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Psychiatry > psychosis > Flashcards

psychosis Flashcards

1
Q

What is psychosis?

A

difficulty perceiving and interpreting reality (i.e. failure of reality testing)
- A clinical syndrome that can be caused by many disorders - focus in research is often schizophrenia

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2
Q

What are the causes of psychosis/ psychotic disorders?

A

Schizoaffective disorder
Bipolar I
Schizophrenia
Drepression with psychotic symptoms
Delusional disorder
Drug induced
Due to other medical condition

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3
Q

What is meant by the term “positive symptoms” vs “negative symptoms”?

A

Positive= addition of/ appearance of abnormal behaviors
Negative= lessening or absence of normal behaviors

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4
Q

What are the positive symptoms of psychosis?

A
  1. Hallucinations (Perception in absence of a stimulus)
  2. Delusions (Disorder of thought content)
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5
Q

What are delusions?

A

Fixed, false belief not in keeping with social/cultural norms. Delusions have a theme/flavour;
Persecutory/Paranoid
Reference
Grandiosity
Religious
Pathological jealously
Nihilistic/Guilt
Somatic
Erotomanic

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6
Q

What are some examples of delusions?

A

[start to lose control/ agency over their body]
- Passivity experiences (belief that their body is not their own)
- 1st rank symptoms:
Thought broadcasting (someone else hearing their thoughts/ put thoughts in their head)
Thought insertion
Thought withdrawal

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7
Q

What are the negative symptoms of psychosis?

A
  1. Alogia:
    Paucity/poverty of speech, little content
    Slow to respond
  2. Avolition/apathy:
    Poor self-care
    Lack of drive/persistence at work/education
    Lack of motivation
  3. Anhedonia/asociality:
    Few close friends
    Few hobbies/interests
    Impaired social functioning
  4. Affective flattening:
    Unchanging facial expressions
    Few expressive gestures
    Poor eye contact
    Lack of vocal intonations
    Limited emotional range
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8
Q

What are the disorganisation symptoms of psychosis?

A
  1. Bizarre behaviour:
    Bizarre social behaviour
    Bizarre clothing/appearance
    Aggression/agitation
    Repetitive/stereotyped behaviours
  2. Formal Thought disorder: (lose focus of the topic of the conversation, talk in rhyme)
    - Lack of logical connection between thoughts
    Word salad
    Derailment/loosening of associations
    Flight of ideas
    Tangential thought
    Circumstantial thought
    [though is connected to speech; speech issues are indicative of thought issue]
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9
Q

Describe the onset of psychosis

A

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

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10
Q

Describe the course of psychosis

A

Often chronic & episodic
Variable

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11
Q

Describe the morbidity of psychosis

A

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

Significant impact on education, employment and functioning

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12
Q

What is the morality rate of psychosis?

A

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

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

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13
Q

Other than the typical symptoms, what else might you look for in appearance and behaviour in someone with psychosis?

A

Bizarre or inappropriate clothing
Psychomotor retardation/agitation
Abnormal movements (medication related)
Self-neglect
Self-harm injuries
Echophenomena (echopraxia, echolalia)

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14
Q

What are the risk factors of psychosis?

A
  1. Genetics
    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
  2. Environmental risk factors
    Drug use, especially cannabis
    Prenatal/birth complications
    Maternal infections
    Migrant status
    Socioeconomic deprivation
    Childhood trauma
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15
Q

How is speech examined during the mental state examination for suspected psychosis?

A

Comment on rate/rhythm/volume
Reduced volume
Reduced intonations – monotonous/lacking in prosody
Normal rate

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16
Q

How is mood examined during the mental state examination for suspected psychosis?

A

Objective:
Euthymic, mildly anxious
Concerned about his experiences
Blunted affect (emotional range)

17
Q

Why is it important to assess for mood in people with psychosis?

A
  • Some affective disorders can cause psychosis (e.g. bipolar disorder, depression) with implications for treatment
  • Depression comorbid with schizophrenia in ~30% of cases (Li et al, 2020)
  • People at high-risk of psychosis often have another mental disorder
  • Lifetime risk of suicide 5% in schizophrenia
18
Q

What are “third person auditory hallucinations”?

A

3rd person – Patient hears voices talking about them

19
Q

What difficulties might you have treating someone with very poor insight into their psychosis?

A

Concordance with treatment
Attendance at follow-up
Would not stay in hospital
Impact on ability to have capacity to consent to treatment

20
Q

How is psychosis managed?

A
  1. Pharmacological:
    Antipsychotic medications
    Often mainstay of treatment
  2. Psychological:
    CBT for psychosis
    Newer therapies like avatar therapy
  3. Social support:
    Supportive environments, structures and routines
    Housing, benefits
    Support with budgeting /employment
21
Q

Describe the mechanism behind antipsychotics

A

neurotransmitter system that is most implicated in the mechanism of antipsychotics is DOPAMINE:
- Increased dopamine activity in mesolimbic dopamine system implicated in causing positive symptoms of psychosis
- Evidence from imaging + drug models + post-mortem studies -> elevated presynaptic dopamine in striatum
- Most antipsychotics are dopamine antagonists. Newer agents (e.g. aripiprazole) are partial agonists

22
Q

What are “Extrapyramidal side effects”?

A

EPSEs= symptoms that can occur in people taking antipsychotic medications.

Includes;
Parkinsonism
Acute dystonic reactions
Tardive dyskinesia
Akathisia

23
Q

What causes Extrapyramidal side effects?

A
  • Remember, we can’t choose where to reduce dopamine
  • Caused by dopamine blockade in the nigrostriatal (extrapyramidal) dopamine system (parts of the brain that enable us to maintain posture and tone)
24
Q

What are the symptoms of Parkinsonism?

A
  1. Bradykinesia
  2. Postural instability
  3. Rigidity - characteristic‘cog-wheeling’
  4. Slow and shuffling gait
    * Festination (chasing centre of gravity)
    * Lack of arm swingin gait – early sign
  5. ‘pill-rolling’ tremor- slow (4-6Hz) movement of the thumb across the other fingers:
25
Q

What makes something a ‘typical’ versus an ‘atypical’ antipsychotic?

A
  • Typical antipsychotics are older agents and have an increased risk of causing EPSE
  • Newer, atypical antipsychotics (e.g. olanzapine) - less likely to cause EPSEs due to 5HT-2A antagonism but can be caused by all antipsychotics
26
Q

How are extrapyramidal side effects managed?

A

Management
Consider lowest therapeutic dose
Use atypical antipsychotics as first line
Change medication
Anticholinergic medications can help e.g. procyclidine

27
Q

What are the side effects of antipsychotics?

A
  • Sedation
  • Constipation
  • Neutropenia (low levels of neutrophils in your blood)
  • Agranulocytosis (A serious condition that occurs when there is an extremely low number of granulocytes (a type of white blood cell))
  • ↑ Prolactin (release suppressed by dopamine)
  • Increased weight gain
  • Increased appetite
  • Diabetes
  • Dysrhythmia
28
Q

What are the long- term management of psychosis?

A

Long term management
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: ~15 years lost

Psychiatry (6 decks)

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