Block 33 Week 4 Flashcards
what does the sural nerve supply?
lateral foot and posterolateral leg
what does the lateral femoral cutaneous nerve supply?
lateral thigh
what does the superficial fibular nerve supply?
antero-lateral aspect of the leg along with the greater part of the dorsum of the foot (with the exception of the first web space, which is innervated by the deep peroneal nerve)
first web space innervation?
deep peroneal nerve
deep fib nerve supplies?
webbing between first and second digits
pulmonary haemorrhage can lead to an elevated?
- TLCO
- to the presence of extra haemoglobin in the lungs that is able to bind to the carbon monoxide due to the high affinity of the molecule.
what arises from the endoderm?
thyroid, parathyroid, thymus
deficiency in which vitamin can lead to impaired collagen synthesis and disordered connective tissue?
vitamin C
hallucinations =
- Perception experienced in the absence of an external stimulus to the corresponding sense organ
Visual hallucinations?
- seeing faces, scenes, images
auditory hallucinations?
- = hearing voices
- 2nd person/ 3rd
Gedankenlautwerden hallucinations?
hallucination where a patient hears voices which anticipate what he or she is about to think, or which state what the patient is thinking as he thinks it.
Echo de la pense hallucinations?
hear voices which echo thoughts just after they have occured
Types of delusions?
reflex hallucinations?
stimulus in one sensory field producing hallucinations in another
disorders of thought involves?
form, flow and content
retardation of thinking?
- Retardation of thinking/Poverty of content is often seen in depression, the train of thought
is slowed down, although still goal directed.
pressure of speech =
seen in mania
disorders of form?
- loosening of association
- flight of ideas
- knights move thinking
- talking past point
- word salad
loosening of association?
(loss of normal structure of thinking - discourse appears (Muddled / illogical)
flight of ideas?
- when the content of speech moves quickly from one idea to another so that one train of thought is not carried to completion before another takes its place.
- The normal logical sequence of ideas is generally preserved although ideas may be linked by distracting cues in the surroundings and from distractions from the words that have beenspoken.
knights move thinking??
odd associations between ideas
word salad?
speech is senseless and repetitive
delusions =
- False belief based on incorrect inference about external reality that is firmly sustained.
- It is a belief that is not one ordinarily accepted by other’s of the person’s culture or religion.
types of delusion?
- delusions of jealousy - delusions that ones partner is unfaithful without having any proof
- grandiose delusions - inflated sense of self
delusional mood?
change in mood preceding a delusion - ‘something is going on’
delusional perception?
-> Delusional perception (linking a normal sensory perception to a bizarre conclusion, e.g. seeing an aeroplane means the patient is the president
delusional memory ?
Memory + delusional significance e.g. Man believes he is of royal decent because the spoon he was fed with as a baby had a crown on it
epidemiology of schizophrenia?
- one in 100
- ages 15-45, but may develop at any age
men tend to develop schiz ?
- males and females equally affected but men tend to develop it earlier at around 20 but women 30
genetics of schiz?
- Genetics- high genetic linkage to schizophrenia.
- One parent with Schizophrenia 10% lifetime(10% increased chance if you have member of family with the condition.
environmental insuts and schiz?
winter or spring births and infections, obstetric complications
personality inc schiz risk?
- Personality – person with underlying Schizotypalpersonality disorder.
stress and schiz?
- upbringing and stressful life events - increased risk of relapse rates
- social stresses - social drift hypothesis
cannabis and schiz?
- substance miuse - heavy cannabis intake at 18 associated w inc risk of psyhcosis
structural brain abn and schiz?
Decreased cortical volume,enlarged ventricles, hypo frontality (associated with negative symptoms and autism.
positive symptoms of schiz?
- presence of problematic behaviours
- Hallucinations (illusory perceptions), especially auditory
- Delusions (illusory beliefs), especially persecutory
- Disorganized thought and nonsensical speech
- Bizarre behaviours
Negative symptoms of schiz?
- absence of healthy behaviours
- Flat affect (no emotion showing in the face)
- Reduced social interaction
- Anhedonia (no feeling of enjoyment)
- Avolition ((less motivation, initiative, focus on tasks)
- Alogia (speaking less)
- catatonia - moving less
3 major phases of schiz?
- prodomal
- active phase
- residual phase
Prodomal phase?
- non specific symptoms can be present for weeks or months preceding the first acute symptoms of Schizophrenia in a young person.
