Psychiatry- Psychotic Disorders Flashcards
What is Schizophrenia?
Severe mental illness characterised by altered perception, thoughts, mood and behaviour and involves chronic/recurrent psychosis impacting social function
What are the subtypes of schizophrenia?
• Subtypes:
- Paranoid (most common)
-Catatonic
-Hebephrenic (disorganised)
-Simple
What is paranoid schizophrenia
(Most common) mainly prominent delusions and hallucinations.
What is catatonic schizophrenia
(psychomotor disturbance): Stupor (being immobile, mute and unresponsive), excitement, posturing (maintaining weird positions), rigidity, waxy flexibility.
What is hebephrenic schizophrenia
(disorganised):
◦ Usually 15-25 years old.
◦ Disorganised speech (neoligisms, knight’s move thinking) and mood.
◦ Inappropriate affect (eg. lauging at something sad).
What is simple schizophrenia
NEGATIVE symptoms only.
What are the risk factors for schizophrenia
• Family history
• Stressful life events (e.g. bereavement, relationship issues, job loss, eviction)
• Childhood trauma (abuse, bullying, separation)
• Cannabis use
What are Schneider’s 1st rank symptoms for schizophrenia (positive symptoms)?
• Delusions:
‣ Fixed false beliefs not in the context with their situation
‣ Typically persecutory/paranoid or grandiose
• Hallucinations: • Typically auditory (thought echo, 3rd person voice: running commentary, voices arguing) • Thought disorders: ◦ Thought insertion: Thoughts are not their own and have been inserted ◦ Thought withdrawal: Thoughts are being removed, can lead to thought block ◦ Thought broadcasting: Everyone can hear their thoughts • Control/Passivity Phenomena: ◦ Bodily sensations controlled by an external influence
What speech disruption symptoms can be present in schizophrenia (positive symptoms)?
• Speech Disruption:
◦ Circumstantiality: Inability to answer a question without giving excessive unneccessary detail (but person does eventually return to original point).
◦ Tangentiality: Wandering from a topic without returning to it, usually with loosely discernible links.
◦ Neologisms: New word formations (may combine two words)
◦ Clang Associations: Ideas are related only by the fact they sound similar or rhyme.
◦ Word Salad: Completely incoherent speech where real words are strung together into nonsense sentences.
◦ Knight’s Move: Unexpected and illogical leaps from one idea to another. More commonly associated with schizophrenia.
◦ Poverty of speech (alogia)
What are the negative symptoms of schizophrenia?
• Flat affect:
‣ Incongruity/blunting of affect
‣ No mood fluctuation
• Social withdrawal
• DEMOTIVATION (avolition)
• Self-neglect
• Catatonia: more commonly associated with schizophrenia than depression
What investigations would be done for schizophrenia?
• Collateral History
• Urine drug screen
• FBC, TFTs, U&Es
• MRI: Hypoactivity in pre-frontal cortex
What is the urgent management for schizophrenia?
◦ Crisis Resolution team and Home Treatment team
What is the non-urgent management for schizophrenia?
‣ Early intervention in Psychosis (EIP) team (for first episode psychosis)- 2 week wait
What is the management of an aggressive and violent psychotic patient
1) Verbal de-escalation or promethazine tablet
2) Lorazepam IM
3) IM haloperidol or Olanzapine rapid tranquilisation
What is the pharmacological management of schizophrenia?
1) Atypical Antipsychotics (6 weeks):
◦ 1) Aripiprazole or quetiapine (less strong + less side effects, start low go slow)
◦ Olanzapine (weight gain) or Risperidone (stronger + more side effects)
◦ Non compliance= Depot (monthly long-acting IM injection) ◦ Augment with Mood stabiliser (lithium) if schizoaffective disorder suspected)
2) Typical Antipsychotics: e.g. Haloperidol, Chlorpromazine
3) Clozapine:
• For treatment resistant schizophrenia (failure to respond to 2 antipsychotics with one being atypical for 6 weeks each)
What is the management of catatonic schizophrenia?
IM lorazepam
What is the psychological management of schizophrenia?
• CBT: offer to all patients (16 or more sessions over 6 months)
• Family therapy: especially if young
What pathophysiological process causes the positive symptoms of psychosis?
‣ Release of excess dopamine from the mesolimbic pathway into the nucleus acumbens causes the positive symptoms of psychosis (cocaine + amphetamines can precipitate this)
What pathophysiological process causes the negative symptoms of psychosis?
‣ Dopamine deficiency in mesocortical circuit causes negative symptoms
What is the mechanism of action of typical antipsychotics + examples?
Typical Antipsychotics (1st gen):
• Dopamine D2 receptor antagonists
• E.g. Haloperidol, Chlorpromazine
What are the two main side effects of typical antipsychotics + what pathway causes them?
‣ Extra-Pyramidal symptoms (nigrostriatal pathway)
‣ Hyperprolactinaemia (tuberoinfundibular pathway):
What are the extra-pyramidal side effects of typical antipsychotics?
• Acute Dystonia:
◦ Involuntary, painful and sustained muscle spasm
◦ Torticollis (deviation of neck)
◦ Oculogyric crisis (upward deviation of eye and cannot look down)
◦ Laryngeal dystonia
◦ ^ onset within hours-days
• Akathisia: ◦ Severe restlessness (pace about, jiggle legs) ◦ ^ onset days-weeks • Parkinsonism: ◦ TRIAD: resting tremor (bilateral as drug-induced), rigidity, bradykinesia ◦ ^ onset years 1. Tardive Dyskinesia: A. Repetitive involuntary movements B. Grimacing, tongue protrusion, lip smacking or rapid blinking C. ^ onset months-years, can be permanent
How to treat acute dystonia?
• Give Procyclidine (anti-cholinergic)
How to treat akathisia?
• Decrease dose/change antipsychotic, add propranolol or benzodiazepines
