Gargi's & Emma's notes - Psychotic Disorders Flashcards
What are the main psychotic disorders?
- schizophrenia,
- schizoaffective disorder,
- delusional disorder
- acute psychoses
Are psycbotic symptoms specific?
non-specific
What are some non-psychiatric causes of psychotic symptoms?
- Organic causes: brain tumour, infarcts, infection, inflammation (HIV, CJD, neurosyphilis, HSV encephalitis), thyroid/parathyroid disorders, temporal lobe epilepsy, B12/niacin/thiamine deficiency, acute porphyria
- Substances: alcohol, cannabis, legal highs, stimulants, hallucinogens, solvents
- Medications: antiparkinsonian drugs, corticosteroids, anticholinergics
What are some other psychiatric causes of psychotic symptoms (not including schizophrenia, etc.)?
- Other mental illness: delirium, dementia, schizotypal PD, neurodevelopmental disorders, depression, mania
What is psychosis?
mental state in which reality is greatly distorted, resulting in symptoms such as delusions, hallucinations and thought disorder
Name some otuer symptoms of psychotic disorder
such as psychomotor abnormalities, mood/affective disturbance, cognitive deficits and disorganised behaviour
What are the symptoms of psychoatic disorders?
What is the definition of schizophrenia?
A psychotic disorder characterised by delusions, hallucinations, thought disorder/disorganised speech, disorganised/catatonic behaviour or negative symptoms
- It must be in the absence of organic disease/alcohol/drugs, and not secondary to elevated/depressed mood
What are the subtypes of schizophrenia?
- Paranoid schizophrenia
- Hebephrenic (disorganised) schizophrenia
- catatonic schizophrenia
- Residual schizophrenia
- Simple schizophrenia
what is Paranoid schizophrenia?
- positive symptoms dominate; negative/catatonic symptoms are not prominent
what is Hebephrenic (disorganised) schizophrenia?
thought disorder, disturbed behaviour and inappropriate/flat affect predominate; delusions/hallucinations are not prominent
What is Catatonic schizophrenia?
- rare form dominated by psychomotor disturbance
What is Residual schizophrenia?
1yr of predominantly chronic negative symptoms which must have been preceded by at least 1 psychotic episode in the past
What is simple schizophrenia?
insidious but progressive decline in social ability and total performance; negative symptoms develop without previous psychotic symptoms , inability to meet the demands of society
What is the aetiology of schizophrenia?
What is the epidemiology of schizophrenia?
- 1% prevalence
- Age of onset: males 28yo, females 32yo
- Men have higher incidence than women (1.4:1) but equal prevalence (possibly due to higher mortality in men)
What are Schneider’s first rank symptoms?
- Auditory hallucinations
- Thought broadcasting
- Controlled thought – delusions of control
- Delusional perception
What 3 stages can the clinical picture of schizophrenia be split up into?
Clinical picture can be divided into 3 stages:
-
At-risk mental state (prodrome)
- Low-grade symptoms, e.g. social withdrawal, loss of interest in work/relationships/etc, irritability, reduction of normal functioning
- No frank psychotic symptoms à difficult to pick up on
- Acute phase: positive symptoms (uncommonly negative symptoms are simultaneous)
-
Chronic phase: negative symptoms
- May last indefinitely can become disabling
What are the ICD-10 diagnostic guidelines criteria for a diagnosis of schizophrenia?
-
One or more of:
- Delusions of thought control: echo, insertion, withdrawal, broadcast
- Delusions of control or passivity
- Running commentary or voices discussing the patient among themselves
- Bizarre delusions
- NB the above are Schneider’s 1st rank symptoms (as well as delusional perception –> normal perception with delusion formed around it, e.g. “red car passed me so I knew I was going to be killed”)
-
OR two or more of:
- Persistent hallucinations in any modality (occur for weeks), or associated with delusions/sustained overvalued ideas
- Thought disorder (e.g. flight of ideas, neologisms etc.)
- Catatonic behaviour
- Negative symptoms
- Symptoms should be present for at least 1 month, and associated with at least 6 months of functional decline
- Should not be diagnosed in the presence of organic brain disease or during acute intoxication/withdrawal
What may the additional motor symptoms be in schizophrenia?
Additional motor symptoms:
echopraxia, mannerisms, stereotypies, tics
What are the possible MSE findings for positive and negative symptoms in schizophrenia?
What are some differentials for ?schizophrenia?
What must be asked in the Hx/MSE/assessment of ?schizophrenia?
