Psychosis

Question 1

What is a simple definition for Psychosis?

Answer 1

Difficulty Perceiving and interpreting Reality

Can be caused by many disorders - focus in research is on schizophrenia

Question 2

What are the positive symptoms of Psychosis?

Answer 2

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.

Question 3

What are some negative symptoms of Psychosis?

Answer 3

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

Question 4

What are the disorganization symptoms in Psychosis?

Answer 4

Bizarre Behaviour - Bizarre social behaviour, clothing, appearance, Aggression/agitation, Repetitive/stereotyped behaviours
Thought Disorder - Derailment, Circumstantial speech, Pressured speech, Distractibility, Incoherent/Illogical speech

Question 5

When is the onset of Psychosis?

Answer 5

Can occur at any age
Peak incidence in early 20s/ adolescence
Peak later in women

Question 6

What is the course like in Psychosis?

Answer 6

Chronic & episodic

Very variable

Question 7

What is the Morbidity in Psychosis?

Answer 7

Substantial, both from disorder itself and increased risk of common health problems e.g. heart disease

Significant impact on education, employment and functioning

Question 8

What is the Mortality in Psychosis?

Answer 8

Substantial

All-cause mortality 2.5x higher, ~15 years life expectancy lost

High risk of suicide in schizophrenia – 28% of excess mortality

Question 9

What is involved in the Psychiatric History?

Answer 9

History of Presenting Concern
Past Psychiatric History
Background History (Family, Personal, Social)
Past Medical History and Medicines
Corroborative History

Question 10

What is included in the History of presenting Concern?

Answer 10

The patient’s description of the presenting problem – nature, severity, onset, course, worsening factors, treatment received
Circumstances leading to arrival to hospital

Question 11

What is included in the Past Psychiatric History?

Answer 11

Any known diagnosis?
Any treatment?
Known to a community team?
Any previous admissions to hospital?

Question 12

What is included in the Background History?

Answer 12

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

Question 13

What is included in the Past Medical History/Medications?

Answer 13

Medical problems = a cause or consequence of
mental disorder or psychiatric treatment Regular medications?
Compliance?
Over the counter medications?
Interactions

Question 14

What is included in the corroborative History?

Answer 14

Informants: relatives, friends, authority

Confidentiality

Question 15

What is included in the Mental state exam?

Answer 15

Appearance and Behaviour
Speech
Mood
Thoughts
Perceptions
Cognition
Insight

Question 16

What is included in Appearance & Behaviour?

Answer 16

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

Question 17

What is Included in speech?

Answer 17

Quantity - less, more, mutism

Rate - slow, fast, pressure of speech

Spontaneity - latency

Volume - quiet, loud

Question 18

What is included in Mood

Answer 18

Subjective
Objective;
- Predominant Mood
- Constancy - emotional lability/incontinence, reduced reactivity/blunting/flattening/ irritability
- Congruity - Cheerful while describing sad events

Question 19

What is included in thoughts?

Answer 19

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

Question 20

What is included in perceptions?

Answer 20

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

Question 21

What is included in Cognition?

Answer 21

Consciousness 
Orientation
Attention and concentration
Memory
Language functioning
Visuospatial functioning

Question 22

What is included in Insight?

Answer 22

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

Question 23

What are environmental risk factors for Psychosis?

Answer 23

Drug use, especially cannabis
Prenatal/birth complications
Maternal infections
Migrant status
Socioeconomic deprivation
Childhood trauma

Question 24

What are the genetics of psychosis?

Answer 24

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

Question 25

What is Psychosis often preceded by?

Answer 25

Prodromal symptoms

Question 26

What hapens in the Diagnosis of Psychotic disorders?

Answer 26

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

Question 27

What are the treatment options for Psychosis?

Answer 27

Pharmacological - Antipsychotic medications, Often the main treatment.

Psychological - CBT, Avatar therapy

Social support - Supportive environments, structures & routines.

Question 28

What neurotransmitter mechanism s most implicated in the mechanism of antipsychotics?

Answer 28

Dopamine…but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine

Question 29

What are the actions of antipsychotics on dopamine receptors?

Answer 29

Most antipsychotics are dopamine antagonists. Aripiprazole is a partial agonist.

Dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms

Question 30

What are the symptoms caused by Antipsychotics?

Answer 30

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

Question 31

What is Parkinsonism?

Answer 31

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:

Question 32

What is Dystonia?

Answer 32

Increased motor tone -> sustained abnormal posture
Can occur shortly after taking dopamine antagonist
Can be acute, frightening, painful, even fatal (laryngeal dystonia)

Question 33

What is Tardive dyskinesia?

Answer 33

Repeated oral/ facial/ buccal/ lingual movements
Initially subtle – can progress to tongue involvement, lip smacking
Increased risk: long-term antipsychotics, female

Question 34

What is Akathasia?

Answer 34

Inner restlessness
Feel compelled to move, but does little to alleviate
Can lead to overt, relentless movement
Legs most commonly affected

Question 35

What is the difference between typical and atypical antipsychotics?

Answer 35

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

Question 36

What should management looklike for antipsychotics?

Answer 36

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

Question 37

What are some other side effects of Antipsychotics?

Answer 37

EPSE’s

Haematological - Agranulocytosis, Neutropenia

Metabolic - Increased appetite, weight gain, diabetes

Gastro - Constipation

Pituitary - Increased prolactin release (suppressed by dopamine)

Cardiac - Dysrhythmia

Question 38

What happens after a psychotic episode?

Answer 38

Some people after an episode of psychosis recover completely and remain well

Majority follow an episodic course, with periods of wellness and relapses

Question 39

What is the long-term management plan for Psychosis?

Answer 39

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