Psychosis Flashcards
What is psychosis?
A group of mental illnesses that features a difficulty perceiving and interpreting reality
Which type of mental illnesses are associated wit psychosis?
Schizoaffective disorder Bipolar I Schizophrenia (1%) Delusional disorder Depression with psychotic features Due to other medical condition Substance related
What are the three domains of psychosis symptoms?
Positive symptoms
Negative symptoms
Disorganisation
What are the two main positive symptoms of psychosis?
Hallucinations
Delusions
What are hallucinations in psychotic patients?
Percepts in absence of a stimulus Auditory Voices commenting on you Voices talking to each other Visual Somatic/tactile Olfactory
What are delusions in psychotic patients?
Fixed, false beliefs, out of keeping with social/cultural background.
Persecutory Control Reference Mind reading Grandiosity Religious Guilt/sin Somatic
Thought broadcasting
Thought insertion
Thought withdrawal
What are the four main negative symptoms of psychosis?
Alogia
Avolution/apathy
Anhedonia
Affective flattening
What term describes a poverty of speech?
Alogia
What is alogia?
Is concerned with paucity of speech, little content and the individual is slow to respond.
What is avolution/apathy?
Poor self-care
Lack of persistence at work/education
Lack of motivation
What is anhedonia/asociality?
Disengaged interest and pleasure within conducting activities.
- Few close friends
- Few hobbies/interests
- Impaired social functioning
What is affective flattening?
Unchanging facial expressions Few expressive gestures Poor eye contact Lack of vocal intonations Inappropriate affect
What are the two main forms of disorganisation symptoms?
Bizarre behaviour
Thought disorder
What is bizarre behaviour?
Bizarre social behaviour
Bizarre clothing/appearance
Aggression/agitation
Repetitive/sterotyped behaviours
What is thought disorder?
Derailment Circumstantial speech Pressured speech Distractibility Incoherent/illogical speech
What is the peak onset of psychosis?
Peak incidence in adolescence/early 20s.
Peak later in women
What is taken in a psychiatric history?
- History of presenting concern- nature, severity, onset, worsening factors, and treatment received
- Past psychiatric history (diagnosis, treatment, community team, previous admissions?)
- Background history (family, personal, social- abuse, alcohol/drug misuse)
- Past medical history and medicine
- Corroborative history
(Educational, occupational history, relationships, separation, childhood illness)
What things are considered when conducting a social history?
- Living arrangements
- Financial issues
- Alcohol and illicit drug use
- Forensic history
What type of history requires consent?
Corroborative history
What 7 key features are assessed in a mental state examination?
Appearance and behaviour Speech Mood Thoughts Perceptions Cognition Insight
How can appearance change in patients with psychosis?
Neglect : Alcoholism, drug addiction, dementia, depression and schizophrenia
Weight loss: Anorexia nervosa, depression, cancer, hyperthyroidism, financial issues/homelessness.
Facial: Depressive, anxious, wooden Parkinsonian
What type of movements are assessed in psychosis patients?
Overactive, restless- manic
Inactive, slow - depressive
Immobile, mute - stupor
Tremors, ticks, choreiform movements, dystonia, tardive dyskinesia
Mannerisms, stereotypes
What four factors are assessed when looking at speech?
Quantity - less, more, mutism
Rate- slow, fast, pressure of speech.
Spontaneity - latency
Volume - quiet, loud
What are primary delusions?
Occurs suddenly
What are secondary delusions?
Arises from previous abnormal idea/experience
What is an illusion?
Misperception of a real external stimulus
What is a hallucination?
= perception in the absence of external stimulus
true perception + 2) coming from outside the head
pseudohallucination = 1) OR 2)
hypnagogic, hypnopompic
auditory – second person, third person visual – Charles Bonnet syndrome olfactory gustatory tactile, of deep sensation
What features are assessed when considering mood in individuals with suspected pyschosis?