- subclinical symptoms
- IEPT usually involved here
active phase of schiz?
- psychotic symptoms, e.g. delusions, hallucinations are prominent with strong affect of distress, anxiety and fear.
- These may resolve spontaneously ( after 4-8 weeks) or continue indefinitely cycling, which means relapse might occur.
residual phase of schiz?
- no longer having any of the prominent psychotic symptoms.
- However, there are some remaining symptoms of the disorder such as eccentric behaviour, emotional blunting, illogical thinking or social withdrawal.
prognosis of schiz?
- 1/3 make complete recovery
- 1/3 experience recurrent episodes of psychosis with some degree of social disability
- 1/3 may remain chronically disabled.
features indicating good prognosis?
- abrupt onset,
- an absence of prodromal disturbances,
- onset in midlife,
- presence of identifiable life stresses,
- absence of blunting/flat affect
- and/or early treatment
schizophrenia involves disruptions in the following dopamine pathways:
- mesolimbic pathway
- mesocortical pathway
- nigrostriatal pathway
- tuberoinfundibular pathway
mesolimbic pathway?
key role in motivation, emotions, rewards andpositive symptoms
mesocortical pathway?
- physiological cognition and executive function (Dorsolateral prefrontal cortex)
- underactivity of dopamine -> negative symptoms
mesocortical pathway - emotions and affect?
- ventomedial prefrontal cortex
- Hypofunction maybe linked to cognitive and negative symptomsn
nigrostriatal pathway?
- contains 80% of brains Dopamine
- involved in motor pathway and Dopaminergic neurons stimulate purposeful movement
tuberoinfundibular pathway?
- influences prolactin release
(Dopamine in the tuberoinfundibular pathway inhibit prolactin release)
dopamine role?
(DA is a neurotransmitter found in the mesolimbic-mesocortical system) and feelings of bliss and pleasure, euphoric, appetite control, controlled motor movements, feel focused
Amphetamine?
dopamine agonist (so can mimic acute schizophrenia)
serotonin?
- setrotonin promotes and improves sleep, improves self esteem, diminishes craving, prevents agitation in depression.> psychosis and agitation
glutamate hypothesis of schiz?
- excitatory amino acid NT
- hypoglutamatergic state can predispose for schizopgrenia
what can block glutamate receptors?
Drugs such as Angel dust, the hallucinogenic drug phencyclidine hydrochloride blocks NMDA Glutamate receptors
DDs of psychosis?
- Schizophrenia (Most common)
- Schizotypal Disorder- and other Personality disorders
- Persistent Delusional Disorder
- Schizoaffective Disorder - psychotic and affective symptoms present in the same episode - mania, depressive or mixed presentation
- brief psychotic disoerder
- Mood disorder with psychotic symptoms like mania with psychosis
specific delusional disorders?
capgras, fregoli delusions, folie a deux, erotomania
management of psychosis?
- assess risk level
- Reducing symptoms and disturbed behaviours
- biological interventions
- psychological interventions
- social interventions
biological management of schiz?
- antipsychotics
- used to treat psychotic symptoms e.g. with bipolar, Tourette’s and medical illnesses like aggression in Dementia
typical AP?
- chlorpromazine
- Haloperidol
- Flupentixol
Typical AP mechanism?
- D2 antagonists
- better for positive symptoms
- cause increased incidence of EPS and NMS
Atypical AP examples?
- risperidone
- olanzapine
- clozapine - Tx resistant cases
mechanism of atypical AP?
- low D2 antagonistic effect
- Acts on Serotonin arid Histamine receptors
- Better on negative symptoms
Atypical AP side effects?
- Cause anticholinergic and metabolic side effects
EPS side effects - 3 hrs?
- through nigrostriatal pathway
- 3 hrs - Acute Dystonia
EPS side effects - 3 days - weeks?
- 3 days – weeks - Bradykinesia
EPS side effects - 3 months?
- 3 months - Akathisia
EPS side effects - tardive dyskinesia?
usually after years
Antihistaminic side effects of AP?
- hyperprolaxtinaemia
- anti-alpha adrenergic side effects
- antimuscarinic
- abn liver function
- seizures
neuroleptic malignant syndrome?
- Neuroleptic malignant syndrome - medical emergency, needs to be taken to A&E
- occurs in minutes - hours
Psycho-education?
accepting the illness, addressing routine/activity scheduling, sleep hygiene, breathing techniques, mindfulness
CBT for schiz?
