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Psychosis Flashcards

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1
Q

What is psychosis

A

A loss of connection with reality
Will include thought disorders, delusions and hallucinations

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2
Q

What is difference between hallucination and illusion

A

Illusion is a misinterpretation of a real external stimulus
Hallucination is percieving a planted modality like a voice in head

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3
Q

What is a delusion

A

A fixed belief contrary to evidence that is outside of cultural norms

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4
Q

What is difference between primary and secondary delusions

A

Primary- completely out of the blue
Secondary- based off mood or another psychotic phenomena

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5
Q

What is an overvalued idea

A

A reasonable belief that is valued and pursued excessively

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6
Q

What are nihilistic or negative delusions seen in

A

Severe depression

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7
Q

What are grandiose delusions seen in

A

Mania

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8
Q

What are differentials for cause of psychosis

A

Organic
- drugs
- delirium
- dementia
Schizophrenia
Delusional disorder
Affective disorder
- depressive psychosis
- manic psychosis

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9
Q

What are extremely bizarre delusions seen in

A

Schizophrenia

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10
Q

What drug is used for tranquilisation in psychosis

A

Lorazepam

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11
Q

What are 3 types of antipsychotics

A

Typical
Atypical
Clozapine

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12
Q

What are advantages and disadvantages of typical antipsychotics

A

Advantages
- effective
- cheap
- able to provide long term injections for those who cant tolerate daily tablets
Disadvantages
- cause distressing EPSEs at normal dose
- increase prolactin
- old

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13
Q

How is clozapine different to all other antipsychotics

A

Clozapine still has affinity for D2 but is very weak
High affinity for serotonin type 2 receptors and D4

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14
Q

Advantages and disadvantages of atypical antipsychotics

A

Advantages
- fewer EPSE’s
- newer
Disadvantages
- only risperidone available as long term injection

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15
Q

What are the typical antipsychotics

A

Phenothiazines
Butryophenones
Thioxanthines
Benzamides

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16
Q

Side effects of typical antipschotics

A

EPSE
- acute dystonia
- parkinsonism
- akathisia
- tardive dyskinesia
Neuroleptic malignant syndrome

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17
Q

How to treat acute dystonia

A

Procyclidine IM

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18
Q

How to treat parkinsonism as EPSE

A

Procyclidine or any anti-muscarinic

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19
Q

How to treat akathisia (restlessness) as EPSE

A

Reduce dose
Consider propanolol

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20
Q

What is tardive dyskinesia

A

Sudden movements of face or body that can not control

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21
Q

SE’s of atypical anti-pschotics

A

Weight gain- most common
Postural hypotension
Drowsiness
EPSEs
DM

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22
Q

What monitor in typical antipychotics

A

BP
Weight
HbA1c
Lipids
Glucose
LFTs

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23
Q

What monitor in typical antipsychotics

A

ECG
BP

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24
Q

What monitor in clozapine

A

FBC weekly
Hba1c
Weight

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25
Q

What are the atypical antipsychotics

A

Olanzapine
Risperidone
Quitiapine
Aripiprazole
Amisulpride

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26
Q

Main side effect of clozapine to worry about

A

Agranulocytosis
Very rare but fatal

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27
Q

Side effects of clozapine and how manage

A

Agranulocytosis- monitor FBC
Constipation- laxatives
Tachycardia- beta blockers
Hypersalivation- treat with hyoscine
Weight gain- monitor weight
DM- monitor HbA1c

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28
Q

What is neuroleptic malignant syndrome

A

Rare but potentially fatal complication of antipsychotic medications
Presents with
- fever
- autonomic dysregulation
- muscle rigidity

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29
Q

Blood findings of neuroleptic malignant syndrome

A

Increased WBC
Creatine phosphokinase increased- can develop rhabdomyolysis

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30
Q

What is schizophrenia

A

Psychotic disorder with negative or positive sx
Disorder of thinking, perceiving and motivation

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31
Q

Outcomes for patients with schizophrenia

A

Tale of 1/3s
1/3 have episode and is treated well
1/3 relapsing remitting
1/3 have for life
5% suicide risk

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32
Q

Management of first episode psychosis

A

Olanzapine
Aripirprazole

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33
Q

What should do if someone comes to A and E with psychosis

A

Refer without delay to early intervention psychosis service- if not available refer to crisis resolution team

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34
Q

Management first line of schizophrenia

A

Atypical antipsychotic- queitapine

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35
Q

When should clozapine be used in schizophrenia

A

If after sequential use of 2 or more antipsychotic drugs for at least 6-8 weeks (at least one is atypical)

