Psychosis Flashcards
How common is schizoprenia?
1% of the population
Define psychosis
A mental disorder in which someone loses contact with reality
Define hallucination and illusion
Hallucination: an abnormal perception in the absence of a stimulus
Illusion: an abnormal perception of a stimulus
What are the characteristics of psychosis?
Delusions and/or perceptions
What are some causes of psychosis or differential diagnoses?
Causes:
- Schizoprenia
- Severe depression or mania
- Drug-induced psychosis
- Acute and transient psychotic episode
- Steroid-induced psychosis
- Schizoaffective disorder
DDx: drug use or withdrawal, delirium, dementia, PD, hypercalcaemia, porphyrias, etc
What is schizophrenia?
A chronic psychotic illness lasting for >6 months in the absence of organic pathology
What are the types of schizoprenia?
- Paranoid
- Catatonic
- Residual (chronic, negative symptoms)
- Hebephrenic/disorganised: child-like behaviour, mood
How is schizophrenia diagnosed?
Diagnosis should be made in secondary care
DSM: at least 1 month of 2 active symptoms with at least 6 months of functional impairment
ICD-10: more focus on first-rank symptoms, lasting at least 1 month with effects over 6 months
Define a delusion
A fixed and firmly held belief that cannot be shaken by evidence to the contrary, and out of keeping with the cultural context
Describe the features of catatonia
- Stupor
- Rigid, motionless
- Automatic obedience
- Waxy flexibility
What are the first rank symptoms of schizoprenia?
- Auditory hallucinations: usually third person, commentary, echo
- Delusional perceptions
- Passivity
- Thought interference: insertion, withdrawal, broadcasting
What are some features of schizoprenia?
- Delusions
- Hallucinations
- Thought disorder
- Negative symptoms: alogia, avolition, anhedonia, affective flattening
- Disturbed behaviour: withdrawal, antisocial
- Depressive features
What are the negative symptoms of schizoprenia?
Alogia: poverty of speech
Avolition: lack of motivation
Anhedonia: lack of pleasure
Affective flattening: lack of expression
In which demographics is schizoprenia more common?
Young males (18-25)
Name some risk factors for schizoprenia
- Young, male
- Family Hx
- Low socioeconomic status
- Substance misuse: specifically cannabis
- History of abuse, neglect, violence
- Perinatal trauma
- Migrants, ethnic minorities
Describe the dopamine hypothesis of schizoprenia
Symptoms of schizoprenia are due to abnormalities of dopamine in certain brain areas:
- Excess DA in the mesolimbic system: positive symptoms
- Lack of DA in the mesocortical system: negative symptoms
Describe the clinical course of schizophrenia
- Prodrome/at-risk mental state: social withdrawal, loss of interest in normal activities
- Acute phase: positive symptoms dominate
- Chronic phase: negative symptoms dominate. Also known as residual schizoprenia
What is the prognosis of schizoprenia?
1/3 improve and have complete recovery
1/3 have some improvement but can have occasional relapse
1/3 no improvement
**The earlier the intervention or the shorter the duration of untreated psychosis (DUP), the better the prognosis. Specifically <3 months
What type of formal thought disorder might you see in a patient with schizoprenia?
- Loosening of associations/knight’s move thinking
- Word salad
- Alogia
How would you investigate a patient presenting with psychotic symptoms?
- History and collateral history
- Physical examination and observations
- Urine drug screen
- ECG
- Bloods: FBC, CRP, U+Es, LFTs, TFTs, cortisol, glucose
- CT/MRI as indicated, especially if visual hallucinations
What are the important components of a risk assessment in someone with schizoprenia? What is important to know when assessing risk to others?
Risk to self: self-harm and suicide, neglect, debts
Risk from others: scams/fraud
Risk to others: paranoia, voices -> violence
-Consider history of substance misuse, previous violence or forensic history, access to weapons, threats
Who is eligible for early intervention services?
Everyone (all ages) with first episode or first presentation of psychosis
Also anyone with at-risk mental state and risk of psychosis in the future
You see a young man in the GP clinic who reports hallucinations and delusions. What would you do next?
