Psych - Psychosis Flashcards
What is psychosis?
difficulty perceiving and interpreting reality
What disorders can cause psychosis?
→ schizoaffective disorder → bipolar I → depression with psychotic features → due to other medical condition → substance-related → schizophrenia (1%) → delusional disorder
What are the symptom domains fo psychosis?
→ positive symptoms
→ negative symptoms
→ disorganisation
What are some positive symptoms of psychosis?
→ hallucinations
→ delusions
What are the features of psychotic hallucinations?
percepts in absence of a stimulus • Auditory • Voices commenting on you • Voices talking to each other • Visual • Somatic/tactile • Olfactory (rare)
What are the features of psychotics delusions
Fixed, false beliefs, out of keeping with social/cultural background • Persecutory • Control • Reference • Mind reading • Grandiosity • Religious • Guilt/sin • Somatic • Thought broadcasting • Thought insertion • Thought withdrawal
What are the negative symptoms of psychosis
→ alogia → anhedonia → abolition / apathy → affective flattening → associality
What is alogia?
→ poverty of speech
→ paucity of speech, little content
→ slow to respond
What is avolition or apathy?
→ poor self-care
→ lack of persistence at work / education
→ lack of motivation
What is anhedonia or asociality?
→ few close friends
→ few hobbies or interests
→ impaired social functioning
What is affective flattening?
→ unchanging facial expression → few expressive gestures → poor eye contact → lack of vocal intonations → inappropriate affect
What are disorganisation symptoms in psychosis?
→ bizarre behaviour
→ thought disorder
What are features of bizarre behaviour?
• Bizarre social behaviour • Bizarre clothing/appearance • Aggression/agitation • Repetitive/stereotyped behaviours
What are features of thought disorder?
- Derailment
- Circumstantial speech
- Pressured speech
- Distractibility
- Incoherent/illogical speech
What is the average onset of psychosis?
→ can occur at any age
→ peak incidence in adolescence or early 20s
→ peak later in women
What is the course of psychosis like?
→ often chronic + episodic
→ very variable
What is the morbidity of psychosis like?
→ Substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
→ Significant impact on education, employment and functioning
What are the rates of mortality in psychosis?
→ substantial
→ all-cause mortality = 2.5x higher
→ 15 years of life expectancy lost
→ high risk of suicide in schizophrenia with 28% excess mortality
When taking a psychiatric history for psychosis, what do you look for?
- History of Presenting Concern
- Past Psychiatric History
- Background History (Family, Personal, Social)
- Past Medical History and Medicines
- Corroborative History
What do you look for in History of Presenting Concern?
- patient’s description of the presenting problem – nature, severity, onset, course, worsening factors, treatment received
- Circumstances leading to arrival to hospital
- WHY NOW?
What do you look for in Past Psychiatric History?
- Any known diagnosis?
- Any treatment?
- Known to a community team?
- Any previous admissions to hospital?
What do you look for in Background + Family History?
- Age of parents, siblings, relationship with them
- Atmosphere at home
- Mental disorder in the family, abuse, alcohol/drugs misuse, suicide
What do you look for in Personal History?
- Mother’s pregnancy and birth
- Early development, separation, childhood illness
- Educational and occupational history
- Intimate relationships
What do you look for in Social History?
- Living arrangements
- Financial issues
- Alcohol and illicit drug use
- Forensic History
What do you look for in Past Medical History + Medicines?
- Regular medications?
- Compliance?
- Over the counter medications?
- Interactions?
What do you look for in Corroborative History?
after gaining consent:
• Informants: relatives, friends, authority
• Confidentiality
What is examined broadly in a Mental State Examination?
- Appearance and Behaviour
- Speech
- Mood
- Thoughts
- Perceptions
- Cognition
- Insight
What do you look for in appearance + behaviour?
- General appearance
- Facial expression
- Posture
- Movements
- Social behaviour
What are the major red flags in General Appearance?
- NEGLECT : alcoholism, drug addiction, dementia, depression, schizophrenia
- WEIGHT LOSS : anorexia nervosa, depression, cancer, hyperthyroidism, financial issues/homelessness
What do you look for in Facial Expressions?
- depressive
- anxious
- wooden, Parkinsonian
What do you look for in Posture?
depressive • hunched shoulders • downcast head + eyes anxious • sitting upright • head erect • hands gripping the chair
What do you look for in movements?
- overactive, restless – manic
- inactive, slow - depressive
- immobile, mute – stupor
- tremors, tics
- choreiform movements
- dystonia
- tardive
- dyskinesia mannerisms
- stereotypes
What do you look for in social behaviours?
- disinhibited
- overfamiliar withdrawn
- preoccupied
- signs of impending violence: raised voice
- clenching fists
- pointed fingers
- intrusion into personal space
What do you look for when observing Speech?
- Quantity : less, more, mutism
- Rate : slow, fast, pressure of speech
- Spontaneity : latency
- Volume : quiet or loud
What do you look for when observing Mood?