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36
Q

What can affect the dose adjustment of clozapine

A

If smoking started or stopped during the treatment

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37
Q

What are the first rank symptoms of schizophrenia

A

Delusional perception
Auditory hallucinations (third person)
Though broadcasting
Delusions of control where actions, emotions driven/controlled by an external force

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38
Q

What psychotherapy can be used for psychosis

A

CBT- can help with paranoia and distressing symptoms

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39
Q

How is catatonia typically managed

A

Benzos
If need can use ECT

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40
Q

What is catatonia

A

Stopping voluntary movements or staying still in very unusual posture

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41
Q

What is strongest risk factor for psychotic disorder

A

Family history

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42
Q

What is best antipsychotic if suffering side effects

A

Arpiprazole- especially increased prolactin

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43
Q

What is a delusional perception

A

You see something ordinary and it triggers a delusional belief

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44
Q

What are the types of schizophrenia

A

Catatonic
Paranoid
Hebrephenic
Simple
Residual

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45
Q

Positive symptoms of schizophrenia

A

Delusions
Thought interference
Hallucinations (typically third person discussing)
Sense of being controlled

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46
Q

Negative symptoms of schizophrenia

A

Reduced motivation
Reduced empathy
Reduced critical thinking
Loose association of thought

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47
Q

What are features of paranoid schizophrenia

A

Dominated by paranoid delusions and hallucinations
Perceptual disturbances common
Other symptoms typically absent or not noticeable

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48
Q

What are features of hebrephenic (disorganised schizophrenia)

A

Fleeting mood, affect, delusions, hallucination and behaviour
Completely unpredictable and disorganised
Childlike and silly manner

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49
Q

When is hebrephenic schizophrenia typically diagnosed

A

15-25

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50
Q

Features of catatonic schizophrenia

A

Fluctuates between states of hyperkinesis and stupor
Psychomotor disturbances
Violent excitement common as well as vivid hallucinations

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51
Q

What happens in simple schizophrenia

A

Is an insidious and progressive development of oddities of conduct unable to meet demands of society and decline in performance
Features of negative schizophrenia without preceding overt psychotic symptoms

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52
Q

What happens in residual schizophrenia

A

Clear progression from early to late stage schizophrenia characterised by long term negative symptoms after preceding hallucinations and delusions
- psychomotor slowing, underactivity, blunting of affect, poverty of speech, poor self care

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53
Q

What is clanging a sign of

A

Mania

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54
Q

What is clanging

A

Making word choice based off the sound of word rather than meaning- allitteration, rhyming and puns which dont make sense common

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55
Q

Factors associated with poor prognosis in schizo

A

Strong family history
Gradual onset
Low IQ
Prodromal phase of social withdrawal
Lack of obvious cause

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56
Q

What are main risk factors for schizo development

A

FHx
Black
Migration
Urban
Cannabis use

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57
Q

What is summary of schizophrenia management

A

First line: Atypical antipsychotic (quetiapine)
Clozapine if resistant to 2 antipsychotics including 1 atypical
CBT
Check CVD rfx

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58
Q

What is risk of atypical antipsychotics in the elderly

A

Stroke and VTE

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59
Q

What is disorder when think you are dead

A

Cotard
Is a big problem as patients do not drink or eat as see as futile

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60
Q

What is cotard syndrome seen in

A

Severe depression
Sometimes schizoprenia

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61
Q

What is syndrome where think partner is cheating with no proof

A

Othello

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62
Q

What is syndrome where think a famous person is in love with her

A

De clerambaults (also known as erotomania)

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63
Q

What is syndrome where think a friend has been replaced by an imposter

A

Capgras
Seen in schizo

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64
Q

What is it called when someone with impaired vision has recurring hallucinations

A

Charles de bonnet

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65
Q

Most common tardive dyskinesia

A

Chewing and jaw pouting

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66
Q

What is seen in acute dystonia

A

Sustained muscle contraction
Examples being torticollis and oculogyric crisis

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67
Q

What is torticollis and oculogyric crises

A

Oculogyric crises- spasmodic movements of eyeballs where they fix typically in upward position
Torticollis- where lateral neck fixes meaning and so is swayed to one side

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68
Q

What is it called when believe body is infected with insects or that they are crawling all over you

A

Delusional parasitosis or Ekbom syndrome

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69
Q

Charles de bonnet does not exclusively occur in presence of visual impairment, what other factors can contribute

