ICL 9.1: Psychosis Flashcards
1
Q
in what order do you address medical illness, psychiatric illness, mood disorder and anxiety disorders?
A
the hierarchy of assessment and treatment of psychiatric symptoms
- medical illness and substance induced: before any psychiatric disorder is considered, a thorough evaluation of other medical illnesses that cause psychiatric symptoms is required, including symptoms that are induced by use, abuse, or withdrawal of substances
- psychotic disorders: next highest in priority of treatment are the psychotic disorders, and a new onset psychotic symptoms deserves a full and complete workup, including blood work and head imaging as indicated
- mood disorders: after psychotic disorders have been evaluated or treated, next most important are the mood disorders like bipolar and depression
- anxiety disorders: after anxiety disorders, the remainder of the psychiatric illnesses fall in line
so if someone has both bipolar and anxiety disorder, then do your best to fully treat the bipolar disorder before moving on to the anxiety disorder
2
Q
what are the steps in assessment of psychosis?
A
- identify the psychotic symptom and time course; the story behind it is very important
if someone is in the hospital for COPD and they’re on high dose steroids and then they’re screaming and agitated with no h/o psychosis, he probably needs to be taken off of prednisone and it’s not a new onset schizophrenia
- obtain full review of symptoms including both physical and mental health
- identify any emergencies
ex. alcohol withdrawal; someone will die if you don’t treat them for that and just think they’re having a schizophrenic crisis - rule out psychotic symptoms due to substances
- rule out if due to a general medical condition
3
Q
what are the 4 ways that someone can be psychotic?
A
- hallucinations
- delusions
- catatonia
- thought disorders
4
Q
what kinds of hallucinations can a psychotic person have?
A
- auditory
- visual
- tactile
- gustatory
- olfactory
5
Q
what kinds of delusions can a psychotic person have?
A
- persecution; paranoia
- control: someone is controlling you or you are controlling others = thought broadcasting vs. thought insertion
- grandeur; you have special powers
- guilty delusions
- somatic; skin picking due to “bugs crawling on you”
- erotomania = someone above you is in love with you
- ideas of reference; you’ve broken with reality
6
Q
what kinds of catatonia can a psychotic person have?
A
- mannerism
- stereotypy
- grimacing
- posturing
- stupor
- mutism
- negativism
- catalepsy
- waxy flexibility
- echolalia
- echopraxia
7
Q
what kinds of thought disorder can a psychotic person have?
A
- disorganized thought
- disorganized speech
- agitation
this is the cruz of schizophrenia! if you imagine your thoughts as a stereotypical stream of consciousness but you see a bunch of rocks in the middle that represent delusions, hallucinations etc. then your stream won’t be flowing very well! this is the thought disorder because your thoughts are not proceeding in a linear, goal-directed way
8
Q
what is the clinical presentation of someone who has disorganized thoughts/behaviors?
A
- decline in overall daily functioning
- unpredictable or inappropriate emotional responses
- behaviors that appear bizarre and have no purpose
- lack of inhibition and impulse control
- speech abnormalities: clanging, loose associations, perseveration, neologisms, tangentiality, illogical statements, derailment
9
Q
what is catatonia?
A
a behavioral syndrome marked by an inability to move normally
this is one of the 4 ways that someone could be classified as psychotic
10
Q
what conditions is catatonia associated with?
A
- schizophrenia (most often)
- mood disorders
- autism
- delirium
- medical comorbidities**
so catatonia can be present in the complete absence in any other psychiatric diagnosis!!!! for example, hypothyroidism and MS have caused catatonia all on their own
- withdrawal from benzodiazepines or clozapine
- neuroleptic malignant syndrome (NMS)
11
Q
what is malignant catatonia?
A
this is different from regular catatonia
it includes features of fever, tachycardia, elevated blood pressure, and autonomic instability
12
Q
what are the medical complications associated with catatonia?
A
- aspiration
- dehydration
- nutritional deficiency
- electrolyte abnormalities
- venous thromboembolism
- acute renal failure
- muscle contractures
- pressure ulcers
- UTIs
- cardiac arrest
- death
13
Q
what is the DSM5 criteria for diagnosing catatonia?**
A
you need 3 or more of the following symptoms:
- stupor
- catalepsy
- waxy flexibility
- mutism
- negativism
- posturing
- mannerism
- stereotypy
- agitation
- grimacing
- echolalia
- echopraxia
- grasping
14
Q
what is stupor?
