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PSYCHIATRY > PSYCHOSIS > Flashcards

PSYCHOSIS Flashcards

1
Q

What is psychosis?

A

when you perceive or interpret reality in a very different way from people around you. It is characterised by perception, thought disorganisation, negative symptoms and psychomotor dysfunction

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2
Q

What are hallucinations?

A

Perception experienced in the absence of an external stimulus

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3
Q

What types of hallucinations can you have?

A

Auditory
Basically
Gustatory
Olfactory
Somatic
Special forms - Hypnogogic, hypnopompic, functional, reflex and extracampine

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4
Q

What are perceptions?

A

The process of making sense of the physical information we recieve from our five sensory modalities

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5
Q

What are illusions?

A

Misperceptions of real external stimuli

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6
Q

What is a pseudohallucination?

A

A perceptual experience which differs from a hallucination in that it appears to arise in the subjective inner space of the mind, not through one o.f the external sensory organs e.g flashbacks in PTSD
It is a term also used to describe hallucinations that patients actually recognise as false perceptions i.e.e they have insight into the fact they are hallucinating

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7
Q

What are elementary hallucinations?

A

Single, unstructured sounds e.g. buzzing or whistling

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8
Q

What are complex hallucinations and how are they classified?

A

Spoken phrases, sentences that are classified as first [erson, second person or third person

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9
Q

What is gedankenlautwerden?

A

An auditory hallucination where a patient hears voices which anticipate what he or she is about to think, or which state what the patient is thinking as he thinks it. E.g. thought echo

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10
Q

What is echo de la pense?

A

Auditory hallucinations where voices echoe thoights just after they have occurred

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11
Q

Whats most likely to cause visual hallucinations?

A

Organic brain disorders e.g. dementia, epilepsy and brain tumours
Psychoactive substance use - alcoho, LSD, glue sniffing

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12
Q

What is an autoscopic hallucination?

A

The experience of seeing an image of oneself in an external space

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13
Q

What is the Charles bonnet syndrome?

A

Condition where pt experience complex visual hallucinations associated with no other psychiatric symptoms or impairment in conciousness
It usually occurs in the elderly and is associated with loss of vision

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14
Q

What are lilliputian hallucinations?

A

Hallucinations of miniature people or animals

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15
Q

What are extracampine hallucinations?

A

False perceptions that occur outside the limits of a persons normal sensory filed e.g. hearing voices from 100 miles away

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16
Q

What are somatic hallucinations? What do they include

A

Hallucinations of bodily sensation
Includes superficial, visceral and kinaesthetic hallucinations

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17
Q

What are superficial somatic hallucinations? What does it involve?

A

Sensations on or just below the skin
May be tactile (skin being touched/pricked), thermal (false perception of heat or cold) or hygric (false perception of fluid)

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18
Q

What are visceral somatic hallucinations?

A

False perceptions of the internal organs e.g. organs stretching or vibrating

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19
Q

What are kinaesthetic somatic hallucinations?

A

False perceptions of joint or muscle sense
E.g. describing limbs being twisted

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20
Q

What are olfactory and gustatory hallucinations? When can they present?

A

False perceptions of smell and taste
Schizophrenia, mood disorders and temporal lobe epilepsy!

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21
Q

What are hypnagogic hallucinations?

A

False perceptions in any modality that occur as a person goes to sleep

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22
Q

What is the fleeting but distressing sensation of free falling just as one is about to fall asleep an exapmple of?

A

A hypnagogic kinaesthetic hallucination

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23
Q

What are hypnopompic hallucinations?

A

False perceptions in any modality that occur when a person wakes up

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24
Q

What is a functional hallucinations?

A

When a normal sensory stimulus is required to precipitate a hallucination in that same sensory modality e.g. voices are heard when the door bell rings

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25
Q

What are reflex hallucinations?

A

When a normal sensory stimulus in one modality is required to precipitate a hallucination in a different sensory modality e.g. voices are heard when the lights switch on

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26
Q

What are thought disorders?

A

a disorganized way of thinking that leads to abnormal ways of expressing language when speaking and writing.
Classified as abnormal beliefs and disorganised thinking

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27
Q

What are examples of disorganised thinking?

A

Poverty of speech
Poverty of content of speech
Pressure of speech
Distractingly speech
Tangentiality/circumstantiality
Loosening of associations
Word salad
Clanging
Neologisms
Loss of goal
Perseveration
Echolalia
Irrelevant answers
Blocking
Stilted speech
Self-reference
Flight of ideas

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28
Q

What is the difference between tangentiality and circumstantiality?

A

Circumstantiality : The goal of the conversation is reached in the end by a circuitous route
Tangentiality: characterised by patients wandering away from a topic without returning to it.

