Psychosis Flashcards
What is psychosis
A loss of connection with reality
Will include thought disorders, delusions and hallucinations
What is difference between hallucination and illusion
Illusion is a misinterpretation of a real external stimulus
Hallucination is percieving a planted modality like a voice in head
What is a delusion
A fixed belief contrary to evidence that is outside of cultural norms
What is difference between primary and secondary delusions
Primary- completely out of the blue
Secondary- based off mood or another psychotic phenomena
What is an overvalued idea
A reasonable belief that is valued and pursued excessively
What are nihilistic or negative delusions seen in
Severe depression
What are grandiose delusions seen in
Mania
What are differentials for cause of psychosis
Organic
- drugs
- delirium
- dementia
Schizophrenia
Delusional disorder
Affective disorder
- depressive psychosis
- manic psychosis
What are extremely bizarre delusions seen in
Schizophrenia
What drug is used for tranquilisation in psychosis
Lorazepam
What are 3 types of antipsychotics
Typical
Atypical
Clozapine
What are advantages and disadvantages of typical antipsychotics
Advantages
- effective
- cheap
- able to provide long term injections for those who cant tolerate daily tablets
Disadvantages
- cause distressing EPSEs at normal dose
- increase prolactin
- old
How is clozapine different to all other antipsychotics
Clozapine still has affinity for D2 but is very weak
High affinity for serotonin type 2 receptors and D4
Advantages and disadvantages of atypical antipsychotics
Advantages
- fewer EPSE’s
- newer
Disadvantages
- only risperidone available as long term injection
What are the typical antipsychotics
Phenothiazines
Butryophenones
Thioxanthines
Benzamides
Side effects of typical antipschotics
EPSE
- acute dystonia
- parkinsonism
- akathisia
- tardive dyskinesia
Neuroleptic malignant syndrome
How to treat acute dystonia
Procyclidine IM
How to treat parkinsonism as EPSE
Procyclidine or any anti-muscarinic
How to treat akathisia (restlessness) as EPSE
Reduce dose
Consider propanolol
What is tardive dyskinesia
Sudden movements of face or body that can not control
SE’s of atypical anti-pschotics
Weight gain- most common
Postural hypotension
Drowsiness
EPSEs
DM
What monitor in typical antipychotics
BP
Weight
HbA1c
Lipids
Glucose
LFTs
What monitor in typical antipsychotics
ECG
BP
What monitor in clozapine
FBC weekly
Hba1c
Weight
What are the atypical antipsychotics
Olanzapine
Risperidone
Quitiapine
Aripiprazole
Amisulpride
Main side effect of clozapine to worry about
Agranulocytosis
Very rare but fatal
Side effects of clozapine and how manage
Agranulocytosis- monitor FBC
Constipation- laxatives
Tachycardia- beta blockers
Hypersalivation- treat with hyoscine
Weight gain- monitor weight
DM- monitor HbA1c
What is neuroleptic malignant syndrome
Rare but potentially fatal complication of antipsychotic medications
Presents with
- fever
- autonomic dysregulation
- muscle rigidity
Blood findings of neuroleptic malignant syndrome
Increased WBC
Creatine phosphokinase increased- can develop rhabdomyolysis
What is schizophrenia
Psychotic disorder with negative or positive sx
Disorder of thinking, perceiving and motivation
Outcomes for patients with schizophrenia
Tale of 1/3s
1/3 have episode and is treated well
1/3 relapsing remitting
1/3 have for life
5% suicide risk
Management of first episode psychosis
Olanzapine
Aripirprazole
What should do if someone comes to A and E with psychosis
Refer without delay to early intervention psychosis service- if not available refer to crisis resolution team
Management first line of schizophrenia
Atypical antipsychotic- queitapine
When should clozapine be used in schizophrenia
If after sequential use of 2 or more antipsychotic drugs for at least 6-8 weeks (at least one is atypical)
What can affect the dose adjustment of clozapine
If smoking started or stopped during the treatment
What are the first rank symptoms of schizophrenia
Delusional perception
Auditory hallucinations (third person)
Though broadcasting
Delusions of control where actions, emotions driven/controlled by an external force
What psychotherapy can be used for psychosis
CBT- can help with paranoia and distressing symptoms
How is catatonia typically managed
Benzos
If need can use ECT
What is catatonia
Stopping voluntary movements or staying still in very unusual posture
What is strongest risk factor for psychotic disorder
Family history
What is best antipsychotic if suffering side effects
Arpiprazole- especially increased prolactin
What is a delusional perception
You see something ordinary and it triggers a delusional belief
What are the types of schizophrenia
Catatonic
Paranoid
Hebrephenic
Simple
Residual
Positive symptoms of schizophrenia
Delusions
Thought interference
Hallucinations (typically third person discussing)
Sense of being controlled
Negative symptoms of schizophrenia
Reduced motivation
Reduced empathy
Reduced critical thinking
Loose association of thought