Subjective Objective Predominant mood Constancy Congruity (Cheerful while describing sad events).
Emotional lability/incontinence/reduced reactivity/blunting/flattening/irritability.
What features of thought are examined when assessing thoughts in individuals with suspected psychosis?
Stream Form Content Preoccupations Morbid thoughts, suicidality Delusions, overvalued ideas Obsessional symptoms
What is insight in terms of assessing a patient’s mental state?
Awareness of onself as presenting phenomena that other people consider abnormal
Recognition that these phenomena are abnormal
Acceptance that these abnormal phenomena are caused by mental illness
Awareness that treatment is required
What type of symptoms typically precede psychosis?
Prodromal symptoms
Changes in social behaviour, social withdrawal and impairments in functioning
What are the environmental risk factors for psychosis?
Cannabis and drug use
Maternal infections
Migrant status
Socioeconomic deprivation Childhood trauma
Prenatal/birth complications
What are the genetic risk factors for psychosis?
Schizophrenia is highly heritable
Highly polygenic
What additional sources of information are available to support a diagnosis of psychosis?
Collateral history from family, friends and work.
Healthcare records: GP, Mental health services.
What difficulties are encountered when treating someone with very poor insight into their psychosis?
Concordance with treatment
Attendance at follow-up
Would not stay in hospital
What are the differentials for psychosis?
Delirium Schizophrenia Personality disorder Dementia Drugs Encephalitis (behavioural changes)
What are the three types of psychosis management?
Pharmacological
Psychological (CBT and avatar therapy)
Social support
Which neurotransmitter system is most implicated in the mechanism of antipsychotics?
Dopamine
Which hormone activity is increased in psychosis?
Increased dopamine activity is implicated in causing reality distortion in psychosis
post-mortem studies reveal elevated presynaptic dopamine in striatum.
How do most antipsychotics work?
They are dopamine antagonists.
Aripirazole is a partial agonist
Why can Parkinson’s be a risk factor for psychosis?
Dopamine agonists which are used in the treatment can cause psychotic symptoms.
What are the common side effects associated antipsychotic medication?
Extrapyramidal side effects
- Parkinsonism
- Acute dystonia
- Tardive dyskinesia
- Akathisia
Antipsychotics can cause post-synaptic dopamine blockade in the extrapyramidal system
Parkinsonism is a common effect
What parkinsonism features are associated with antipysychotic drug use?
Rigidity- Characteristic cog-wheeling
Slow and shuffling gait
Lack of arm swing in gait- early sign
Pill rolling tremor - slow movement of the thumb across other fingers
What is acute dystonia?
Increased motor tone –> Sustained abnormal posture
Can occur shortly after taking dopamine antagonist
What is tardive dyskinesia?
Repeated oral/facial/buccal/lingual movements.
Initially subtle- can progress to tongue involvement, lip smacking.
increased risk: Long term antipsychotics, female
What is akathisia?
Inner restlessness (hand streotypy)
Feel compelled to move, but does little to alleviate
Can lead to overt, relentless movement.
Legs most commonly affected
What are ‘typical’ antipsychotics?
Commonly cause extrapyramidal side effects at therapeutic doses, definition is NOT based on pharmacology/drug target.
What is the main difference between atypical and typical antipsychotics?
Atypical drugs are less likely to cause ESPEs.
What is the management of extra-pyramidal side effects in patients receiving antipsychotics?
Avoid them in the first place: Atypical antipsychotics usually first-line.
Change medication, anticholinergic medications can help e.g procyclidine.
What are the haematological side effects of antipsychotics?
Agranulocytosis
Neutropenia
What are the metabolic side effects of antipsychotics?
Increased appetite
Weight gain
Diabetes
What are the cardiac side effects of antipsychotics?
Dysrhythmia
Long QTc,
What are the pituitary side effects of antipsychotics?
Increased prolactin release
What are the gastrointestinal side effects of antipsychotics?
Constipation
