psychosis Flashcards
What is psychosis?
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
What are the causes of psychosis/ psychotic disorders?
Schizoaffective disorder
Bipolar I
Schizophrenia
Drepression with psychotic symptoms
Delusional disorder
Drug induced
Due to other medical condition
What is meant by the term “positive symptoms” vs “negative symptoms”?
Positive= addition of/ appearance of abnormal behaviors
Negative= lessening or absence of normal behaviors
What are the positive symptoms of psychosis?
- Hallucinations (Perception in absence of a stimulus)
- Delusions (Disorder of thought content)
What are delusions?
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
What are some examples of delusions?
[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
What are the negative symptoms of psychosis?
- Alogia:
Paucity/poverty of speech, little content
Slow to respond - Avolition/apathy:
Poor self-care
Lack of drive/persistence at work/education
Lack of motivation - Anhedonia/asociality:
Few close friends
Few hobbies/interests
Impaired social functioning - 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:
Bizarre social behaviour
Bizarre clothing/appearance
Aggression/agitation
Repetitive/stereotyped behaviours - 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]
Describe the onset of psychosis
Onset:
Can occur at any age
Peak incidence in adolescence/early 20s
Peak later in women
Describe the course of psychosis
Often chronic & episodic
Variable
Describe the morbidity of psychosis
Substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
Significant impact on education, employment and functioning
What is the morality rate of psychosis?
All-cause mortality 2.5x higher, ~15 years life expectancy lost
High risk of suicide in schizophrenia - 28% of excess mortality
Other than the typical symptoms, what else might 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)
What are the risk factors of psychosis?
- 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 - Environmental risk factors
Drug use, especially cannabis
Prenatal/birth complications
Maternal infections
Migrant status
Socioeconomic deprivation
Childhood trauma
How is speech examined during the mental state examination for suspected psychosis?
Comment on rate/rhythm/volume
Reduced volume
Reduced intonations – monotonous/lacking in prosody
Normal rate
How is mood examined during the mental state examination for suspected psychosis?
Objective:
Euthymic, mildly anxious
Concerned about his experiences
Blunted affect (emotional range)
Why is it important to assess for mood in people with psychosis?
- 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
What are “third person auditory hallucinations”?
3rd person – Patient hears voices talking about them
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
How is psychosis managed?
- Pharmacological:
Antipsychotic medications
Often mainstay of treatment - Psychological:
CBT for psychosis
Newer therapies like avatar therapy - Social support:
Supportive environments, structures and routines
Housing, benefits
Support with budgeting /employment
Describe the mechanism behind antipsychotics
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
What are “Extrapyramidal side effects”?
EPSEs= symptoms that can occur in people taking antipsychotic medications.
Includes;
Parkinsonism
Acute dystonic reactions
Tardive dyskinesia
Akathisia
What causes Extrapyramidal side effects?
- 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)
What are the symptoms of Parkinsonism?
- Bradykinesia
- Postural instability
- Rigidity - characteristic‘cog-wheeling’
- Slow and shuffling gait
* Festination (chasing centre of gravity)
* Lack of arm swingin gait – early sign - ‘pill-rolling’ tremor- slow (4-6Hz) movement of the thumb across the other fingers:
What makes something a ‘typical’ versus an ‘atypical’ antipsychotic?
- 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
How are extrapyramidal side effects managed?
Management
Consider lowest therapeutic dose
Use atypical antipsychotics as first line
Change medication
Anticholinergic medications can help e.g. procyclidine
What are the side effects of antipsychotics?
- 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
What are the long- term management of psychosis?
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
