Psychosis Flashcards
What is a simple definition for Psychosis?
Difficulty Perceiving and interpreting Reality
Can be caused by many disorders - focus in research is on schizophrenia
What are the positive symptoms of Psychosis?
Hallucinations - Auditory, Voices commenting on you, voices talking to each other, visual, somatic/tactile, olfactory (rare)
Delusions: Fixed false beliefs, out of keeping with social/cultural background. Persecutory, Control, Reference, Mind reading, Grandiosity, Religious, Somatic, Thought insertion/withdrawal.
What are some negative symptoms of Psychosis?
Alogia - Poverty of speech; Paucity, little content, slow response.
Avolution - Poor self-care, lack of persistence at work/education, Lack of motivation.
Anhedonia - Few close friends, few hobbies/interests, impaired social functioning.
Affective Flattening - Unchanging facial expressions, Few expressive gestures, poor eye contact, lack of vocal intonations, Inappropriate affect
What are the disorganization symptoms in Psychosis?
Bizarre Behaviour - Bizarre social behaviour, clothing, appearance, Aggression/agitation, Repetitive/stereotyped behaviours
Thought Disorder - Derailment, Circumstantial speech, Pressured speech, Distractibility, Incoherent/Illogical speech
When is the onset of Psychosis?
Can occur at any age
Peak incidence in early 20s/ adolescence
Peak later in women
What is the course like in Psychosis?
Chronic & episodic
Very variable
What is the Morbidity in Psychosis?
Substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
Significant impact on education, employment and functioning
What is the Mortality in Psychosis?
Substantial
All-cause mortality 2.5x higher, ~15 years life expectancy lost
High risk of suicide in schizophrenia – 28% of excess mortality
What is involved in the Psychiatric History?
History of Presenting Concern Past Psychiatric History Background History (Family, Personal, Social) Past Medical History and Medicines Corroborative History
What is included in the History of presenting Concern?
The patient’s description of the presenting problem – nature, severity, onset, course, worsening factors, treatment received
Circumstances leading to arrival to hospital
What is included in the Past Psychiatric History?
Any known diagnosis?
Any treatment?
Known to a community team?
Any previous admissions to hospital?
What is included in the Background History?
Family;
Age of parents, siblings, relationship with them
Atmosphere at home
Mental disorder in the family, abuse, alcohol/drugs misuse, suicide
Personal; Mother’s pregnancy and birth Early development, separation, childhood illness Educational and occupational history Intimate relationships
Social History; Living arrangements Financial issues Alcohol and illicit drug use Forensic History
What is included in the Past Medical History/Medications?
Medical problems = a cause or consequence of
mental disorder or psychiatric treatment Regular medications?
Compliance?
Over the counter medications?
Interactions
What is included in the corroborative History?
Informants: relatives, friends, authority
Confidentiality
What is included in the Mental state exam?
Appearance and Behaviour Speech Mood Thoughts Perceptions Cognition Insight
What is included in Appearance & Behaviour?
General Appearance - neglect: alcoholism, drug addiction, dementia, depression, schizophrenia
weight loss: anorexia nervosa, depression, cancer, hyperthyroidism, financial issues/homelessness
Facial expression - degressive, anxious, wooden “Parkinsonian”
Posture - Depressive; hinched shoulders, downcast head + eyes. Anxious - sitting upright, head erect, hands gripping the chair.
Movements -overactive, restless – manic, inactive, slow - depressive immobile, mute – stuportremors, tics, choreiform movements, dystonia, tardive dyskinesia
mannerisms, stereotypes
Social Behaviour - disinhbited, overfamiliar, withdrawn, preoccupied, signs of impending violence, raised voice, clenching fists, pointed fingers, intrusion into personal space
What is Included in speech?
Quantity - less, more, mutism
Rate - slow, fast, pressure of speech
Spontaneity - latency
Volume - quiet, loud
What is included in Mood
Subjective
Objective;
- Predominant Mood
- Constancy - emotional lability/incontinence, reduced reactivity/blunting/flattening/ irritability
- Congruity - Cheerful while describing sad events
What is included in thoughts?
