Psychosis

Question 1

Definition of delusion?

Answer 1

Fixed, false, strange or irrational belief which is firmly held in spite of evidence to the contrary, and which is not normally accepted by other members of the same culture/group

Question 2

What is a somatic delusion?

Answer 2

False belief that one’s bodily functions are abnormal- e.g. delusions of parasitosis, delusions of terminal illness

Question 3

What are the three key features of psychosis?

Answer 3

Hallucinations
Delusions
Though disorder

Question 4

Causes of increased morbidity/mortality in psychotic patients?

Answer 4

Suicide
T2DM (many antipsychotics cause weight gain)
Respiratory disease due to increased rate of smoking
Cardiovascular disease due to smoking, TD2M, sedation causing reduced activity, adverse lipid profile as a result of antipsychotics
Social exclusion e.g. don’t attend clinics

Question 5

Psychosis is usually heralded by…

Answer 5

Gradual decrease in cognitive or social functioning, characterised by development of negative symptoms

Question 6

Investigations which may be useful in undifferentiated suspected psychosis?

Answer 6

LFTs and macrocytosis might suggest alcohol misuse
Urine toxicology
Syphilis serology
HIV serology
CT head

Question 7

What are the three main “categories” of psychosis?

Answer 7

1. Affective psychosis e.g. severe depression, bipolar disorder
2. Delusional psychosis e.g. schizophrenia
3. Organic psychosis e.g. alcohol withdrawal

Question 8

Risk factors for psychosis (5)

Answer 8

Early adulthood (80% age 16-30)
Family history, particularly a first-degree relative
Living in inner-city areas
History of prolonged cannabis use
BAME ethnicity

Question 9

Commonest form of psychosis?

Answer 9

Schizophrenia

Question 10

Important “organic” causes of psychosis

Answer 10

Drug-induced
Temporal lobe epilepsy
Encephalitis
Dementia
Delirium

Question 11

First-line treatment in newly diagnosed schizophrenia?

Answer 11

Atypical antipsychotics e.g. risperidone, olanzapine

Question 12

When should depot formulations be considered? (2)

Answer 12

Patient preference

Non-compliance with medication

Question 13

Management of schizophrenia? (2)

Answer 13

Oral antipsychotic in combination with psychological therapy

Question 14

Aim of treatment in schizophrenia?

Answer 14

Reduce acute phase symptoms and return patients to baseline level of function

Question 15

Differences between first and second generation antipsychotics

Answer 15

2nd generation- act on a range of receptors, fewer EPSEs, lower risk of tardive dyskinesia. More likely cause weight gain and glucose intolerance

1st generation- act by blocking D2 receptors in the brain

Question 16

Examples of atypical antipsychotics? (5)

Answer 16

Aripiprazole
Risperidone
Quetiapine
Olanzapine
Clozapine

Question 17

Examples of EPSEs (4)

Answer 17

Parkinsonism (e.g. bradkinesia and tremor)
Dystonia
Akathisia (restlessness)
Tardive dyskinesia

Question 18

a) Class of medication which can be used to reduce symptom burden from EPSE; b) example of drug

Answer 18

a) Anticholinergic

b) Procyclidine

Question 19

Which type of EPSE is procyclidine not licensed for?

Answer 19

Tardive dyskinesia

Question 20

Why do most antipsychotics cause hyperprolactinaemia?

Answer 20

Anti-psychotics are dopamine receptor antagonists, and dopamine inhibits prolactin release

Question 21

Clinical manifestations of hyperprolactinaemia?

Answer 21

Sexual dysfunction
Reduced bone mineral density
Menstrual disturbance
Breast enlargement
Galactorrhoea
Possibly increased risk of breast cancer

Question 22

Cardiovascular/CVD risk side-effects of antipsychotics?

Answer 22

QTc prolongation
Hypotension
Weight gain and diabetes

Question 23

Syndrome characterised by hyperthermia, rigidity, tachycardia, labile BP and sweating

Answer 23

Neuroleptic malignant syndrome

Question 24

Monitoring of antipsychotics

Answer 24

1. Baseline ECG
2. Weekly weights for 6 weeks, then at 12 weeks, then yearly
3. Routine bloods, fasting glucose, HBA1C and lipids at baseline, 12 weeks then yearly

Question 25

When is clozapine indicated?

Answer 25

Schizophrenia when unresponsive to conventional antipsychotics, or where not tolerated

Question 26

Special considerations for clozapine?

Answer 26

Risk of agranulocytosis- needs regular monitoring

Question 27

Best atypical for avoiding weight gain?

Answer 27

Aripiprazole