Psychosis

Question 1

Delusions: a __-___ belief firmly held despite evidence to the contrary, and out of keeping with the individual’s __ __.

Fixed refers to the inability to be “___” of the false belief.

Answer 1

Delusions: a fixed-false belief firmly held despite evidence to the contrary, and out of keeping with the individual’s cultural background.

Fixed refers to the inability to be “unconvinced” of the false belief.

Question 2

Delusion Subtypes:

___: could not happen ever; example-med student is a reincarnation of dead father

__-__: could happen; example- med student is a CIA agent

__: fearing you’ll be harmed

___: loved at a distance, usually by a celebrated person

__: thinking you are better than others, claiming you are more successful than you are

__: unfaithful spouse without evidence, lots of checking on the spouse

__: thinking you have a missing part of the body

___ of __: seeing delusional significance in a neutral stimulus

__ __: grandiose delusion in a manic person

__ __: grandiose delusion in a depressed person

Answer 2

Bizarre: could not happen ever; example-med student is a reincarnation of dead father

Non-bizarre: could happen; example- med student is a CIA agent

Persecutory: fearing you’ll be harmed

Erotomanic: loved at a distance, usually by a celebrated person

Grandiose: thinking you are better than others, claiming you are more successful than you are

Jealous: unfaithful spouse without evidence, lots of checking on the spouse

Somatic: thinking you have a missing part of the body

Delusions of reference: seeing delusional significance in a neutral stimulus

Mood congruent: grandiose delusion in a manic person

mood incongruent: grandiose delusion in a depressed person

Question 3

Hallucainations

Answer 3

Hallucinations: a perception without a stimulus. Contrast with illusions, which are misinterpretations of a stimulus, and not psychotic symptoms. All sensory modalities can yield hallucinations.

• Auditory: the most common in psychiatry
• Visual: common in psychiatry but suggestive of an organic cause
• Somatic
• Olfactory: relatively uncommon in psychiatry
• Gustatory

Question 4

hallucinations vs illusions.

Answer 4

hallucinations: perception WITHOUT a stimulus

Illusion: misinterpretations of a stimulus. NOT psychotic.

Question 5

List the general DDx for the cause of a delusion or hallucination

Answer 5

Psychiatric

• schizo+
• mood disorder
• borderline personality disorder

Organic

• delirium (inattention, confusion key)
• dementia
• medical condition, substance/iatrogenic

Normal (~10%)

• hypnagogic/hypnopompic hallucination [falling asleep, waking up]
• bereavement
• sensory deprivation

Question 6

What is the DSM-5 criteria for diagnosis of schizophrenia?

A. __ or more of the following symptoms present for a significant portion of time during a __ period (or less if successfully treated). At least one symptom must be 1, 2 or 3

• *1. __
• *2. __
• *3. Disorganized __
• 4. Grossly disorganized or ___ ___*
• 5. ____ (affective flattening, alogia or avolition)

B. Social/Occupational __: For a significant portion of the time since the onset of the disturbance, one or more areas of functioning such as work, interpersonal relations or self-care are markedly below the level achieved prior to onset.

C. __: Continuous signs of the disturbance persist for __ months. This __-month period of disturbance must include at least ___ month (less if treated) of symptoms that meet criteria __, and may include periods of __ or residual symptoms. During the prodrome or residual periods, signs of disturbance may be manifested by only __ symptoms or criteria A symptoms in attenuated form (such as odd beliefs or unusual perceptual experiences).

D. __ disorder and __ disorder with psychotic features have been ruled out.

E. The disturbance is not due to the direct ___ effects of a substance (e.g. a drug of abuse or a medication) or a general medical condition.

F. If there is a history of ___ then an additional diagnosis of schizophrenia is only made if prominent ___ or ___ are present for one month.

Answer 6

What is the DSM-5 criteria for diagnosis of schizophrenia?

A. Two or more of the following symptoms present for a significant portion of time during a 1-month period (or less if successfully treated). At least one symptom must be 1, 2 or 3

• *1. Delusions
• *2. Hallucinations
• *3. Disorganized speech
• 4. Grossly disorganized or catatonic behaviour*
• 5. Negative symptoms (affective flattening, alogia or avolition)

B. Social/Occupational Dysfunction: For a significant portion of the time since the onset of the disturbance, one or more areas of functioning such as work, interpersonal relations or self-care are markedly below the level achieved prior to onset.

