Psychosis Flashcards
Define PSYCHOSIS.
Psychosis refers to a state in which an individual is unable to differentiate between reality and false perception.
Psychosis has FOUR key features:
- hallucinations
- delusions
- thought disorder
- abdominal / disorganised behaviour
Outline / describe the hierarchy of diagnosis according to ICD-10.
- organic conditions (e.g. TBI, encephalopathy, delirium, dementia, epilepsy)
- intoxication / withdrawal (e.g. alcohol, benzodiazepines, methamphetamines)
- schizophrenia (e.g. schizoaffective disorder, psychotic depression)
- affective disorders (e.g. uni polar or bi polar depression)
- anxiety / stress related conditions
- personality disorders
Define “HALLUCINATION.”
Hallucination describes an abnormal sensory experience that occurs in the absence of an appropriate stimuli.
Types of hallucinations include:
- visual
- auditory
- tactile
- olfactory
- gustatory
Define “DELUSION.”
Delusions are false and fixed beliefs that (1). require no proof or evidence (2). are held with conviction and resistant to change, despite contradictory evidence (3). create a false reality for the patient.
Types of delusions include:
- paranoid / persecutory delusions
- grandiose delusions
- somatic delusions
- nihilistic delusions
- reference delusions
- passivity phenomenon
- thought control
- delusional jealousy
Define PARANOID DELUSION.
A false and fixed idea that the individual is being followed, tracked, deceived etc.
Typically begins with neighbours “spying on them…”
Define PERSECUTORY DELUSION.
A false and fixed belief that the individual, or their loved ones, are being conspired against.
Define GRANDIOSE DELUSION.
A false and fixed belief that the individual is of greater importance / has special talents etc.
For example, individual believes that they are God.
Define NIHLISTIC DELUSION.
A false and fixed belief that a component of the person is non-existent / dying… or that the world is non-existent.
Define GUILT DELUSION.
A false and fixed belief that the individual is responsible for a crime or act that they did not commit.
Define REFERENCE DELUSION.
A false and fixed belief that causal events are linked to individuals.
For example, newsreaders / television / radio are speaking or communicating with the person.
Define PASSIVITY PHENOMENON.
Passivity phenomenon describes a phenomenon in which the individual believes that their thoughts, actions or bodily habits are controlled by others.
Passivity phenomenon can be described in terms of:
- passivity of affect
- passivity of volition
- somatic passivity
Identify the four components of THOUGHT CONTROL.
- thought insertion
- thought withdrawal
- thought blocking
- thought broadcasting
These components of thought disorder are considered part of the FIRST RANK Symptoms of Schizophrenia.
Define DELUSIONAL JEALOUSY.
A fixed and false belief regarding the infidelity of one’s partner.
Define THOUGHT DISORDER.
Formal thought disorder can relate to either the form or stream of one’s thoughts.
Thought disorder may relate to:
- circumstantial thoughts
- tangential thoughts
- flight of ideas
- loosening of association
- neoglisms
- thought blocking, insertion, withdrawal and broadcasting
- echolalia
- alogia
Outline the DOPAMINE HYPOTHESIS in regard to pathogenesis of psychosis.
Dopamine is a neurotransmitter synthesised from the amino acid tyrosine.
There are four major pathways that dopamine acts on in the brain:
- mesolimbic pathway
- mesocortical pathway
- nigrostriatal pathway
- tuberohypophyseal pathway
According to the DOPAMINE HYPOTHESIS, the symptoms of schizophrenia are due to both (a). reduced dopamine acting at D1 receptors (excitatory) within the mesocortical pathway, leading to the NEGATIVE SYMPTOMS (b). increased dopamine acting at D2 receptors (inhibitory) within the mesolimbic pathway, leading to POSITIVE SYMPTOMS
Outline the role of GLUTAMATE in the pathogenesis of psychosis.
