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1 - Y5 Psych > Gargi's & Emma's notes - Psychotic Disorders > Flashcards

Gargi's & Emma's notes - Psychotic Disorders Flashcards

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1
Q

What are the main psychotic disorders?

A
  • schizophrenia,
  • schizoaffective disorder,
  • delusional disorder
  • acute psychoses
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2
Q

Are psycbotic symptoms specific?

A

non-specific

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3
Q

What are some non-psychiatric causes of psychotic symptoms?

A
  • 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
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4
Q

What are some other psychiatric causes of psychotic symptoms (not including schizophrenia, etc.)?

A
  • Other mental illness: delirium, dementia, schizotypal PD, neurodevelopmental disorders, depression, mania
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5
Q

What is psychosis?

A

mental state in which reality is greatly distorted, resulting in symptoms such as delusions, hallucinations and thought disorder

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6
Q

Name some otuer symptoms of psychotic disorder

A

such as psychomotor abnormalities, mood/affective disturbance, cognitive deficits and disorganised behaviour

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7
Q

What are the symptoms of psychoatic disorders?

A
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8
Q

What is the definition of schizophrenia?

A

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
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9
Q

What are the subtypes of schizophrenia?

A
  • Paranoid schizophrenia
  • Hebephrenic (disorganised) schizophrenia
  • catatonic schizophrenia
  • Residual schizophrenia
  • Simple schizophrenia
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10
Q

what is Paranoid schizophrenia?

A
  • positive symptoms dominate; negative/catatonic symptoms are not prominent
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11
Q

what is Hebephrenic (disorganised) schizophrenia?

A

thought disorder, disturbed behaviour and inappropriate/flat affect predominate; delusions/hallucinations are not prominent

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12
Q

What is Catatonic schizophrenia?

A
  • rare form dominated by psychomotor disturbance
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13
Q

What is Residual schizophrenia?

A

1yr of predominantly chronic negative symptoms which must have been preceded by at least 1 psychotic episode in the past

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14
Q

What is simple schizophrenia?

A

insidious but progressive decline in social ability and total performance; negative symptoms develop without previous psychotic symptoms , inability to meet the demands of society

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15
Q

What is the aetiology of schizophrenia?

A
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16
Q

What is the epidemiology of schizophrenia?

A
  • 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)
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17
Q

What are Schneider’s first rank symptoms?

A
  • Auditory hallucinations
  • Thought broadcasting
  • Controlled thought – delusions of control
  • Delusional perception
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18
Q

What 3 stages can the clinical picture of schizophrenia be split up into?

A

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
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19
Q

What are the ICD-10 diagnostic guidelines criteria for a diagnosis of schizophrenia?

A
  • 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
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20
Q

What may the additional motor symptoms be in schizophrenia?

A

Additional motor symptoms:

echopraxia, mannerisms, stereotypies, tics

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21
Q

What are the possible MSE findings for positive and negative symptoms in schizophrenia?

A
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22
Q

What are some differentials for ?schizophrenia?

A
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23
Q

What must be asked in the Hx/MSE/assessment of ?schizophrenia?

A
  • 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?
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24
Q

What other investigations must be conducted for ?schizophrenia?

A

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

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25
Q

Which investigations must be conducted before prescribing antipsychotics for schizophrenia?

A

before giving antipsychotics:

  • BMI, BP, lipids, glucose/HbA1c
  • U&Es, LFTs
  • ECG
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26
Q

What should 1st presentation of schizophrenia be treated with in the GP setting?

A

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

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27
Q

When should a patient presenting with schizophrenia at the GP be admitted?

A

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
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28
Q

What is the Tx for schizophrenia in the secondary care setting?

A
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29
Q

What is the discharge plan (from inpatient secondary care) for schizophrenia?

A

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
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30
Q

What is the Tx if presentation of schizophrenia is due to if episode is due to psychotic decompensation or antipsychotic resistance?

A
  • review doses and consider starting different antipsychotic
31
Q

What is the main factor influencing choice of antipsychotic (for schizophrenia)?

A

Main factor influencing choice is tolerability (e.g. olanzapine/quetiapine cause more weight gain than aripiprazole)

32
Q

Do antipsychotics reduce positive symptoms and negative symptoms of schizophrenia?

A
  • Antipsychotics reduce positive symptoms but not negative
33
Q

What is the Tx for severe agitation or violence in schizophrenia?

A
  • IM antipsychotic (e.g. IM olanzapine)
  • IM lorazepam
34
Q

What are the Tx settings for ongoing management of schizophrenia?

A
  • 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
35
Q

What is the Tx for ongoing management of schizophrenia?

A
  • 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
36
Q

What is the Tx for treatment-resistant schizophrenia?

A
  • 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
37
Q

When is ECT used in schizophrenia?

A
  • For severe catatonic symptoms
38
Q

Which psychosocial interventions can be offered for ongoing management of schizophrenia?