C. Duration: Continuous signs of the disturbance persist for 6 months. This 6-month period of disturbance must include at least 1 month (less if treated) of symptoms that meet criteria A, and may include periods of prodromal or residual symptoms. During the prodrome or residual periods, signs of disturbance may be manifested by only negative symptoms or criteria A symptoms in attenuated form (such as odd beliefs or unusual perceptual experiences).

D. Schizoaffective disorder and Mood disorder with psychotic features have been ruled out.

E. The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse or a medication) or a general medical condition.

F. If there is a history of Autism then an additional diagnosis of schizophrenia is only made if prominent delusions or hallucinations are present for one month.

Question 7

examples of catatonic behaviour

Answer 7

1. akinetic mutism
2. catatonic posturing
3. waxy flexibility

Question 8

outline the Course: three types of progression for schizophrenia

Answer 8

• Good outcome (20%): single or multiple episodes recover to almost the original level of function
• Typical course (50%): recovery from acute psychotic episodes but with gradual increase in inter-episode disability due to worsening negative symptoms
• Worst outcome (30%): psychotic episode which resists treatment, leading to chronic illness and early and severe disability

Question 9

DA hypothesis for the etiology of schizophrenia:

Dopamine Hypothesis: Postulates overactivity of dopaminergic transmission in SCZ particularly in the ___ projection. Dopamine releasing drugs (amphetamines/cocaine/L Dopa) cause psychosis. Antipsychotic drugs block postsynaptic ___ receptors. PET scans demonstrate dopaminergic overactivity

Answer 9

Dopamine Hypothesis: Postulates overactivity of dopaminergic transmission in SCZ particularly in the mesolimbic projection. Dopamine releasing drugs (amphetamines/cocaine/L Dopa) cause psychosis. Antipsychotic drugs block postsynaptic D2 receptors. PET scans demonstrate dopaminergic overactivity

Question 10

Investigations of schizophrenia:

Answer 10

Investigations of schizophrenia: usually just on first presentation

• Urine: drug screen for cocaine, amphetamines, cannabis

• CT brain scan: CWC says don’t do this; but if you did, you often see dilated ventricles/small medial temporal lobes in schizophrenia but not diagnostic. CT (if done) is to rule out strokes and tumours.

• Blood tests: CBC, lytes, LFT, glucose, cholesterol, TG

• ECG: QTc prolongation secondary to antipsychotics

Question 11

first line treatment for schizophrenia

Answer 11

first line: atypical antipsychotics (risperidone, olanzepine)

Question 12

side effects of atypical antipsychotics (first line treatment for schizophrenia)

Answer 12

sedation, weight gain, metabolic syndromes, hyperprolactinemia

Question 13

haloperidol is a second line treatment for schizophrenia and is an example of ____ antipsychot

Answer 13

typical antipsychotic.

side effects: sedation, anticholinergic effects, extrap yramdal side effects

Question 14

extrapyramidal side effects are seen in ___ antipsychotic types, like haloperidol. What is the mechanism of action of these side effects and what are the 4 groups of effects?

Answer 14

seen in TYPICAL APS.

MOA: DA blockade in the basal ganglia

1. acute dystonia
2. parkinsonism
3. akathesia
4. tarfive dyskinesia

Question 15

why do you need to do weekly CBC monitoring if a person is on clozapine for schizophrenia? (third line)

Answer 15

atypical antipsychotic for treatment-resistant patients

Question 16

Duration of biological treatment for schizophrenia

Answer 16

Duration of biological treatment; relapse of medication is 90% likely, so after 1 episode, continue medication for at least 1 year of stability. After multiple episodes, continue medication for at least 5 years if it’s possible to obtain compliance.

Question 17

The main symptoms are hyperpyrexia (>38.5 C) and severe muscle rigidity. The mortality is 20%. Treatment is to remove antipsychotics and apply life support measures, usually in an intensive care unit.

Answer 17

neuroleptci malignant syndrome (NMS)

Complications:

• Disease complications: suicide (10%, usually in early years or after hospital discharge), violence (higher than average population but less than substance abuse)
• Neuroleptic Malignant Syndrome (NMS): A very rare but serious complication of treatment with antipsychotics. The main symptoms are hyperpyrexia (>38.5 C) and severe muscle rigidity. The mortality is 20%. Treatment is to remove antipsychotics and apply life support measures, usually in an intensive care unit.