A

Advanced age
Social isolation
Cognitive impairment

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70
Q

What is a pseudohallucination

A

When hallucinate but realise they are not real

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71
Q

What is it called when see recently dead loved one but realise they are not real

A

Pseudohallucination
Normal part of grieving process and reassure are not a sign of psychosis

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72
Q

Psychosis which persists less than a month with return to normal self

A

Brief psychotic disorder

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73
Q

Which congenital defects are SSRIs assocaited with in pregnancy

A

Cardiac

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74
Q

What type of drug is chlorpromazine

A

Typical anti-psychotic

75
Q

What effect does stopping smoking have on clozapine levels

A

Increases them as it inhibits CYP450

76
Q

If miss clozapine for 2 days what do you need to do

A

Re-titrate to old dose and request plasma level assay

77
Q

What is alogia

A

Poverty of speech

78
Q

What is avolition

A

Poor motivation

79
Q

What is used to treat tardive dyskinesia

A

Tetrabenzine

80
Q

If multiple people in same room have developed delirium what is first line investigation

A

Pulse oximetry from CO poisoning

81
Q

What is an extracampine hallucination

A

When perceive something beyond the limits of human sensory field
eg- voice being projected from Mars

82
Q

What is an elemental hallucination

A

Simple hallucination such as flashes of light or noises

83
Q

What is thought echo

A

When thoughts of patients appear to be spoken out loud

84
Q

What is a pareidolic illusion

A

the tendency for perception to impose a meaningful interpretation on a nebulous stimulus, usually visual, so that one sees an object, pattern, or meaning where there is none
Like seeing a face in fire

85
Q

How are acute and transient psychotic episodes diagnosed

A

Time interval between first symptom and full presentation of disease should be less than 2 weeks
No evidence of drugs or organic disease

86
Q

How are delusions classified

A

Persecutory
Grandiose
Somatic
Nihilistic
Referential

87
Q

What differs hallucinations from pseudohallucinations

A

They will actually try to look for source of voice
Pseudohallucinations are often voices in head versus hallucinations are in wall

88
Q

What is perseveration

A

When give a response correctly but then afterwards keep giving that response even though incorrect

89
Q

What is verbigeration

A

No sense at all

90
Q

What are the first rank hallucinations

A

Third person running commmentary
Thought echo- where all thoughts are spoken by someone else

91
Q

How is schizophrenia diagnosed

A

2 psychotic symptoms for over a month or 1 psychotic and 1 other symptom

92
Q

Difference between BPAD, schizo and schizoaffective disorder

A

BPAD- psychosis at extremes of mood
Schizophrenia- normal variation in mood with psychosis any time
Shizoaffective- great variations in mood but with psychosis at any point unrelated to mood

93
Q

Difference in presentation of psychosis men versus women

A

Men- late teens/young 20s
Women- 25-35

94
Q

Why is life expectancy reduced in schizo

A

Suicide
Dont look after eachother

95
Q

What is MOA of aripiprazole

A

Partial dopamine agonist

96
Q

First line antipsychotics for schizophrenia

A

Risperidone
Amisulpride
Zipradisdone

97
Q

CBT for schizophrenia

A

Normalisation of psychotic symptoms
How to manage hallucinations
Delicately approach the delusions and try to prove is not right

98
Q

When is disorientation in space and time seen

A

Wernickes

99
Q

What are chlorpromazine and promethazine

A

Anti-histamines

100
Q

What is theory behind psychosis

A

Excess dopamine in the mesolimbic pathway promotes positive symptoms
Dopamine deficiency in the mesocortical circuit promotes negative symptoms as prefrontal cortex key in aetiology of negative and cognitive symptoms

101
Q

What are 4 dopamine pathways in the brain

A

Mesocortical- cognitive function and inhibition
Mesolimbic- reward system
Nigrostriatal- part of movement pathway
Tuberoinfundibular- inhibits prolactin

102
Q

What % of dopamine receptor blockade is needed for clinical benefits

A

60-80

103
Q

Which anti-psychotics are used for rapid tranquilisation

A

Olanzapine or haloperidol

104
Q

Order of tranquilisations if needed

A

1st- benzos try oral first
2nd- promethazine
3rd- haloperidol or olanzapine

105
Q

What antipsychotic can prolong QTc

A

Haloperidol

106
Q

What is needed prior to using haloperidol for tranquilisation

A

An ECG to show no QT prolongation

107
Q

What worried about when using antipsychotics for tranq

A

Resp depression

108
Q

Parkinsonism features

A

Bradykinesia
Pill rolling temor
postural insability
hypomimia
shuffling gait
Bilateral presentation

