Psychoses Flashcards
What is the definition of a delusion?
A belief, unshakeably held, which is outside of the individual’s usual social and cultural belief system
What is ‘psychosis’?
Psychosis is a mental illness that prevents people from being able from being able to distinguish between the real world and the imaginary world.
What is the difference between loosening of thought and flight of ideas?
Both involve jumping between one topic to another, but in ‘flight of ideas’ there is a discernible link between the ideas (it might be a cue or a rhyme etc.) while in ‘loosening of thought’ there is no link between the topics
What is the difference between an illusion and a hallucination?
Illusions are disturbances of perception based on an external stimulus, while hallucinations have no external stimulus
What types of hallucinations can a person get?
Auditory (most common type in psychiatry) Visual Olfactory Gustatory Somatic - Tactile, kinestetic, visceral
What are the two types of disturbance of perception?
Illusion
Hallucination
What is a hallucination?
A disturbance of perception which is not based on an external stimulus.
Give 2 positive symptoms of schizophrenia
Hallucinations
Delusions
What is an ‘overvalued idea’?
A type of disturbance of thought connect, where a person has a thought which is culturally reasonable but they take it to the boundaries of acceptability. The tenacity of the thought is usually less than a delusion (i.e. they have some insight into the thought being unreasonable)
Give 2 types of disturbances of thought content
Overvalued ideas
Delusions
What is the difference between a primary and secondary delusion?
Primary - Comes out of the blue e.g. ‘MI5 is following me’
Secondary - The person experiences a hallucination and attributes the delusions to this e.g. ‘I can hear voices talking about me and I therefore know that MI5 is following me’
What is a grandiose delusion?
The person believes they are of great importance, have supernatural powers, enormous wealth etc.
What is a persecutory delusion?
Belief that a person or organisation is conspiring to harm / follow / kill the person e.g. ‘MI5 are following me’
What is a delusion of reference?
Belief that a person / event / object which is unrelated to the person has a personal significance to them. They may believe that something in the media is specifically directed at them, or that the media is trying to convey a message directly to them. This may involve TV personalities, stories, etc.
What is Beck’s cognitive triad?
Negative thoughts of the self, the world and the future
What are the two types of ‘misidentification’ delusions?
Capgras syndrome - The belief that someone known to them is an identically looking imposter
Fregoli’s syndrome - Belief that a stranger is actually familiar to them but in disguise
What is a delusion of control?
Belief that someone outside their body is controlling their behaviour
What is neologism?
Where a person will make up words which make sense to them but have no sense in reality
What is ‘talking past the point’?
Where the person will come very close to talking about the subject matter but never quite get there
What is perseveration?
Where the person keeps returning to the same topic of thought over and over, repeating themselves. Example: Dr: What is the capital of Italy? P: Rome Dr: What is the name of this object? P: Rome
What is the difference between a second and third person auditory hallucination?
Hearing voices:
Second person - The voices are talking directly to the patient
Third person - The voices are talking to each other about the patient
List some organic causes of psychosis
Delirium Epilepsy Dementia Drugs e.g. steroids, dopamine agonists Substance misuse e.g. LDS, cocaine, ecstasy Space occupying lesion HIV etc.
What is the difference in prevalence of schizophrenia between men and women?
There is no difference in prevalence, but men tend to be affected earlier and more severely than women
What is the lifetime risk of schizophrenia?
1%
What are the 5 first rank symptoms of schizophrenia?
- Auditory hallucinations (3rd person auditory, running commentary, or ‘echo de la pensee’ i.e. their own thoughts being spoken aloud)
- Thought withdrawal, insertion, broadcast
- Somatic delusions
- Delusional perception
- Delusions of control
What are the 3 neurochemical changes thought to relate to the development of schizophrenia?
Increased dopamine Decreased glutamate Increased serotonin (5-HT)
What is the prognosis in schizophrenia?
- About 25% of those with first psychotic episode will experience no relapse
- 65% are susceptible to relapses or continue to have symptoms
- 10% cannot function outside of hospital
- Increased risk of suicide and higher mortality rate than general population
What must you warn the patient about how long it takes for antipsychotic medication to work?
It is not an immediate effect - it may take 2-4 weeks to have a clinical effect on the symptoms
What is the mainstay of treatment for schizophrenia?
Dopamine antagonists (primarily acting on post synaptic D2 receptors)
Give an example of a low potency typical antipsychotic
Chlorpromazine
Give an example of a high potency typical antipsychotic
Haloperidol
Which causes less extra-pyramidal side effects: Low potency or high potency typical antipsychotics?
Low potency
What are some extra-pyramidal side effects?
Dystonia
Parkinsonism
Akathisia
Tardive dyskinesia
Give the name of an antimuscarinic drug which can be given in acute episodes of dystonia caused by antipsychotic medication
Procyclidine (given IV or IM in these situations)
What is dystonia?
Typical EPSE resulting from antipsychotic use. Characterised by maximum contraction of muscle groups which are involuntary and sustained.