- Thorough history, collateral history, MSE, risk assessment
- Do you ever see/hear things that other people don’t?
- Do you ever hear your thoughts spoken aloud? Or have thoughts put into/taken out of your head?
- Are you afraid that somebody is trying to harm you?
- Have you noticed people are doing or saying things that have a special meaning for you?
- Do you have any special abilities or powers?
- Does it seem like you are being controlled/influenced by some external force?
What other investigations must be conducted for ?schizophrenia?
Bloods: UE, LFT, Ca, FBC, glucose, VDRLs (for syphyilis), TFTs, PHT, cortisol, turmour markers
Imaging: CT/MRI, CXR if indicated by Hx
Urine: UDS (urine tox screen), MCS
Other: EEG, 24h urinary cortisol, 24h catecholamines or 5-HIAA if suspected pheo or carcinoid, OT assessment of ADLs, social worker assessment of finances or housing, collateral hx
Which investigations must be conducted before prescribing antipsychotics for schizophrenia?
before giving antipsychotics:
- BMI, BP, lipids, glucose/HbA1c
- U&Es, LFTs
- ECG
What should 1st presentation of schizophrenia be treated with in the GP setting?
Treat with
- 1st line: 2nd generation / atypical antipsychotics (olanzapine, risperidone, amisulpride, quetiapine) OR long acting benzodiazepine (diazepam) to control non-acute anxiety or behavioural disturbance
- 2nd line: 1st generation / typical antipsychotics (haloperidol, chlorpromazine) titrate up with clinical effect or need for sedation
refer to Community Mental Health Services
When should a patient presenting with schizophrenia at the GP be admitted?
Need for admission:
- High risk of suicide or homicide
- Illness-related behaviour that endangers relationships
- Severe symptoms – psychotic, depressive or catatonic
- Lack of capacity to cooperate or comply with treatment
- Failure of outpatient tx
- Significant changes in meds for patient or recurrent history of relapse
- Need to address comorbid conditions
- Home treatment teams act as gatekeepers to see if patients can be safely managed at home or if
- admission is needed
What is the Tx for schizophrenia in the secondary care setting?
What is the discharge plan (from inpatient secondary care) for schizophrenia?
Formalise with a care programme approach – CPA
- Assess clinical and other needs
- Formulate care plan
- Arrange discharge planning meeting with patient, carers, staff – will they be discharged to the HTT etc
- Appoint care manager or case co Ordinator who should be contacted if concern
- Maintain contact with patient
- Decide on criteria for recall / other interventions
- Document all people involved in care package and what their roles are
- Arrange to meet in a group
What is the Tx if presentation of schizophrenia is due to if episode is due to psychotic decompensation or antipsychotic resistance?
- review doses and consider starting different antipsychotic
What is the main factor influencing choice of antipsychotic (for schizophrenia)?
Main factor influencing choice is tolerability (e.g. olanzapine/quetiapine cause more weight gain than aripiprazole)
Do antipsychotics reduce positive symptoms and negative symptoms of schizophrenia?
- Antipsychotics reduce positive symptoms but not negative
What is the Tx for severe agitation or violence in schizophrenia?
- IM antipsychotic (e.g. IM olanzapine)
- IM lorazepam
What are the Tx settings for ongoing management of schizophrenia?
- Inpatient admission if still a risk to self or others
- Long-term community management by CMHTs or outreach teams; regular outpatient follow-up
- If stable and well-controlled, may be managed in primary care
What is the Tx for ongoing management of schizophrenia?
- Pharmacological management:
- Antipsychotics
- Choice based on tolerability
- Consider depot preparations for poor adherence
- Length of treatment:
- 1-2yrs after 1st episode (but relapse rates are high à 80%)
- Usually on antipsychotics long-term
- Benzodiazepines (lorazepam)
- For short-term relief behavioural disturbance, insomnia, aggression and agitation
- Antipsychotics
What is the Tx for treatment-resistant schizophrenia?
- Lack of satisfactory clinical improvement despite sequential use of at least 2 antipsychotics for 6-8wks, at least one of which should be an atypical antipsychotic
- If patient appears treatment resistant…
- Reassess diagnosis
- Check concordance
- Check psychological therapies have been offered
- Assess for comorbid substance use
-
If treatment resistance is confirmed, offer clozapine
- There must be no contraindications and patient must agree with oral medication and regular monitoring
- Sometimes antidepressants and lithium are used to augment, esp if significant affective symptoms
When is ECT used in schizophrenia?
