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