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29
Q

What is echolalia?

A

Repeating words or phrases of the interviewer

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30
Q

What is flight of ideas?

A

when someone talks quickly and erratically, jumping rapidly between ideas and thoughts.

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31
Q

What is clanging?

A

speech in which word choice is governed by word sound rather than meaning; word choice may show rhyming or punning associations

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32
Q

What is knights move thinking?

A

Aka loosening of association

unexpected, and illogical, connections between ideas.

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33
Q

What is thought blocking?

A

When pt experiences a sudden cessation to their flow of thought, often mid-sentence

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34
Q

What are expamples of disorders of thought content?

A

Delusions
Overvalued ideas
Obsessional thinking
Magical thinking

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35
Q

What are delusions?

A

A false belief based on incorrect inference about external reality that is firmly sustained
It’s not a belief ordinarily accepted by others of the persons culture/religion

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36
Q

How can we classify delusions?

A

Primary or secondary
Mood congruent or mood incongruent
Bizarre or non-bizarre

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37
Q

What are primary delusions?

A

Do not occur in response to any previous psycho pathological state

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38
Q

What are secondary delusions?

A

Delusions occurring as a consequence of pre-existing psycho pathological states

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39
Q

Whats the difference between mood congruent and mood incongruent delusions?

A

Mood congruent are when the contents of the delusions are appropriate to the patients mood
Incongruent is when its opposite

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40
Q

What are bizarre vs non-bizarre delusions

A

Bizarre delusions are those which are completely impossible e.g. the belief that aliens have planted radioactive detonators in the pt brain
Non-bizarre - involve situations that could possibly occur in real life, such as being followed, deceived or loved from a distance

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41
Q

What are persecutory delusions?

A

False belief that one is being harmed, threatened, cheated, harassed etc

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42
Q

What are grandiose delusions?

A

False belief that one is exceptionally powerful, talented or important (including having magical powers)

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43
Q

What are delusions of reference?

A

False belief that certain objects, people, or events have intense personal significance and refer specifically to oneself e.g. tv newsreader is taking to them

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44
Q

What are religious delusions?

A

False belief pertaining to a religious theme

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45
Q

What is erotomania?

A

False belief that another person is in love with one

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46
Q

What is clerambault syndrome?

A

A woman believes that a man, frequently older and of a higher status, is in love with her

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47
Q

What is morbid jealousy/othello syndrome?

A

False belief that one’s lover has been unfaithful

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48
Q

What are examples of delusions of misidentification?

A

Capgras syndrome
Fregoli syndrome

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49
Q

What is Capgras syndrome?

A

Belief that a familiar person has been replaced by an exact double - an imposter

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50
Q

What is Fregoli syndrome?

A

Belief that a complete stranger is actually a familiar person already known to one and is in disguise

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51
Q

What are nihilistic delusions?

A

False belied that oneself, others or the old is non-existent or about to end
In severe forms pt claim that nothing, even themselves exists

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52
Q

What are somatic delusions?

A

individual believes something is wrong with part or all of their body

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53
Q

What are delusions of control/passivity?

A

False belief that one’s thoughts, feelings, actions or impulses are controlled by an external agency
It includes delusions of thought control - insertion, withdrawal, broadcasting

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54
Q

What are delusions of guilt?

A

The person feels guilty to an extent that it may not be real. The person may believe that he or she is responsible for some great disaster with which there can be no possible connection.

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55
Q

Whats the risk with morbid jealousy?

A

Risk of homocide!

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56
Q

What group of people is morbid jealousy common in?

A

Alcoholism, organic psychosis especially dysfunction of frontal lobe, paranoid psychosis, schizophrenia, and affective disorder

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57
Q

What is folie a deux?

A

Induced delusional disorder
an identical or similar mental disorder affecting two or more individuals who are close; usually one has a diagnosed psychotic disorder and the other does not. Treated by separating the individuals

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58
Q

What are overvalued ideas?

A

A plausible belief that a pt becomes preoccupied with to an unreasonable extent. This causes considerable distress to the pt or those living around them.
Distinguished from delusions by the lack of a gross abnormality in reasoning i.e. they can often given fairly logical reasons for their beliefs

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59
Q

What are typical disorders that feature overvalued ideas?

A

Anorexia nervosa
Hypochondriacal disorder
Dysmorphophobia
Paranoid personality disorder
Morbid jealousy

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60
Q

What are positive symptms?

A

Symptoms that are actively produciced e.g. delusions, hallucinations, loosening of association, bizarre speech or behaviour

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61
Q

What are negative symptoms?

A

A clinical deficit
Include a marked apathy, poverty of thought/speech, blunt fo affect, social isolation, poor self care and cognitive deficits

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62
Q

Whats the usual presentation order of pos and neg symptoms in psychosis?