Question 18

Criteria:

A- criteria A, D and E of schizophrenia. ie/ 2 out of delusions, hallucinations, disorganized thought, disorganized behaviour and negative symptoms.

Not a mood disorder, and not substance induced or due to a medical condition.

B- the episode lasts over 1 month but less than 6 months

Prevalence: 0.1%, treatment is the same as for schizophrenia.

Course: approximately 70% proceed to schizophrenia.

What is this?

Answer 18

schizophreniform disorder (schizophrenia in waiting)

Question 19

three key criteria for Brief Psychotic Disorder

Answer 19

Criteria:

A- one or more of delusions*, hallucinations*, disorganized speech*, grossly disorganized or catatonic behaviour

(*one of them must be starred)

B- duration of at least 1 days but less than one month, with full return to premorbid functioning

C- not schizophrenia, schizoaffective disorder, a mood disorder, or due to a substance or general medical condition

Cause: commonly stress induced. More often found in the presence of a cluster A or B personality disorder.

Course: 50% proceed to another psychotic disorder. Brief onset and recovery are similar to a substance induced psychosis, which needs excluding

Treatment: as for the initial treatment of schizophrenia, but antipsychotics are used only while the patient is symptomatic and then withdrawn. A period of follow up observation is recommended to see if another psychotic disorder emerges.

Question 20

key substances that can cause substance induced psychotic disorder

Answer 20

cocaine, amphetamines, hallucinogens, PCP, cannabis, alcohol, opiates, L-Dopa, ritalin, steroids

Question 21

Presence of symptoms that satisfy the criteria for both schizophrenia AND a mood disorder during the same episode. May be schizo depressed or schizomanic.

Treatment; usually involves treatment for both schizophrenia and the mood disorder (antipsychotics and antidepressants/mood stabilizers)

Prognosis: lies between two disorders – better than schizophrenia, worse than a mood disorder

Schizoaffective disorder differs from a mood disorder with psychotic symptoms, by the presence of at least two weeks of psychotic symptoms in the absence of a mood episode

Answer 21

schizoaffective disorder

Question 22

type of psychotic symptom more predominant in psychotic disorder due to medical condition

Answer 22

Criteria:

• Prominent hallucinations or delusions
• Evidence from history, examination or lab tests that a general medical condition is etiological
• Not better accounted for by another mental disorder
• Not exclusively occurring in delirium

*Evidence: no past psychotic diagnosis, presence of a medical disorder known to be linked to psychosis, older age of onset, visual hallucinations more than auditory

Causes: neoplastic brain tumor, epileptic (temporal lobe epilepsy), infectious (AIDS, syphilis), degenerative (parkinsons, huntingtons), vascular, cushings, immunological (MS, SLE)

Treatment: treat the underlying medical condition, antipsychotic meds in addition if symptoms are severe or slow to resolve, or if the underlying medical condition is untreatable.

Question 23

Delusions for at least one month

Never meeting criteria A for schizophrenia

Apart from the impact of delusions, functioning is not markedly impaired, and behaviour not markedly odd.

Mood symptoms (if present) are brief compared to delusions)

Not due to a substance or general medical condition

Answer 23

Delusional disorder

Question 24

subtypes of delusional disorder

Answer 24

Persecutory

Somatic→ tends to present to dermatologists or plastic surgeons

Jealous→ screen for danger to spouse

Erotomanic → screen for danger to subject of delusional love

Grandiose

Question 25

46 year old man, whose psychotic symptoms are paranoid delusions and delusions of reference, presents to psychiatry for the first time ever. Otherwise his work life and homelife are stable.

Answer 25

consider delusional disorder

• too old for schizo
• stable homelife and work life, married– less demographically likely to be schizo or schizoaffective or schizotypal or schizophreniform

Question 26

what is Folie a Deux

Answer 26

Criteria

A delusion develops in an individual in the context of a close relationship with another person, who has an already established delusion

The delusion is similar to that of the already established delusion

The disturbance is not better accounted for by another psychotic disorder.

Epi: very rare, more common in isolated couples, with older age. The patient with the shared delusion is often more passive than, and has less intelligence than the index case.

Treatment:

1) Geographically separate the two individuals, to confirm the diagnosis in the more passive patient by seeing it settle.
2) Antipsychotics may be needed both in the index case, and (less often) in the patient with the shared delusion.
3) Lessen the geographical and social isolation of the couple.

Prognosis: depends on the prognosis of index case, how much the couple reconnects with each other, and how much they remain isolated from the rest of the world.