109
Q

Female specific effects of antipsychotics

A

Amenorrhoea

110
Q

If suffering from hyperprolacinaemia what do with antipsychotic

A

Do not necessarily replace with aripiprazole
Can use it as adjunct

111
Q

QTC normal ranges in men and women

A

Men less than 440
Women less than 470

112
Q

What antipsychotic use if prolonged QTC

A

Aripiprazole
Zuclopenthixol

113
Q

Management of neuroleptic malignant syndrome

A

Stop drug
Cooling devices
transfer to ITU
Fluids
Benzos- for agitation and to relax muscles
Bromocriptine

114
Q

What are types of though alienation

A

Though withdrawal- thoughts removed from head
Thought insertion- where thoughts are placed in ones head
Though broadcasting- where think people hear thoughts

115
Q

What is best management of early psychosis

A

Low dose aripiprazole
Education and support

116
Q

With which EPSE is it appropriate to reduce dose of antipsychotic

A

Restlessness

117
Q

What is fregoli syndrome

A

When think a stranger is being impersonated by someone you know

118
Q

What are PET scan findings of schizophrenia

A

Hypoactivity of prefrontal cortex
Enlarged cerebral ventricles

119
Q

What is PET scan finding in OCD

A

Hyperactivity in prefrontal cortex

120
Q

What drug can be given for delirium

A

Haloperidol

121
Q

What drug is used to treat hypersalivation in clozapine treatment

A

Hyoscine

122
Q

What is it when 2 people share a delusion

A

Folie a deux
Typically between 2 codependant people

123
Q

What is best treatment of folie a deux

A

Separating the 2 people

124
Q

If admitting patient on ward with schizo what would be pharmacological treatment

A

Atypical antipsychotic
Procyclidine and benzo PRN

125
Q

What type of delusion is a delusional perception

A

Primary

126
Q

What is best way of assessing risk to others

A

Historical clinical risk- 20

127
Q

What is best way of assessing for psychopathy

A

PCL-R

128
Q

Side effect when mix clozapine with lithium

A

Hypersalivation- treat with hyoscine

129
Q

What is management of delirium

A

If patient very distressed try verbal calm down techniques
- if unsuccessful AND others are at threat then tranquilise

130
Q

If patient very agitated on ward what are techniques used

A

Verbal deescalation
If not successful use IM lorazepam
Physcial restraint
Seclusion

131
Q

What is a delusional disorder

A

No other psychotic symptoms but 1 single delusion is symptom

132
Q

Criteria for a delusion to be a delusion

A

Patient is certain of it
Can’t be shown evidence to contrary
Falsity

133
Q

What is a delusion of reference

A

When you think something in real world is related to you even if it isnt

134
Q

What are persecutory delusions

A

Where have belief are going to be harmed or mistreated

135
Q

In primary psychotic disorders what is most common type of hallucination

A

Auditory

136
Q

Organic causes of psychosis- infective

A

Enchephalitis/meningitis
Neurosyphylis
Toxoplasmosis

137
Q

Autoimmune causes of encephalitis

A

Auto-immune encephalitis
Get anti-NMDA receptor

138
Q

Nutritional causes of psychosis

A

Pellagra
B12 defic

139
Q

Endocrine causes of psychosis

A

Hyperthyroid
Cushings

140
Q

Prescribed drugs causing psychosis

A

Steroids
Anti-cholinergics
Methylpoda
Excess levothyroxine
Anti-malarials, anti-retrovirals, isoniazid

141
Q

Psychological interventions for schizophrenia

A

CBT
Family therapy- all family members of someone with schizo should be offered family therapy

142
Q

Purpose of family therapy in schizophrenia

A

Improve relationships and communication between family members
Explain that relapse more common when family more concerned/overinvolved

143
Q

Social interventions for schizophrenia

A

Vocational rehab
Sheltered employment
Individual job searching and liasing with employers

144
Q

What is only anti-pyschotic which can treat negative psychotic symptoms

A

Clozapine

145
Q

Where does mesolimbic pathway project to and from

A

Ventral tegmental area to ventra striatum in basal ganglia

146
Q

What is difference in MOA between atypical vs typical anti-psychotics

A

Typical- D2 antagonism
Atypical- Less affinity for D2, also on serotonin

147
Q

How often is FBC measured in clozapine

A

Weekly for first 18 weeks
18 weeks- 1 year- fortnightly
Beyond 1 year- monthly

148
Q

How does FBC testing in clozapine classify patients

A

Red, amber, green
Red- stop immediately
Amber- measure twice weekly until green
Green- continue