- psycho-education
- family therapy
family therapy for schiz?
- awareness of relapse symptoms, supporting structure, looking after the patient
social interventions?
- rehabiliation
- social support
rehabilitation?
- Return to education/work, re-establishing family functioning, management of substance-misuse etc.
social support for schiz?
- Housing & Accommodation Issues, Access to benefits etc.
approach for chronic enduring psychosis
CPA - Care Programme Approach
First rank symptoms of schiz?
- auditory hallucinations:
- hearing thoughts spoken aloud
hearing voices referring to himself / herself, made in the third person - auditory hallucinations in the form of a commentary
- thought withdrawal, insertion and interruption
- thought broadcasting
- somatic hallucinations
- delusional perception
- feelings or actions experienced as made or influenced by external agents
psychosis may be present in:
–Severe depression
–Mania
–Delirium (acute presentation, not chronic)
–Dementia
–Neuropsychiatric disorders such as Parkinson’s
- Side-effects of drugs eg steroids, amphetamines
epidemiology of schizophrenia?
- 1% lifetime prevalence of schizophrenia
- incidence: around 15 new cases per 100000 per annum
onset of schiz: the prodome?
- begins in young adulthood
- Children who go on to develop schizophrenia often have subtle premorbid motor, linguistic and social dysfunction
- Gradual functional decline: fall off in school/college, loss of friends, odd behaviours, ideas, beliefs etc
- May go on for months or years
Schiz MSE - appearance
may be dishevelled, neglected, wearing special or inappropriate clothes or things that are not clothes
Schz MSE - behaviour?
may be overactive or underactive: may make strange gestures or odd purposeless movements: may be responding to hallucinations
Schiz - mood?
usually not depressed or elated: can be angry, suspicious, withdrawn, fatuous, vacant, perplexed or ‘flat’ with facial expression to match
Schiz - talk?
may be fluent but unintelligible, or very limited: may be preoccupied with abnormal mental content
Schiz - cognition is often?
impaired
DDs for schiz - always consider?
- Always consider drug induced psychosis: cannabis, stimulants, hallucinogens
psychosis could also be?
- Psychosis can be brief, stress related and not schizophrenia
affective psychosis?
- Affective psychosis – look for elation/depression
organic psychosis?
- rare
- temporal lobe epilepsy, SOL, brain trauma, ICU, dementia in older ppl
psychosis - managemet plan?
- AP are mandatory in established cases
- Most relapses are caused by non-compliance and/or substance abuse
- Early intervention in psychosis services
For ppts with first episode of psychosis offer:
*oral antipsychotic medication in conjunction with psychological interventions (family intervention and individual CBT,
the first episode of psychosis?
- education abt disorder and treatment
- Need to help patient and family resolve related matters: education, training, finances, social integration
- Need to determined if this is bona fide schizophrenia or persistant substance induced psychotic disorder, and treat accordingly
stigma =
refers to a cluster of negative attitudes and beliefs that motivate the general public to fear, reject, avoid, and discriminate against people with mental illnesses.
common/ case law is ?
the development of legal standards that have been tested in a court of law over time.
statute law =
law passed by Acts of Parliament.
common law?
*A person with a mental illness is an autonomous individual, ie is presumed to have capacity to consent to or refuse treatment, unless it is shown to be otherwise.
To have capacity to give informed consent a person must be able to:
–Understand the information given
–Retain that information long enough to make a decision
–Weigh it in the balance free from either internal or external pressures
–Communicate the decision
mental capacity act?
- enshires principals of common law as regards to the treatment of persons who lack capacity into statute law
Mental Health Act (1983)?
- The MHA allows for assessment, treatment and in-patient care for persons with a mental disorder and governs the procedure by which that care is given.
- The use of the Mental Health Act is not determined by an assessment of capacity, but rather by the presence or absence of a mental disorder.
suicide risk in schiz?
- to oneself - about 10-15% suicide risk in schizophrenia
- particularly high in young, educated people early in the course of their illness.
risk to others in schiz?
- to others - risk of violence, minor aggression
other risks w schiz?
- self neglect - due to postive and negatve symptoms
- vulnerability of patients to stigma
ideas of reference?
the patient receives special messages from the media, or interprets ordinary events as having special meaning. Not as overwhelming as delusional perception
passitivity experiences =
the patient’s thoughts, moods, bodily sensations or behaviour, which they may experience as abnormal for them, are imposed upon them by an outside agency.
disorder of mood =
incongruous or inappropriate affect. Usually causeless laughter or smiling. May be embarrassing eg laughing when a wreath fell off the coffin at a funeral.
main diagnostic features of schiz?
