🤯Psychiatry🤯 - Psychosis Flashcards
What is the definition of psychosis?
Difficulty perceiving and interpreting reality
What disorders are typically associated with “psychotic disorders”?
Schizoaffective disorder
Schizophrenia
Bipolar type 1
Delusional disorders
What 3 domains can psychotic symptoms be separated into?
Positive symptoms
Negative symptoms
Disorganisation symptoms
What are positive symptoms?
Hallucinations
Delusions
What are hallucinations?
Perception in absence of a stimulus
Can occur in any sensory modality
Auditory (1st, 2nd, 3rd person)
Visual (consider organic cause)
How are hallucinations different to illusions?
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)
What are delusions and give some examples of types of delusions?
Fixed, false beliefs not in keeping with social/cultural norms
Persecutory/paranoid
Grandiosity, religious, nihilistic/guilt, somatic, erotomanic (leads to stalking)
Passivity experiences
What are negative symptoms?
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
What are disorganisation symptoms?
Bizarre behaviours
Formal thought disorder
When can psychosis onset?
Can occur at any age
Peak incidence in adolescence/early 20s
Peak later in women
What is the course of psychosis?
Often chronic and episodic
Variable prognosis
What is the morbidity of psychosis?
Substantial, both from disorder itself and increased risk of common health problems
What is the mortality of psychosis?
15-20 life years lost
High risk of suicide in schizophrenia - 28% excess mortality
What signs often precede psychosis?
Prodromal symptoms:
6-18 months before psychosis develops
Increasing isolation
Poor self care
Social withdrawal
Declining academic performance
What are some common risk factors for psychosis?
Environmental risk factors:
Drug use, particularly cannabis
Prenatal/birth complications
Socioeconomic deprivation/migrant status
Childhood trauma
Genetics:
Highly heritable (esp. schizophrenia)
Highly polygenic
What signs might you look for in someone with psychosis?
Bizarre or inappropriate clothing
Psychomotor retardation/agitation, abnormal movements (medication related)
Self-neglect, self-harm injuries
Stupor and mutism
Why is assessing mood important for psychosis?
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
What is meant by “thought content”?
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
What is thought disorder?
Breakdown in the train of thought and logical connections between different thoughts
What are the various forms of thought disorder, in increasing severity
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
What is a pseudohallucination?
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
Explain the significance of cognitive impairment in those affected by schizophrenia
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
What is insight, in the context of mental health disorders as a wider subject
The awareness into your own mental state, symptoms and need for treatment
What difficulties may be experienced with treating someone with poor insight into their psychosis (or any mental health disorder)?
Concordance with treatment
Attendance at follow-up
Willingness to be admitted to hospital
Impact on ability to have capacity to consent to treatment
What is the next step with a first episode psychosis presentation?
Many people who have a first episode psychosis will not have another
Follow up for 3 years under Early Intervention in Psychosis Services
What are the 3 types of managements options for mental health disorders?
Pharmacological
Psychological
Social support
BioPsychoSocial model
What are the pharmacological management options for psychosis?
Antipsychotic medications
Often mainstay of treatment
What are the psychological management options for psychosis?
CBT - cognitive behavioural therapy
Newer therapies, such as avatar therapy
What are the social support management options for psychosis?
Supportive environments, structures, routines
Housing, benefits
Support with budgeting/employment
What neurotransmitter system is most implicated in the mechanism of antipsychotics (and give the others that are affected too)?
Dopamine - but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine
Which drug actions on dopamine receptors would be most likely to improve psychotic symptoms?
Antagonist
Because increased dopamine activity is implicated in causing reality distortion in psychosis
What is the primary driving factor that is implicated in causing the positive symptoms seen in psychosis?
Increased dopamine activity in mesolimbic dopamine system
Why can Parkinson’s medications cause psychotic effects?
They are dopamine agonists
Excess dopamine - can lead to distorted reality perception
What broad category of side effects can arise from antipsychotic medications?
Extrapyramidal side effects (ESPEs)
What are ESPEs and why do they occur as a side effect of antipsychotic medications?
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
Why does the amount of dopamine in a person’s brain need to be carefully managed?
Too little dopamine = Parkinson’s like symptoms (Parkinsonism)
Too much dopamine = Psychotic symptoms
What are the classic features of Parkinsonism?
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:
How can ESPEs be managed?
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)
Outline atypical antipsychotic drugs
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)
Broadly outline the other side effects that antipsychotics can have
