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Year 4 - Mental Health > Psych - Psychosis > Flashcards

Psych - Psychosis Flashcards

1
Q

What is the strongest risk factor for developing a psychotic condition e.g. schizophrenia?

A

Family History

Risk of developing schizophrenia:

  • monozygotic twin has schizophrenia = 50%
  • parent has schizophrenia = 10-15%
  • sibling has schizophrenia = 10%
  • no relatives with schizophrenia = 1%
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2
Q

Name some risk factors for psychotic disorders.

A
  • Family history (main one)
  • Black Caribbean - RR 5.4
  • Migration - RR 2.9
  • Urban environment- RR 2.4
  • Cannabis use - RR 1.4
  • Birth complications
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3
Q

Name some organic causes of psychosis?

A
  • Drug misuse:
    • corticosteroids, dopaminergic drugs (L-dopa, amantadine), anticholinergics, opiods, Abx (ciprofloxacin)
  • Alcohol misuse
  • Neurodegenerative:
    • dementia, PD, Alzheimer’s disease
  • Neurological:
    • focal impaired awareness seizures (prev called ‘complex partial’), stroke, space occupying lesion, MS, temporal lobe epilepsy
  • Endocrine:
    • thyroid disease, cushing’s disease
  • Infection:
    • post encephalitic state, tertiary syphilis, malaria
  • Delirium:
    • hypercalaemia, ICU psychosis, sepsis, medication interaction or withdrawal etc.
  • Nutritional:
    • Vitamin B12 deficiency
  • Autoimmune:
    • SLE, sarcoidosis
  • Liver or Kidney failure
  • Acute porphyria (build up of porphyrins e.g. acute intermittent porphyria)
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4
Q

What are Schneider’s 1st rank symptoms for schizophrenia?

A

4 categories:

  1. Auditory hallucinations:
    • 2 or more voices discussing pt in 3rd person
    • thought echo
    • voices commenting on the pt’s behaviour
  2. Thought disorder:
    • thought insertion
    • thought withdrawal
    • though broadcasting
  3. Pasivity phenomena:
    • bodily influence - bodily sensations being controlled by external influence
    • made actions/impulses/feelings - experiences which are imposed on the individual or influenced by others
  4. Delusional perceptions:
    • 2 stage process - 1) a normal object is percieved then 2) there is a sudden intense delusional insight into the objects meaning e.g. ‘The traffic light is green therefore I am the King’
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5
Q

What are the flaws of Schneider’s 1st rank symptoms for schizophrenia?

A
  • Schneider’s symptoms are not specific for schizophrenia (8% of psychotic pts with them don’t have schizophrenia)
  • 20% of pts with chronic schizophrenia never have a 1st rank symptom
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6
Q

What features of schizophrenia are there besides Schneider’s symptoms (which are positive symptoms)?

A
  • Alogia (poverty of speech - lack of unprompted additional content)
  • Vague speech
  • Anhedonia
  • Avolition (poor motivation)
  • Impaired sight
  • Blunting/incongruity of affect (inappropriate emotion for circumstances)
  • Neoligisms
  • Catatonia:
    • Stuporous catatonia - stupor (hold rigid poses), mutism, waxy flexibility, repetitive movements
    • Excited catatonia - bizarre, non-goal directed hyperactivity + impulsiveness
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7
Q

What treatments are appropriate for a 1st episode of psychosis?

A
  1. Oral antipsychotic medication AND
  2. Psychological intervention e.g. family intervention + individual CBT
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8
Q

Which of the following are common side-effects of anti-psychotics?

  • Hypokalaemia
  • ↑ prolactin
  • Diabetes
  • Sedation
  • Weight loss
A
  1. ↑ Prolactin
  2. Diabetes
  3. Sedation
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9
Q

Before starting anti-psychotic medication what baseline tests need to be done?

A
  • Weight (plotted on chart)
  • Waist circumference
  • HR + BP
  • Fasting blood glucose, HbA1c
  • Lipid profile
  • Prolactin levels
  • Nutritional status / diet
  • Assessment of movement disorders
  • ECG (under special circumstances e.g. recommended in drug summary, if pt has cardiovascular risks or CVD)
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10
Q

What are the criteria for detaining someone under Section 2 of the MHA?

A

2 criteria - both must be met:

  1. Person is suffering from a mental disorder of a nature or degree which warrants their detention in hospital for assessment (or for assessment followed by treatment) for at least a limited period
  2. Person ought to be detained in the interest of their own health or safety or with a view to the protection of others
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11
Q

What are the details relating to sectioning under section 2 of MHA?

