorhinal cortex

Question 38

What drugs are usually used to treat psychosis?

Answer 38

Common typical antipsychotics are Haloperidol, Trifluoperazine and Sulpride. Commonly used atypical antipsychotics are Risperidone, Olanzapine and Quetiapine.

Question 39

When is clozapine used in treatment for psychosis? What are the side effects?

Answer 39

Clozapine may be used in those patients who either do not respond or cannot tolerate other antipsychotics. As clozapine can cause agranulocytosis, such patients need to have regular checks (initially weekly) of their white blood count and neutrophil and platelet levels. They also must be monitored clinically with signs of infections, such as sore throat or development of influenza.

Question 40

when is ECT the treatment of choice the schizophrenic patients?

Answer 40

Role of electroconvulsive therapy (ECT), may be the treatment of choice in patients with

• Catatonic symptoms
• Severe depressive symptoms with high suicide risk
• Severe mania with risk of harm to self or others, or risk of exhaustion
• Occurs only rarely these days (because of the ready availability and early use of antipsychotics)

Question 41

The central antidopaminergic activity of neuroleptics give rise to the following types of extrapyramidal side effects

• _____________ including a resting tremor, bradykinesia, cogwheel rigidity, postural abnormalities and a festinant gait
• Dystonias, which are _____________________, such as tongue protrusion, grimacing, opisthotonos (involving most of the the body), spasmodic torticollis (involving the neck) and oculogyric crisis (involving movement of the eyes superiorly and to one side
• _____________, in which a disagreeable inclination to move leads to restlessness
• __________________ , which is abnormal involuntary movements of the face, limbs, and respiratory muscles including chewing and sucking movements, tongue protrusion, grimacing, finger movements, clenching and torticollis.

Answer 41

Parkisonian symptoms ;

abnormal involuntary facial and bodily movements caused by slow and continuous muscle contraction or spasm;

Akathisia;

Tardive dyskinesia;

Question 42

The term +++++++++++++++s is used to refer to episodic disorders in which both symptoms of a mood disorder and schizophrenic symptoms are prominent within the same episode of illness, either simultaneously or within a few days of each other. The occurrence of mood- incongruent delusions or hallucinations in mood disorders does not change the diagnosis from that of a mood disorder to schizoaffective disorder.

When schizophrenic and manic symptoms are prominent in the same episodes of illness, the disorder is termed schizoaffective disorder, manic type. The patient usually makes a full recovery.

In schizoaffective disorder, depressive type, schizophrenic and depressive symptoms are prominent in the same side of illness. The prognosis of this subtype is not as good as that of the manic subtype where there being greater chance of patients going on to develop negative symptoms of schizophrenia.

Answer 42

schizoaffective disorder

Question 43

What is othello syndrome?

Answer 43

Pathological (delusional) jealousy
- The patient holds the delusional belief that his/ her partner is being unfaithful and will go to great lengths to find evidence e.g. belongings may be searched regularly and the partner may be constantly interrogated or followed. Also called the Othello syndrome, morbid jealousy, erotic jealousy, sexual jealousy, psychotic jealousy and conjucal paranoia, pathological or delusional jealousy is more common in men.

Question 44

What is Erotomania (de Clerambault’s syndrome)

Answer 44

The patient holds the delusional belief that someone else, usually of a higher social or professional status, or a famous personality or in some way “unattainable”. The patient may initially believe that because the other person is of a higher status it is not possible to tell the patient explicitly that he or she is loved and rejections may be seen as actually representing coded messages of love. Eventually the rejections may lead to animosity and bitterness on the part of the patient.

In hospital and outpatient clinic psychiatry, patients are more likely to be female than male, whereas in forensic psychiatry male patients are more common. Overall, females outnumber males.

Question 45

What is Cotard’s syndrome?

Answer 45

Cotard’s syndrome is a nihilistic delusional disorder in which the patient believes for e.g. that all his wealth has gone or that relatives or friends no longer exist. It may take a somatic form with the patient believing that part of his body does not exist. It can be secondary to very severe depression or to an organic disorde

Question 46

What is capgras syndrome?

Answer 46

Although capgras syndrome is also called the illusion of doubles, it is not an illusion but a delusion disorder. The essential feature of this rare symptom is a patient who is familiar to the patient is believed to have been replaced by a double. This disorder is more common in females, with the apparently replaced person often being a relative e.g. husbands. Common primary causes are schizophrenia, mood disorder and organic disorder. Derealization commonly occurs.

Question 47

What is fregoli syndrome?

Answer 47

The patient believes that a familiar person who is often the patient’s persecutor, has taken on different appearances. The person recognizes this person in others who may look completely different from the actual other person. Primary causes include schizophrenia and organic disorder.