Psychosis Flashcards
Define psychosis
- Psychosis is the difficulty perceiving and interpreting reality
- It is caused many disorders with focus in research often in schizophrenia
Give examples of psychotic disorders
Schizophrenia
Schizoaffective disorder
Bipolar I
Depression with psychotic features
Delusional disorder
Due to another medical condition
Substance related
How heritable and polygenic is schizophrenia
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
What are the three categories of symptoms of psychosis?
Positive symptoms
Negative symptoms
Disorganised symptoms
What are the positive symptoms of psychosis
Delusions
Hallucinations
What are hallucinations? Give examples.
The presence of sensory phenomena in the absence of an external stimulus
These can be:
Auditory
VIsual
Somatic/ tacile
Olfactory (rare)
Voice commenting on you
Voices talking to each other
What are delusions? Give examples
Fixed, false beliefs which are out of keeping with social/ cultural background
These may be:
Persecutory
Jealousy
Control
Mind reading
Reference
Grandiosity
Religious
Guilt
Somatic
Sexual
Thought (broadcasting, withdrawal, insertion)
What are the negative symptoms of psychosis
Alogia
Avolition/ apathy
Anhedonia/ asociality
Affective flattening
What is alogia?
The poverty of speech
Includes
-paucity of speech (little content)
-slow to respond
What is anhedonia/ sociality?
Lack of pleasure
- Few close friends
- Few close hobbies
- Impaired social functioning
What is avolition/ apathy?
Complete lack of motivation and self care
- Lack of persistence at work/education
- Lack of motivation
What is affective flattening
- Unchanging facial expressions
- Few expressive gestures
- Poor eye contact
- Lack of vocal intonations
- Inappropriate affect
What are the disorganisation symptoms of psychosis?
Bizarre behaviour
Thought disorder
Give examples of bizarre behaviour in psychosis
Bizarre social behaviour
Bizarre clothing/ appearance
Agression/ agitation
Repetitive/stereotyped behaviour
Give examples of thought disorder in psychosis
Derailment
Distractability
Pressure of speech
Circumstantial speech
Incoherent/ illogical speech
What is psychosis often preceded by?
- Prodromal symptoms: These can be changes in social behaviour e.g. social withdrawal, and impairments in functioning
- People at high risk of developing psychosis often have/had another mental disorder like affective disorders earlier in life
What environmental risk factors are there for psychosis?
- Drug use, esp cannabis
- Prenatal/birth complications
- Maternal infections
- Migrant status
- Socioeconomic deprivation
- Childhood trauma
What is the age of onset of psychosis?
- Can occur at any age
- Peak incidence = early 20s
- Peak later in women
Describe the course of psychosis
- Often chronic & episodic
- Very variable
Why is morbidity substantial in psychosis?
- Substantial because:
- disorder itself increases morbidity
- disorder can increase risk of common health problems, and therefore increase morbidity indirectly
- Significant impact on education, employment & functioning
Why is mortality substantial in psychosis?
- 2.5x increased risk of mortality
- estimated 15 years life lost
- high risk of suicide among schizophrenia- 28% of excess mortality
What happens after a psychotic episode?
How is psychosis managed in the long term?
- Some completely recover after an episode, most follow an episodic course with periods of wellness and relapses
- Long term management includes:
- Community follow up
- Managing antipsychotic side effects e.g. weight, diabetes
- Health promotion- reducing risk factors e.g. smoking, diet
What is the psychiatric history?
Psychiatric history is the history of the patient that involves multiple segments that help in diagnosing and understanding patients problem
What does psychiatric history consist of?
History of PC
Past psychiatric history
Past medical history/ medication
Bacgkround history
Corroborative history
What is history of PC in psychiatric history?
- Description of presenting problem, what brings the patient to see doctor, why now
- Includes the characteristics of problem:
- Nature
- Severity
- Onset
- Course
- Worsening factors
- Treatment received
what 4 things are figured out from past psychiatric history?
- Any known current diagnosis?
- Any ongoing or previous treatment?
- Known to community team?
- Any previous hospital admissions?
What is included in background history in psychiatric history?
- Family history
- Age of parents, siblings, relationship at home
- Atmosphere at home
- Mental disorder in family or household
- Any family drug use or abuse or suicide
- Personal history
- Mother pregnancy and birth
- Early development, separation, childhood illness
- Education and occupational history
- Intimate relationship
- Social history
- Living arrangements
- Financial issues
- Alcohol & illicit drug use
- Forensic history - have they cause previous harm to anyone
What is included in past medical/ medicine history in psychiatric history?
- taking any current medications, including over the counter
- any allergies to certain medications
- What are interactions with medication like?
- compliance
Who do we take a corroborative history for and what is it used for?
Informants - relatives, friends, authority
Used for further clarification
What is it important to ask for/ maintain when taking a corroborative history?
- Confidentiality
- Need patient consent if you want to inform relatives
What is the Mental State Examination?
MSE is a snapshot of patient current mental state
What does MSE consist of?
Appearance and behaviour
Speech
Mood
Thoughts
Perception
Cognition
Insight
What do we look for under appearance and behaviour in the MSE?
- General Appearance
- If neglect, think - alcoholism, drug addiction, dementia, depression, schizophrenia
- If weight loss, think - hyperthyroidism, cancer, depression, anorexia, financial issues
- Facial Expression
- Depressive
- Anxious
- “wooden” Parkinsonian - mask like
- Posture
- Depressive - Hunched shoulders, downcast head & eyes
- Anxious - Sitting upright, head erect, hands gripping chair
- Movement
- Manic (overactive, restlessness)
- Depressive (inactive, slow)
- Stupor (immobile, mute)
- tremors, tics, choreiform movements
- Dystonia
- Tardive Dyskinesia
- Mannerism, stereotypes
- Social behaviour
- Withdrawal, preoccupied
- Disinhibited, overfamiliar
- Signs of impending violence (Raised voice, clenching fist, pointed fingers, intrusion of personal space)
Specifically in psychosis patients
- Bizarre or inappropriate clothing e.g. no shoes
- Agitation/aggression
- Poor personal hygiene or neglect of self care (negative symptoms)
- Injuries- people with psychosis are far more likely to be victims of violence
What do we look for under speech in the MSE?
