Disordered Thinking Flashcards
Definition of a hallucination
Perceptions which, to the patient are indistinguishable from reality, and occur in the absence of an external stimulus. They can take the form of visual, auditor (most common), taste, smell and tactile hallucinations.
Definition of delusion
False beliefs which are held with conviction by the patient despite contradictory evidence. Can take the form of delusions of reference, of control and of persecution.
Definition of thought disorder
impairment in the ability to form thoughts from logically connected ideas. Presents clinically in the patient’s speech.
Definition of an illusion
Misperceptions fo real external stimuli. Can occur in healthy people
Types of auditory hallucinations
Elementary e.g. buzzing, whistling. Complex e.g. first, third, second person.
Charles Bonnet Syndrome
Presence of complex visual hallucinations with no other psychiatric symptoms or consciousness impairment. Associated with loss of vision.
Hypnagogic hallucinations
Occur as patient goes to sleep
Hypnopompic hallucinations
Occur as patient wakes up.
Mood congruent and mood incongruent delusions
Congruent = contents of the delusion are appropriate to the patient’s mood. Incongruent are not in line with the patient’s mood.
Capgras syndrome
Delusion that a familiar person has been replaced by an imposter.
Fregoli syndrome
Delusion that a stranger is actually a person the patient is familiar with.
Nihilistic delusions
Delusion that the patient or other or the whole word are going to end or that nothing actually exists.
Primary delusions
Cause of delusion is not understandable, invade all aspects of patient’s life. Patient becomes suspicious and perplexed.
Secondary delusions
Consequence of a pre-exisiting psychopathological state.
Extracampine hallucination
Altered perception outside the sensory field.
Differential diagnosis of a psychotic patient
Schizophrenia Manic episode of bipolar disorder Schizoaffective disorder Lewy body dementia Drug or alcohol abuse Drug or alcohol withdrawal Delirium PTSD Autism spectrum disorder
Risk factors for psychosis/schizophrenia
Genetics esp 1st degree relative. Stress, traumatic life experience. Cannabis misuse Migration Birth complications. Brain abnormalities such as reduced size.
Prodromal period/At risk of mental state
Emotional and behaviour change leading to social withdrawal and impaired functioning of patient.
Subclinical psychotic symptoms may occur. or transient psychotic symptoms which are brief and intermittent. The period occurs before episode of full-on psychosis.
First rank symptoms of schizophrenia
1) Delusions of perception e.g. communicate with aliens, have superpower.
2) Delusions of thought (insertion, broadcast, echo).
3) Delusions of control (something making their body move or act)
4) Auditory hallucinations (audible, arguing voices running commentary).
Other symptoms of schizophrenia
Over-valued ideas.
Breaks or interpolations of thought flow.
Catatonic behaviour (fixed posture, rigid, stupor)
Echopraxia.
Tics
Negative symptoms of schizophrenia
Apathy
Reduced speech
Blunting or incongruity of emotional response.
Social withdrawal.
Diagnosis of schizophrenia
1 or more of the first rank symptoms or any two of the other symptoms.
Must be present for most of 1 month or more.
Marked impairment on patient’s functioning.
In absence of organic brain disorder. – > Investigations might include: LFT+gamma GT, FBC, urine drug screen, b12&folate, head CT, U&E.
Management of first episode of psychosis
Refer to crisis team or early intervention psychiatry team. May need to use Mental Health Act to admit.
Identify suicide risk.
Individual CBT
Trial antipsychotic medication.
Care plan for crisis event, advance statement, close contact information.
Topics for discussion of routine psychosis review
Care programme approach. Social needs. Mental health and symptom control. Treatment adherence. Physical wellbeing. Drug and smoking use. Re-assess risk. Continuity of care. Adverse effects of any medication.
Pharmacology for schizophrenia
Affinity for post-synaptic D2 receptors.
Typical/first generation antipsychotics = Haloperidol, Promazine, Chlorpromazine.
Atypical/Second generation antipsychotics = Olanzapine, Risperidone, Clozapine. Fewer extrapyramidal side effects.
Extrapyramidal side effects
Parkinsonism (rigidity, tremor, bradykinesia).
Akathasia (restless)
Tardive dyskinesia (lip smacking, blinking)
Acute dystonic reaction (sudden painful muscle contractions)
Side effects of atypical antipsychotics
Sedation
Weight gain
Arrhythmia and prolonged QT interval
Decrease seizure threshold in epileptic patients.
Last resort antipsychotic/Rx for resistant psychosis and need for monitoring
Clozapine.
Monitor neutrophils as causes agranulocytosis - FBC
Biopsychosocial formulation
Creates an integrated history of the patient looking at more than just the medical aspect of their life. Look at predisposing, precipitating, perpetuating and protective factors in past, present and future of patient.
Schizoaffective disorder
Symptoms of schizophrenia together with mood problems (mania or depression).
Iatrogenic and psychosis inducing drugs
Cannabis, LDS, ecstasy.
Antiparkinson drugs (dopamine)
Corticosteroids.
Anticholinergic drugs e.g. dementia drugs Donepezil.
Neuroleptic malignancy syndrome
Rare ADR of antipsyhotics.
Life-threatening and need to cease treatment immediately.
S+S = fever, altered mental state, muscle rigidity and autonomic dysfunction (incontinence, tachycardia, sweating).
Ix = metabolic acidosis, high creatinine kinase, high WCC.
Rx = A to E resuscitation, cooling blanket, stop antipsychotic medication, benzodiazepines if agitated, IV Dantrolene in malignant hypothermia.
Acute dystonic reaction
Extrapyramidal ADR.
Occurs within hours of drug administration.
Intermittent spasmodic or sustained involuntary contractions of muscles
Rx = Procyclidine
Catatonia
Symptom of schizophrenia.
Muscle rigidity and increased tone.
Create abnormal movements, posture and tone. E.g. catatonic waxy flexibility, catatonic negativism.
Munchausen’s syndrome
A person believes and acts like they have a medical disorder when in fact they do not. They may act to purposely cause symptoms e.g Diabetic taking in too much insulin.
Metabolic effects of anti-psychotics
hyperlipidemia, hypercholesterolemia, hyperglycemia and weight gain
5 side extrapyramidal side effects of antipsychotics
Acute dystonic reaction (hrs) Parkinsonism (weeks) Akathisia (months) Tardive dyskinesia (years) Neuroepileptic malignancy syndrome
Acute dystonic reaction
Occurs within hours of drug administation. Muscle spasms and contractions. Torticollis (neck twisting) Buccolingual crisis Rx with procyclidine
Parkinsonism
Resting tremor
Rigidity
Bradykinesia
Rx with procyclidine
Akathisia
Restlessness
Rx with propranolol and cyproheptadine
Tardive dyskinesia
Chewing, grimacing and other repetitive involuntary movements.
Irreversible but try tetrabenazine.
Other side effects of antipsychotics
Hyperprolactinaemia
Weight gain
Drowsyness
Lowered seizure threshold.