Risk assessment
Refer urgently to the early intervention service
Describe the overall management approach in people with psychosis
Biopsychosocial!! MDT!
- Bio: check for any organic causes. Give antipsychotics
- Psycho: CBT and/or family intervention, arts therapy
- Social: support with housing, education, employment, finances. Peer support.
Describe the management of someone with first episode psychosis presenting to secondary care
Risk assessment and capacity!! Consider need for admission
Biopsychosocial approach with EIS MDT
-Bio: start antipsychotic eg. olanzapine
-Psych: start CBT and/or family intervention
How long should someone take antipsychotic medication for after an acute episode?
Typically recommended that they take medication for 1-2 years, as the risk of relapse is high if they stop during this period
*But obv, no one can be forced to take it so capacity must be assessed
If a person with known schizoprenia presents to GP with suspected relapse, what is the appropriate action? What should happen then?
Refer to crisis team in secondary care for assessment
Secondary care should assess symptoms, risk and capacity and consider any need for admission/home treatment, medication changes etc
Who is on the MDT in EIS?
Main point of contact is the care coordinator (usually specialist nurse, social worker). Psychiatrist, psychologist, specialist mental health nurses, social worker, etc also involved
What is rehabilitation for psychosis?
Program for people with treatment resistant symptoms or other comorbid mental health conditions eg. substance misuse, neurodevelopmental problems
Involves daily living skills, social skills training, substance misuse counselling etc
What are some different antipsychotic medications?
Typical (1st gen): haloperidol, chlorpromazine
Atypical (2nd gen): olanzapine, risperidone, aripiprazole, clozapine
What is the mechanism of action of antipsychotics?
Most are D2-R antagonists
- Typicals have higher action
- Atypicals are also 5HT2-R antagonists
What are the side effects of typical antipsychotics?
Extra-pyramidal side effects -Tardive dyskinesia -Acute dystonia -Akathisia -Parkinsonism Cardiac side effects eg. QTc prolongation Hyperprolactinaemia
What are the side effects of atypical antipsychotics?
Weight gain Metabolic syndrome: T2DM, hyperlipidaemia Sedation Anticholinergic effects Hyperprolactinaemia Neuroleptic malignant syndrome
What is tardive dyskinesia? What is the management?
A complication of long-term antipsychotic use. Syndrome characterised by choreoathetoid movements
Mx: avoid anticholinergics. Decrease antipsychotic dose/stop.
What is akathisia? What is the management?
A subjective feeling of restlessness leading to fidgeting, pacing, etc
Mx: reduce antipsychotic/change. Benzos.
What is dystonia? What is the management?
Abnormal muscle tone resulting in spasm/abnormal posture.
Presents as torticollis or oculogyric crisis
Mx: anticholinergics eg procyclidine. Reduce antipsychotics
What should be done before starting antipsychotic medication? How should they be monitored?
Measure: -Weight -Blood pressure and pulse -HbA1c, lipids, prolactin -ECG Monitoring: monitor for symptom improvement and complications. Measure BP, HbA1c, lipids at 12 weeks, 1 year, then anually. Weight weekly for 6 weeks -12 weeks-1 year.
Describe the signs and symptoms of neuroleptic malignant syndrome
- Muscle stiffness and rigidity
- Altered consciousness
- Hyperthermia
- Autonomic instability: ^ HR, sweating
What is the management of neuroleptic malignant syndrome?
- Stop antipsychotics immediately
- Admission for IV fluids
- May need ITU, dialysis, muscle relaxant
What are the complications of NMS?
- Rhabdomyolysis
- AKI
- Metabolic acidosis
Which antipsychotics have extra monitoring in addition to normal?
Risperidone: prolactin
Clozapine: FBC weekly
What is treatment resistant schizoprenia? What is the management?
Schizoprenia unresponsive to trial of 2 different antipsychotic drugs at sufficient dosage for 6 weeks
Mx: clozapine
What are the consequences/side effects of clozapine?
Agranulocytosis
Constipation
Seizures
Cardiac effects
