Psychosis Flashcards
What is psychosis?
Difficulty perceiving and interpreting reality
What are the different types of psychotic disorder?
- schizophrenia
- schizoaffective disorder
- bipolar type I
- delusional disorder
- substance-related psychosis
- due to other medical conditions
What is schizophrenia?
significant alteration in perception, thoughts, mood and behaviour
What are the risk factors for schizophrenia?
- family history, highly heritable and polygenic
- cannabis use
- prenatal/birth complications
- maternal infections
- migrant status
- socioeconomic deprivation
- childhood trauma
What 3 domains are symptoms classed into?
- Positive symptoms
- Negative symptoms
- Disorganisation
What is a hallucination?
- perceptions in the absence of a stimulus
- audiotry (voices), visual, somatic or olfactory
What is a delusion?
- Fixed, false beliefs, out of keeping with social/cultural background
- persecutory, grandiose, religious, mind reading, thought broadcasting, insertion, withdrawal
What are positive symptoms?
- An aspect added onto their usual perception/experience
- hallucinations and delusions
What are negative symptoms?
The loss of an aspect of perception of day to day living
The 4As of negative symptoms?
- Alogia
- Anhedonia/asociality
- Avolition/apathy
- Affective flattening
What are disorganisation symptoms?
- Bizarre behaviour
- Thought Disorders
What is the onset of psychosis?
- can occur at any age
- peak incidence in adolescence (early 20s)
- tends to peak later in women
What is the course of psychosis?
- Often chronic and episodic
- Very variable (person to person)
What is the morbidity of psychosis?
Substantial
- both from the disorder and increased risk of common health problems
- Large impact on education, employment and functioning
What impact does psychosis have on mortality?
Substantial
- loss of 15 years from life expectancy
- High risk of suicide in schizophrenia - 28% (in excess)
What should you know about previous hospital admissions for patients with psychosis?
Whether the patient consented to the admission or was detained by the mental health act
What should you ask in a family history of a patient with psychosis?
- Mental disorders in the family
- History of abuse, addiction, suicide
- At home environment
- Family relationship
Which drugs increase the risk of psychosis?
Cannabis
Impact of steroids on mental health?
Very large and significant possible impact
Corroborative history? DELETE
- Needs consent to divulge
- Informants
What does a mental state examination assess?
- Appearance + Behaviour
- Speech
- Mood
- Thoughts
- Perceptions
- Cognition
- Insight
How to determine if there is pressure of speech?
If you cannot interrupt them while they’re speaking
What comes first in psychotic depression?
- The extreme depression causes the psychosis
- unable to be challenged
When should a cognition exam be done during a psychotic episode?
treat them first, then assess cognition
What is involved in the long term management of psychosis?
- community follow up
- managing anti-psychotic side effects
- health promotion/education
What are the side effects of anti-psychotics?
- Extra-pyramidal side effects
- Sedation
- Agranulocytosis
- Neutropenia
- Increased appetite
- Weight gain
- Diabetes
- Dysrhythmia
- Long QT complex
- increased prolactin
- Constipation
What is Tardive dyskinesia?
- Repeated oral/facial/buccal/lingual movements
- initially subtle, progesses to tongue involvement, lip smacking
What increases the risk of tardive dyskinesia?
- Long term antipsychotics
- Female
What causes EPSEs (extrapyramidal side effects)?
antipsychotics can cause a post-synaptic dopamine blockade in the basal ganglia of the extrapyramidal system (responsible for posture and tone)
What are the 4 main types of EPSEs?
- Parkinsonism
- Acute Dystonia
- Tardive Dyskinesia
- Akathisia
What is Parkinsonism?
- Rigidity (‘cog-wheeling’)
- Slow and shuffling gait
- Lack of arm swing in gait (early sign)
- ‘pill-rolling’ tremor (slow 4-6Hz movement of the thumb across the other fingers)
What causes Parkinson’s?
Low dopamine
What is the difference between ‘typical’ and ‘atypical’ antipsychotics?
‘typical’ antipsychotics tend to cause EPSEs at therapeutic doses.
What are the typical antipsychotics?
- first gen
- haloperidol
- fluphenazine
What are the atypical antipsychotics?
- new gen
- risperidone
- olanzapine
- aripiprazole
What is the management of EPSEs?
- avoidance (atypical antipsychotics first line)
- change medication
- anticholinergic medications can
- use lowest theraputic dose
What is acute dystonia?
- increased motor tone > sustained abnormal posture
- can occur shortly after a dopamine antagonist
- can be: acute, frightening, painful and fatal (laryngeal dystonia)
What is Akathisia?
- Inner restlessness
- Feel compelled to move, but little/no relief
- can lead to overt, relentless movement
- most often affects legs
What is the pathophysiology of psychosis?
- Increased dopamine activity
- elevated presynaptic dopamine in the striatum
- causes reality distortion
What are most antipsychotics classed as?
- Dopamine antagonists
- occasionally partial agonists
What drugs can cause psychotic symptoms?
Dopamine agonists used to manage Parkinsons disease
What are the main 3 forms of treatment?
- Pharmacological
- Psychological
- Social support
What does psychological support of psychosis involve?
- CBT for psychosis
- newer therapies (like avatar therapy)
What does social support involve after a psychotic break?
- supportive environments, structures and routines
- housing, benefits
- financial support
What is Insight?
- awareness and recognition that the presenting phenomena is abnormal
- Acceptance that the abnormal phenomena is caused by mental illness
- awareness that treatment is required and different treatment recommendations
What is cognition?
- Consciousness
- Orientation
(can they get to an appointment?) - Memory
- Attention
- Language functioning
What is the syndrome associated with visual hallucinations?
Charles Bonnet Syndrome
What is involved in the Thoughts part of a mental exam?
- flight of ideas, association loss
- Morbid thoughts, suicidal thoughts
- primary and secondary delusions
- obsessional thoughts and compulsions
What is the difference between primary and secondary delusions?
Primary: occurs suddenly
Secondary: arises from previous abnormal idea/experience
What is the term used to describe a shared delusion?
folie à deux
Thoughts to flag?
- paranoia
- grandiose/expansive
- jealousy
- obsessive control
- possession of thought (insertion, withdrawal or broadcasting)
Flags in mood?
- Emotional lability/incontinence
- Reduced reactivity/blunting/flattening
- Increased irritability
- Congruity (happy when describing sad events?)
Flags in Speech?
Quantity - less/more/mutism Rate Latency Volume
Flags in appearance?
- neglect
- weight loss
- posture
- facial expressions
- movements
- social behaviour
What does weight loss often indicate?
- anorexia nervosa
- depression
- cancer
- hyperthyroidism
- financial distress
What is involved in a past medical history?
- any regular medications?
- compliance/adherence?
- over the counter?
- interactions?
What is involved in a personal history?
- birth difficulties?
- early development, childhood trauma?
- education and job history?
- intimate relationships?
What is in a past psychiatric history?
- any known diagnosis?
- any treatment?
- known to a community team?
- previous hospital admissions
What is Alogia?
- paucity of speech
- slow responses
What are signs of Anhedonia/Asociality?
- few close friends
- few hobbies and interests
- impaired social function
What are signs of Avolution/Apathy?
- poor 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 intonation
What is bizarre behaviour?
- bizarre social behaviour
- odd clothing/appearance
- aggression/aggitation
- repetitive/stereotypes behaviour
What is thought disorder?
- derailment
- circumstantial speech
- pressured speech
- distractibility
- incoherent/illogical speech