A

Usually positive symptoms first and negative symptoms develop after

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63
Q

Does psychosis always present with psychomotor function?

A

No its very rare and is invariably due to EPS from neuroleptic medication but it can occur from the disease itself
Cause is unknown

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64
Q

What is catatonic behaviour?

A

Any excessive or decreased motor activity that is apparently purposeless and includes abnormalities of movement, tone or position

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65
Q

What are common motor symptoms seen in schizophrenia?

A

Catatonic rigidity
Catatonic posturing
Catatonic negativism
Catatonic waxy flexibility
Catatonic excitement
Catatonic stupor
Echopraxia
Mannerisms
Stereotypies
Tics

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66
Q

Whats the most common cause of psychosis?

A

Schizophrenia

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67
Q

Whats the ICD10 diagnostic criteria for schizophrenia?

A

1 or more of the following symptoms
• thought echo, insertion, withdrawal or broadcast
• Delusions of control or passivity; delusional perception
• Hallucinatory voices in third person giving a running commentary or discussing the pt amongst themselves
• persistent delusions
Or
2 or more of the following :
• persistent hallucinations
• Thought disorganisation
• Catatonic symptms
• Negative symptoms

Symptoms should be present for at least 1 month.
It should not be diagnosed in the presence of an organic brain disease or during drug intoxication or alcohol withdrawal.

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68
Q

What are schneider’s first rank symptoms?

A

• Delusional perception
• Delusions of thought control: insertion, withdrawal, broadcast
• Delusions of control: passivity experiences of feelings, impulse and somatic
• Hallucinations: audible thoughts, voices arguing or discussing the patient, voices giving a running commentary

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69
Q

Whats the course of schizophrenia?

A

Some people have episodes of illness lasting weeks or months with full remission of symptoms between each episode
others have a fluctuating course in which symptoms are continuous
others again have very little variation in their symptoms of illness over the course of years.

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70
Q

What are the stages of schizophrenia?

A

Premorbid
Prodromal
Active phase
Residual phase

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71
Q

What is the prodromal phase of schizophrenia?

A

The stage before psychosis onset which can last from a few days to 18 months. It’s characterised by increasing distress and a decline in personal and social functioning.

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72
Q

Whats the epidemiology of schizophrenia?

A

1% population
1.5-3% have psychosis

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73
Q

What is the typical age of onset for schizophrenia?

A

Men 15-25
Women 25-35 and second peak at 45-50

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74
Q

Whats the prevalence in m:w for schizophrenia?

A

1:1

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75
Q

What are the aetiological factors for schizophrenia?

A

Genetics
Environmental insults - late winter or spring births, second trimester influenza infections, obstetric complications
Underlying schizotypal PD
Upbringing with relatives who display high expressed emotion e.g. highly critical or over protective
Stressful life events
Social stressors
Substance misuse - heavy cannabis use in adolescence
Brain abnormalities - ventricular enlargement and reduced brain size
Neurotransmitter abnormalities

76
Q

What neurotransmitter abnormalities are present in schizophrenia?

A

Overactivity of the mesolimbic pathway in the brain and decreased activity in Mesocortical pathway

77
Q

Whats the function of mesolimbic pathways? What does increased dopamine activity cause?

A

key role in motivation, emotions and rewards. Increased dopamine activity causes positive sympotms

78
Q

Whats the function of mesocortical pathways? What does decreased dopamine activity cause?

A

Functions in physiological cognition and executive function
Hypofunction = cognitive and negative sympotms

79
Q

What is the social drift hypothesis?

A

mental illness can inhibit socioeconomic attainment and lead people to drift into the lower social class or never escape poverty
Mental illness -> lower class

80
Q

What is social causation hypothesis?

A

asserts that experiencing economic hardship increases the risk of subsequent mental illness.

Lower class -> mental illness

81
Q

What is the residual phase of schizophrenia?

A

No longer having any prominent psychotic symptoms but some remaining symptoms of the disorder which are mostly negative e.g. social withdrawal

82
Q

Whats the prognosis of schizophrenia?

A

1/3 make complete recovery
1/3 experience recurrent episodes of psychosis with some degree of social disability
1/3 remain chronically diables

83
Q

What factors indicate a good prognosis of schizophrenia?

A

Abrupt onset
Absence of prodromal disturbances
Onset in midlife
Presence of identifiable life stresses
Absence of flat affect
Appropriate early treatment and care

84
Q

What are risk factors for schizophrenia?