A

Section 2

  • Duration: 28 days for assessment
  • Treatment: can be given against pt wishes
  • Application: AMHP or nearest relative on recommendation of 2 docs
  • Discharge: Pt can appeal to tribunal, discharge by Responsible Clinician, Hospital managers or nearest realtive
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12
Q

What are the details relating to a section 3 under MHA?

A

Section 3

  • Duration: 6 months for treatment
  • Treatment: can be given against pt wishes (for 1st 3 months then consent required or 2nd opinion)
  • Application: AMHP + recommendation of 2 docs, 1 of whom must be section 12 approved (must have seen pt in last 24 hrs)
  • Discharge: Pt can appeal to tribunal, discharge by Responsible Clinician, Hospital managers or nearest realtive
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13
Q

What are the details relating to a section 4 under MHA?

A

Section 4

  • Duration: 72hr for emergency assessment (done when section 2 would cause a delay)
  • Treatment: given under common law
  • Application: AMHP or nearest relative on recommendation of any doc (seen pt in last 24 hrs)
  • Discharge: no appeal, can only be discharged by Responsible Clinician
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14
Q

What are the details relating to section 5(2) under the MHA?

A

Section 5(2)

  • Duration: 72hr holding order for a pt already voluntarily admitted to hospital (A+E counts as being in community)
  • Treatment: given under common law
  • Application: Any doctor
  • Discharge: no appeal, can only be discharged by Responsible Clinician
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15
Q

What are the details relating to section 5(4) under the MHA?

A

Section 5(4)

  • Duration: 6 hrs holding order for a pt already voluntarily admitted to hospital
  • Treatment: given under common law
  • Application: Registered nurse
  • Discharge: no appeal
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16
Q

What is the main mechanism of action of anti-psychotic medication?

A

Dopamine antagonists

Block dopamine transmission in mesolimbic pathways

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17
Q

Anti-psychotics are associated with extra-pyramidal side-effects (traditionally typical anti-psychotics but not strictly true).

Give examples of extra-pyramidal side effects (EPSEs).

A

EPSEs:

  • Parkinsonism
  • Acute dystonia - sustained muscle contraction e.g.
    • torticollis - asymmetrical head/neck bend
    • oculogyric crisis - dystonic reation to drugs/medication causing prolonged involuntary upward deviation of eyes
  • Akathisia (severe restlessness)
  • Tardive dyskinesia (involuntary repetitive movements e.g. chewing or pouting fof jaw
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18
Q

What drug can be given to manage extra-pyramidal symptoms (e.g. caused by antipsychotics)?

A

Procyclidine

  • Anticholinergic - exerts anti-parkinsonian effect by reducing the effect of cholinergic excess caused by dopamine deficiency
  • Treatment of drug-induced parkinsonism, akathisia, acute dystonia
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19
Q

The risk of which 2 vascular events is increased by anti-psychotics in the elderly?

A
  1. VTE
  2. Stroke
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20
Q

What are some common non extra-pyramidal side effects of anti-psychotics?

A
  • Antimuscarinic:
    • dry mouth, blurred vision, urinary retention, constipation
  • Anti-histamine action:
    • Sedation, weight gain
  • Raised prolactin:
    • galactorrhoea (spontaneous flow of milk from breast), impaired glucose tolerance
  • Neuroleptic malignant syndrome:
    • Pyrexia, muscle rigidity, confusion, variable BP, sweating, tachycardia
    • ↑ WBCs + ↑ LFTs
    • Mortality = ~ 10%
  • ↓ seizure threshold (greater with atypicals)
  • Prolonged QT interval (particularly haloperidol)
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21
Q

What are 4 complications of Neuroleptic Malignant Syndrome?

A
  1. Rhabdomyolysis
  2. Hyperkalemia
  3. Kidney failure
  4. Seizures
22
Q

High potency typical anti-psychotics:

  • Mechanism of action?
  • More likely to exhibit what side-effects?
  • Examples
A
  • MoA:
    • D2 receptor antagonists
  • Side-effects:
    • Higher risk of extra-pyramidal side effects due to high affinity for D2 receptor
  • Examples:
    • Haloperidol
    • Sulpiride
    • Pimozide
    • Fluphenazine and Flupentixol
23
Q

Low potency typical anti-psychotics:

  1. Mechanism of action?
  2. More likely to exhibit what side-effects?
  3. Examples
A
  • MoA:
    • D2 receptor antagonists
  • Side-effects:
    • More cardiotoxic + anticholinergic side effects e.g. hypotension and sedation (↓ affinity for D2 but tends to interact with non-dopaminergic receptors)
  • Examples:
    • Chlorpromazine
    • Thioridazine
24
Q

By what mechanism do atypical anti-psychotics act?

A

serotonin-dopamine antagonists (SDAs)

25
Q

Give some examples of the atypical anti-psychotics.

