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Psychiatry > Psychosis > Flashcards

Psychosis Flashcards

1
Q

Positive symptoms

A
  • Too much DA in mesolimbic (ventral tegmentum to limbic) system
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2
Q

Negative symptoms

A
  • Too little DA in mesocortical (ventral tegmentum to cortex)
  • Flat affect, alogia, avolition, apathy
  • More debilitating re social/occupational
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3
Q

Movement symptoms (Parkinsonian rigidity, bradykinesia, tremors; akathisia, dystonia spasms)

A
  • DA hypoactivity (too little DA to suppress ACh) in nigrostriatal (substantia nigra to basal ganglia)
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4
Q

Hyperprolactinemia SE of antipsychotics

A
  • Too little DA to regulate prolactic release in tuberoinfundibular pathway (hypothalamus to anterior pituitary)
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5
Q

Typical antipsychotics

A
  • D2 receptor blockers
  • High potency (EPS): Fluphenazine, Haloperidol, Pimozide
  • Low potency (cardiotoxic and anticholinergic): Chlorpromazine, Thioridazine
  • 3-5% per year TD, highest in women with affective d/o
  • Dystonia highest in young males
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6
Q

Atypical antipsychotics

A
  • SDAs (serotonin-dopamine 2 blockers)
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7
Q

Risperidone (Risperdal)

A
  • More like a typical at doses >6mg daily
  • EPS
  • Most likely atypical to induce hyperprolactinemia
  • Wt gain, sedation dose-dep
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8
Q

Olanzapine (Zyrexa)

A
  • Wt gain, hyperTG, hyperChol, hyperGlycemia, hyperProlactinemia (less than risperidone), Transaminitis in 2%
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9
Q

Quetiapine (Seroquel)

A
  • Most likely to cause orthostatic hypotension
  • Wt gain, hyperTG, hyperChol, hyperGlycemia (less than olanzapine)
  • Transaminitis in 6%
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10
Q

Ziprasidone (Geodon)

A
  • NO WT GAIN
  • QT prolongation
  • Hyperprolactinemia (less than risperidone)
  • Up to 100% absorption with food
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11
Q

Aripiprazole (Abilify)

A
  • Unique MoA as D2 partial agonist
  • NO WT GAIN
  • Low EPS, no QT prolong, low sedation
  • 2D6 (fluoxetine, paroxetine), 3A4 (carbamazepine, ketoconazole) interactions warrant adj dosing. Potential intolerability d/t akathisia/activation
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12
Q

Clozapine (Clozaril)

A
  • Reserved d/t SE profile
  • Agranulocyosis requires weekly blood draws for 6 months, then 12wks for 6 months
  • Seizures (esp with lithium)
  • Assoc with the most sedation, wt gain, transaminitis
  • HyperTG, hyperChol, hyperGly, nonketotic hyperosmolar coma and death
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13
Q

Iloperidone (Fanapt)

A
  • Titrate over 4 days d/t orthostatic hypotension
  • BID dosing
  • Low EPS, akathisia, wt gain, metabolic d/o
  • Inh 2D6 (fluox, parox) and 3A4 (keto, CMZ), can increase blood levels 2x!
  • QT prolongation
  • Not for hepatic illness
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14
Q

Asenapine (Saphris)

A
  • No titration needed
  • BID dosing. SubL
  • Sedation, somnolence, akathisia
  • Low wt gain and metabolic d/o
  • Inh 1A2
  • Not for hepatic illness
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15
Q

Lurasidone (Latuda)

A
  • Once daily, no titration
  • No QT prolong, less wt gain and metabolic d/o
  • Must take with food
  • Akathisia, sedation
  • Limit to 40mg with renal or hepatic illness
  • C/I with 3A4 inhibitor/inducer
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16
Q

Man with schizophrenia presents with muscle rigidity, fever, AMS, orthostatic hypoT. Found to have leukocytosis, CPK, LFTs elevated.

A
  • NMS
17
Q

Man with schizophrenia presents with acute dystonia, Parkinson syndrome, akathisia.

A
  • EPS. Due to lack of DA inhibition of ACh in nigrostriatal pathway (SN to BG).
  • Tx with anticholinergic such as benztropine, trihexyphenidyl, diphenhydramine. DA facilitator Amantadine. BB propranolol.
  • Watch for anticholinergic SE if on TCA.
18
Q

21M admitted for psychosis. Treatment naive. What baseline blood work prior to starting an antipsychotic?