A

Stressful life events -associated with a 3.2-fold increased risk of psychotic disorders.
Childhood adversity — associated with a 2.8-fold increased risk of psychotic disorders.
Family heritage — 2 to 5-fold increased risk in south-Asian and black populations compared with the white population.
Migration— associated with a 3-fold increased risk of schizophrenia. I
Urban living — associated with a 2.4-fold increased risk of schizophrenia.
Cannabis use — associated with a 40% increased risk of psychotic illness. This risk increases with heavier use, use starting in adolescence, and use of compounds with a high tetrahydrocannabinol content.
Other substance use —amphetamines, cocaine, ketamine, LSD, or inhaled substances such as toluene and certain types of glue, can cause acute psychosis. Heavy use may also lead to long-term psychotic symptoms that may persist for years after the last exposure.
Medication use — high-dose corticosteroid use can precipitate psychosis.
Early life factors — such as exposures in utero to medication, maternal stress, nutritional deficiency, and infection; intrauterine growth restriction, birth and postnatal trauma.
Parental age — a paternal age of > 40 years and parental age of < 20 years have both been associated with an increased risk of schizophrenia.
Exposure to the protozoan parasite Toxoplasma gondii — associated with a two-fold increase in risk of schizophrenia

85
Q

Where is the ‘best place to treat’ for psychosis?

A

First episode best inpatient
Significant risk of harming self or others, or self neglect

86
Q

Whats the glutamate hypothesis for psychosis?

A

schizophrenia symptoms and cognitive impairment are due to hypofunction of NMDARs and excessive glutamate release, especially in brain areas including prefrontal cortex and hippocampus
Drugs such as phencyclidine hydrochloride (angel dust) block NMDA glutamate receptors and can mimic schizophrenia symptoms

87
Q

Whats the serotonergic hypothesis for psychosis?

A

Chronic widespread stress-induced serotonergic overdrive in the cerebral cortex in schizophrenia, especially in the anterior cingulate cortex and dorsolateral frontal lobe
LSD works at central serotonin receptors and can cause psychosis

88
Q

How do we investigate psychosis?

A

FBC
LFT
TFT
Urine drug screen
ECG
Serum cholesterol –full screening
Calcium bone screening, vitamin b12 and folate
U&E
Glucose and HBA1c
Bone profile
?CT scan if older to rule out organic causes

89
Q

Whats the management for psychotic disorders?

A

A therapeutic trial of an oral antipsychotic in conjunction with any or all of the following:
- Family intervention
- Individual CBT
- Arts therapies may be offered, particularly to help with negative symptoms.
Psychoeducation is also recommended

Monitoring of the person’s health and the effects of antipsychotic drug treatment for at least the first 12 months, or for a longer duration until the person’s condition has stabilized.

A care plan that includes:
- A crisis plan.
- An advance statement
- Key clinical contacts in case of emergency or impending crisis.

90
Q

What should you do if you suspect someone’s in the prodromal phase of schizophrenia?

A

Refer to early intervention in psychosis. (EIP)

91
Q

What is EIP?

A

multi-disciplinary teams set up to seek, identify and reduce treatment delays at the onset of psychosis and promote recovery by reducing the probability of relapse following a first episode of psychosis.

92
Q

How should you manage someone you think is at risk of a psychotic disorder?

A

Individual CBT and/or family intervention.
Any required treatment for co-existing anxiety disorders, depression, emerging personality disorders, or substance misuse (where appropriate).

93
Q

What are some complications of psychosis?

A

Premature death — on average, people with schizophrenia die around 15 years earlier than people in the general population - due to Increased risk of suicide, increased risk of certain physical disorders, including: CVD, T2 diabetes, smoking-relayed illness and cancer
Social exclusion
Substance misuse

94
Q

What proportion of those with schizophrenia misuse drugs?

A

1/3rd

95
Q

Whats the risk of suicide in those with schizophrenia?

A

5-13% (20x higher than gen pop)

96
Q

Whats the pharmacological management used to treat psychosis?

A

Typical and atypical antipsychotics

97
Q

Whats first line antipsychotic for treating psychosis?

A

There is no first-line antipsychotic drug suitable for all people with psychosis, and (except for clozapine) little meaningful difference in efficacy. Choice depends on the person’s personal choice, medication history, degree of sedation required, risk of particular adverse effects, and the degree of negative symptoms

98
Q

Whats the moa of typical antipsychotics?

A

D2 receptor antagonists in the brain

99
Q

Whats the moa of atypical antipsychotics?

A

Act transiently on D2 receptors as well as D3, D4 and 5-HT
They also have an effect on muscarinic, alpha adrenergic 1 and histamine H1 receptors as well

100
Q

What symptoms do typical/atypical antipsychotics treat best?

A

Typical - better at positive sympotms. May worsen or have no effect on negative symptoms
Atypical - good at both positive and negative symptoms

101
Q

How does D2 antagonistic potency vary with typical vs atypical antipsychotics?