- The main diagnostic features are delusions, hallucinations, thought disorder and lack of insight.
what to consider in a first presentation of psychosis?
- Consider intoxication (e.g. cannabis, alcohol, amphetamines) or drug overdose (accidental or suicidal) in first presentation of psychosis or in an acute exacerbation in a patient with established schizophrenia.
RF for schiz?
- Family history
- Social isolation
- Migrants
- Family problems
- Heavy cannabis use in adolescence
- Intrauterine and perinatal complications
- Intrauterine infection, particularly viral
- Abnormal early cognitive/neuromuscular development
red flags in schiz - suicidal thoughts?
- Severe social problems
- Self-neglect
- Hallucinations, especially command in nature
- Passivity phenomena
I & C in schiz?
I - Shame and stigmatisation common
C - concerns abt social isolation/ losing their job
General examination - appearance?
Appearance. Is there evidence of neglect or abuse? Assess the general nutritional state.
GE - dystonias?
Acute dystonias and severe systemic reactions to antipsychotics may occur.
GE - alcohol?
Look for signs of alcoholic liver disease (e.g. scratch marks, jaundice, palmar erythema, spider naevi).
organic psychosis?
*Cognitive impairment is obvious and severe
*Conscious impairment
*Hallucinations/delusions
*Delirium including drug induced, DTs, ITUs
What can cause organic psychosis?
*Psychosis owing to an underlying medical condition eg Korsakow, hepatic encephalopathy, herpes encephalitis, cancer, leukodystrophy etc
*Dementia
*Learning disability
not organic psychosis?
*May have cognitive impairment – subtle
*Clear consciousness
*Not drugs, alcohol, physical illness, brain insult, neurodegenerative disorder, etcetera
*Comes down to schizophrenia and related syndromes, mood disorder with psychotic symptoms
organic vs inorganic psychosis?
- organic: concious impairment and cognitive impairment severe
- inorganic: clear conciousness and subtle cognitive impairment
Might be a first episode of schizophrenia if:
Positive family history (not just schizophrenia)
*Shy quiet no friends not very bright
*Does drugs on their own/to excess/over a lengthy period
*Cannabis, stimulants, NMDA antagonists
*Gradual fall off in personal and social function
*Prodrome of neurotic symptoms – depression, anxiety, OCD etc
*No obvious temporal relationship to drug abuse: insidious onset
- Fails to resolve itself especially if treated
Greater chance of organicity when:
- older patient
- greater cognitive impairment
- greater impairment of conciousness
- more acute onset (includes drug/ alcohol psychoses)
- greater fluctations in cognition and psychotic symptoms
schiz diagnostic criteria?
*2 of 5 symptom groups (can be less)
*Functional impairment
*> 6 months
Schizophreniform disorder?
*Don’t need functional impairment
*Less than 6 months but more than 1
affective psychosis - bipolar?
- bipolar - can have dels/ hals but should be mood congruent - although often persecutory
affective psychosis - depression?
- depresion - can have depressive delusions and hallucinations but not common and can be dangerous
Schizoaffective disorder?
mood disorder most of the time, but have the 2 of 5 with abnormal mood and then > 2 weeks with just delusions or hallucinations
what is a delusional disorder?
- disorders with overvalued ideas
- Erotomania, grandiose, jealous, persecutory, somatic, pseudocyesis etc
what can be preserved w delusional disorder?
- Function preserved: beliefs are plausible
- Can be part of something else eg bipolar, PD
brief psychotic disorder?
*Brief psychotic disorder: 1 of 4 (no neg symps)
*> 1 month: may be stress induced
For section 2, a person is unable to make a decision for himself if he can’t:
(a) to understand the information relevant to the decision,
(b) to retain that information,
(c) to use or weigh that information as part of the process of making the decision, or
(d) to communicate his decision (whether by talking, using sign language or any other means).
what are the motor disorders?
> Catatonia
Motor and behavioural aspects of affective disorders
Motor and behavioural aspects of schizophrenia
catatonia?
- predominantly motor disorder
- thought to be related to affective disorders
- Catatonic symptoms may be found as part of chronic schizophrenia and occasionally in organic cerebral disorders.
catatonia - symptoms?