A
no psychomotor activity
not actively relating to environment
one of the criteria of catatonia
15
Q
what is catalepsy?
A
rigidity; passive induction of a posture held against gravity
one of the most notorious symptoms of catatonia
one of the criteria of catatonia
16
Q
what is waxy flexibility?
A
slight, even resistance to position by examiner
often will remain in the new position
one of the most notorious symptoms of catatonia
one of the criteria of catatonia
17
Q
what is mutism?
A
no, or very little verbal response
one of the criteria of catatonia
18
Q
what is negativism?
A
opposition or no response to instructions or external stimuli
if you tell someone to do something and they don’t do it
one of the criteria of catatonia
19
Q
what is posturing?
A
spontaneous and active maintenance of a posture against gravity
one of the criteria of catatonia
20
Q
what are mannerisms?
A
odd, circumstantial caricature of normal actions
one of the criteria of catatonia
21
Q
what is stereotypy?
A
repetitive, abnormally frequency, non-goal-directed movements
one of the criteria of catatonia
22
Q
what is agitation?
A
agitation that does not appear to be influenced by external stimuli
one of the criteria of catatonia
23
Q
what is grimacing?
A
contortion of facial features
one of the criteria of catatonia
24
Q
what is echolalia?
A
mimicking another’s speech
one of the criteria of catatonia
25
what is echopraxia?
mimicking another's movements
one of the criteria of catatonia
26
what are the 2 types of catatonia?
1. stuporous
| 2. excitable
27
what are some of the signs of stuporous catatonia?
1. ambitendency = appears "stuck" metrically
2. anorexia
3. automatic obedience
4. gegenhalten = opposition/resistance to examiner's motor examination
5. grasp reflex
6. rigidity
7. staring
8. withdrawal
can look like an abounded delirium
28
what are some of the signs of excitable catatonia?
while any of the signs associated with stuporous catatonia may also be present, these additional signs are suggestive of the excitable catatonia subtype
1. autonomic abnormalities; vacillation of any vital sign above or below normal range
2. combativeness
3. excitement
4. impulsivity
5. psychosis; hallucinations and/or delusions
29
how do you treat catatonia?
1. consider stopping the antipsychotic medication
it's because catatonia could be on the same spectrum with NMS which is a bad side effect of antipsychotics; so it's kind of like the chicken and the egg trying to figure out what's causing it
NMS = a rare reaction to antipsychotic drugs that treat schizophrenia, bipolar disorder, and other mental health conditions; it affects the nervous system and causes symptoms like a high fever and muscle stiffness
2. benzodiazepines (adavan) -- work so fast!
3. electroconvulsive therapy (ECT)
4. amantadine, memantine; used for neurocognitive disorders but can be used for catatonia
30
what is the difference between catalepsy and cataplexy?
CATALEPSY
rigid body, posturing and can include waxy flexibility
associated with catatonia and the NT involved is dopamine
CATAPLEXY
a sudden and transient episode of muscle weakness with full conscious awareness, typically triggered by emotions like laughing, crying or terror
associated with narcolepsy and the NT involved is orexin
31
what are delusions?
a fixed, false belief that an individual believes, despite being given rational information
is the delusion bizarre or non-bizarre?
is the delusion mood congruent, incongruent, or neutral?
32
what are the 3 stages of something becoming a full blown delusion?
1. preoccupations
obsessions, compulsions, suicidal or homicidal thoughts
2. ideas of reference
misinterpretation of importance of actual incidents and events in the outside world having direct personal reference
3. delusion = fixed false beliefs
33
why are other conditions outside psychotic disorders sometimes treated with antipsychotics? which conditions does this include?
antipsychotic medications are used for severe conditions outside psychotic disorders because for example, when OCD gets severe, it kind of slides along the continuum of delusions and can end up being a full blown delusion
continuum = preoccupations --> ideas of reference --> delusions
ex. delusional disorder, body dysmorphic disorder, eating disorder, somatization disorders, PTSD, OCD, agoraphobia
34
what is an illusion?
a misinterpretation of an existing sensory stimulus
so it's something that actually happened but you misinterpreted it
35
what is a hallucination?
a sensory perception in the *absence* of a sensory stimulus -- so nothing has actually happened!
can be auditory, visual, olfactory, tactile or gustatory
consider any HEENT and neurological conditions super high in your differential before saying someone has straight up psychotic hallucinations
36
what are positive vs. negative psychotic symptoms?
positive symptoms are added to your behaviors
negative symptoms are symptoms that should be there like emotional connection, but are not
negative symptoms are what cause the most overall disability in psychotic patients
positive and negative symptoms are usually mentioned in reference to schizophrenia but they can be used with other conditions too
37
what are some examples of positive symptoms?