Glutamate is a neurotransmitter that acts at NMDA receptors throughout the brain. NMDA receptors are excitatory receptors that activate Ca++ channels, causing depolarisation.
Glutamate is also believed to act at dopamine receptors, causing hypo / hyper activity in the mesocortical and mesolimbic pathway respectively.
DSM-V Criteria: SCHIZOPHRENIA
A. At least TWO of the following symptoms present consistently for >1 month duration (at least ONE of the symptoms must either be hallucinations or delusions)
- delusions
- hallucinations
- thought disorder
- grossly disorganised or catatonic behaviour
- negative symptoms
B. Since the onset of symptoms, level of functioning in at least ONE of the following areas has been reduced:
- work
- social life / inter-personal relationships
- education
C. Continuous signs of disturbance for > 6 months
D. Psychotic depression (uni polar or bi polar) and schizoaffective disorder have been excluded
E. Symptoms are not due to organic cause or physiological effects of a drug / substance
Specifiers:
- first episode psychosis
- +/- catatonia
- level of severity (e.g. acute, partial remission, full remission)
DSM-V Criteria: BRIEF PSYCHOTIC EPISODE
A brief psychotic episode fulfils criteria A + D + E for SCHIZOPHRENIA, however, symptoms resolve within one month and patient returns to pre-morbid baseline.
Specifiers:
- acute stressors
- post partum
- catatonia
- severity
DSM-V Criteria: SCHIZOPHRENIFORM DISORDER
Schizphreniform disorder fulfils criteria A + D + E for SCHIZOPHRENIA, however, symptoms are present for between one to six months duration and patient returns to pre-morbid baseline.
DSM-V Criteria: SCHIZOAFFECTIVE DISORDER
A. Concurrent mood disorder (bipolar or unipolar depression) + Criteria A for SCHIZOPHRENIA
B. Delusions +/- hallucinations occur in the absence of mood symptoms for at least two weeks over the duration of the illness
C. Symptoms of major mood disorder are present for the majority of the illness lifetime
D. Symptoms are NOT attributed to organic pathology or the physiological effects of a substance / drugs
N.B Bipolar subtype is more common in young people; unipolar subtype is more common in older adults
DSM-V Criteria: DELUSIONAL DISORDER
A. Presence of one or more delusions for > 1 month duration
B. Criteria A for schizophrenia has never been met
C. Functioning is NOT impaired
D. If depressive symptoms occur, there are brief compared to the delusional disorder
E. Symptoms are not attributed to physiological effects of a drug or an organic pathology
Identify the POSITIVE and NEGATIVE symptoms of schozprenia.
POSITIVE SYMPTOMS
- hallucinations
- delusions
- thought disorder
- disorganised or catatonic behaviour
NEGATIVE SYMPTOMS
- anhedonia (lack of motivation)
- affective flattening (blunt affect)
- alogia (reduced speech)
- avolition / apathy
- attentional impairment
Outline some factors that are more suggestive of a positive prognosis.
✔️ acute onset ✔️ known precipitant ✔️ older age at onset ✔️ no family history of psychosis or mood disorders ✔️ adherence to medication ✔️ no drug / alcohol / substance use ✔️ mainly positive symptoms ✔️ good insight into condition
Outline the principles of management for schizophrenia.
- early identification and treatment of first episode of psychosis (within 12 months)
- optimisation of therapeutic relationship
- engagement with family and support networks as appropriate
- tailor the therapy to account for individual age, gender, symptoms, severity, goals etc.
- psychotherapy should be undertaken along with pharmacotherapy
- patients should be commenced on pharmacotherapy with the lowest possible dose to obtain symptom control
- monitoring for side effects
Pharmacotherapy should include:
✔️ antipsychotics (SGA preferred over FGA)
✔️ antidepressants for management of mood symptoms
✔️ benzodiazepines (acutely) for management of agitation / aggression
✔️ cessation of drug and alcohol