- obstruction
- Ambitendence
- Automatic obedience
- Echolalia, echopraxia
- Stupor, catalepsy (not making any movement), posturing
- stereotypy and mannerism
catatonia - obstruction?
Sudden arrest of fluent movement (spoke in the wheel) i.e. shakes hands, rocking backwards and forwards when sitting.
catatonia - Ambitendence?
Alternating co-operation and opposition
catatonia - characteristic features?
Stupor, catalepsy (not making any movement), posturing
Catatonia - sterotypy?
Repetitive purposeless (non-goal directed) movement (includes verbal)
catatonia - mannerism?
Repetitive purposeful movement, goal directed (includes grimaces)
Motor and Behavioural aspects of affective disorders can involve?
- agitiation
- retardation
- stupor
- manic stupor
agitation?
- can occur in depression
- repetitive and usually purposeless movement which when marked may be mistaken for manic overactivity.
- The difference is that in mania, several different activities are begun and none completed.
stupor?
- reduction in activity which accompanies a variety of disorders including depression, mixed affective states and schizophrenia.
- Catatonia, depression, dissociation and organic disorders may be underlying.
manic stupor?
rare, bipolar mixed state characterised by flight of ideas + gross motor retardation + elevation of mood
Motor and Behavioural aspects of schizophrenia?
- in chronic schiz, there is a general reduction of behaviour including speech due to depression, negative symptoms, medication side effects
- but ppts prone to impulsivity
lability in mania?
- Lability (changeability) may involve brief period of tearfulness and subjective misery but concomitants of true depression are lacking.
- Lability refers to changeability of mood and is usually accompanied by pronounced emotional reactions.
(emotional disorders in psychosis) - Incontinence
(dramatic displays of emotion, often for no reason, i.e. organic, dementia, head injuries) in which catastrophic emotional displays occur often entirely without precipitants.
mood in acute schizo?
- may be variable
- Perplexity (a sense of puzzlement) or suspiciousness may occur.
most common emotional disorder in schiz?
- The most common emotional disorder in chronic schizophrenia is apathy
- when applied to an emotional response = flattening of affect
blunting =
reduction in changeability of mood.
incongruity =
refers to the apparent mismatch (in the eye of the observer) between the content of speech and the affect – so ,for example, a person talking about the death of a beloved pet whilst laughing.
pressure of speech (mania) =
Difficulty in interrupting – incessant need to talk
Flight of ideas (mania) =
Loss of coherent goal-directed thinking with increasingly obscure associations between ideas; connections between thoughts may be based on:
- chance relationships
- clang associations
- distracting stimuli
- verbal associations
clang association?
- mania
- Linking words because they sound similar
Knights move thinking?
- schiz
- Similar to flight of ideas but the omitted connection bears a more tangential relation to the whole – think of the speech as like a knight jumping around on a chess board.
Loosening of associations, poverty of content ?
- schiz
- Mild varieties of spoken schizophrenic FTD where the content seems vague and meaningless despite adequate volume of speech.
Schizophasia, word salad (schizophrenia):
Thought disorder so bad that the person is speaking gibberish. Severe variety of Schizophrenic FTD where speech is virtually incomprehensible
Derailment (fusion, drivelling)?
- S
- Schneider’s subtypes of schizophrenic thought disorder. Difficult to tell apart, sometimes coexist.
perseveration?
Uncontrollable repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus, usually caused by brain injury or other organic disorder.
Primary vs secondary delusions?
- A primary delusion is one that is not understandable in terms of other psychopathology.
- A secondary delusion is comprehensible in terms of altered mood, hallucinosis, cognitive impairment, thought disorder or other delusions.
types of primary delusional?
- delusional intuition
- delusional mood
- delusional memory
delusional mood?
not a thought, but a mood, i.e. like being uneasy or a feeling that things have been changed. Usually ends in a delusional perception.
delusional memory?
- delusional memory - remember something that happened as a child
- both perception and interpretation are retrospective
Overvalued ideas?
An overvalued idea is an idea which is in itself comprehensible or socially acceptable which has come to dominate the patient’s life and is pursued by him beyond the bounds of reason.
Overvalued ideas are usually associated w?
a disorder of personality (especially paranoid) but may be accentuated by mood disorder.
types of delusions - persecution?
- commonest type
found in affective disorders, organic disorders, paranoid schizophrenia and delusional disorders of other type.
delusions of reference?
