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Psychiatry STG > Delusional Disorders > Flashcards

Delusional Disorders Flashcards

1
Q

Schizophrenia

A

Patient suffers from Psychotic Symptoms and Functional Impairment; In
Delusional Disorders, Experiences of Delusions but no evidence of Hallucinations or other Schizophrenia-Characteristic Symptoms
o Schizophrenia has variable course, frequently chronic and relapsing; Care is
considerable burden onto carers including family
o Presents either as Acute or Chronic Syndromes

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2
Q

Schizophrenia: Epidemiology

A

• 10-20 per 100,000; M>F; In males, 15-35yrs mean, and older in females
• Might be higher in certain Afro Caribbean groups; Prevalence higher in SES deprived,
especially homeless population

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3
Q

Acute Syndrome: Thoughts

A 
Hallucinations, Persecutory Ideas, Delusions of
Reference, Social Withdrawal and Impaired
Performance at work
o Vs Negative Symptoms – Loss of
Function seen in Chronic Schizophrenia
o Might appear entirely normal; Some
might be awkward, preoccupied, odd;
Might react spontaneously
unpredictably, or appear perplexed
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4
Q

Acute Syndrome: Mood Changes

A

Depression, Anxiety, Irritability
or Euphoria; Either due to disorder, response to
insight into nature of disease, or SE to
Antipsychotic medication
o Blunting Affect – Reduction in normal
variation of mood
o Incongruity of Affect – Emotion not in keeping with situation

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5
Q

Acute Syndrome: Speech and Thought

A

Hard to follow; Might be vague and difficult to grasp; Might develop
into definite abnormalities (Formal Thought Disorders)
o Difficult dealing with Abstract ideas (Concrete Thinking)
o Preoccupation with vague Pseudoscientific or Mystical Ideas
o Lack of Connection between Ideas expressed by patient (Loosening of Associations)
o Can progress to becoming totally incoherent (Word Salad); May also be disorders
with Stream of thought (Pressure, Poverty, Blocking)

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6
Q

Acute Syndrome: Delusions

A

Primary (Without morbid antecedents e.g. not preceded by ideas or events) or Secondary; May be preceded by ‘Delusional Mood’ (Perplexing sense of something being
amiss or changed) or Hallucinations
o Persecutory, Reference, Control, Thought Insertion, Withdrawal or Broadcasting

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7
Q

Acute Syndrome: Auditory Hallucinations

A

Most frequent; Simple Noises, Complex Voices or Music
o Voices may speak thoughts aloud (Echoing), or give commands etc; Sometimes two
or more voices might discuss the patient in third-person
o Other types of Hallucinations less frequently and seldom without other kinds of
hallucinations; Visual, Tactile, Olfactory, Gustatory and Somatic might occur, and may
be interpreted in a delusional way

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8
Q

Acute Syndrome: Insight

A

Insight is usually impaired; Most do not accept that experiences are from illness but instead actions of other people; Often accompanied by unwillingness to accept treatment

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9
Q

Chronic Syndrome

A

Negative Symptoms – Underactivity and
Disorganised Behaviour, Lack of Drive, Social
Withdrawal, Emotional Apathy, Thought
Disorder and Cognitive Impairment

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10
Q

Schizophrenic Defect State

A 
Impaired Volition (Drive and Initiative); Inactive or Engaging in Aimless and Repeated Activity; Impairment of Personal Hygiene, Appearance, Social Encountered, Breaking
Social Conventions (e.g. Obscenities,
Disinhibition), Hoarding
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11
Q

Movement (Catatonic) Disorders

A 
Stupor and
Excitement (Uncontrolled motor activity)
o Odd, repetitive movements;
=Stereotypies if not goal directed;
If goal directed =Mannerisms
o Might have disorders of Muscle tone;
Might maintain awkward posture
without apparent distress (Waxy Flexibility)
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12
Q

Chronic Syndrome: Speech

A

Speech is often abnormal, reflecting similar Thought Disorders seen in Acute Syndrome

