Psychosis Flashcards
What is psychosis?
A collection of symptoms in which a patient experiences a significant alteration in perceptions, thoughts, mood and behaviour, involving an inability to distinguish between subjective experience and objective reality and characterised by a lack of insight
What are the main symptoms psychosis?
Hallucinations Delusions Thought disorder Loss of insight Self-referential experiences Ideas of reference
What is a hallucination?
A perception which occurs in the absence of an external stimulus
A misrepresentation of inner experience as having external origin
What is a delusion?
A fixed, falsely held belief held with unshakeable conviction
What is the difference between primary and secondary delusions?
Primary - arrive fully formed without need for explanation
Secondary - attempts to explain anomalous experiences
Which is more common - primary or secondary delusions?
Secondary
What are thought disorders?
Any disturbance in cognition that adversely affects language and thought content, and thereby communication
What are examples of thought disorder?
Passivity phenomenon Thought interference Loosening of associations Knight's move thinking Neologisms Circumstantiality Tengentiality Verbigeration
What is passivity phenomenon?
The feeling that the patient’s actions, feelings, urges aren’t their own
What is thought interference?
The feeling that the patient’s thoughts not their own, being withdrawn, broadcast, blocked
What is loosening of associations?
Speech is muddled, illogical, difficult to follow and cannot be clarified
What is Knight’s move thinking?
Jumps from topic to topic with no logical connection between them
What are neologisms?
An abnormality of speech in which the patient makes up a new word or phrase or uses existing words or phrases in bizarre ways which have no generally accepted meaning but which have idiosyncratic meaning to the patient
What is circumstantiality?
When the patient talks around the point but gets there eventually
What is tangentiality?
When the patient talks around the point and never actually gets to it
What is verbigeration?
Individual words don’t connect and sentences make no sense whatsoever
What are self-referential experiences (paranoia)?
The belief that external events are related to oneself
How are persecutory thoughts different to paranoia?
Paranoia is when you think unrelated things are related to you
Persecutory is only when you think someone is out to get you/others
What are ideas of reference?
Innocuous or coincidental events are ascribed significant meaning
What are psychiatric causes of psychosis?
Schizophrenia
Scizoaffective disorder
Mania
Depression
What are organic causes of psychosis?
Dementia Delirium Huntington's SLE Syphilis Hyperthyroidism Hypoglycaemia Parkinson's HIV/AIDS Syphilis
What cause of psychosis do auditory hallucinations make more likely?
Schizophrenia
What cause of psychosis do visual hallucinations make more likely?
Drugs
What cause of psychosis do tactile hallucinations make more likely?
Delirium
Alcohol withdrawal
What drugs can cause psychosis?
Cannabis Amphetamine Levodopa Steroids Antimalarials Anticonvulsants Antipsychotics Antidepressants
The withdrawal of which substances can cause psychosis?
Alcohol
Benzodiazepines
What is the treatment for drug-induced psychosis?
Cessation of use of the causative drug - usually takes about 4 weeks
When are psychosis symptoms mood congruent?
In mood disorders
What are features of psychosis in depression?
Delusions of worthlessness, guilt, nihilism
Auditory hallucinations that are derogatory, insulting or threatening
Cottard’s syndrome - belief that the body has already died
Typically second person
Affirming their perception of themself
What are features of psychosis in mania?
Delusion of grandeur, special ability, persecution, religiosity
Hallucination tend to be second person and auditory
Flight of ideas
What is schizoaffective disorder?
The diagnosis that bridges the gap between bipolar and schizophrenia
When psychosis and mood symptoms are present in equal measure
Who is schizophrenia most common in?
Men
Lower socioeconomic class
Onset in young adulthood
What is the aetiology of schizophrenia?
Multi-factorial neurodevelopment disorder
Genetics (80% inherited)
Environmental factors (obstetric complications, childhood CNS infection, early cannabis use)
Psychological factors (stress, adverse life events, psychoactive drug use)
What biological changes happen in schizophrenia?