The interpretation of events as self-referential in a delusional way. Usually found accompanying other types of delusions e.g. grandiose or persecutory
delusions - dysmorphobia?
- The belief that a part of one’s body is appreciably (by others) deformed or misshapen.
- May be monosymptomatic or exist with a more widespread delusional disorder or schizophrenia.
delusions - jealousy?
- Associated with psychoses and alcohol abuse. May exist monosymptomatically.
- CONSIDER RISK.
delusions - De Clerambault’s syndrome ?
- the belief that another person loves the patient.
- It is a variety of Erotomania (overvalued love for somebody else), which involves the belief by the patient that he/she and another are in love.
- Found in delusional disorder – schizophrenia.
nihilistic delusions?
- associated w S and depression
- Nihilism refers to the belief that a part of the body is absent (i.e. something was there and has gone).
- Sometimes associated with delusions of enormity, (e.g. that if the person empties his bladder the whole world will be drowned).
Nihilistic delusions said to be associated w visual hallucinations in ?
Cotard’s syndrome
Grandiose delusions?
- Belief in special powers, purpose, etc.
- Found in mania, paranoid schizophrenia and also occasionally in paranoia
delusions - Capgras’ syndrome?
involves the belief that a close person has been replaced by a stranger.
delusuons - fregoli syndrome?
involves the belief that one familiar individual has replaced various strangers.
Communicated delusion?
- folie a deux - madness of 2
- Principal already psychotic, transmits ideas to associate, who then becomes psychotic.
- Usually associate’s psychosis remits following separation.
- Principal often in a relationship of dominance with associate (e.g. older sister, parent).
delusions - hypochondriasis?
Usually found in depression. May be associated with persecutory ideas in schizophrenia.
illusions?
- An illusion is an involuntary false perception consequent on a real object in which a transformation of the object takes place.
- Illusions often occur at extreme of tiredness and emotion, but may accompany other abnormal perceptions in psychotic, toxic or organic states.
hypogognic/ hynopompic hallucinations?
- Hypnogogic (going to sleep) and Hypnopompic (arising from sleep) hallucinations occur at either end of the sleep period.
- The commonest is a voice calling the person’s name. Should arise suspicion that people may have narcolepsy.
Dysmorphophobia?
belief that a part (or parts) of the body are appreciably deformed, misshapen
typical AP?
- D2 antagonists in the mesolimbic pathway
- EPS and hyperprolactinaemia common
ATypical AP?
- act on variety of receptors - D2,D3, D4, sertonin
- EPS side effecs and hyperprolactinaemia less common
- metabolic side effects predominate
Atypical AP - 3 examples?
- olanzapine
- risperidone
- clozapine
biological model of psychosis?
- most strongly linked: dopamine
- The positive symptoms of psychotic disorders are believed to be caused by excess dopamine in the mesolimbic tract.
- overactivation of D2 receptors
other NTs in psychosis?
- decreased function of the NMDA glutamate receptor
- ACh inbalance
indications of AP?
- schizophrenia
- acute mania
- MDD with psychotic features
- delusional disorder
- Tourette disorder
Clozaepine?
- used when the patient has failed multiple trials of standard AP therapies
- useful for the Tx of tardive dyskinesia
typical AP side effects?
- sig EP side effects
- H1 blockade -> sedation
TAPs - anticholinergic side effects?
dry mouth, constipation, urinary retention are common with low potency dopamine receptor antagonists like chlorpromazine
which typical AP paticularly lowers seizure threshold?
chlorpromazine
haloperidol cardiac side effects?
abnormal heart rhythm, ventricular arrhythmia, torsades de pointes
chlorpromazine side effects?
blue-gray discoloration and benign pigmentation of the lens and cornea
TAPs - dopamine blockage in the tuberoinfundibular tract ->
- Increased serum prolactin concentrations along with galactorrhea, breast enlargement, amenorrhea, impotence in men, and anorgasmia in women
AP side effects - neuroleptic malignant syndrome
- rare but fatal
- The onset of symptoms is over 24 to 72 hours
symptoms of neuroleptic malignant syndrome?
- with increased temperature,
- severe muscular rigidity,
- confusion, agitation,
- elevation in white blood cell count,
- elevated creatinine phosphokinase concentrations,
- elevated liver enzymes, myoglobinuria, and acute renal failure.
risk of neuroleptic malignant syndrome is higher w?
TAPs but can also occur w atypicals
Atypical APs are associated w ?