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13
Q

Chronic Syndrome: Affect

A

Blunted Affect with Incongruous Emotion

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14
Q

Chronic Syndrome: Hallucinations

A

Hallucinations are common, similar to the forms in Acute Syndrome

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15
Q

Chronic Syndrome: Delusions

A

May be held with little emotion; May be encapsulated from rest of the patient’s beliefs (E.g. Delusions of persecution only limited to specific beliefs)

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16
Q

Chronic Syndrome: Cognitive Impairments

A

May be held with little emotion; May be encapsulated from rest of the patient’s beliefs (E.g. Delusions of persecution only limited to specific beliefs)

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17
Q

Chronic Syndrome: Insight

A

Insight often impaired; Does not recognise illness, not convinced about need for treatment

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18
Q

Age of Onset

A

Adolescents and Young Adults typically include Thought Disorder, Mood
Disturbance and Disrupted Behaviour; In Older Adults, Paranoid Symptoms are more
common, and Disrupted Behaviour less frequent

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19
Q

Outcomes

A

• Illness is generally more severe in males
• 20% will have Acute Illness with Complete Recovery; 50% Recurrent Illness with Persistent Deficits; 20% Chronic Illness with Persistent Functional Disability; 10% Suicide
o Suicide Risk if high in younger patients, when insight still present and
understands likely effect of illness
• Overstimulating environment increases positive symptoms and converse
• Family – Relapse more likely if critical, hostile or
Emotional Overinvolvement; Reducing contact
by increasing day care, or Family Therapy

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20
Q

Diagnosis of Schizophrenia Category A

A 
≥1 for 1/12
• Delusions
• Hallucinations
(Especially if Running
Commentary, or
Conversing)
• Disorganised Speech
• Grossly Disorganised or
Catatonic Behaviour
• Negative Symptoms
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21
Q

Diagnosis of Schizophrenia

Category B

A

Social and Occupational Dysfunction etc

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22
Q

Diagnosis of Schizophrenia : Category C

A

Duration – Continuous signs persist for at least 6/12;
Includes 1/12 of Category A; May include Prodromal or
Residual Periods; Negative, or ≥2 Cat A symptoms

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23
Q

Diagnosis of Schizophrenia : Category D

A

Rule-out Schizoaffective and Mood Disorder (No, or
relatively brief Major Depressive, Manic or Mixed
during active Schizophrenia Symptoms)

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24
Q

Diagnosis of Schizophrenia : Category E

A

Rule-out Substance Abuse or General Medical

25
Q

Diagnosis of Schizophrenia : Category F

A

If there is history of Autism or other Developmental

Disorder, Prominent Delusions or Hallucinations ≥ 1/12

26
Q

Schneider’s First Rank Symptoms

A

Auditory Hallucinations (Echoing, Commentary, Third
Person), Somatic Hallucinations, Thought Withdrawal or Insertion, Broadcasting, Delusional
Perception, Delusions of Control

27
Q

Differential Diagnosis

A

If Delusions, without other symptoms of Schizophrenia – Persistent Delusional Disorder

28
Q

Organic Syndromes Mimicking Schizophrenia

A

o Substance Abuse (E.g. Amphetamine, Cocaine, MDMA, LSD; Cannabis rarely causes Frank Psychosis but may precipitate relapse)
o Iatrogenic Drugs – Especially Steroids and Dopamine Agonists
o Temporal Lobe Epilepsy – If condition is brief and evidence of clouding of
consciousness; In few, Chronic TLE gives rise to persistent state
o Delirium – Might be mistaken from Acute Syndrome, especially if prominent
Hallucinations and Delusions; Clouding of Consciousness not seen in Schizophrenia
o Dementia – Memory Disorder not seen in Schizophrenia
o Diffuse Brain Diseases e.g. Neurosyphilis (General Paralysis of the Insane)

29
Q

Psychotic Mood Disorder

A

Degree and Persistence of Mood Disorder, Congruence of Hallucinations or Delusions with Prevailing Mood, Nature of Prominent Symptoms
o If Prominent Affective Symptoms – Schizoaffective Disorder