What are features of paranoid schizophrenia
Dominated by paranoid delusions and hallucinations
Perceptual disturbances common
Other symptoms typically absent or not noticeable
What are features of hebrephenic (disorganised schizophrenia)
Fleeting mood, affect, delusions, hallucination and behaviour
Completely unpredictable and disorganised
Childlike and silly manner
When is hebrephenic schizophrenia typically diagnosed
15-25
Features of catatonic schizophrenia
Fluctuates between states of hyperkinesis and stupor
Psychomotor disturbances
Violent excitement common as well as vivid hallucinations
What happens in simple schizophrenia
Is an insidious and progressive development of oddities of conduct unable to meet demands of society and decline in performance
Features of negative schizophrenia without preceding overt psychotic symptoms
What happens in residual schizophrenia
Clear progression from early to late stage schizophrenia characterised by long term negative symptoms after preceding hallucinations and delusions
- psychomotor slowing, underactivity, blunting of affect, poverty of speech, poor self care
What is clanging a sign of
Mania
What is clanging
Making word choice based off the sound of word rather than meaning- allitteration, rhyming and puns which dont make sense common
Factors associated with poor prognosis in schizo
Strong family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious cause
What are main risk factors for schizo development
FHx
Black
Migration
Urban
Cannabis use
What is summary of schizophrenia management
First line: Atypical antipsychotic (quetiapine)
Clozapine if resistant to 2 antipsychotics including 1 atypical
CBT
Check CVD rfx
What is risk of atypical antipsychotics in the elderly
Stroke and VTE
What is disorder when think you are dead
Cotard
Is a big problem as patients do not drink or eat as see as futile
What is cotard syndrome seen in
Severe depression
Sometimes schizoprenia
What is syndrome where think partner is cheating with no proof
Othello
What is syndrome where think a famous person is in love with her
De clerambaults (also known as erotomania)
What is syndrome where think a friend has been replaced by an imposter
Capgras
Seen in schizo
What is it called when someone with impaired vision has recurring hallucinations
Charles de bonnet
Most common tardive dyskinesia
Chewing and jaw pouting
What is seen in acute dystonia
Sustained muscle contraction
Examples being torticollis and oculogyric crisis
What is torticollis and oculogyric crises
Oculogyric crises- spasmodic movements of eyeballs where they fix typically in upward position
Torticollis- where lateral neck fixes meaning and so is swayed to one side
What is it called when believe body is infected with insects or that they are crawling all over you
Delusional parasitosis or Ekbom syndrome
Charles de bonnet does not exclusively occur in presence of visual impairment, what other factors can contribute
Advanced age
Social isolation
Cognitive impairment
What is a pseudohallucination
When hallucinate but realise they are not real
What is it called when see recently dead loved one but realise they are not real
Pseudohallucination
Normal part of grieving process and reassure are not a sign of psychosis
Psychosis which persists less than a month with return to normal self
Brief psychotic disorder
Which congenital defects are SSRIs assocaited with in pregnancy
Cardiac
What type of drug is chlorpromazine
Typical anti-psychotic
What effect does stopping smoking have on clozapine levels
Increases them as it inhibits CYP450
If miss clozapine for 2 days what do you need to do
Re-titrate to old dose and request plasma level assay
What is alogia
Poverty of speech
What is avolition
Poor motivation
What is used to treat tardive dyskinesia
Tetrabenzine
If multiple people in same room have developed delirium what is first line investigation
Pulse oximetry from CO poisoning
What is an extracampine hallucination
When perceive something beyond the limits of human sensory field
eg- voice being projected from Mars
What is an elemental hallucination
Simple hallucination such as flashes of light or noises
What is thought echo
When thoughts of patients appear to be spoken out loud
What is a pareidolic illusion
the tendency for perception to impose a meaningful interpretation on a nebulous stimulus, usually visual, so that one sees an object, pattern, or meaning where there is none
Like seeing a face in fire
How are acute and transient psychotic episodes diagnosed
Time interval between first symptom and full presentation of disease should be less than 2 weeks
No evidence of drugs or organic disease
How are delusions classified
Persecutory
Grandiose
Somatic
Nihilistic
Referential
What differs hallucinations from pseudohallucinations
They will actually try to look for source of voice
Pseudohallucinations are often voices in head versus hallucinations are in wall
What is perseveration
When give a response correctly but then afterwards keep giving that response even though incorrect