- associated w sig weight gain and development of metabolic syndrome
risperidone is assoc w ?
dizziness, anxiety, sedation, and extrapyramidal side effects
Olanzapine is associated w?
weight gain, increased appetite, and somnolence
clozapine is associated w?
- hypersalivation, tachycardia, hypotension, and anticholinergic side effects
clozapine - monitoring required?
- Clozapine can cause clinically important agranulocytosis, leukopenia, and therefore requires monitoring of white blood cells and absolute neutrophil count.
rehabilitation for psychosis is for thos w ?
- for those w complex psychosis
- treatment resistant psychosis
- recurrent admissions or extended stays
principles of rehabilitation for psychosis?
- recovery-orientated approach - shared ethos and agreed goals, sense of optimism and aims to reduce stihma
- deliver individualised, person-centred care through collaboration and shared decision making
rehab for psychosis - be offered the ? envir?
- be offered in the least restrictive environment and aim to help people progress from more intensive support to greater independence
- recognise need for supported accomodation
MDTs for psychosis rehabiliatation services - who is involved??
- rehabilitation psychiatrists
- practitioner psychologists
- nurses
- occupational therapists
- social workers
- support workers (including peer support workers)
- specialist mental health pharmacists.
programmes and interventions for psychosis should develop a ? and offer ? group activities?
- services should develop a culture that promotes improving daily living skills
- offer structured group activities (social, leisure or occupational) aimed at improving interpersonal skills.
interventions that can be offered for psychosis rehab?
- educational opportunities such as recovery colleges
- substance misuse interventions
managing relapse?
- Risk of harm to the person - self harm, suicide, accidental injury, command hallucinations
- level of family/ social support
- Timing — be aware that the highest risk of suicidetends to be around the time of a psychotic episode and shortly after hospital discharge.
risk - history?
- Previous violence, whether investigated, convicted or unknown to the criminal justice system
- Relationship of violence to mental state
- Lack of supportive relationships
- Poor concordance with treatment, discontinuation or disengagement
- Impulsivity
- Alcohol or substance use, and the effects of these
- Early exposure to violence or being part of a violent subculture
- stable RF or a change in them?
- evidence of recent stressors, losses or threat of loss
- Are the family/carers at risk? History of domestic violence
- Lack of empathy
risk - envir?
- risk on release from restricted settings
- Access to potential victims, particularly individuals identified in mental state abnormalities
- Access to weapons, violent means or opportunities
- Involvement in radicalisation.
risk - mental state?
- Evidence of symptoms related to threat or control, delusions of persecution by others, or of mind or body being controlled or interfered with by external forces, or passivity experiences
- Voicing emotions related to violence or exhibiting emotional arousal (e.g. irritability, anger, hostility, suspiciousness, excitement
- Specific threats or ideas of retaliation
- Grievance thinking
- Thoughts linking violence and suicide (homicide–suicide)
- Thoughts of sexual violence
- Evolving symptoms and unpredictability
- Signs of psychopathy
- restricted insight
rates of S across ethnic groups?
- rates of psychotic disorders like schizophrenia can be as much as 5x higher in some ethnic minority groups such as people of black Caribbean or African heritage in the UK.
- Ethnic minority status was associated with more than double the odds of psychotic disorders.
what can explain the inc risk of psychosis in ethnic minorties?
- Linguistic distance from the majority group, and social disadvantage, were both associated with nearly double the odds of psychosis, which appeared to mostly explain the increased risk faced by ethnic minority groups
culture and schiz diagnosis?
- variation between countries when it comes to diagnosing schizophrenia - overdiagnosis due to ethnic background
culture - acceptance of S symptoms in certain cultires?
- One issue is that positive symptoms such as the hallucination or hearing voices may be more acceptable in African cultures because of cultural beliefs in communication with ancestors, and therefore people are more ready to acknowledge such experiences - when reported to psychiatrists this is seen as abnormal, ethnocentric approach
culture - over-interpretation of symptoms?
- over-intrepretation of the symptoms of black people during diagnosis - cultural differences in language and mannerisms, difficulties in relating between black patients and white therapists,
schiz diagnosis - age?
- most commonly diagnosed between the ages 15-35
- women tend to present when older (peak in the late twenties, compared to a peak in the early twenties in men).
ICD crieria: in patients suffering from psychotic episodes lasting for at least one month, it can be diagnised if 1+ of the following is present:
- Thought echo, thought insertion or withdrawal, or thought broadcasting.