- For severe catatonic symptoms
Which psychosocial interventions can be offered for ongoing management of schizophrenia?
Psychological interventions:
- Psychoeducation
- Support and education to family
- Family therapy may be helpful à reduction of expressed emotion, reducing stigma
- CBT
- Used for persisting hallucinations/delusions
- Can help patients with poor insight come to terms with illness; recognise early signs of relapse
- Social skills training
- Effective in decreasing negative symptoms
Social interventions:
- Financial benefits, occupation, accommodation, daytime activities, social supports
Before starting antipsychotic, do an ECG if ____;
- Specified in product characteristics
- Personal Hx of cardiovascular disease
- Physical exam has identified high cardiovascular risk – high BP
- Service user admitted as inpatient
What are the side effects of atypical antipsychotics?
o Olanzapine – helps with positive symptoms but weight gain
o Quietiapine – QT prolongation, need ECG
o Risperidone – increase prolactin + aggression
o Aripiprazole – expensive but no SE – use in patients with metabolic syndrome
What are the main side effects of typical antipsychotics?
EPS:
-
Acute dystonia – TX with anticholinergic eg IV procyclidine
- Early onset – hours
- Involuntary
- Painful, sustained muscle spasm – torticollis ▪ Oculogyric crisis
- Tongue and sternocleidomastoid
-
Akathisia – hours-weeks
- Unpleasant restlessness of lower limbs – change or decrease dose ▪ Add propranolol or BDZ
-
Parkinsonism – days-weeks
- 1) resting tremor 2) rigidity 3) bradykinesia – change or decrease dose, add anticholinergic eg. procyclidine IV
-
Tardive dyskinesia – months-years
- Rhythmic involuntary movements
- Continuous, slow, writhing movements – oral or lingual/limbs ▪ Tend to be irreversible
- Decrease antipsychotic
- Avoid anticholinergic
- Can give atypical SSRI or clozapine
What is a major side effect of antipsychotics that patients must be warned about? Describe it
Neuroleptic malignant syndrome
- Muscle stiffness, rigidity, altered consciousness, autonomic disturbance (fever, tachycardia, labile BP), raised CK and WCC
- Acute renal failure secondary to rhabdomyolysis can lead to death
- Normally when increasing or changing dose of drug
What is the Tx of neuroleptic malignant syndrome?
TX:
- immediately stop antipsychotic,
- admit to medical ward or ITU,
- hydration and O2,
- monitoring,
- dantrolene and bromocriptine
What is the mechanism of action of clozipine?
Block D1 and D4 receptors, superior because of 5HT blockade and increased GABA turnover
What are the side effects of clozapine?
Anticholinergic, antihistaminic, anti-adrenergic SE
- Constipation
- Fever
- BP derangement
- Sedation
- Seizures
- Acute dystonia
- Weight gain
What is an important drug that clozapine interacts with?
Lithium –
- increase seizure risk,
- anticholinesterase inhibitors,
- smoking increases clearance = ↓ plasma concentration;
- plasma concentration ↑ by caffeine
What are some contraindications to clozapine?
- previous or current neutropenia or blood dyscrasias,
- previous MI or pericarditis,
- cardiomyopathy,
- liver disease
What is the major side effect/complication of clozapine that patients must be warned about?
FATAL AGRANULOCYTOSIS –
- leukopenia, eosinophilia, leucocytosis
- fatal myocarditis, cardiomyopathy, PE
Which other bloods must be done for patients on clozapine?
- – regular blood tests for WCC
- (weekly for 18 weeks – every 2 weeks for year – monthly indefinitely)
Does clozapine decrease mortality?
Evidence that it reduces mortality in schizo due to decreased suicide
What is schizoaffective disorder?
Both schizophrenic and mood symptoms present in the same episode of illness, either simultaneously or within a few days of each other
- The mood symptoms should meet the criteria for either a depressive or manic episode; psychotic symptoms should meet diagnosis for schizophrenia
- Psychosis must not be secondary to mood disturbance
What are the 2 classifications of schizoaffective disorder according to ICD-10?
ICD-10 codes it as either manic type or depressed type
What is the aetiology of schizoaffecive disorder?
- Similar to schizophrenia
- 1st degree relatives of patients with schizoaffective disorder have increased risk of mood disturbances and schizophrenia
What is the epidemiology of schizoaffective disorder?