Stream - pressure, poverty, blocking
Form - flight of ideas, loosening of associations, perseveration
Content;
- Preoccupations
- Morbid thoughts, suicidality
- Delusions, overvalued ideas: Primary - occurs suddenly, Secondary - arises from previous abnormal idea/ experience. Delusional mood/perception/memory shared delusion= folie a deux
Delusions, overvalued ideas - paranoid, hypochondrial
- Obsessional symptoms - Obsessional thoughts, compulsions
What is included in perceptions?
Illusions - misperceptions of a real external stimulus
Hallucinations - perception in the absence of external stimulus true perception + 2) coming from outside the head pseudohallucination = 1) OR 2) hypnagogic, hypnopompic auditory – second person, third person visual – Charles Bonnet syndrome olfactory gustatory tactile, of deep sensation
Distortions
What is included in Cognition?
Consciousness Orientation Attention and concentration Memory Language functioning Visuospatial functioning
What is included in Insight?
Awareness of oneself as presenting phenomena that other people consider abnormal
Recognition that these phenomena are abnormal
Acceptance that these abnormal phenomena are caused by mental illness
Awareness that treatment is required
Acceptance of the specific treatment recommendati
What are environmental risk factors for Psychosis?
Drug use, especially cannabis Prenatal/birth complications Maternal infections Migrant status Socioeconomic deprivation Childhood trauma
What are the genetics of psychosis?
Schizophrenia is highly heritable: ~46% concordance in MZ twins
Highly polygenic – lots of genes of small effect sizes, but ones found so far account for ~20% of known genetic risk
What is Psychosis often preceded by?
Prodromal symptoms
What hapens in the Diagnosis of Psychotic disorders?
Heterogeneity within disorder categories
Takes time to observe before giving a diagnosis like schizophrenia
Many people who have a first episode psychosis will not have another
What are the treatment options for Psychosis?
Pharmacological - Antipsychotic medications, Often the main treatment.
Psychological - CBT, Avatar therapy
Social support - Supportive environments, structures & routines.
What neurotransmitter mechanism s most implicated in the mechanism of antipsychotics?
Dopamine…but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine
What are the actions of antipsychotics on dopamine receptors?
Most antipsychotics are dopamine antagonists. Aripiprazole is a partial agonist.
Dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms
What are the symptoms caused by Antipsychotics?
post-synaptic dopamine blockade in the extrapyramidal system (parts of the brain that enable us to maintain posture and tone)
Parkinsonism
Acute Dystonia
Tardive Dyskinesia
Akathisia
What is Parkinsonism?
Rigidity - characteristic‘cog-wheeling’
Slow and shuffling gait
Lack of arm swingin gait – early sign
‘pill-rolling’ tremor- slow (4-6Hz) movement of the thumb across the other fingers:
What is Dystonia?
Increased motor tone -> sustained abnormal posture
Can occur shortly after taking dopamine antagonist
Can be acute, frightening, painful, even fatal (laryngeal dystonia)
What is Tardive dyskinesia?
Repeated oral/ facial/ buccal/ lingual movements
Initially subtle – can progress to tongue involvement, lip smacking
Increased risk: long-term antipsychotics, female
What is Akathasia?
Inner restlessness
Feel compelled to move, but does little to alleviate
Can lead to overt, relentless movement
Legs most commonly affected
What is the difference between typical and atypical antipsychotics?
Typical’ antipsychotics commonly cause extrapyramidal side effects at therapeutic doses. Definition is NOT based on pharmacology/drug targetNewer, atypical antipsychotics (e.g. olanzapine) – less likely to cause EPSEs
But can be caused by all antipsychotics
What should management looklike for antipsychotics?
Avoid them in the first place: atypical antipsychotics usually first-line
Change medication
Anticholinergic medications can help e.g. procyclidine
Patients need to be fully-informed about risks
What are some other side effects of Antipsychotics?
EPSE’s
Haematological - Agranulocytosis, Neutropenia
Metabolic - Increased appetite, weight gain, diabetes
Gastro - Constipation
Pituitary - Increased prolactin release (suppressed by dopamine)
Cardiac - Dysrhythmia
What happens after a psychotic episode?
Some people after an episode of psychosis recover completely and remain well
Majority follow an episodic course, with periods of wellness and relapses
What is the long-term management plan for Psychosis?
Community follow-up
Managing antipsychotic side effects e.g. weight, diabetes
Health promotion: reducing risk factors e.g. smoking, diet
All-cause mortality 2.5x higher in schizophrenia: ~14 years lost