- Delusions of control, influence or passivity,clearly referred to body or limb movements or specific thoughts, actions, or sensations; delusional perception.
- Hallucinatory voicesgiving a running commentary on the patient’s behaviour, or discussing him between themselves, or other types of hallucinatory voices coming from some part of the body.
- Persistent delusionsof other kinds that are culturally inappropriate and completely impossible
ICD - can be diagnosed in patients suffering from a psychotic episode lasting for at least one month if two (or more) of the following are present:
- Persistent hallucinationsin any modality, when occurring every day for at least one month, when accompanied by delusions (which may be fleeting or half-formed) without clear affective content, or when accompanied by persistent over-valued ideas.
- Neologisms, breaks or interpolations in the train of thought,resulting in incoherence or irrelevant speech.
- Catatonic behaviour,such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.
- “Negative” symptomssuch as marked apathy, paucity of speech, and blunting or incongruity of emotional responses (it must be clear that these are not due to depression or to neuroleptic medication).
types of schiz?
- paranoid
- hebephrenic
- catatonic
- undiffereniated
Paranoid S?
- Predominant symptom is that of what are stable, normally paranoid delusions.
- These are often accompanied by hallucinations (often auditory)
what is usually absent in paranoid S?
catatonic symptoms and those of abnormal affect, volition and speech are normally absent.
Hebephrenic schizophrenia?
- Affective symptoms are prominent with abnormal behaviour.
- Negative symptoms are significant and social isolation may result.
Cataonic schiz?
- Predominant symptoms are those of psychomotor disturbance, and may exhibit both hyperkinesis and stupor as well as automatic obedience and negativism.
- Other features may include episodes of violent excitement.
Ix for schiz?
- ECG - evaluate for long QT if considering antipsychotics
- Thyroid function
- Syphilis serology
- Bloodborne virus screen
- Autoimmune screen(e.g. ANA, anti-DS DNA for Lupus)
preventing psychosis - referral to specialist services in patients who are distressed with declining social function and:
- Transient or attenuated psychotic symptomsor
- Other experiences or behaviour suggestive of possible psychosisor
- A first-degree relative with psychosis or schizophrenia
Role of EIPs?
- EIP teams are often the first group to review patients with a new episode of psychosis or schizophrenia.
- The teams consist of psychiatrists, psychologists, community psychiatric nurses, social workers and support workers.
Baseline Ix before starting AP:
- Weight
- Height
- Waist circumference
- Pulse and blood pressure
smoking and AP?
smoking can impact the efficacy of antipsychotics (particularly clozapine and olanzapine)
CBT for schiz?
- indiv
- family
indiv CBT?
- CBT aims to help patients explore their conditions.
- It looks to help patients create links between their thoughts, feelings and actions with their experience of schizophrenia.
CBT - patients are encouraged to?
re-evaluate how their perceptions may relate to symptoms.
family CBT?
- should include the patient suffering from schizophrenia if possible as well as their main carer
- have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work.
First line for psychotic symptoms?
- oral atypical AP
- cognitive behavioural therapy should be offered to all patients
what should be modified when considering use of AP?
- close attention should be paid to cardiovascular risk-factor modification due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
for ppl w first episode psychosis offer:
- oral AP
- psych interventions - family CBT and individual CBT
Mx - ppl at risk of psychosis?
- For people who are at risk of developing a psychotic disorder, specialist mental health services will usually offer treatment with individual CBT with or without family intervention.
monitoring for AP?
should be monitored for effects for 12 months or until the person’s condition has stabilised (whichever is the longest)
Mx of an acute behavioural disturbance - de-escalation?
- calming techniques and distractions
- offer the child or young person the opportunity to move away from the situation in which the violence or aggression is occurring, for example to a quiet room or area
- aim to build emotional bridges and maintain a therapeutic relationship.
Mx of an acute behavioural disturbance - restrictive interventions?
- only use if all attempts to defuse the situation have failed and child or young person becomes aggressive or violent.
- monitor wellbeing closely
what is used for rapid tranquilisation?
- IM lorezepam
- IM haloperidol combined with iM promethazine
complications of psychotic disorders include:
- An increased risk of premature death due higher ratesof suicide, cardiovascular disease, and type 2 diabetes.
- Difficulties in social functioning.
- Substance misuse.
high vs low risk of harm w a psychotic disorder?
- high risk of harm: same-day mental health assessment by the early intervention in psychosis
- not at high risk of harm: EIP team