A
  1. Risperidone
  2. Quetiapine
  3. Aripiprazole
  4. Olanzapine
  5. Clozapine
  6. Amisulpiride (highly selective for D2 + D3, no serotonin action, less weight gain, may cause hyperprolactinemia)
26
Q

Risperidone (atypical)

  • Forms available?
  • Associated side effects?
A

Risperidone

  • Forms:
    • Reg tabs, immediate release tabs, IM depot
  • Side -effects:
    • Most likely of atypicals to cause extra-pyramidal side effects
    • Most likely of atypicals to cause hyperprolactinemia
    • Weight gain + sedation common
27
Q

Olanzapine (atypical)

  • Forms?
  • Associated side effects?
A

Olanzapine

  • Forms:
    • Reg tabs, immediate release tabs, IM injection
  • Side-effects:
    • May cause hypetriglyceridemia, hypercholesterolemia and hyperglycemia (even without weight gain)
    • May cause hyperprolactinemia (< risperidone)
    • May cause transaminits - ↑ liver transaminases (2%)
28
Q

Quetiapine (atypical)

  • Forms?
  • Associated side effects?
A

Quetiapine

  • Forms:
    • Reg tabs only
  • Side-effects:
    • Most likely to cause orthostatic hypotension
    • May cause transaminits - ↑ liver transaminases (6%)
    • May cause hypertriglyceridemia, hypercholesterolemia and hyperglycemia (even without weight gain)
    • May have weight gain (< than in olanzapine)
29
Q

Aripiprazole (atypical)

  • Forms?
  • Associated side-effects?
A

Aripiprazole

  • Forms:
    • Reg tabs and IM depot
  • Side-effects:
    • Low EPSEs, Low sedation, no QT prolongation
    • Not associated with weight gain
    • Can be quite stimulating –> thus a short-term benzodiazapine may be needed alongside (if pt often agitated)
30
Q

Clozapine (atpical)

  • Forms?
  • Associated side-effects?
A

Clozapine

  • Forms:
    • Reg tab only
    • Reserved for treatment resistant schizophrenia
  • Side-effects:
    • Agranulocytosis (0.5-2%) –> weekly bloods x 6 months, then every 2 weeks x 6 months
    • ↑ risk of seizures (especially if lithium is also prescribed)
    • Most associated with sedation, weight gain and LFT derangement
    • May cause hypertriglyceridemia, hypercholesterolemia and hyperglycemia
31
Q

Which of the following are risk factors for schizophrenia?

  • Smoking cannabis
  • A family history of schizophrenia
  • Birth complications
  • Living in isolated areas
  • Being born in the summer months
A
  1. Smoking cannabis
  2. A family history of schizophrenia
  3. Birth complications
32
Q

Which of the following is correct for schizophrenia?

  • 5% of patients will commit suicide
  • The onset is generally earlier in men
  • 80% of patients will have more than one episode in the first 5 years
  • The lifetime prevalence is 5%
  • It does not run in families
A
  1. 5% of patients will commit suicide
  2. The onset is generally earlier in men
  3. 80% of patients will have more than one episode in the first 5 years
33
Q

In the treatment of schizophrenia, which of the following are true?

  • ECT is usually used in treatment resistance
  • Clozapine is more effective than other antipsychotics
  • Depot antipsychotic preparations are more likely to be used when compliance is a problem
  • Antipsychotics mainly work on the noradrenaline neurotransmitters in the brain
  • Atypical antipsychotics have more extrapyramidal side effects than typical ones
A
  1. Clozapine is more effective than other antipsychotics
  2. Depot antipsychotic preparations are more likely to be used when compliance is a problem
34
Q

For a patient’s 1st episode of psychosis what is the recommended treatment plan?

A
  1. Oral antipsychotic medication AND
  2. Psychological interventions e.g. family intervention and individual CBT

Note: if pt wants to try psychological intervention alone, advise that these are more effective in conjunction with an antipsychotic

35
Q

What non-specific monitoring is involved for antipsychotics?

A
  1. Record response to treatment e.g. symptoms, behaviour
  2. Emergence of movement disorders
  3. Weight –> weekly for 6 weeks, then at 12 weeks, then 1 year then annually
  4. Waist circumference –> annually
  5. HR + BP –> at 12 weeks and then 1 year, then annually
  6. Fasting blood glucose + HbA1c + blood lipids –> at 12 weeks, at 1 year and then annually
  7. ECG - at baseline
  8. Adherance monitoring
36
Q

What are the details of section 135 of the MHA?

A

Section 135

  • Duration: used once - warrant to access premises to remove patient to place of saftey
  • Treatment: no treatment
  • Application: 1 doctor, AMHP or police
  • Discharge: allows for further assessment - then conversion to dif section if needed
37
Q

What are the details of section 136 of the MHA?