A

Typical - high potency
Atypical - low potency

102
Q

What side effects are more likely with typical antipsychotics?

A

EPS
Tarditive dyskinesia
NMS
Hyperprolactinemia

103
Q

What side effects are more likely with atypical antipsychotics?

A

Anticholinergic SE - dry mouth, blurred vision, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, tachycardia, and decreased sweating
Metabolic SE - impaired glucose tolerance, weight gain, lipid disturbances

104
Q

Which antipsychotics are first line since 2002?

A

Atypical
For new patients or for those on atypical antipsychotics who experience inadequate symptom control or adverse SE

105
Q

When do you offer clozapine?

A

After trying 2 antipsychotics (one of which must be atypical)
I.e. for treatment resistant cases

106
Q

Why is clozapine not offered first line?

A

Risk of agranulocytosis

107
Q

What are extrapyramidal side efefcts?

A

parkinsonian symptoms - bradykinesia and tremor
dystonia - uncontrolled muscle spasm in any part of the body
akathisia - restlessness
tardive dyskinesia - abnormal involuntary movements of lips, tongue, face, and jaw - irreversible!

108
Q

When are EPS most likely to occur?

A

most likely to occur with high doses of high-potency first-generation antipsychotic drugs such as the piperazine phenothiazines (fluphenazine decanoate and trifluoperazine), the butyrophenones (benperidol and haloperidol), and the first-generation depot preparations.

Lower risk on atypical

109
Q

What are the risks of prescribing antipsychotics in the elderly with dementia?

A

associated with a small increased risk of mortality and an increased risk of stroke or transient ischaemic attack
Furthermore, elderly patients are particularly susceptible to postural hypotension.

110
Q

What are the recommendations for prescribing antipsychotics in the elderly?

A
  • Antipsychotic drugs should not be used in elderly patients with dementia, unless they are at risk of harming themselves or others, or experiencing agitation, hallucinations or delusions that are causing them severe distress.
  • The lowest effective dose should be used for the shortest period of time.
  • Treatment should be reviewed regularly; at least every 6 weeks (earlier for in-patients).
111
Q

When parkinsonian symptoms are recognised in EPS caused by antipsychotics, what is the management?

A

treatment should be reviewed with the aim of reducing exposure to high-dose and high-potency antipsychotic drugs.
Anticholinergics can be offered to help relieve symptoms burden

112
Q

Who is tardive dyskinesia most likely in?

A

Elderly women

113
Q

Why do antipsychotics cause hyperprolactinemia?

A

Most antipsychotic drugs, both first- and second-generation, increase prolactin concentration to some extent because dopamine inhibits prolactin release.

114
Q

Which antipsychotics are most likely to cause symptomatic hyperporlactinaemia?

A

Risperidone, amisulpride, sulpiride, and first-generation antipsychotic drug

115
Q

D

A
116
Q

How do you manage antipsychotic-induced hyperprolactinaemia?

A

switching to an antipsychotic that is less likely to be associated with hyperprolactinaemia
or adding aripiprazole (partial dopamine agonist)
or a dopamine agonist (bromocriptine or cabergoline) to the treatment regimen.

117
Q

What are the symptoms of hyperprolactinaemia?

A

sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, galactorrhoea, and a possible increased risk of breast cancer.

118
Q

What causes the EPS from antipsychotics?

A

dopamine blockade or depletion in the basal ganglia - nigrostriatal pathway

119
Q

why can antipsychotics cause sexual dysfunction?

A

Blockade of dopamine D2 receptors in the tuberoinfundibular pathway by antipsychotics may decrease the libido, impair arousal, and impair orgasm indirectly, by leading to elevated prolactin levels. Cholinergic receptor antagonism may induce erectile dysfunction by reducing peripheral vasodilation.

120
Q

Which antipsychotics have the highest risk of causing sexual dysfunction?

A

Risperidone, haloperidol, and olanzapine

121
Q

Which antipsychotics have the lowest risk of causing sexual dysfunction?

A

aripiprazole and quetiapine.

122
Q

What cardiovascular risk can antipsychotics cause?

A

tachycardia, arrhythmias, and hypotension and QT-interval prolongation

123
Q

Which antipsychotic is most likely to cause QTc prolongation?

A

Pimozide

also a higher probability of QT-interval prolongation in patients using any intravenous antipsychotic drug, or any antipsychotic drug or combination of antipsychotic drugs with doses exceeding the recommended maximum.

124
Q

How do antipsychotics cause postural hypotension?

A

α1-adrenergic blockade

125
Q

What are the risks of postural hypotension?

A

Syncope and dangerous falls related to injuries

126
Q

Which antipsychotics are most likely to cause postural hypotension?