Changes in dopamine signalling pathways in the brain
Lack of gliosis (reactive change of glial cells in response to damage to the central nervous system)
Ventricular enlargement and alteration fo CSF flow
Decrease in white matter volume
What are the ‘first rank’ symptoms of schizophrenia?
3rd person auditory hallucinations
Thought insertion, broadcast or removal
Passivity phenomenon
Delusions
Describe the hallucinations of schizophrenia?
3rd person auditory hallucinations that give a running commentary or discussion of the patient
Describe the delusions of schizophrenia?
Persistent
Culturally inappropriate or completely impossible
What are the additional symptoms of schizophrenia? (other than first rank ones)
Other types of hallucinations Incoherent or irrelevant speech Neologisms Breaks or interruptions in train of thought Catatonic behaviour Negative symptoms
What symptoms of schizophrenia are ‘positive’ symptoms?
Delusions
Hallucinations
Thought disorder
Passivity phenomena
What symptoms of schizophrenia are ‘negative’ symptoms?
Apathy Social withdrawal Self neglect Poverty of thought Reduced social performance Blunted and incongruent affect Reduced motivation
What is a ‘blunted’ affect?
Reduced outward display of emotions
What is an ‘incongruent’ affect?
React inappropriately to social circumstance
What are the prodromal symptoms of schizophrenia?
Gradual onset Non-specific symptoms Odd ideas and experiences Eccentricity Altered affect
What is the diagnostic criteria for schizophrenia?
At least 1 first rank
Or at least 2 additional symptoms
Present for at least 1 month
Not explained by another cause
When is schizophrenia diagnosed if the patient also meets the criteria for a manic or depressive episode?
If the schizophrenic symptoms were present before the disturbance of mood developed
What are the subtypes of schizophrenia?
Paranoid Disorganised/hebephrenic Catatonic Simple Undifferentiated Residual
What is pathetic most common subtype of schizophrenia?
Paranoid schizophrenia
What is paranoid schizophrenia?
3rd person auditory hallucinations and delusional beliefs about self, with these often being persecutory
What is disorganised/hebephrenic schizophrenia?
Affective changes are prominent
Delusions and hallucinations are fleeting
Behaviour irresponsible and unpredictable
The mood is shallow and inappropriate, thought is disorganised, speech is incoherent
A tendency to social isolation and negative symptoms
What is catatonic schizophrenia?
Movement disorder predominates - characterised by unusual, limited and sudden movements Mutism, stupor Posturing Negativism Command automatism
What is posturing?
Maintenance of odd postures
What is negativism?
Resistance to command or attempts to be moved
What is command automatism?
The patient will do whatever you ask them to
What is simple schizophrenia?
Negative symptoms are most predominant early and worsen
Positive symptoms are rarely experienced
Rare
What is undifferentiated schizophrenia?
Some signs of paranoid, hebephrenic or catatonic but not obviously fitting into one type alone
What is residual schizophrenia?
When there is a history of psychosis but the patient currently only experiences the negative symptoms
What are good prognostic indicators for schizophrenia?
Female
Older age of onset
Family history of mood disorder
Marked mood disturbance, especially elation
What are bad prognostic indicators for schizophrenia?
Male Early age of onset childhood, adolescence) Insidious onset Prolonged duration of undiagnosed psychosis Poor premorbid adjustment in life Co-morbid substance misuse Social isolation Cognitive impairment Disorganised subtype Multiple first rank symptoms
What is the mainstay of treatment for schizophrenia?
Antipsychotics (typical or atypical)
What are examples of typical antipsychotics?
Haloperidol
Chlorpromazine
What is the mechanism of typical antipsychotics?
Block dopamine D2 receptors - they are dopamine antagonists
Results in inhibition of the mesolimbic and nigrostriatal pathways - where delusions, hallucinations, thought disorders arise
Reduce symptoms and prevent relapse
What are the side effects of antipsychotics?
Extrapyramidal side effects Sedation Neuroepileptic malignant syndrome Hyperprolactinaemia Akathisia Anti-cholinergic effects QT prolongation Increased appetite and weight gain
What are the different extrapyramidal side effects?
