Psychosis Flashcards
Psychosis is a term used to describe
a person experiencing things differently from those around them.
Psychotic features include:
hallucinations (e.g. auditory)
delusions
thought disorganisation
agitation/aggression
neurocognitive impairment (e.g. in memory, attention or executive function)
depression
thoughts of self harm
Psychotic thought features
alogia: little information conveyed by speech
tangentiality: answers diverge from topic
clanging
word salad: linking real words incoherently → nonsensical content
Psychotic symptoms may occur in a number of conditions:
schizophrenia
depression (psychotic depression, a subtype more common in elderly patients)
bipolar disorder
puerperal psychosis
brief psychotic disorder: where symptoms last less than a month
neurological conditions e.g. Parkinson’s disease, Huntington’s disease
prescribed drugs e.g. corticosteroids
certain illicit drugs e.g. cannabis, phencyclidine
The peak age of first-episode psychosis is around
15-30 years
The atypical antipsychotics were developed due to
the problematic extrapyramidal side-effects which are associated with the first generation of typical antipsychotics.
Typical antipsychotics
Mechanism of action
Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways
Typical antipsychotics
Adverse effects
Extrapyramidal side-effects and hyperprolactinaemia common
Typical antipsychotics
Examples
Haloperidol
Chlopromazine
Atypical antipsychotics
Mechanism of action
Act on a variety of receptors (D2, D3, D4, 5-HT)
Atypical antipsychotics
Adverse effects
Extrapyramidal side-effects and hyperprolactinaemia less common
Metabolic effects
Atypical antipsychotics
Examples
Clozapine
Risperidone
Olanzapine
typical antipsychotics Extrapyramidal side-effects (EPSEs)
Parkinsonism
acute dystonia
akathisia
tardive dyskinesia
acute dystonia is
sustained muscle contraction (e.g. torticollis, oculogyric crisis)
acute dystonia mx
procyclidine
akathisia is
severe restlessness
tardive dyskinesia is
late onset of choreoathetoid movement
abnormal, involuntary
may occur in 40% of patients
may be irreversible
most common is chewing and pouting of jaw
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
reduced seizure threshold less/greater with atypicals
greater
which drug particularly prolong QT
haloperidol)
neuroleptic malignant syndrome tetrad
pyrexia
muscle rigidity
autonomic lability: typical features include hypertension, tachycardia and tachypnoea
agitated delirium with confusion
S/E antipsychotics?
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin
may result in galactorrhoea
due to inhibition of the dopaminergic tuberoinfundibular pathway
impaired glucose tolerance
Antipsychotics frequency of monitoring
Full blood count (FBC), urea and electrolytes (U&E), liver function tests (LFT)
at the start of therapy
annually
clozapine requires much more frequent monitoring of FBC (initially weekly)
Antipsychotics frequency of monitoring
Lipids, weight
at the start of therapy
at 3 months
annually
Antipsychotics frequency of monitoring
Fasting blood glucose, prolactin
at the start of therapy
at 6 months
annually
Antipsychotics frequency of monitoring
Blood pressure
baseline
frequently during dose titration
Antipsychotics frequency of monitoring
Electrocardiogram
baseline
Antipsychotics frequency of monitoring
Cardiovascular risk assessment
annually
typical/Atypical antipsychotics should now be used first-line in patients with schizophrenia
Atypical antipsychotics should now be used first-line in patients with schizophrenia
Adverse effects of atypical antipsychotics
weight gain
clozapine is associated with agranulocytosis hyperprolactinaemia
Examples of atypical antipsychotics
clozapine olanzapine risperidone quetiapine amisulpride aripiprazole
Which atypical antipsychotics higher risk of dyslipidemia and obesity
Olanzapine
Which atypical antipsychotics generally good side-effect profile, particularly for prolactin elevation
aripiprazole
Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment.
true
Clozapine should be introduced if schizophrenia is
not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
Adverse effects of clozapine
agranulocytosis (1%), neutropaenia (3%)
reduced seizure threshold - can induce seizures in up to 3% of patients
constipation
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
Dose adjustment of clozapine might be necessary if what is started or stopped during treatment.
smoking
ICD10 definition of hallucination:
false sensory perception in the absence of an external stimulus. Maybe organic, drug-induced or associated with mental disorder.
generally accepted definition that a pseudohallucination is
a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.
An example of a pseudohallucination is a hypnagogic hallucination which occurs when transitioning from wakefulness to sleep. These are experienced vivid auditory or visual hallucinations which are fleeting in duration and may occur in anyone
true
The relevance of pseudohallucinations in practice is that patients may need reassurance that these experiences are normal and do not mean that they will develop a mental illness.
true
Pseudohallucinations commonly occur in people who are
grieving
Charles-Bonnet syndrome (CBS) is characterised by
persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.
Charles-Bonnet syndrome (CBS) Risk factors include:
Advanced age Peripheral visual impairment Social isolation Sensory deprivation Early cognitive impairment
Charles-Bonnet syndrome (CBS) The most common ophthalmological conditions
associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract
Well-formed complex visual hallucinations are thought to occur in 10-30 per cent of individuals with severe visual impairment.
Prevalence of CBS in visually impaired people is thought to be between 11 and 15 per cent.
CBS is equally distributed between sexes and does not show any familial predisposition.
true
CBS generally not a transient experience
true
CBS ?% find the hallucinations themselves an unpleasant or disturbing experience
a third
Cotard syndrome is
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.
Cotard syndrome is associated with
severe depression and psychotic disorders.
De Clerambault’s syndrome
also known as erotomania, is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.
Othello’s syndrome is
Othello’s syndrome is pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.