A

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
39
Q

Before starting antipsychotic, do an ECG if ____;

A
  • Specified in product characteristics
  • Personal Hx of cardiovascular disease
  • Physical exam has identified high cardiovascular risk – high BP
  • Service user admitted as inpatient
40
Q

What are the side effects of atypical antipsychotics?

A

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

41
Q

What are the main side effects of typical antipsychotics?

A

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
42
Q

What is a major side effect of antipsychotics that patients must be warned about? Describe it

A

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
43
Q

What is the Tx of neuroleptic malignant syndrome?

A

TX:

  • immediately stop antipsychotic,
  • admit to medical ward or ITU,
  • hydration and O2,
  • monitoring,
  • dantrolene and bromocriptine
44
Q

What is the mechanism of action of clozipine?

A

Block D1 and D4 receptors, superior because of 5HT blockade and increased GABA turnover

45
Q

What are the side effects of clozapine?

A

Anticholinergic, antihistaminic, anti-adrenergic SE

  • Constipation
  • Fever
  • BP derangement
  • Sedation
  • Seizures
  • Acute dystonia
  • Weight gain
46
Q

What is an important drug that clozapine interacts with?

A

Lithium –

  • increase seizure risk,
  • anticholinesterase inhibitors,
  • smoking increases clearance = ↓ plasma concentration;
  • plasma concentration ↑ by caffeine
47
Q

What are some contraindications to clozapine?

A
  • previous or current neutropenia or blood dyscrasias,
  • previous MI or pericarditis,
  • cardiomyopathy,
  • liver disease
48
Q

What is the major side effect/complication of clozapine that patients must be warned about?

A

FATAL AGRANULOCYTOSIS –

  • leukopenia, eosinophilia, leucocytosis
  • fatal myocarditis, cardiomyopathy, PE
49
Q

Which other bloods must be done for patients on clozapine?

A
  • – regular blood tests for WCC
  • (weekly for 18 weeks – every 2 weeks for year – monthly indefinitely)
50
Q

Does clozapine decrease mortality?

A

Evidence that it reduces mortality in schizo due to decreased suicide

51
Q

What is schizoaffective disorder?

A

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
52
Q

What are the 2 classifications of schizoaffective disorder according to ICD-10?

A

ICD-10 codes it as either manic type or depressed type

53
Q

What is the aetiology of schizoaffecive disorder?

A
  • Similar to schizophrenia
  • 1st degree relatives of patients with schizoaffective disorder have increased risk of mood disturbances and schizophrenia
54
Q

What is the epidemiology of schizoaffective disorder?

A
  • Less common than schizophrenia – lifetime prevalence 0.3%
  • Presents in early adulthood
  • F>M
55
Q

What are the signs and symptoms of schizoaffective disorder?

A
  • 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
56
Q

What are the investigations for ?schizoaffective disorder?

A
  • Same as schizophrenia
  • Thorough history and collateral history to confirm that one type of symptoms did not precede the other
57
Q

What is the management of schizoaffective disorder?

A

Similar to schizophrenia

  • Antipsychotics –> used for both types but more effective in manic
  • Adjunct antidepressants for depressive type and mood stabilisers for manic type
58
Q

What is the definition of acute/transient psychosis?

A

Sudden onset psychosis,

  • Onset in <2wks
  • resolving in <3 months;
59
Q

What is the aetiology of acute/transient psychosis?

A
  • 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
60
Q

What is the epidemiology of acute/transient psychosis?

A
  • Prevalence 0.1-0.5% general population
  • F>M
61
Q

What are the symptoms of acute/transient psychsosis?

A
  • Psychotic symptoms (may be identical to schizophrenia)
  • Resolves completely within a few months (often days-weeks
  • Variable – perplexity, inattention, formal thought disorder, delusions, hallucinations
62
Q

What are the differentials for ?acute/transient psychosis?

A
  • Organic – dementia or delirium
  • BPAD, depression
  • Substance misuse
  • Personality disorder
  • Schizo
63
Q

What are the investigations for ?acute/transient psychosis?

A
  • 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
64
Q

What is the Tx for acute/transient psychosis?

A

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
65
Q

What is delusional disorder?

A

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
66
Q

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?

A

persistent delusional disorder

67
Q

What is the aetiology of delusional disorder?

A
68
Q

What are the risk factors for delusional disorder?

A
  • Old age,
  • social isolation,
  • group delusions,
  • low socioeconomic status,
  • premorbid personality disorder,
  • sensory impairment,
  • immigration,
  • FHX,
  • head injury HX,
  • substance abuse
69
Q

What is the epidemiology of delusional disorder?

A
  • 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
70
Q

What are the signs and symptoms of delusional disorder?

A
  • 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
71
Q

What is induced delusional disorder (folie a deux)?

A
  • 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
72
Q

What are the differentials for ?delusional disorder?

A
73
Q

What are the investigations for ?delusional disorder?

A
  • Thorough Hx, MSE
  • exclude organic causes
  • mainly same as for ?schizophrenia
74
Q

What is the Tx for delusional disorder?

A

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

1 - Y5 Psych (23 decks)

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