Acute dystonia
Parkinsonism
Tardive dyskinesia
What is acute dystonia?
Painful, sustained contractions of muscles, usually in the eyes, jaw or neck
Occurs within a few minutes-hours of starting treatment
What is used to treat acute dystonia?
Procyclidine
What are the symptoms of parkinsonism?
Resting tremor Shuffling gait Reduced facial expressions Cogwheel rigidity Bradykinesia
What is tardive dyskinesia?
Repetitive, uncontrollable, involuntary contraction of the muscles of the face, tongue and upper body
Typically presents as excessive blinking, lip smacking, facial grimaces
Seen with long term use and is non-reversible
Are extrapyramidal side effects of antipsychotics seen more often with typical or atypical antipsychotics?
Typical
What is neuroleptic malignant syndrome?
Rare serious complication of typical antipsychotics
What is the presentation of neuroleptic malignant syndrome?
Increased muscle tone and bradykinesia Pyrexia Changing pulse/BP swinging from increased to decreased > Rhabdomyolysis > Acute renal failure > Coma > Death
What do blood tests show in neuroleptic malignant syndrome?
Raised WCC
CK in the thousands
What is the management of neuroleptic malignant syndrome?
Stop antipsychotic
Rapid cooling, renal support
Skeletal muscle relaxants - e.g. dantrolene
Dopamine agonists - e.g. bromocriptine
Why do anti-psychotics cause hyperprolactinaemia?
Prolactin release inhibited by dopamine so dopamine antagonists cause increased release of prolactin
What are the symptoms of hyperprolactinaemia?
Women: galactorrhea, decreased libido, decreased arousal, anorgasmia, amenorrhoea, anovulation
Men: gynaecomastia, erectile dysfunction, oligospermia, decreased libido
Decreased bone mineralisation
Decreased bone density
Fractures
What is akathisia?
Restlessness
Pacing and unable to stand still
Leads to poor sleep
How is akathisia treated?
Beta blockers
Benzodiazepines
What are anti-cholinergic side effects?
Dry mouth
Blurred vision
Constipation
What are examples of atypical antipsychotics?
Olanzapine Quetiapine Aripiprazole Risperidone Amisulpride Clozapine
What is the mechanism of atypical antipsychotics?
Block D2 dopamine receptors
And receptors for other neurotransmitters
Which side effects are most common in atypical antipsychotics?
Weight gain Sedation Hyperprolactinaemia Sexual dysfunction Increased risk of seizures Extrapyramidal side effects
Which is the most effective antipsychotic?
Clozapine
When is clozapine used, and why?
Treatment resistant schizophrenia
Bad side effects
What are the side effects of clozapine?
Agranulocytosis Myocarditis Weight gain Sedation Hypersalivation Cardiomyopathy PE Constipation that can lead to gastric paresis, obstruction and perforation
What is treatment resistant schizophrenia?
Illness that does not respond to two adequate trials (6 weeks) of two different anti-psychotics, one of which was an atypical
What is needed for patients on clozapine?
Regular blood testing because of agranulocytosis
Hyoscine hydrobromide for treatment of hypersalivation
Titration to therapeutic dose
What type of antipsychotics are first line?
Atypical - but differs depending on which side effects are appropriate/inappropriate for different patients
What antipsychotic would you give to avoid extrapyramidal side effects?
An atypical
What antipsychotic would you give to avoid sedation?
Haloperidol
Risperidone
What antipsychotic would you give to provide sedation?
Olanzapine
Chlorpromazine
What antipsychotic would you give to avoid weight gain?
Haloperidol
Aripiprizole
What antipsychotic would you give in treatment resistant schizophrenia?
Clozapine
What antipsychotic would you give if compliance is an issue?
Depot risperidone
Which other situations can antipsychotics be used in?
Anxiety - olanzapine
Bipolar as a mood stabiliser or for acute depression or mania
Rapid tranquilisation
