Case 2 - Psychosis Flashcards
What is the strongest risk factor for developing a psychotic condition e.g. schizophrenia?
Family History
Risk of developing schizophrenia:
- monozygotic twin has schizophrenia = 50%
- parent has schizophrenia = 10-15%
- sibling has schizophrenia = 10%
- no relatives with schizophrenia = 1%
Name some risk factors for psychotic disorders.
- Family history (main one)
- Black Caribbean - RR 5.4
- Migration - RR 2.9
- Urban environment- RR 2.4
- Cannabis use - RR 1.4
- Birth complications
Name some organic causes of psychosis?
Drug misuse:
- corticosteroids, dopaminergic drugs (L-dopa, amantadine), anticholinergics, opioids, Abx (ciprofloxacin)
- Alcohol misuse
- Neurodegenerative:
dementia, PD, Alzheimer’s disease - Neurological:
focal impaired awareness seizures (prev called ‘complex partial’), stroke, space occupying lesion, MS, temporal lobe epilepsy - Endocrine:
thyroid disease, cushing’s disease - Infection:
post encephalitic state, tertiary syphilis, malaria - Delirium:
hypercalaemia, ICU psychosis, sepsis, medication interaction or withdrawal etc. - Nutritional:
Vitamin B12 deficiency - Autoimmune:
SLE, sarcoidosis - Liver or Kidney failure
- Acute porphyria (build up of porphyrins e.g. acute intermittent porphyria)
What are Schneider’s 1st rank symptoms for schizophrenia?
4 categories:
Auditory hallucinations:
- 2 or more voices discussing pt in 3rd person
- thought echo
- voices commenting on the pt’s behaviour
Thought disorder:
- thought insertion
- thought withdrawal
- though broadcasting
Passivity phenomena:
- bodily influence - bodily sensations being controlled by external influence
- made actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
Delusional perceptions:
- 2 stage process:
- 1) a normal object is percieved then
- 2) there is a sudden intense delusional insight into the objects meaning e.g. ‘The traffic light is green therefore I am the King’
What are the flaws of Schneider’s 1st rank symptoms for schizophrenia?
- Schneider’s symptoms are not specific for schizophrenia (8% of psychotic pts with them don’t have schizophrenia)
- 20% of pts with chronic schizophrenia never have a 1st rank symptom
What features of schizophrenia are there besides Schneider’s symptoms (which are positive symptoms)?
- Alogia (poverty of speech - lack of unprompted additional content)
- Vague speech
- Anhedonia
- Avolition (poor motivation)
- Impaired sight
- Blunting/incongruity of affect (inappropriate emotion for circumstances)
- Neoligisms
- Catatonia:
- Stuporous catatonia - stupor (hold rigid poses), mutism, waxy flexibility, repetitive movements
- Excited catatonia - bizarre, non-goal directed hyperactivity + impulsiveness
What treatments are appropriate for a 1st episode of psychosis?
- Oral antipsychotic medication AND
- Psychological intervention e.g. family intervention + individual CBT
Which of the following are common side-effects of anti-psychotics?
- Hypokalaemia
- ↑ prolactin
- Diabetes
- Sedation
- Weight loss
- ↑ Prolactin
- Diabetes
- Sedation
Before starting anti-psychotic medication what baseline tests need to be done?
- Weight (plotted on chart)
- Waist circumference
- HR + BP
- Fasting blood glucose, HbA1c
- Lipid profile
- Prolactin levels
- Nutritional status / diet
- Assessment of movement disorders
- ECG (under special circumstances e.g. recommended in drug summary, if pt has cardiovascular risks or CVD)
What are the criteria for detaining someone under Section 2 of the MHA?
2 criteria - both must be met:
- Person is suffering from a mental disorder of a nature or degree which warrants their detention in hospital for assessment (or for assessment followed by treatment) for at least a limited period
- Person ought to be detained in the interest of their own health or safety or with a view to the protection of others
What are the details relating to sectioning under section 2 of MHA?
Section 2
- Duration: 28 days for assessment
- Treatment: can be given against pt wishes
- Application: AMHP or nearest relative on recommendation of 2 docs
- Discharge: Pt can appeal to tribunal, discharge by Responsible Clinician, Hospital managers or nearest relative
What are the details relating to a section 3 under MHA?
Section 3
- Duration: 6 months for treatment
- Treatment: can be given against pt wishes (for 1st 3 months then consent required or 2nd opinion)
- Application: AMHP + recommendation of 2 docs, 1 of whom must be section 12 approved (must have seen pt in last 24 hrs)
- Discharge: Pt can appeal to tribunal, discharge by Responsible Clinician, Hospital managers or nearest relative
What are the details relating to a section 4 under MHA?
Section 4
- Duration: 72hr for emergency assessment (done when section 2 would cause a delay)
- Treatment: given under common law
- Application: AMHP or nearest relative on recommendation of any doc (seen pt in last 24 hrs)
- Discharge: no appeal, can only be discharged by Responsible Clinician
What are the details relating to section 5(2) under the MHA?
Section 5(2)
- Duration: 72hr holding order for a pt already voluntarily admitted to hospital (A+E counts as being in community)
- Treatment: given under common law
- Application: Any doctor
- Discharge: no appeal, can only be discharged by Responsible Clinician
What are the details relating to section 5(4) under the MHA?
Section 5(4)
- Duration: 6 hrs holding order for a pt already voluntarily admitted to hospital
- Treatment: given under common law
- Application: Registered nurse
- Discharge: no appeal
What is the main mechanism of action of anti-psychotic medication?
Dopamine antagonists
Block dopamine transmission in mesolimbic pathways
Anti-psychotics are associated with extra-pyramidal side-effects (traditionally typical anti-psychotics but not strictly true).
Give examples of extra-pyramidal side effects (EPSEs).
EPSEs:
- Parkinsonism
- Acute dystonia - sustained muscle contraction e.g.
- torticollis - asymmetrical head/neck bend
- oculogyric crisis - dystonic reaction to drugs/medication causing prolonged involuntary upward deviation of eyes
- Akathisia (severe restlessness)
- Tardive dyskinesia (involuntary repetitive movements e.g. chewing or pouting of jaw
What drug can be given to manage extra-pyramidal symptoms (e.g. caused by antipsychotics)?
Procyclidine
- Anticholinergic - exerts anti-parkinsonian effect by reducing the effect of cholinergic excess caused by dopamine deficiency
- Treatment of drug-induced parkinsonism, akathisia, acute dystonia
The risk of which 2 vascular events is increased by anti-psychotics in the elderly?§
VTE
Stroke
What are some common non extra-pyramidal side effects of anti-psychotics?
Antimuscarinic:
- dry mouth, blurred vision, urinary retention, constipation
Anti-histamine action:
- Sedation, weight gain
Raised prolactin:
- galactorrhoea (spontaneous flow of milk from breast), impaired glucose tolerance
Neuroleptic malignant syndrome:
- Pyrexia, muscle rigidity, confusion, variable BP, sweating, tachycardia
- ↑ WBCs + ↑ LFTs
- Mortality = ~ 10%
↓ seizure threshold (greater with atypicals)
Prolonged QT interval (particularly haloperidol)