- Quantity- less/more/mutism
- Rate- slow, fast, pressure of speech
- Spontaneity- latency
- Volume
What do we look for under mood in the MSE?
- Subjective → when you directly ask how mood is
- Objective → how you perceive their mood is without asking
- Predominant mood
- Constancy
- Emotional incontinence/lability
- Reduced reactivity/blunting/flattening
- irritability
- Congruity (cheerful when describing sad events)
Why is it important to assess for mood in people with psychosis?
- Some affective disorders can cause psychosis (e.g. bipolar, depression) with implications for treatment
- People at high risk of psychosis often have another mental disorder
- Depression is comorbid with schizophrenia in 30% of cases
What do we look for under thought in the MSE?
-Stream (spontaneous thought production)
- Form (How you are thinking, flight of ideas)
- Content (What you are thinking of)
- Preoccupation (thoughts that are constantly on your mind)
- Morbid thoughts (suicidality)
- Delusions
- Obsessional thoughts
- Compulsions
What are the 3 types of delusions?
- Primary- occurs suddenly
- Secondary- arises from previous abnormal experiences (i.e. hallucinations, delusions)
- Shared delusion (folie a deux)- same delusion shared by 2 individuals, solution is to separate the 2 people
Obsessional thoughts- give examples
- dirt and contamination
- aggressive actions
- orderliness
- disease
- sex
- religion
Compulsions- give examples
- checking
- cleaning
- counting
- dress rituals
What do we look for under perceptions in the MSE?
lllusions (Misperception of external stimulus)
Hallucinations
- Pseudohallucination- Sensory experience vivid enough to be considered hallucination but considered by person unreal
- Hypnogogic (transition state of consciousness from awake to sleep)
- Hypnopompic (transition state of consciousness from sleep to awake)
- Auditory - second person, third person
- Visual (Charles Bonnet syndrome- seeing things that aren’t there when your eyes start to deteriorate- can be simple patterns or detailed images of people/places/things)
- Olfactory
- Tactile/deep sensation
Distortion (thoughts that distort one’s perception of reality)
What do we look for under cognition in the MSE?
- Consciousness
- Orientation
- Memory
- Language
- Attention + concentration
- Visuospatial functioning
What do we look for under insight in the MSE?
- Awareness of oneself as presenting phenomena that other people consider abnormal
- Recognition that these phenomena are abnormal
- Acceptance that these abnormal phenomena caused by mental illness
- Awareness that treatment required
- Acceptance of treatment
What are the 3 different types of treatment options available for psychosis?
- Pharmacological- - Antipsychotic meds, often mainstay of treatment
- Psychological
- Cognitive behavioural therapy
- avatar therapy
- Social support- what does this include?
- Supportive environment, structures and routines
- Housing, benefits
- Support with budgeting/employment
What neurotransmitter system is most implicated in the mechanism of antipsychotics?
What others?
Dopamine- but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine
What is increased dopamine activity associated with in psychosis?
What evidence shows increased dopamine activity and where?
- In causing reality distortion in psychosis
- Evidence from imaging, drug models and post mortem studies show elevated presynaptic dopamine in striatum
What kind of drugs are most antipsychotics?
Name an exception
- Dopamine antagonists
- Aripiprazole is a partial agonist
What type of drugs can cause psychotic symptoms due to excess dopamine?
Dopamine agonists like those used in Parkinson’s disease
What are Extra Pyramidal Side Effects (EPSEs) of antipsychotics?
Side effects that are caused by post-synaptic dopamine blockage in the extra pyramidal system (parts of brain that enable us to maintain posture and tone)
What examples of EPSEs are there?
Parkinsonism
Dystonia
Tardive dyskinesia
Akathisia
Parkinsonism symptoms
- Rigidity- characteristic cog-wheeling
- Slow and shuffling gait
- Lack of arm swing in gait - early sign
- Pill rolling tremor- slow movement of thumb across other fingers
Dystonia symptoms
- Increase muscle tone → abnormal contraction and posture
- Spasm
- Can occur shortly after taking dopamine antagonist
- Can be acute, frightening, painful, even fatal (laryngeal dystonia)
Tardive dyskinesia symptoms
- Repeated oral/facial/buccal/lingual movements
- Initially subtle - can progress to tongue involvement, lip smacking
- Increased risk include long term antipsychotics use, female
Akathisia symptoms
- Inner restlessness
- Feel compelled to move but do little to alleviate
- Can lead to overt, relentless movement
- Legs most commonly affected, in constant movement
What makes something a ‘typical’ vs ‘atypical’ antipsychotic
- Typical cause EPSE
- Atypical e.g. olanzapine are less likely to cause EPSE
How do we manage EPSEs?
- Avoid them in the first place- atypical antipsychotics are usually first line, typical usually old psychotics
- Change medication
- Anticholinergic medications can help e.g. procyclidine
- Fully inform patients about risks
What are side effects of antipsychotics?
- CNS → EPSEs, sedation
- Haematological → agranulocytosis, neutropenia
- Metabolic → increased appetite, weight gain, diabetes
- GI → constipation
- Pituitary → more prolactin (release suppressed by dopamine)
- Cardiac → dysrhythmia, long QTc (can cause palpitations, fainting, seizures)