1. delusions
2. hallucinations
3. distortions in language or communication
4. disorganized speech
5. disorganized behavior
6. catatonic behavior
7. agitation
38
what are some examples of negative symptoms?
1. alogia (complete lack of speech)
2. affective blunting
3. asociality
4. anhedonia
5. avolition (no motivation)
6. attentional impairment
7. memory
8. planning
9. decision making
39
which NTs play a role in the pathogenesis of psychiatric symptoms?
1. dopamine = motivation, pleasure, reward
2. noradrenaline = alertness, energy
3. serotonin = obsessions, compulsions
40
which NTs are excitatory vs. inhibitory vs. both?
EXCITATORY
1. glutamate
2. aspartate
3. NO
INHIBITORY
1. glycine
2. GABA
3. serotonin
4. dopamine
BOTH
1. ACh
2. NE
41
which NTs are mainly involved in psychosis?
1. glutamate
2. dopamine
3. GABA2
42
what are the normal functions of dopamine in the brain?
1. movement
2. memory
3. pleasure and reward
4. behavior and cognition
5. attention
6. inhibition of prolactin production
7. sleep
8. mood
9. learning
43
what are the normal functions of dopamine outside the brain, in the body?
DA functions in several parts of the peripheral nervous system
1. in blood vessels it inhibits NE release and acts as a vasodilator (relaxation)
2. in the kidneys, it increases sodium and urine excretion
3. in the pancreas, it reduces insulin production
4. in the digestive system, it reduces GI motility and protects intestinal mucosa
5. in the immune system, it reduces lymphocyte activity
44
what are the effects of excess dopamine?
1. unnecessary movements
2. repetitive tics
3. psychosis
4. hypersexuality
5. nausea
most anti-psychotics are dopamine antagonists! and some are even effective anti-nausea agents!
45
what are the effects of dopamine insufficiency?
1. negative symptoms of schizophrenia
2. pain
3. parkinson's
4. restless legs syndrome
5. ADHD
6. lack of motivation, fatigue, apathy, procrastination, low libido, sleep problems, mood swings, hopelessness, memory loss, inability to concentration
46
what is the mesocortical pathway?**how is it effected in schizophrenia?
it connects the brainstem of the ventral tegmental area to ALL the areas of the cortex
this pathway is hypoactive in schizophrenia
it's involved with causing the *negative symptoms* of schizophrenia like cognitive dysfunction, lack of planning, etc.
47
what is the mesolimbic pathway?**how is it effected in schizophrenia?
it connects the brainstem to the limbic system in the cortex; specifically the nucleus accumbens
this pathway is hyperactive in schizophrenia
it's involved with causing the *positive symptoms* of schizophrenia like hallucinations, delusions and catatonia
48
what is the nigrostriatal pathway?** how is it effected in schizophrenia?
it's involved with movement and connects the substantia nigra to the basal ganglia
there's no dysregulation of this system in schizophrenia but antipsychotics can decrease dopamine and cause pseudoparkinsonism with tremors, rigidity, and bradykinesia --> antipsychotics don't cherrypick which pathways are effected, it just reduced dopamine in all the pathways in the brain
49
what is the tuberoinfundibulnar pathway?**how is it effected in schizophrenia?
it's involved with hormones and connect the hypothalamus to the pituitary gland --> it's responsible for hormonal dysregulation!
there's no dysregulation of this system in schizophrenia, however antipsychotics can cause hyperprolactinemia by inhibiting dopamine’s regular functioning of inhibiting prolactin
50
which receptors are associated with glutamate?**
one of the important ones in the brain is NMDA receptors which tend to be located on the brain circuits that regulate dopamine release
51
what is the relationship of PCP and ketamine to glutamate?**
PCP and ketamine bind to NMDA glutamate receptors and block/antagonize them --> these people look like they have schizophrenia!