149
Q

What is it called when someone presents with schizophrenia prodromal appearing history but only negative symptoms which present

A

Described as ‘at risk mental sate’ - presents in young people who withdraw from all activities

150
Q

How long can delirium symptoms last for

A

6 months- beyond which they need assessment

151
Q

If on remand and need transferring to hospital for mental health treatment what is section used

A

48

152
Q

If committed crime and deemed to be insane how are you maanged

A

Kept in hospital under a section 37 or (41)
Treated for mental health condition

153
Q

If are a sentenced prisoner and need transfer to hospital for mental health treatment what is section used

A

47

154
Q

For both remanded and sentenced prisoners when being transferred to hospital, what section is used for when crime is serious

A

Section 49 as includes a restriction order

155
Q

Who orders a restriction order to be added to a section 47 or 48

A

Court

156
Q

Psychopathy traits

A

Glib and superficial
Inflated and arrogant self-appraisal
Lacks remorse
Lacks empathy
Deceitful and manipulative
Early behavioural problems
Adult antisocial behaviour
Impulsive
Poor behavioural controls
Irresponsible

157
Q

Whar are 3 main risks to look out for in clozapine treatment

A

Agranulocytosis
Intestinal obstruction
Myocarditis

158
Q

Causes of delirium

A

Infection
Change in environement
Medication
Alcohol withdrawal
Surgery
Constipation
Urine retention
Dehydration
Hyponatraemia

159
Q

What is used to detect/screen delirium

A

Confusion assessment method

160
Q

How does confusion assessment work

A

Acute onset and Inattention
With 1 of
- disorganised thinking
- altered consciousness

161
Q

How is delirum managed

A

Create safe environment
Painkillers and treat cause
1 to 1 nursing with all those who interact being aware of situation and how to deal with the patient

162
Q

If have a twin with schizo, what is chance of you developing it

A

1 in 2

163
Q

When removing an anti-psychotic because of a side effect how do it

A

Slowly as not only risk of psychotic relapse but also worsening sx

164
Q

What is schizoaffective disorder

A

When psychotic symptoms of schizophrenia such as first rank sx present alongside extremes of mood symptoms

165
Q

What are the 2 types of schizoaffective disorder

A

Manic type
Depressive type
Based on the mood symptoms present

166
Q

Are mental health disorders seen as a risk factor for harm to others

A

No they are more likely to be a victim

167
Q

Which antipsychotic particularly associated with weight gain and DM

A

Olanzapine

168
Q

If someone has history of DM and HTN what antipsychotic use

A

Typical

169
Q

First step in management of neuroleptic malignancy

A

Cooling and fluids

170
Q

Management of schizoaffective disorder

A

Lithium and antipsychotic

171
Q

What other than antipsychotics can cause NMS

A

Missed dopamine agonist dose

172
Q

What typically precipitates NMS

A

Abruptly withholding a dopamine agonist or anti-psychotic

173
Q

How manage if have long QT evidence on ECG

A

Discuss with cardiology- do not immediately cessate

174
Q

What is couvade syndrome

A

When mimic a pregnant womens symptoms

175
Q

What is particularly associated with ekbom syndrome

A

B12 deficiency

176
Q

What can be used to minimise fall risk in a delirium patient

A

Bed rails

177
Q

Management of autoimmune encephalitis

A

IVIG
Steroids

178
Q

Management of agitation in neuropsychiatric conditions such as autoimmune encephalitis

A

Second gen antipsychotics like risperidone

179
Q

How does clozapine toxicity present

A

Confusion
Drowsiness
Ataxia
Tachycardia

180
Q

What can precipitate clozapine toxicity

A

Infections

181
Q

What do for someone with an at risk mental state with a first degree relative who has schizophrenia

A

Refer immediately

182
Q

What are delusions of guilt

A

Where think deserved to be punished for something very small and insignificant

183
Q

What is thought blocking

A

When stop talking and then all of a sudden continue speaking about a different topic

184
Q

What is difference between thought withdrawal and blocking

A

In both patients randomly stop talking
Withdrawal- stop talking then begin talking about same thing
Blocking- stop talking then start talking about different topic

Psych (Owen) (9 decks)

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