A

Section 136

  • Duration: 24hrs - allows police to remove person from public place for saftey
  • Treatment: no treatment
  • Application: police (must remain in attendance until further assessment is arranged)
  • Discharge: allows for assessment - then conversion to dif section if needed
38
Q

What qualifies a a deprivation of liberty? (DoL)

A

“The person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements”

  1. Continuous supervision + control = not necessarily 24/7 but a significant amount of the time, staff deciding activites e.g. meals, bedtimes, leisure
  2. Not free to leave = includes hypothetical cases e.g. if pt is unable to leave but would be stopped if they could
  3. Lacks capacity to consent
39
Q

What are deprivation of liberty safeguards (DoLS)?

A

A set of checks to make sure that any care restricting a person’s liberty is both appropriate + in best interests

  1. ​Provide pt with a representative (often a relative or friend)
  2. Give pt / representative right to challenge DoL via court
  3. Provide a mechanism for DoL to be reviewed + monitored regularly
40
Q

Where can a DoLS assesment be done?

A
  • Only applicable in England + Wales
  • Only apply for people in either:
    1. Care homes
    2. Hospitals
41
Q

Who requests a DoLS and who from?

A

Care provider (care home or hospital) requests a

DoLS assessment from the local authority

42
Q

Who carries out a DoLS assessment?

A

At least 2 people needed:

  1. Best interests assessor (often qualified social worker, nurse, OT or psychologist –> must not be involved in pt’s care)
  2. Mental health assessor (doctor capable of assessing if pt has a ‘mental disorder’)
43
Q

What is an ‘urgent’ DoLS?

For how long does this last?

A

Urgent DoLS:

  • Hospital or care home grant themselves an urgent DoLS authorisation
  • Valid for 7 days
  • Must apply for normal DoLS assessment at same time
  • Can be extended 7 days if normal assessment not done in time
44
Q

How does smoking affect treatment with antipsychotic medication?

A
  1. Cigarette smoke ↑ activity of CYP 1A2 enzymes –> thus ↓ concentration of many drugs, including clozapine + olanzapine –> thus higher doses are needed in smokers
  2. Smoking cessation whilst on antipsychotics –> may require ↓ antipsychotic dose (as effective dose will have ↑) –> failure to do so can cause ↑ antipsychotic side effects
45
Q

If Clozapine is not taken for 48hrs from when it was last due, what is required?

A

Clozapine treatment regime starts at beginning i.e.

back to 12.5 mg 1-2 times a day (for 1st day)

46
Q

What ‘Risks’ can mental health patients be exposed to?

A
  • Harm to self:
    • self-harm, suicide
  • Harm to others:
    • physical, mental, sexual, child, arson
  • Neglect:
    • of self (bathing, nutrition), of dependents
  • Vulnerability:
    • sexual abuse, financial abuse, illicit drug exposure
  • Environmental:
    • Homelessness, housing issues
47
Q

What is the Acetylcysteine (Parvolex) used for?

A
  1. Mucolytic - in CF and COPD
  2. Paracetamol overdose (given IV)
48
Q

If Clozapine at a therapeutic dose proves ineffective in the management of treatment resistant schizophrenia what further measures can be taken?

A

Augment the clozapine with Amisulparide which is …

  • Atypical antipsychotic
  • D2 and D3 receptor antagonist
  • Low risk of movement disorders + high risk of hyperprolactinemia
49
Q

A 34-year old woman has been started on clozapine for treatment resistant schizphrenia and is now on 275mg orally daily.

Which adverse effect is most likely to be caused by the clozapine?

  • Neutropenia
  • Constipation
  • Hypothyroidism
  • Dry mouth
  • Weight loss
A

Constipation

  • Neutropenia is rare (3%)
  • Clozapine doesn’t cause hypothyroidism
  • Clozapine causes hypersalivation
  • Clozapine does cause weight gain but not as commonly as it causes constipation
50
Q

For atypical antipsychotics:

  1. Which commonly cause hyperprolactinemia?
  2. Which strongly impact QTc?
  3. Which are best known for weight gain?
A
  1. Hyperprolactinemia = risperidone + amisulpiride
  2. ↑ QTc = cloazpine
  3. Significant weight gain = olanzapine + clozapine
51
Q

For typical antipsychotics:

  1. Which has the fewest side effects?
  2. Which is known for postural hypotention and sedation?
  3. Which is associated with Parkinsonism?
A
  1. Fewest side effects = sulpiride
  2. Postural hypotension + sedation = chlorpromazine
  3. Parkinsonism = Haloperidol (all others to lesser extent)

Year 4 - Mental Health (6 decks)

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