Psychosis Flashcards
What is psychosis?
Difficulty perceiving and interpreting reality - a clinical syndrome that can be caused by many disorders
What are the different types of psychotic disorder?
Schizoaffective disorder
Depression with psychotic symptoms
Bipolar
Schizophrenia
Delusional disorder
Drug induced
Due to other medical conditions
What are the positive symptoms of psychosis?
Hallucinations
Delusions
What are hallucinations?
Perception in absence of stimulus
Can occur in any sensory modality
Describe the different types of auditory hallucination
1st (thought echo), 2nd, 3rd person
Running commentary
Command hallucinations
What is a delusion?
Fixed, false belief not in keeping with social/cultural norms
What are the different themes of delusion?
Persecutory/Paranoid
Reference
Grandiosity
Religious
Pathological jealously
Nihilistic/Guilt
Somatic
Erotomanic
What are passivity experiences and what are some examples?
Belief that one’s thoughts or actions are influenced or controlled by an external agent
- Thought broadcasting
- Thought insertion
- Thought withdrawal
What are the negative symptoms of psychosis?
Alogia
- Paucity/poverty of speech, little content
- Slow to respond
Anhedonia/asociality
- Few close friends
- Few hobbies/interests
- Impaired social functioning
Avolition/apathy
- Poor self-care
- Lack of drive/persistence at work/education
- Lack of motivation
Affective flattening
- Unchanging facial expressions
- Few expressive gestures
- Poor eye contact
- Lack of vocal intonations
- Limited emotional range
What are the disorganisation symptoms of psychosis?
Bizarre behaviour
Formal thought disorder
Describe bizarre behaviour
Bizarre social behaviour
Bizarre clothing/appearance
Aggression/agitation
Repetitive/stereotyped behaviours
Describe formal thought disorder and its different presentations
Lack of logical connection between thoughts
- Word salad
- Derailment/loosening of associations
- Flight of ideas
- Tangential thought
- Circumstantial thought
Describe the onset of psychosis
Can occur at any age
Peak incidence in adolescence/early 20s
Peak is later in women
Describe the course of psychosis
Often chronic and episodic
Variable presentations and prognosis
Describe morbidity associated with psychosis
Substantial - due to disorder itself and increased risk of other health problems, e.g. heart disease
Significant impact on education, employment and functioning
Describe mortality associated with psychosis
All-cause mortality 2.5x higher, ~15 years life expectancy lost
High risk of suicide in schizophrenia - 28% of excess mortality
Psychosis is often preceded by what symptoms?
‘Prodromal’ symptoms
Changes in social behaviour and impairments in functioning
What are the ‘prodromal’ symptoms of psychosis often misdiagnosed as?
Depression
What are the genetic risk factors of schizophrenia?
Highly heritable ~46% concordance in MZ twins
Highly polygenic - lots of genes of small effect sizes but together account for ~20% of known genetic risk
What are the environmental risk factors for schizophrenia?
Drug use, esp. cannabis
Prenatal/birth complications
Maternal infections
Migrant status
Socioeconomic deprivation
Childhood trauma
Outline some additional sources of information for a history
Collateral history (with consent):
- Family
- Friends
- Work/education
Healthcare records:
- GP
- Contact with mental health services
- Presentations to A+E
What may you look for in appearance and behaviour in someone with psychosis?
Bizarre or inappropriate clothing
Psychomotor retardation/agitation
Abnormal movements (medication related)
Self-neglect
Self-harm injuries
Echophenomena (echopraxia, echolalia)
Why is it important to assess for mood in people with psychosis?
Some affective disorders, e.g. bipolar and depression can cause psychosis - has implications for treatment
Depression is comorbidities with schizophrenia in ~30% of cases
People at high-risk of psychosis often have another mental disorder
Lifetime risk of suicide is 5% in schizophrenia
What cognitive impairments are associated with schizophrenia?
Working memory and executive functioning impairments
Poorer educational attainment (from childhood)
What difficulties might you have treating someone with very poor insight into their psychosis?
Concordance with treatment
Attendance at follow-up
Would not stay in hospital
Impact on ability to have capacity to consent to treatment
Why wouldn’t you diagnose schizophrenia on the basis of a single consultation?
Heterogeneity within disorder categories
Takes time to observe before giving a diagnosis like schizophrenia
Many people who have a first episode of psychosis will not have another
What are the different management routes for psychosis?
Pharmacological:
- Antipsychotic medications
Psychological:
- CBT
- Avatar therapy
Social support:
- Supportive environments, structures and routines
- Housing, benefits
- Support with budgeting/employment
Increased activity of what hormone is implicated in causing positive symptoms of psychosis?
Increased dopamine activity in the mesolimbic dopamine system (elevated presynaptic dopamine in striatum)
Most antipsychotics are what?
Dopamine antagonists
However, newer agents (e.g. aripiprazole) are partial agonists
What can dopamine agonists used in Parkinson’s Disease cause?
Psychotic symptoms
What are extrapyramidal side effects of dopamine antagonists caused by and what do they include?
Caused by dopamine blockade in the nigrostriatal (extrapyramidal) dopamine system (parts of the brain that enable us to maintain posture and tone)
Includes:
- Parkinsonism
- Acute dystonic reactions
- Tardive dyskinesia
- Akathisia
Describe Parkinsonism symptoms
Bradykinesia
Postural instability
Rigidity - characteristic ‘cog-wheeling’
Slow and shuffling gait
- Festination (chasing centre of gravity)
- Lack of arm swing in gait - early sign ‘pill-rolling’ tremor
Describe the ‘pill-rolling’ tremor in Parkinsonism
Slow (4-6 Hz) movement of thumb across other fingers
What makes something an ‘atypical’ vs ‘typical’ antipsychotic?
Typical - older agents, increased risk of causing EPSEs
Atypical - newer, e.g. Olanzapine, less likely to cause ESPEs due to 5HT-2A antagonism
However, can be caused by all antipsychotics
What are some other side effects of antipsychotics?
CNS: ESPEs and sedation
Haematological: Agranulocytosis, neutropenia
Metabolic: Increased appetite, weight gain, Diabetes
Gastrointestinal: Constipation
Pituitary: Increased prolactin
Cardiac: Dysrhythmia, long QTc