this prevents calcium ion flux into the cell which leads to elevated cortical glutamate which leads to negative symptoms and cortical dysfunction
this suggests that dopaminergic deficits in schizophrenia may also be secondary to underlying glutamatergic dysfunction
52
what is the hypothesis for what causes schizophrenia?
if there's dysfunction of the NMDA glutamate receptor then you'll have lower glutamate transmission
glutamate normally is excitatory but since there's lower levels of glutamate inside the cell due to NMDA receptor dysfunction, then GABA levels also decrease since they're in a balance and its whole function is to counteract the glutamate (glutamate is the precursor for GABA also)--> now you have a run away train of dopamine since it's no longer being inhibited by GABA which causes positive symptoms like delusions and hallucinations
also if you have lower excitatory activity from lower glutamate levels, you'll also get negative symptoms like autism and inactivity
so you have too much dopamine released in the nucleus accumbens which causes positive symptoms and too little dopamine released in the prefrontal cortex which results in negative symptoms
medications that indirectly enhance NMDA receptor function via the glycine modulatory site reduce negative symptoms and improve cognitive functioning in individuals with schizophrenia on antipsychotics
53
what is primary psychosis?
psychosis due to psychiatric illnesses
so if someone has schizophrenia, they're more likely to include auditory hallucinations, prominent cognitive symptoms, and complicated delusions
54
what is secondary psychosis?
psychosis due to an underlying non-psychiatric illness
more likely to include abnormal vital signs, visual hallucinations, illicit drug use
compared to a primary psychiatric illness, delirium tends to have fluctuating consciousness, disorientation, with cognitive and memory impairment
55
how can you tell what the causes of psychosis are?
you can’t immediately know the cause of psychosis based on the psychotic symptoms alone
a new-onset episode of psychosis cannot be considered a symptom of a psychiatric disorder until other causes of psychosis are ruled out
obtaining a history from a patient with psychotic symptoms may be challenging; you might have to obtain collateral information from family members
since psychosis is a symptom of an underlying disorder, understanding which comorbid symptoms, and their timelines are important will be key to identifying the cause of psychosis
56
what is the long list of causes that should be considered in the differential when someone has psychosis?**
1. delirium: hypo-hyper glycemia, hypoxia, ICU psychosis, medication interactions or withdrawal, sepsis, electrolyte or metabolic abnormalities, sleep deprivation
2. autoimmune disorders: MS, SLE, temporal arteritis
3. endocrine disorders: addisons, cushing disease, diabetes, thyroid disease
4. genetic, heritable conditions: Wilsons
5. heme-oncologic conditions: porphyria, ovarian teratoma, small cell lung cancer
6. nutritional conditions: vitamin B deficiency, folate, niacin, thiamine
7. neurologic conditions: dementia, encephalitis, encephalopathy epilepsy, parkison, migraine, seizures, normal pressure hydrocephalus, brain abscess, subdural hematoma
8. infectious causes: encephalitis, HIV, meningitis, syphilis
9. pharmacologic cause: medication side effect, abuse, withdrawal
10. organ disease: hepatic, renal
11. substance use: intoxication, alcohol withdrawal, delirium tremens
57
what do you do during a workup for psychosis?
1. generally, a CBC, CMP, TSH, urine toxicology is recommended for workup of all psychiatric conditions
CMP includes liver function!
2. consider a time course and other applicable labs may become evident (B vitamin levels, heavy metals, ESR, ANA, viral workup)
3. consider head CT/brain MRI
4. keep “zebras” in mind like acute intermittent porphyria
58
what is the hierarchy of assessment and differential diagnosis for psychosis?
1. substance induced
prescribed mediations, stimulants, caffeine, steroids, illicit/recreational drugs
2. psychiatric causes
schizophrenia, schizoaffective disorders, brief psychotic disorder, delusional disorder, mood disorder with psychotic features, personality disorders
3. medial/organic causes
major organ systems, neurologic, autoimmune, metabolic, endocrine, nutritional, infectious
59
how do you treat psychosis?
1. patient safety
2. treat the underlying cause
3. biopsychosocial considerations
4. symptom recovery
5. disease states
6. offer oral medications first, IM if very agitated
60
at what point can you officially diagnose a psychiatric disorder?
you can only diagnose a psychiatric disorder after a complete and thorough general medical evaluation
they are diagnoses of exclusion!!
61
what is the definition of psychosis?
a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.