30
Q

Personality Disorders

A

Prolonged observation for First-rank symptoms

31
Q

Aetiology of Schizophrenia: Genetic

A

Strong Evidence for Genetic Factors (10-15% risk in Siblings and child of one affected parent,
and 40% if two affected parents, vs Lifetime risk 1%); Heritability 80%
o Genes believed to have effect on Neurodevelopment and Synaptic Functioning
o Also believed to predispose to several mental disorders; Actual disorder depends on
complex interaction between Genetics and Environment

32
Q

Aetiology of Schizophrenia: Environmental

A

Environmental – Risk factors include Abnormalities in Pregnancy, Foetal Development
(?Foetal Hypoxia), Low SES, Heavy Cannabis Consumption, Stressful Life Events
o High Emotional Expression – Strongly expressed feelings especially critical comments;
may lead to high relapse rates

33
Q

Aetiology of Schizophrenia: Biochemical

A

• Response to Antipsychotic drugs suggests Biochemical basis (D2 receptors); Evidence of
increased Dopaminergic Transmission in Basal Ganglia (Acute) and Diminished in PFC

35

• Dopaminergic transmission not believed to be primary problem; Likely due to upstream
alterations in Glutamate Transmission

34
Q

Aetiology of Schizophrenia: Neurodevelopmental

A

Schizophrenia as a Neurodevelopmental Disorder
o Reduced Parahippocampal, Temporal, Amygdala and Hippocampal Volumes, and
increased Lateral Ventricular Volumes
o Dermatoglyphic Abnormalities, sometimes associated with CNS Developmental
disorders, and ‘Soft’ Neurological signs
o Gliosis was not found post-mortem in Schizophrenic patients, suggesting that
abnormalities occurred early in life and did not trigger inflammatory reaction
o More likely than controls to have developmental problems in childhood

35
Q

Current Model of Aetiology

A

suggest Polygenetic Susceptibility Interacting with Early Environment leading
to abnormal Brain Maturation (Pruning, Myelination, Apoptosis); Leads to Observable
Childhood Abnormalities, and if Environmental Risk Factors are present – Onset

36
Q

Assessment of Schizophrenia

A

Majority treated within Specialist Services;
First presentation by primary care; Delayed
treatment associated with poor outcomes
o Need to be familiar with assessment
and rapid referral

37
Q

Assessment of Schizophrenia: Non Urgent

A

Non-urgent – Often from relatives/collateral;
Obtain good description of behaviour and
symptoms, assess Functional Impairment (E.g.
Occupational, Relationships), Risk Assessment
o Persuade patient to accept referral to
Specialist Mental Health
o If refused, discuss with Psychiatrist and consider compulsory order

38
Q

Assessment of Schizophrenia: Acutely Disturbed

A

Unwise to be alone with such patient until Risk Assessment made
o Attempt should be made to remove physical restraint while ensuring helpers close
o Main task to exclude Acute Organic or Non-Psychotic Disorder; Difficult to distinguish
between Schizophrenia and Mania (although Immediate Management is the same)
o Need for Admission depends upon – Severity, Nature of Psychotic Symptoms and
Risk, Social Support and Insight
o Compulsory powers might be necessary; Alternatives include Intensive Community
Treatment (Home treatment often preferred by patients and relatives)

39
Q

Management of Schizophrenia : Early Intervention

A

• Early intervention – Referral to Specialist Services; Antipsychotics not be started in Primary
care for first presentation, unless done with consult with consultant psychiatrist

40
Q

Management of Schizophrenia : Antipsychotic

A

Extrapyramidal, Cardiovascular, Hormonal side effects and patient preference
o Record Weight, Waist Circumference, Sats, Fasting Glucose HbA1c, Lipids and
Prolactin; Assessment of Movement Disorders and Nutritional Status

41
Q

Management of Schizophrenia : Psychological

A

Psychological Intervention (Family, Individual CBT)