- Less common than schizophrenia – lifetime prevalence 0.3%
- Presents in early adulthood
- F>M
What are the signs and symptoms of schizoaffective disorder?
- Symptoms of depression or mania at the same time as psychotic symptoms (positive or negative)
- Psychotic and affective symptoms must be the same severity –> one cannot be more prominent
What are the investigations for ?schizoaffective disorder?
- Same as schizophrenia
- Thorough history and collateral history to confirm that one type of symptoms did not precede the other
What is the management of schizoaffective disorder?
Similar to schizophrenia
- Antipsychotics –> used for both types but more effective in manic
- Adjunct antidepressants for depressive type and mood stabilisers for manic type
What is the definition of acute/transient psychosis?
Sudden onset psychosis,
- Onset in <2wks
- resolving in <3 months;
What is the aetiology of acute/transient psychosis?
- May be genetic vulnerability –> more common if FHx
- More common in people with personality disorders
- May be triggered by acute stress or can occur for no apparent reason at all
What is the epidemiology of acute/transient psychosis?
- Prevalence 0.1-0.5% general population
- F>M
What are the symptoms of acute/transient psychsosis?
- Psychotic symptoms (may be identical to schizophrenia)
- Resolves completely within a few months (often days-weeks
- Variable – perplexity, inattention, formal thought disorder, delusions, hallucinations
What are the differentials for ?acute/transient psychosis?
- Organic – dementia or delirium
- BPAD, depression
- Substance misuse
- Personality disorder
- Schizo
What are the investigations for ?acute/transient psychosis?
- Same Ix as schizophrenia (may present in same way)
- Cannot be officially diagnosed until patient has returned to normal pre-morbid functioning within a few months
- Rapid assessment is key
What is the Tx for acute/transient psychosis?
Pharmacological treatment:
- Give antipsychotics +/- benzodiazepines
- Consider tapering and discontinuing antipsychotic when symptoms resolve à treatment is generally not needed past 1 month
Psychological interventions:
- Psychoeducation
- Family education
- CBT
Social interventions:
- Remove precipitating stressors
After symptoms have resolved –> monthly to monitor for recurrence of symptoms
- If symptoms return, another diagnosis (i.e. schizophrenia) should be considered
What is delusional disorder?
Development of a single delusion or a set of related delusions that are usually persistent (at least 3 months)
- Schizophrenic symptoms (e.g. delusions of control, negative symptoms) and clear/persistent auditory hallucinations rule out this diagnosis
- However there may be occasional/transient auditory hallucinations, esp in elderly, if they are not typically schizophrenic and only form part of the overall picture
- absence of prominent hallucinations
- no thought/mood disorder/flattening of affect
What is the probable diagnosis if a patient with development of a single delusion or a set of related delusions have symptoms that last for >3 months?
persistent delusional disorder
What is the aetiology of delusional disorder?
What are the risk factors for delusional disorder?
- Old age,
- social isolation,
- group delusions,
- low socioeconomic status,
- premorbid personality disorder,
- sensory impairment,
- immigration,
- FHX,
- head injury HX,
- substance abuse
What is the epidemiology of delusional disorder?
- Onset in middle age; may persist throughout the patient’s life
- M>F
- Men are more likely to have paranoid delusions; women are more likely to have erotomanic delusions
What are the signs and symptoms of delusional disorder?
-
A single delusion or set of related delusions
- The content of the delusion is very variable à include persecutory, grandiose, erotomanic and hypochondriacal delusions
- May be fleeting hallucinations – not typically schizophrenic in nature
- Affect, speech and behaviour are all normal
- social skills well-preserved
What is induced delusional disorder (folie a deux)?
- Rarely, patients may present with an induced delusional disorder (folie a deux), which occurs when a non-psychotic patient with close emotional ties to another person suffering from delusions begins to share those delusional ideas themselves
- The delusions in the non-psychotic patient tend to resolve when the two are separated
What are the differentials for ?delusional disorder?
What are the investigations for ?delusional disorder?
- Thorough Hx, MSE
- exclude organic causes
- mainly same as for ?schizophrenia
What is the Tx for delusional disorder?
Difficult to treat due to low insight
Inpatient treatment required if delusions cause patient to be a threat to themselves or others
Pharmacological therapy:
- Antipsychotics
- Antidepressants (SSRIs) if necessary
Psychological therapy:
- To facilitate treatment adherence and provide education about illness
- Psychoeducation
- Social skills training (e.g. not discussing delusions in social situations)
- CBT
- Family therapy