What is akathisia?
Restlessness, usually of the lower limbs, and the inability to sit still
Procyclidine is useful for treating which types of extra-pyramidal side effect?
Dystonia
Parkinsonism
What might be considered for ‘treatment’ of tardive dyskinesia?
Tetrabenzine
Give 6 examples of atypical antipsychotics
Risperidone Olanzapine Quetiapine Amisulpride Aripriazole Clozapine
List some important side effects of typical antipsychotic medication
- Extra-pyramidal side effects
- Drowsiness
- Hyperprolactinaemia
- Cardiovascular disease
- Prolonged QT interval
- Metabolic syndrome: Weight gain, hyperglycaemia, deranged cholesterol
- Reduced seizure threshold
- Postural hypotension
- Anticholinergic side effects
- Risk of neuroleptic malignant syndrome
What is the drug of choice for ‘treatment resistant schizophrenia’?
Clozapine
What pre-treatment tests and monitoring are required for clozapine?
Pre-treatment: ECG and FBC
Monitoring: BP and Pulse
FBC check weekly for 18 weeks, then fortnightly for 1 year then monthly after that
Why is it important to check the FBC of a patient taking clozapine?
Can (rarely) cause neutropenia and agranulocytosis which may not happen until 8-10 weeks after treatment started.
Why is it potentially dangerous to stop smoking whilst taking clozapine?
Smoking causes increased levels of clozapine, so stopping smoking without checking the levels of clozapine can cause dangerously high levels
Give some side effects of clozapine
Sore throat, fever Hypersalivation Constipation Seizures Urinary incontinence Drowsiness / sedation Hypotension Tachycardia Metabolic problems: Significant weight gain, hyperglycaemia, raised cholesterol PE Myocarditis Cardiomyopathy Neutropenia / agranulocytosis
What might be a useful blood marker for checking a patient’s compliance with risperidone? Why?
Prolactin levels - Risperidone causes significantly raised prolactin so if the patient has been taking their medication, their prolactin will be raised
Which drug causes least amount of EPSEs and so can be useful if patients are suffering with side effects?
Quetiapine
What is the key side effect to remember with olanzapine?
Metabolic effects - Significant weight gain, dysregulation of glucose (increased risk of diabetes)
What would be the first-line treatment for an acute episode of psychosis?
Atypical antipsychotic e.g. olanzapine, risperidone, quetiapine
Benzodiazepine e.g. diazepam (if agitated / aggressive for sedation)
Give 3 types of disturbance of thought stream
Pressure of thoughts
Poverty of thoughts
Thought block
What is ‘pressure of thoughts’?
When a person talks, usually quite quickly, about a varied number of topics and is usually quite hard to follow
What is ‘poverty of thoughts’?
Few thoughts, lacking in variation, may be repetitive
What is ‘thought block’?
Stream of thought suddenly becomes interrupted - the patient may report that their mind has gone blank
What is a pseudo hallucination?
Voices heard by a patient which may either appear to come from within their head or from the outside world, but the patient recognises them as unreal
What is schizophreniform disorder?
Often a provisional diagnosis before a true diagnosis of schizophrenia. Symptoms persist for more than 1 month but less than 6 months.
What type of delusions are see in mood disorders?
Mood congruent delusions:
e.g. Mania = Grandiose
Depression = Nihilistic, persecutory, etc.
Give 2 key risk factors for schizophrenia
1) Cannabis use - associated with a 2.5x higher risk, increased with earlier use
2) Family history - strong genetic involvement
Give some poor prognostic factors for schizophrenia
Male Younger age at onset Insidious onset Longer duration of episode Drug use Social isolation Negative symptoms Poor compliance with treatment Family history
What are the negative symptoms of schizophrenia?
Social withdrawal Flat affect Lack of pleasure from activities Decreased speech Lack of motivation Poor memory
Give 1 drug which is particularly associated with causing severe EPSEs
Haloperidol
What is neuroleptic malignant syndrome?
Life threatening syndrome caused by antipsychotic medication which is though to be due to a profound dopamine deficient. Tends to affect patient who have recently started on antipsychotics.
List some features of neuroleptic malignant syndrome
Lead pipe rigidity Confusion Fluctuating BP Tachycardia Fever Raised CK
How might you treat neuroleptic malignant syndrome?
Stop all antipsychotics Monitor observations: HR, RR, Temp May need ITU admission if rigidity affecting respiration Bromocriptine = Dopamine agonist Sedation using benzodiazepines Dantrolene = Muscle relaxant
True / False: Quetiapine causes raised prolactin
False - Quetiapine does not raise prolactin levels and so is useful is a patient is experiencing these effects on other medications
List some general side effects of atypical antipsychotics
Increased cardiovascular and cerebrovascular event risk
Sexual dysfunction
Metabolic syndrome: Weight gain, deranged cholesterol, hyperglycaemia
Increased risk of seizures
Dizziness, postural hypotension
Reduced seizure threshold is more of a problem in typical or atypical antipsychotics?
Atypical