What is verbigeration
No sense at all
What are the first rank hallucinations
Third person running commmentary
Thought echo- where all thoughts are spoken by someone else
How is schizophrenia diagnosed
2 psychotic symptoms for over a month or 1 psychotic and 1 other symptom
Difference between BPAD, schizo and schizoaffective disorder
BPAD- psychosis at extremes of mood
Schizophrenia- normal variation in mood with psychosis any time
Shizoaffective- great variations in mood but with psychosis at any point unrelated to mood
Difference in presentation of psychosis men versus women
Men- late teens/young 20s
Women- 25-35
Why is life expectancy reduced in schizo
Suicide
Dont look after eachother
What is MOA of aripiprazole
Partial dopamine agonist
First line antipsychotics for schizophrenia
Risperidone
Amisulpride
Zipradisdone
CBT for schizophrenia
Normalisation of psychotic symptoms
How to manage hallucinations
Delicately approach the delusions and try to prove is not right
When is disorientation in space and time seen
Wernickes
What are chlorpromazine and promethazine
Anti-histamines
What is theory behind psychosis
Excess dopamine in the mesolimbic pathway promotes positive symptoms
Dopamine deficiency in the mesocortical circuit promotes negative symptoms as prefrontal cortex key in aetiology of negative and cognitive symptoms
What are 4 dopamine pathways in the brain
Mesocortical- cognitive function and inhibition
Mesolimbic- reward system
Nigrostriatal- part of movement pathway
Tuberoinfundibular- inhibits prolactin
What % of dopamine receptor blockade is needed for clinical benefits
60-80
Which anti-psychotics are used for rapid tranquilisation
Olanzapine or haloperidol
Order of tranquilisations if needed
1st- benzos try oral first
2nd- promethazine
3rd- haloperidol or olanzapine
What antipsychotic can prolong QTc
Haloperidol
What is needed prior to using haloperidol for tranquilisation
An ECG to show no QT prolongation
What worried about when using antipsychotics for tranq
Resp depression
Parkinsonism features
Bradykinesia
Pill rolling temor
postural insability
hypomimia
shuffling gait
Bilateral presentation
Female specific effects of antipsychotics
Amenorrhoea
If suffering from hyperprolacinaemia what do with antipsychotic
Do not necessarily replace with aripiprazole
Can use it as adjunct
QTC normal ranges in men and women
Men less than 440
Women less than 470
What antipsychotic use if prolonged QTC
Aripiprazole
Zuclopenthixol
Management of neuroleptic malignant syndrome
Stop drug
Cooling devices
transfer to ITU
Fluids
Benzos- for agitation and to relax muscles
Bromocriptine
What are types of though alienation
Though withdrawal- thoughts removed from head
Thought insertion- where thoughts are placed in ones head
Though broadcasting- where think people hear thoughts
What is best management of early psychosis
Low dose aripiprazole
Education and support
With which EPSE is it appropriate to reduce dose of antipsychotic
Restlessness
What is fregoli syndrome
When think a stranger is being impersonated by someone you know
What are PET scan findings of schizophrenia
Hypoactivity of prefrontal cortex
Enlarged cerebral ventricles
What is PET scan finding in OCD
Hyperactivity in prefrontal cortex
What drug can be given for delirium
Haloperidol
What drug is used to treat hypersalivation in clozapine treatment
Hyoscine
What is it when 2 people share a delusion
Folie a deux
Typically between 2 codependant people
What is best treatment of folie a deux
Separating the 2 people
If admitting patient on ward with schizo what would be pharmacological treatment
Atypical antipsychotic
Procyclidine and benzo PRN
What type of delusion is a delusional perception
Primary
What is best way of assessing risk to others
Historical clinical risk- 20
What is best way of assessing for psychopathy
PCL-R
Side effect when mix clozapine with lithium
Hypersalivation- treat with hyoscine
What is management of delirium
If patient very distressed try verbal calm down techniques
- if unsuccessful AND others are at threat then tranquilise
If patient very agitated on ward what are techniques used
Verbal deescalation
If not successful use IM lorazepam
Physcial restraint
Seclusion
What is a delusional disorder
No other psychotic symptoms but 1 single delusion is symptom
Criteria for a delusion to be a delusion
Patient is certain of it
Can’t be shown evidence to contrary
Falsity
What is a delusion of reference
When you think something in real world is related to you even if it isnt
What are persecutory delusions
Where have belief are going to be harmed or mistreated
In primary psychotic disorders what is most common type of hallucination
Auditory
Organic causes of psychosis- infective
Enchephalitis/meningitis
Neurosyphylis
Toxoplasmosis
Autoimmune causes of encephalitis
Auto-immune encephalitis
Get anti-NMDA receptor
Nutritional causes of psychosis
Pellagra
B12 defic
Endocrine causes of psychosis
Hyperthyroid
Cushings
Prescribed drugs causing psychosis
Steroids
Anti-cholinergics
Methylpoda
