Psych Written - Psychotic & Dissociative Disorders Flashcards
Clozapine monitoring
Requires normal FBC before starting Tx
THEN weekly FBC (for 18 weeks)
THEN bi-weekly (for 1 year)
THEN monthly
Standard anti-psychotic monitoring
BMI + waist circumference
BP
Bloods - FBC, LFTs, U&Es, lipids, glucose (+OGTT and HbA1c if abnormal)
+/- prolactin (if Sx or specific med - risperidone)
+/- EEG (older people, high dose med, clozapine)
How long should anti-psychotics generally be continued?
at least 3 years after 1st episode psychosis
longer if recurrent psychotic episodes
Indication for clozapine?
Treatment resistant SCZ
defined as:
- 2 unsuccessful trials of antipsychotic
- at least 1 being atypical
- for minimum 6 weeks
- at therapeutic dose
What is DUP? Why does it matter?
Duration of untreated psychosis = time from first clear psychotic Sx until start of effective Tx
Longer DUP = greater damage to cognitive abilities, insight, social
Aim to keep DUP < 3months
Indications for atypical antipsychotic?
1st line in new psychosis
Unacceptable SE from typical agent
Relapse on typical agent
Psychological Tx in psychotic disorders?
CBT - emphasis on reality testing + helping client to spot illogical thinking
Cognitive remediation therapy (CRT) - useful for negative Sx, improved neurocognitive skills
Family intervention - reduces high expressed emotion (e.g. over involvement, criticism) which can be detrimental
Arts therapy - often as group, can be effective during acute episode or for negative Sx in chronic phase
Lifetime suicide risk in psychotic disorders?
10%
Highest RF for suicide in psychotic disorders?
Intelligent young male with high premorbid IQ
Early after diagnosis
After first admission
Co-existing depression
Pathophysiology of negative Sx in SCZ
Dopamine under activity in mesocortical tracts
Pathophysiology of positive Sx in SCZ
Excess dopamine in mesolimbic tracts
Strongest RF for SCZ?
Family Hx
Other SCZ risk factors
Migration Black Caribbean Urban environment Cannabis (esp skunk) Increased paternal age Winter born Social disadvantage Childhood adversity Obstetric complications
Diagnostic criteria for SCZ
1 of the first rank Sx
OR 2 of:
- persistent hallucination in any modality
- thought disorder
- catatonai
- negative Sx
for at least 1 month
1st rank Psychotic Sx
Thought disorder / alienation
- broudcasting
- withdrawal
- insertion
Passivity phenomena
Auditory hallucinations
- numerous 3rd person discussions ‘he/she is …’
- running comentary
- thought echo (repeats thoughts aloud just after)
Delusional perceptions - ordinary stimulus triggers delusional belief e.g. it was cloudy so I was God
Features of Paranoid SCZ subtype?
Prominent hallucinations (Usually) persecutory delusions
Features of Catatonic SCZ subtype
Psychomotor disturbance
- stupor
- excitement
- posturing
- rigidity
- waxy flexibility
- automatic obedience
- perseveration
Management approach to SCZ
Bio: Antipsychotics –> Clozapine if Tx resistant
Psycho: CBT, CRT, behavioural family therapy, arts therapy
Social:
• Social skills training – improve interpersonal skills
• Psychoeducation
• Carer support – carers’ groups, social services
• +/- Admission
• Rehabilitation
Good prognostic factors in SCZ
Patient factors:
- Older age of & acute onset
- Female
- No personality problems
- High premorbid IQ
- No substance misuse
Disease factors
- Positive Sx
- Prominent mood component
- Obvious precipitant
- Tx compliance
Environment
- No family Hx SCZ
- Married, good social support
- Low expressed emotion
Criteria for diagnosis of Schizoaffective disorder
Satisfy criteria for SCZ AND mood disorder - during same episode
NOT the same as primary mood disorders where psychotic Sx emerge secondary to mood issues (as the mood becomes most extreme)
- psychotic depression
- mania with psychotic sx
Criteria for diagnosis of Acute & Transient Psychosis
<2 weeks between first appearance of Sx and fully developed disorder
No evidence of drug use or organic disease (including HX of another MH problem)
Abrupt onset of delusions, hallucinations & incoherent speech
Precipitated by acute stressful event
Criteria for diagnosis of delusional disorder
Delusions lasting >3 months
without clear mood disturbance
lacking other SCZ Sx
Tx of delusional disorders
1st line = Olanzapine
Features of Hebephrenic SCZ
Disorgansied, chaotic mood, behaviour & speech
Shallow or inappropriate affect
Aimless bvehaviour
Delusions & hallucinations less prominent
Often described as ‘childlike’
Features of simple SCZ
negative Sx only
never shown positive Sx
Features of residual SCZ
prominent negative Sx
remain after delusions/hallucinations subside
Dissociative identity disorder - key features
2+ distinct personality states
Differences in emotion, behaviours, consciousness, memory, perception, cognition, sensation + movement
‘Memory gaps’ when recalling every events, personal info & traumatic events
That is NOT part of accepted cultural/religious practice
Dissociative amnesia - key features
inability to recall important autobiographical info
cannot be explained by normal forgetting
localised & selective e.g. sexual assault OR generalised e.g. entire teenage years
Depersonalisation - key features
experiences of unreality, detachment, or movement
where individual feels as if they are observing their own thoughts/feelings/sensations/body/actions
Derealisation disorder - key features
experiences of unreality or attachment in relation to surroundings
e.g. people/objects feel unreal, dreamlike, foggy or distorted
Dissociative fugue - key features
amnesia + purposeful travel (beyond the usual everyday range)
behaviour may appear ‘normal’ to outside observers
Tx for dissociative disordeers
Bio:
- naltrexone (non selective opioid antagonist)
- lamotrigine in depersonalisation/derealisation
- antidepressants for associated depression, anxiety, panic attacks
Psycho:
- CBT
- EMDR
- dialectical behaviour therapy
- family therapy
- ?hypnosis for DID
Social:
- journaling to improve awareness & notice worsening sx
- mindfulness
+/- inpatient admission if suicidality or self harm
Thought disorders
Thought alienation (a first rank Sx) - broadcasting, withdrawal, insertion
Flight of ideas - rapid changes in topic BUT there are some connections, may be linked to cue in the surrounding environment, elicited by associations stemming from the topic or merely by words (clang associations)
Knight’s move thinking - illogical or no link between topics
Tangentiality - excessive or irrelevant detail, des NOT ever reach essential point of a conversation/desired answer to Q
Circumstantiality - digresses to give unnecessary and often irrelevant details before arriving at the main point.
