🤯Psychiatry🤯 - Psychosis

Question 1

What is the definition of psychosis?

Answer 1

Difficulty perceiving and interpreting reality

Question 2

What disorders are typically associated with “psychotic disorders”?

Answer 2

Schizoaffective disorder
Schizophrenia
Bipolar type 1
Delusional disorders

Question 3

What 3 domains can psychotic symptoms be separated into?

Answer 3

Positive symptoms
Negative symptoms
Disorganisation symptoms

Question 4

What are positive symptoms?

Answer 4

Hallucinations
Delusions

Question 5

What are hallucinations?

Answer 5

Perception in absence of a stimulus
Can occur in any sensory modality
Auditory (1st, 2nd, 3rd person)
Visual (consider organic cause)

Question 6

How are hallucinations different to illusions?

Answer 6

An illusion is misperceiving an existing stimulus (e.g. thinking a coat on a hanger is a man when its dark)
A hallucination is when there is no stimulus at all (e.g. seeing a man even thought there is no coat on a hanger)

Question 7

What are delusions?

Answer 7

Fixed, false beliefs not in keeping with social/cultural norms
Persecutory/paranoid
Grandiosity, religious, nihilistic/guilt, somatic, erotomanic (leads to stalking)
Passivity experiences

Question 8

What are negative symptoms?

Answer 8

Alogia - poverty of speech, slow question responses
Anhedonia/asociality - few close friends/hobbies/interests
Avolition/apathy - lack of self-care/drive/motivation
Affective flattening - lack of facial expression

Question 9

What are disorganisation symptoms?

Answer 9

Bizarre behaviours
Formal thought disorder

Question 10

When can psychosis onset?

Answer 10

Can occur at any age
Peak incidence in adolescence/early 20s
Peak later in women

Question 11

What is the course of psychosis?

Answer 11

Often chronic and episodic
Variable prognosis

Question 12

What is the morbidity of psychosis?

Answer 12

Substantial, both from disorder itself and increased risk of common health problems

Question 13

What is the mortality of psychosis?

Answer 13

15-20 life years lost
High risk of suicide in schizophrenia - 28% excess mortality

Question 14

What signs often precede psychosis?

Answer 14

Prodromal symptoms:
6-18 months before psychosis develops
Increasing isolation
Poor self care
Social withdrawal
Declining academic performance

Question 15

What are some common risk factors for psychosis?

Answer 15

Environmental risk factors:
Drug use, particularly cannabis
Prenatal/birth complications
Socioeconomic deprivation/migrant status
Childhood trauma
Genetics:
Highly heritable (esp. schizophrenia)
Highly polygenic

Question 16

What might you look for someone with psychosis?

Answer 16

Bizarre or inappropriate clothing
Psychomotor retardation/agitation, abnormal movements (medication related)
Self-neglect, self-harm injuries
Stupor and mutism

Question 17

Why is assessing mood important for psychosis?

Answer 17

Some affective disorders can cause psychosis (e.g. bipolar, depression)
Depression comorbid with schizophrenia in ~30% cases)
People at high risk of psychosis often have other mental disorders

Question 18

What is meant by “thought content”?

Answer 18

Thought insertion
“I do think things that aren’t me… they’re putting thoughts in my brain”
Denied thought broadcasting or thought withdrawal (passivity phenomena)
Paranoid/persecutory delusions

Question 19

What is thought disorder?

Answer 19

Breakdown in the train of thought and logical connections between different thoughts

Question 20

What are the various forms of thought disorder, in increasing severity

Answer 20

Circumstantial - longwinded responses that eventually answer a given question
Tangential - train of thought goes off on tangents. Logical connections but question isn’t answered
Flight of ideas - Trains of thought loosely connected. May be connected by meaning semantics, sounds, rhyming or puns
Derailment - Unrelated and unconnected trains of thought
Word salad - Complete breakdown of logical connection between words and thoughts

Question 21

What is a pseudohallucination?