Excess levothyroxine
Anti-malarials, anti-retrovirals, isoniazid
Psychological interventions for schizophrenia
CBT
Family therapy- all family members of someone with schizo should be offered family therapy
Purpose of family therapy in schizophrenia
Improve relationships and communication between family members
Explain that relapse more common when family more concerned/overinvolved
Social interventions for schizophrenia
Vocational rehab
Sheltered employment
Individual job searching and liasing with employers
What is only anti-pyschotic which can treat negative psychotic symptoms
Clozapine
Where does mesolimbic pathway project to and from
Ventral tegmental area to ventra striatum in basal ganglia
What is difference in MOA between atypical vs typical anti-psychotics
Typical- D2 antagonism
Atypical- Less affinity for D2, also on serotonin
How often is FBC measured in clozapine
Weekly for first 18 weeks
18 weeks- 1 year- fortnightly
Beyond 1 year- monthly
How does FBC testing in clozapine classify patients
Red, amber, green
Red- stop immediately
Amber- measure twice weekly until green
Green- continue
What is it called when someone presents with schizophrenia prodromal appearing history but only negative symptoms which present
Described as ‘at risk mental sate’ - presents in young people who withdraw from all activities
How long can delirium symptoms last for
6 months- beyond which they need assessment
If on remand and need transferring to hospital for mental health treatment what is section used
48
If committed crime and deemed to be insane how are you maanged
Kept in hospital under a section 37 or (41)
Treated for mental health condition
If are a sentenced prisoner and need transfer to hospital for mental health treatment what is section used
47
For both remanded and sentenced prisoners when being transferred to hospital, what section is used for when crime is serious
Section 49 as includes a restriction order
Who orders a restriction order to be added to a section 47 or 48
Court
Psychopathy traits
Glib and superficial
Inflated and arrogant self-appraisal
Lacks remorse
Lacks empathy
Deceitful and manipulative
Early behavioural problems
Adult antisocial behaviour
Impulsive
Poor behavioural controls
Irresponsible
Whar are 3 main risks to look out for in clozapine treatment
Agranulocytosis
Intestinal obstruction
Myocarditis
Causes of delirium
Infection
Change in environement
Medication
Alcohol withdrawal
Surgery
Constipation
Urine retention
Dehydration
Hyponatraemia
What is used to detect/screen delirium
Confusion assessment method
How does confusion assessment work
Acute onset and Inattention
With 1 of
- disorganised thinking
- altered consciousness
How is delirum managed
Create safe environment
Painkillers and treat cause
1 to 1 nursing with all those who interact being aware of situation and how to deal with the patient
If have a twin with schizo, what is chance of you developing it
1 in 2
When removing an anti-psychotic because of a side effect how do it
Slowly as not only risk of psychotic relapse but also worsening sx
What is schizoaffective disorder
When psychotic symptoms of schizophrenia such as first rank sx present alongside extremes of mood symptoms
What are the 2 types of schizoaffective disorder
Manic type
Depressive type
Based on the mood symptoms present
Are mental health disorders seen as a risk factor for harm to others
No they are more likely to be a victim
Which antipsychotic particularly associated with weight gain and DM
Olanzapine
If someone has history of DM and HTN what antipsychotic use
Typical
First step in management of neuroleptic malignancy
Cooling and fluids
Management of schizoaffective disorder
Lithium and antipsychotic
What other than antipsychotics can cause NMS
Missed dopamine agonist dose
What typically precipitates NMS
Abruptly withholding a dopamine agonist or anti-psychotic
How manage if have long QT evidence on ECG
Discuss with cardiology- do not immediately cessate
What is couvade syndrome
When mimic a pregnant womens symptoms
What is particularly associated with ekbom syndrome
B12 deficiency
What can be used to minimise fall risk in a delirium patient
Bed rails
Management of autoimmune encephalitis
IVIG
Steroids
Management of agitation in neuropsychiatric conditions such as autoimmune encephalitis
Second gen antipsychotics like risperidone
How does clozapine toxicity present
Confusion
Drowsiness
Ataxia
Tachycardia
What can precipitate clozapine toxicity
Infections
What do for someone with an at risk mental state with a first degree relative who has schizophrenia
Refer immediately
What are delusions of guilt
Where think deserved to be punished for something very small and insignificant
What is thought blocking
When stop talking and then all of a sudden continue speaking about a different topic
What is difference between thought withdrawal and blocking
In both patients randomly stop talking
Withdrawal- stop talking then begin talking about same thing
Blocking- stop talking then start talking about different topic