A

Second generation antipsychotics - clozapine and quetiapine

127
Q

Which antipsychotics least likely to cause hyperglycaemia and diabetes?

A

Fluphenazine, decanoate and haloperidol
Amisulpride and aripiprazole

128
Q

Which antipsychotics are most likely to cause weight gain?

A

Clozapine and olanzapine

129
Q

What monitoring is required for antipsychotics?

A

Monitor weight, fasting glucose, HbA1c, blood lipid concentration, ECG, blood pressure, FBC, U&Es, LFTs

130
Q

When are antipsychotic depot injections considered?

A

for patients with psychosis or schizophrenia who prefer such treatment after an acute episode or where avoiding non-adherence to antipsychotic medication is a clinical priority.

131
Q

What are the risks of antipsychotic depot injections?

A

higher incidence of adverse-effects such as EPS

132
Q

Why can antipsychotics increase the risk for seizures?

A

They lower the seizure threshold - particularly clozapine

133
Q

When might you use benzodiazepines in psychosis?

A

when associated with agitated or violent behaviour, can require urgent pharmacological tranquillisation or sedation

134
Q

What social interventions might be done for managing psychosis?

A

Rehabilitation - returning to work/school, reestablishing family functioning, managing substance misuse
Social support - housing, benefits
CPA

135
Q

What is the Care programme approach?

A

A care plan and a care coordinator

136
Q

What is De Clerambaults syndrome?

A

characterized by the delusional idea, usually in a young woman, that a man whom she considers to be of higher social and/or professional standing is in love with her - erotomania

137
Q

What is cotard syndrome?

A

a rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary - associated with severe depression and psychotic disorders.

138
Q

What is a pseudohallucination?

A

The key difference between pseudohallucinations and true hallucinations is that patients with pseudohallucinations understand that what they are seeing isn’t real i.e. they have insight

139
Q

What is neuroleptic malignant syndrome?

A

A potentially life threatening condition involving excessive inhibition of dopamine receptors characterised by fever, autonomic and mental state changes and severe muscle rigidity

140
Q

What proportion of those on antipsychotics does NMS affect

A

3%
Men:women 2:1

141
Q

When does NMS tend to have its onset?

A

Within 2 weeks of treatment initiation/withdrawal

142
Q

What can cause NMS?

A

• typical antipsychotics
• Atypical antipsychotics
• Anti-dopaminergic antiemetics - metoclopramide, domperidone and prochlorperazine
• Withdrawal of dopaminergic medications - levodopa and amantadine
• Others e.g. lithium toxicity, phenelzine and some TCA antidepressants

143
Q

How does NMS present?

A

• Altered mental status: often presents with agitation and delirium. Catatonia can be present. May progress to severe encephalopathy and coma.
• Rigidity: felt as a generalised increase in tone and may be severe. Other motor abnormalities can be present.
• Fever (>38º): less pronounced with second-generation antipsychotics. May be >40º.
• Dysautonomia: describes abnormalities in the autonomic nervous system. Thus, often termed ‘autonomic instability’. Leads to tachycardia, labile blood pressure, profuse sweating (i.e. diaphoresis) and/or arrhythmias.

144
Q

What are risk factors for developing NMS?

A

• rapid increase in medication dosing
• Addition of new medication
• Depot formulations
• Male pt 2x risk
• Young patient
• Dehydration or malnourishment
• Exhaustion
• Pre-existing co-morbidity
• Conditions with neuroleptic sensitivity e.g. LD and dementia with lewy bodies

145
Q

How do we investigate NMS?

A

• FBC to exclude leukocytosis and all kinds of haemolysis
• Blood cultures to exclude septic shock
• LFTs to exclude hepatic failure
• BUN and creatinine to exclude renal failure
• Calcium, phosphate, potassium and sodium levels - risk of AKI in these pt can cause electrolyte imbalances. Calcium will be raised due to release from muscle
• CK level (will be raised!)
• Serum iron
• Urine myoglobin
• Arterial blood gas analysis
• Coagulation studies
• Serum and urine toxicology screening

146
Q

How do we manage NMS?

A

Remove offending agent
Restart treatment if cause is secondary to withdrawal
Aggressive volume resuscitation
Serial monitoring and correction of electrolyte imbalance
Control hyperthermia by cooling method
ICU admission for monitoring of complications
??Use of dopaminergic agonists to control symptoms e.g. bromocriptine and amantadine (no clinical evidence!?)
Dantrolene - a muscle relaxant to manage rigidity
ECT

147
Q

Whats the nigrostriatal pathway and Whats its function?

A

a bilateral dopaminergic pathway in the brain that connects the substantia nigra pars compacta in the midbrain with the dorsal striatum (i.e., the caudate nucleus and putamen) in the forebrain. Function is to influence voluntary movement. Contains about 80% of the brains dopamine!