• Subjective Mood
• Objective Mood
- Predominant mood
- Constancy : emotional lability / incontinence reduced / reactivity / blunting / flattening / irritability
- Congruity : cheerful while describing sad events
What do you look for when looking at Thoughts?
• Stream • Form • Content - Preoccupations - Morbid thoughts, suicidality - Delusions, overvalued ideas - Obsessional symptoms
What is looked for in terms of delusions?
- primary – occurs suddenly
- secondary – arises from previous abnormal idea / experience (hallucination / mood / delusion)
- folie à deux : delusional mood / perception / memory shared delusion
What is looked for in terms of overvalued ideas?
- paranoid of reference
- grandiose/ expansive
- guilt / worthlessness
- hypochondriacal
- jealousy
- sexual/ amorous
- religious
- control
- concerning the possession of thought (insertion, withdrawal, broadcast)
What are obsessional symptoms to look for in psychosis?
- obsessional thoughts: dirt and contamination, aggressive actions, orderliness, disease, sex, religion
- compulsions: checking, cleaning, counting, dressing rituals
What do you look for in patient perceptions?
- Illusions
- Hallucinations
- Distortions
What is an illusion?
misperception of a real external stimulus
What is a hallucination?
perception in the absence of external stimulus
What are the 2 subsets of hallucinations?
1) true perception
2) coming from outside the head
What are the different types or features of hallucinations?
- hypnagogic : transitional state of consciousness between wakefulness and sleep
- hypnopompic : occur in the morning as you’re waking up
- auditory : second person, third person
- visual : Charles Bonnet syndrome
- olfactory
- gustatory
- tactile, of deep sensation
What is Charles Bonnet syndrome?
a person whose vision has started to deteriorate to see things that aren’t real
What are the different aspects of Cognition?
- Consciousness
- Orientation
- Attention and concentration • Memory
- Language functioning
- Visuospatial functioning
What kind of insight is witnessed in psychosis?
• Awareness of oneself as presenting phenomena that other people consider abnormal
• Recognition that these phenomena are abnormal
• Acceptance that these abnormal phenomena are caused by mental
illness
• Awareness that treatment is required
• Acceptance of the specific treatment recommendations
What are the management options for psychosis?
- pharmacological
- psychological
- social support
What is involved in psychological management for psychosis?
- CBT for psychosis
* newer therapies like avatar therapy
What is involved in social support for those with psychotic disorders?
- supportive environments, structures + routines
- housing + benefits
- support with budgeting + employment
What kind of drugs are antipsychotics usually?
- Dopamine Antagonists
* some partial agonists
Why aren’t dopamine agonists used?
- increased dopamine activity is implicated in causing reality distortion
- evidence = elevated presynaptic dopamine in striatum
What is an example of a partial agonist used to treat psychosis?
Aripiprazole (less effective though)
What are the side effects of antipsychotics (dopamine antagonists)?
- Parkinsonism
- Acute Dystonia
- Tardive Dyskinesia
- Akathisia
What is Parkinsonism?
- Rigidity - characteristic ‘cog-wheeling’
- Slow and shuffling gait
- Lack of arm swing in gait – early sign
- ‘pill-rolling’ tremor - slow (4-6Hz) movement of the thumb across the other fingers
What is dystonia?
- Increased motor tone -> sustained abnormal posture
- Can occur shortly after taking dopamine antagonist
- Can be acute, frightening, painful, even fatal (laryngeal dystonia)
What is tardive dyskinesia?
- Repeated oral/ facial/ buccal/ lingual movements
- Initially subtle – can progress to tongue involvement, lip smacking
- Increased risk: long-term antipsychotics, female
What is akathisia?
• Inner restlessness • Feel compelled to move, but does little to alleviate • Can lead to overt, relentless movement • Legs most commonly affected
Why do these side effects occur?
Antipsychotics can cause post- synaptic dopamine blockade in the extra-pyramidal system
What is the extrapyramidal system?
parts of the brain that enable us to maintain posture and tone
What is an atypical antipsychotic?
less likely to cause extrapyramidal side effects
What is a typical antipsychotic?
commonly causes extrapyramidal side effects
What is an example of an atypical antipsychotic?
olanzapine
How are EPSEs managed?
• Avoid them in the first place:
atypical antipsychotics usually
first-line
• Change medication
• Anticholinergic medications can help e.g. procyclidine
• Patients need to be fully-informed about risks
What are some other side effects of antipsychotics?
- sedation
- agranulocytosis
- neutropenia
- increased appetite
- weight gain
- diabetes
- dysrhythmia
- long QTc
- increased prolactin (release surpassed by dopamine so)
- constipation
What is involved in long-term management of psychosis?
- Community follow-up
- Managing antipsychotic side effects e.g. weight, diabetes
- Health promotion: reducing risk factors e.g. smoking, diet