42
Q

Management of Schizophrenia : Immediate

A

Drugs for immediate behavioural control e.g. Benzodiazepines might be required

43
Q

Management of Schizophrenia : Affective Component

A

If behaviour suggests affective psychosis (E.g. Bipolar, Unipolar Psychotic Depression) – Treat
as Bipolar Disorder or Depressive Disorder

44
Q

Antipsychotics

A

D2 and 5-HT2A antagonism; Various other activity on other D, 5HT subtypes,
Alpha Adrenergic, Muscarinic and Histamine Receptors

45
Q

Examples of Typical Antipsychotics

A

Haloperidol, Chlorpromazine, Prochlorperazine

46
Q

SE of Typical Antipsychotics

A

Tends to produce Extrapyramidal SE (EPS),
which includes Neuroleptic Malignant Syndrome
(Fever, Rigidity, Autonomic Dysfunction, Altered
Mental Status)

47
Q

Examples of Atypical Antipsychotics

A

Risperidone, Olanzapine, Quetiapine, Clozapine

48
Q

SE of Atypical Antipsychotics

A

Fewer EPS but more metabolic effects e.g.
Weight Gain, Hyperglycaemia
Clozapine is effective for treatment-resistant
Schizophrenia, but risk of Seizures and
Agranulocytosis (<1%)

49
Q

SE of both Antipsychotics

A

Sedation,Anticholinergic/Antiadrenergic Effects (Dry Mouth, Constipation, Blurred Vision, Urinary
Retention and Tachycardia); Increased Prolactin leads to Galactorrhoea and Oligomenorrhoea

50
Q

If fail to respond to two trials of first-line antipsychotics

A

consider Clozapine
o Cognitive Therapy might also improve drug-resistant hallucinations and delusions by removing pre-occupation with symptoms

51
Q

After starting Antipsychotics

A

symptoms of Excitement, Irritability and Insomnia improves within few days; Hallucinations might improve over several weeks
• Patient should not be left un-occupied (which might lead to being absorbed into symptoms) or overstimulated (prolonged acute symptoms); Suitable programme of activity

52
Q

ECT

A

ECT is not regularly used; Might be required if severe Depressive symptoms, or rare cases of
Catatonic Stupor which occurs in Chronic Schizophrenia; Rapidly effective in both
o Also, effective in Acute Syndrome but is simpler and as beneficial
o Postpartum Psychosis – ECT indicated as rapid response is particularly important

53
Q

Associated Depressive Symptoms

A

Antidepressants or Lithium, especially if Schizoaffective

54
Q

Management of Aggressive Behaviour

A

Risk Assessment; Threats should be taken seriously;

Close Observation or Compulsory orders; Calm, Reassuring, Consistent Environment

55
Q

Prevention of Relapse

A

Aim to control symptoms with Antipsychotic drugs while making daily arrangements that protects the patients from too many stressors and return as far as possible to ADLs
o Continue Antipsychotics for 6/12 at tolerable dose
o Family Therapy aimed at reducing critical comments, and improving family’s
knowledge of disorder can reduce Relapse

56
Q

Continued Pharmacotherapy

A

Intramuscular Depot injections improve adherence
o Long-term Typical Antipsychotics lead to Tardive Dyskinesia in 15% after 4yrs
o Difficult to predict who requires drugs (20% remain well without); Case-by-case
judging benefit of continuing treatment
o Anticholinergic Drugs reduce Parkinsonian SE, but increased likelihood of Dyskinesia

57
Q

MDT

A

Systematic Assessment of Medical and Social Needs; MDT involvement and care planning,
involvement of Experienced Community Psychiatric Nursing
o Key coordinator of care, monitoring mental state, Administering Depot injections,
Monitoring Compliance, Arranging/Carrying out Psychotherapies, Psychoeducation
and Liaison with other care workers

58
Q

Psychosocial Care

A

Social Skills, Employment Training, Cognitive Remediation

Psychiatry STG (12 decks)

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