148
Q

Whats the mesocortical pathway and Whats its function?

A

dopaminergic pathway that connects the ventral tegmentum to the prefrontal cortex. Functions include cognition and executive function (dorsolateral prefrontal cortex), emotions and affect (ventromedial prefrontal cortex

149
Q

Whats the mesolimbic pathway and Whats its function?

A

a dopaminergic pathway in the brain which connects the ventral tegmental area in the midbrain to the ventral striatum of the basal ganglia in the forebrain. The ventral striatum includes the nucleus accumbens and the olfactory tubercle. The function is to play a role in reward, motivation, desire and positive symptoms of schizophrenia.

150
Q

Whats the tuberoinfundibular pathway and Whats its function?

A

a dopaminergic pathway in that brain which connects the arcuate nucleus in the tuberal region of the hypothalamus to the median eminence. The function is to inhibit secretion of prolactin,

151
Q

Outline the moa of antipsychotics on the dopaminergic pathways

A

Mesolimbic = reduces positive symptoms
Mesocortical = reduces negative symptoms and cognitive changes
Nigrostriatal = extrapyramidal side effects (most common are akathisia, acute dystonia and parkinsonism) and tarditive dyskinesia
Tubuloinfundibiudlar - hyperprolactinaemia. hormone changes e.g. elevated cortisol

152
Q

Whats the causes the hyperthermia and dysautonomia in NMS?

A

Central D2 receptor blockage in hypothalamus

153
Q

Whats the causes the muscle rigidity and tremor in NMS?

A

Dopamine blockage in nigrostriatal pathways

154
Q

Whats the causes the muscle breakdown in NMS?

A

Direct toxic effects of neuroleptics on skeletal muscle = increased calcium release from sarcoplasmis reticulum = increased contractility of muscle

155
Q

Whats the causes the altered cognition in NMS?

A

Blockage of mesocortical pathway dopaminergic transmission

156
Q

What are complications of NMS?

A

• Rhabdomyolysis - Myonecrosis due to reduced blood flow to muscles caused by dehydration, labile blood pressure, tachycardia etc. Muscle cell death causes release of CK and myoglobulin. Can lead to renal failure!
• Seizures - due to hyperthermia and metabolic imbalances
• Encephalopathy, stupor or coma
• Cardiac arrhythmias - torsades de pointes and cardiac arrest
• DIC
• Venous thromboembolism
• Respiratory failure from chest wall rigidity, PE or aspiration pneumonia

157
Q

What are the schizophrenia subtypes?

A

Paranoid
Hebephrenic
Catatonic
Undifferentiated
Postschizophreic depresson
Residual
Simple

158
Q

What is paranoid schizophrenia?

A

dominated by presence of delusions and hallucinations.

159
Q

What is Hebephrenic schizophrenia?

A

chategorused by thought disorganisation, disturbed behaviour and inappropriate or flat affect.

160
Q

What is catatonic schizophrenia?

A

characterised by 1 or more catatonic symptoms

161
Q

What is undifferentiated schizophrenia?

A

insufficiency symptoms to meet criteria for any subtypes OR so many symptoms that criteria for more than one subtype is met

162
Q

What is postschizophrenic depression?

A

general criteria for schizophrenia must have been meet within past 12 months and one of the conditions in criterion 2 must still be present. Depressive symptoms must be sufficiently prolonged, severe and extensive to meet criteria for at least a mild depressive episode

163
Q

What is residual schizophrenia?

A

1 year predominantly chronic negative symptoms which must have been preceded by at least one clear cut psychotic episode in the past

164
Q

What is simple schizophrenia?

A

slow but progressive development, over a period of at least 1 year of all 3 of the following… significant and consistent change in overall quality of some aspects of personal behaviour, gradual appearance and depending of negative symptoms and a marked decline in social/scholastic or occupational performance. At no time are there any of the criteria for general schizophrenia nor are there hallucinations of delusions.

165
Q

What are acute and transient psychotic disorserS?

A

Psychosis that is acute and can be triggered by things like stress and lack of sleep

166
Q

What is schizoaffective disorder?

A

Presentation of both schizophrenic and mood symptoms that present in the same episode of illness, either simultaneously or within a few days of each other. The mood symptoms should meet the criteria for either a depressive or manic episode and should have at least 1 of the typical schizophrenic symptoms (first-rank symptoms).

167
Q

How can schizoaffective disorder be classified?

A

Dependaning on the particularl mood symptoms displayed, this disorder can be closed as schizoaffective disorder manic type or depressed type.

168
Q

What is a persistent delusional disorder?