Answer 21

True hallucinations must be phenomenologically indistinguishable from a true perception (e.g. voices must be perceived as originating from outside, not inside, a person’s head)
Insight typically preserved in pseudohallucinosis
Example would be someone being aware that a voice is coming from their own head, maintaining insight and also being able to distinguish it from voices outside of their head

Question 22

Explain the role of cognitive impairment in schizophrenia

Answer 22

Commonly affects working memory and executive function
Poorer educational attainment (from childhood)
Cognitive impairment is stable over time and independent of psychotic symptoms
Cognitive impairments are difficult to treat and cause morbidity

Question 23

What is insight, in the context of mental health disorders as a wider subject

Answer 23

The awareness into your own mental state, symptoms and need for treatment

Question 24

What difficulties may be experienced with treating someone with poor insight into their psychosis (or any mental health disorder)?

Answer 24

Concordance with treatment
Attendance at follow-up
Willingness to be admitted to hospital
Impact on ability to have capacity to consent to treatment

Question 25

What is the next step with a first episode psychosis presentation?

Answer 25

Many people who have a first episode psychosis will not have another
Follow up for 3 years under Early Intervention in Psychosis Services

Question 26

What are the 3 types of managements options for mental health disorders?

Answer 26

Pharmacological
Psychological
Social support
BioPsychoSocial model

Question 27

What are the pharmacological management options for psychosis?

Answer 27

Antipsychotic medications
Often mainstay of treatment

Question 28

What are the psychological management options for psychosis?

Answer 28

CBT - cognitive behavioural therapy
Newer therapies, such as avatar therapy

Question 29

What are the social support management options for psychosis?

Answer 29

Supportive environments, structures, routines
Housing, benefits
Support with budheting/employment

Question 30

What neurotransmitter system is most implicated in the mechanism of antipsychotics?

Answer 30

Dopamine - but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine

Question 31

Which drug actions on dopamine receptors would be most likely to improve psychotic symptoms?

Answer 31

Antagonist
Because increased dopamine activity is implicated in causing reality distortion in psychosis

Question 32

What is the primary driving factor that is implicated in causing the positive symptoms seen in psychosis?

Answer 32

Increased dopamine activity in mesolimbic dopamine system

Question 33

Why can Parkinson’s medications cause psychotic effects?

Answer 33

They are dopamine agonists
Excess dopamine - can lead to distorted reality perception

Question 34

What broad category of side effects can arise from antipsychotic medications?

Answer 34

Extrapyramidal side effects (ESPEs)

Question 35

What are ESPEs and why do they occur as a side effect of antipsychotic medications?

Answer 35

Caused due to the fact that they are dopamine antagonists
Dopamine blockade in the nigrostriatal (extrapyramidal) dopamine system - extremely similar mechanism to that of Parkinson’s
Parkinson’s = lack of dopaminergic neurons and synaptic dopamine

Question 36

Why does the amount of dopamine in a person’s brain need to be carefully managed?

Answer 36

Too little dopamine = Parkinson’s like symptoms (Parkinsonism)
Too much dopamine = Psychotic symptoms

Question 37

What are the classic features of Parkinsonism?

Answer 37

Bradykinesia
Postural instability
Rigidity - characteristic‘cog-wheeling’
Slow and shuffling gait
Festination (chasing centre of gravity)
Lack of arm swingin gait – early sign
‘pill-rolling’ tremor- slow (4-6Hz) movement of the thumb across the other fingers:

Question 38

How can ESPEs be managed?

Answer 38

Counsel about risk
Use lowest therapeutic dose
Use atypical as first line
Change medication to a more movement sparing agent
Anticholinergic medications can help (e.g. procyclidine)

Question 39

Outline atypical antipsychotic drugs

Answer 39

Antipsychotics divided into older typical drugs and newer atypical drugs
Also referred to as first and second generation
Atypical antipsychotics associated with a lower risk of EPSE
Less likely to cause EPSEs due to 5HT-2A antagonism (context, not required)

Question 40

Broadly outline the other side effects that antipsychotics can have

Answer 40