A

The development of a single or set of delusions for the period of at least 3 months is the most prominent, or only, symptom. It usually has its onset in middle age and expressed delusions may persist throughout the patients life.
They may include persecutory, grandiose and hypochondriacal delusions. Typically, schizophrenic delusions e.g. delusions of thought control or passivity, exclude the diagnosis.
Hallucinations, if present, tend to only be fleeting.
Affects speech and behaviour are all normal and these patients usually have well-preserved personal and social skills.

169
Q

What are induced delusional disorders?

A

non-psychotic patients with close emotional ties to another person suffering from delusions begin to share those delusional ideas themselves. These tend to resolve when the two are separated.

170
Q

What is schizotypak disorder?

A

A disorder characterized by eccentric behaviour and anomalies of thinking and affect which resemble those seen in schizophrenia, though no definite and characteristic schizophrenic anomalies occur at any stage. The symptoms may include a cold or inappropriate affect; anhedonia; odd or eccentric behaviour; a tendency to social withdrawal; paranoid or bizarre ideas not amounting to true delusions; obsessive ruminations; thought disorder and perceptual disturbances; occasional transient quasi-psychotic episodes with intense illusions, auditory or other hallucinations, and delusion-like ideas, usually occurring without external provocation. There is no definite onset and evolution and course are usually those of a personality disorder.

171
Q

What are some causes of psychosis?

A

Schizophrenia
Acute and transient psychotic disorder
Schizoaffective disorder
Persistent delusional disorders
Schizotypal PD
Severe depression/mania with psychotic symptoms
Organic - HIV, malaria, syphilis, dementia,
Substance induced psychosis
Delirium ad dementia

172
Q

How are extrapyramidal side effects treated?

A

With Anticholinergics e.g. procyclidine
(They increase dopamine)

173
Q

What is procyclidine used to treat?

A

treatment of drug-induced parkinsonism, akathisia and acute dystonia, Parkinson’s disease, and idiopathic or secondary dystonia

174
Q

What are some questions to ask about auditory hallucinations?

A

“Do you ever hear noises or voices when there is nobody else there?”
“Can you hear them in your ears, or are they in your mind?”
“How many voices are there?”
“Do you recognise the voices?”
“What do they say?”
“Do they tell you to do things and do you obey?”
“Do they tend to comment on what you are doing or thinking?”
“Are the voices present all the time?”
“Does anything make them better or worse?”
“Do you ever find yourself having a conversation with them?”
“Do you smell or see anything at the same time that you hear these voices?”

175
Q

What questions can you ask about somatic hallucinations?

A

“Do you ever feel that someone or something is touching you when there is nobody there?”
“Have you ever felt like you’ve been assaulted despite nobody being present?”
“Have you ever felt like insects are crawling beneath your skin?”

176
Q

What questions could you ask about thought blocking?

A

Do you feel able to think clearly?”
“Do you ever experience your thoughts suddenly stopping as though there were no thoughts left?”
“What is it like? How do you explain it?”

177
Q

What questions could you ask about thought withdrawal?

A

“Is there anything like hypnosis or telepathy going on?”
“Is there anyone or anything taking thoughts out of your head?”

178
Q

What questions could you ask about thought insertion?

A

“Are your thoughts your own?”
“Is there anyone/anything putting thoughts into your head that you know are not your own?”
“How do you know they aren’t yours? Where do they come from?”

179
Q

What questions could you ask about thought broadcasting?

A

“Can anyone hear your thoughts? For example, can I hear what you are thinking right now?”
“Do you ever hear your own thoughts echoed or repeated?”

180
Q

What questions can you ask to explore delusional perception?

A

“Do you sometimes have thoughts that others tell you are false?”
“Do you have any beliefs that aren’t shared by others you know?”
“Do you ever feel that people are out to do you harm?”
“Do you ever feel that specific events in the world are related to you in some way?”
“When you watch the television/listen to the radio/hear something, do you feel that the stories are referring to you or something that you have done?”

181
Q

What questions can you ask to explore passivity?

A

“Do you ever feel as though you are being controlled by someone or something?”
“Do you ever think that someone or somebody is controlling you?”
“Are your thoughts/mood/actions under your control or is someone forcing you to behave in this way?”

182
Q

What is torticollis?

A

Also known as wryneck
Twisting of the neck that causes the head to rotate and tilt at an odd angle

183
Q

What is oculogyric spasm?

A

spasmodic movements of the eyeballs into a fixed position, usually upwards

184
Q

What are examples of acute dystonia?

A

Sustained muscle contraction e.g. torticollis and oculogyric crisis

185
Q

What is tardive dyskinesia?

A

involuntary movements of the tongue, lips, face, trunk, and extremities that occur in patients treated with long-term dopaminergic antagonist medications. Most common are chewing and pouting of jaw
May be irreversible

PSYCHIATRY (20 decks)

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