A
  • Fasting lipids, glucose, LFTs, CBC
  • If he has high cholesterol, consider using Aripiprazole, Risperidone, or Ziprasidone. (No Quetiapine or Olanzapine)
  • Risperidone 3mg BID -> “uncomfortable in my skin like I can’t sit still” = akathisia = increased suicide risk! Tx with anticholinergic or propranolol.
19
Q

29W presents to ED by police after screaming at Starbucks and threw coffee at barista. “I need to be taken to jail. I contaminated someone with a virus.” WBC 11.2, K 3.2, negative Utox, fully oriented, no LOC.

A

MDD with psychotic features

20
Q

Brief psychotic episode

A
  • Delusion/halluc/disorg speech/disorg or catatonic behavior for < 1 month with eventual return to previous functioning
21
Q

Personality disorders that look like psychosis

A

Borderline (think they hear people talking trash), paranoid, schizotypal, OCD

22
Q

Substance induced psychosis

A

Need to resolve within a month of sobriety (including marijuana). Except for methamphetamine, which can last longer. Otherwise primary psychosis.

23
Q

Mood congruent delusions

A

Depression - personal inadequacy, guilt, disease, death, deserved punishment;
Mania - themes of worth, power, knowledge, special relationship to deity;
Mood incongruent - control, persecution, thought broadcasting, thought insertion

24
Q

MDD with psychotic features

A

Must have psychosis only while depressed; 18.5% of MDD patients; tx with antidep + antipsych; ECT (especially elderly and pregnant)

25
Q

ECT in MDD with and with psychotic features

A

95% remission in MDD with psychosis; 83% in those with just MDD

26
Q

BD 1, manic or mixed, with psychotic features

A

Manic or mixed and exhibiting psychotic features; 25% of BD1 patients; Tx with mood stabilizer + antipsychotic; ECT if mixed or nonresponder; catatonia - tx with BZDs

27
Q

Schizophrenia

A

> /= 2 symptoms for most of 1 month, continuous signs of disturbance for 6 months. Must have at least one of core positive (delusions, hallucinations, disorganized speech); others: disorganized or catatonic behavior, negative symptoms of flat affect, alogia, avolition, apathy; If hear two voices, only need one symptom; Must cause significant social/occupational dysfx; Affects 1-2% population; Male dx 17-27yo, Females 17-37yo; Only 10% cases after 45yo

28
Q

Schizophrenia sub-types

A

Paranoid (most common); Disorganized; Catatonic

29
Q

Genetics of schizophrenia

A

Proband increases prevalence of schizoid, schizotypal, schizoaffective, delusional disorder; 40-50% concordance in monozygotic twins; Other 50% unidentified environmental factors including in utero exposure

30
Q

Pathophysiology of schizophrenia

A

Increase in normal age-associated pruning FRONTOPARIETAL SYNAPSES during adolescence and young adulthood; MESOCORTICAL and MESOLIMBIC dopamine pathways

31
Q

Addiction in schizophrenia

A

47%; 4.6x risk; 3x for EtOH; 6x for drugs

32
Q

Schizophrenia illness course

A

90% do not return to pre-ilness social and vocational; 10% die by suicide; 1/3 severe with repeat hospitalization; 1/3 moderate with occasional hosp; 1/3 no further hosp but residual symptoms, interpersonal diff, most cannot maintain employment

33
Q

Schizoaffective disorder

A
  • Uninterrupted period of MDE or mixed episode after schizophrenia criterion met
  • Periods where delusions/halluc present for >2 wks without prominent mood symptoms
  • Mood disorder criteria met for substantial portion of illness
  • 0.7% prevalence
  • Tx antipsychotic; If depressed type add antidep; If BD type add mood stabilizer
34
Q

Substance-induced psych disorder

A
  • Prominent halluc or delusions
  • Evidence that symptoms developed within a month of intoxication or withdrawal (except meth), and substance etiologically related to disturbance
  • Symptoms cannot have started prior to taking med or be more sever than could be reasonably caused by amount of substance
  • Cocaine, EtOH, amphet, cannabis, LSD, PCP, NMDA, ketamine, inhalants, opioids
35
Q

Psychosis d/t GMC

A
  • Brain tumor, seizure, delirium, HD, MS, Cushing’s, Vitamin def, ‘Lyte abnormality, thyroid, uremia, SLE, HIV, wellbutrin, steroids, antimalarials
36
Q

Delusional Disorders

A
  • Delusion of at least 1 month, not schizophrenia, functional, no mood or substance, non-bizarre(?);
  • 0.03% prevalence; mean 40yo; females 1.2-1.6>1;
  • Subtypes: erotomanic, grandiose, persecutory, jealous, somatic, mixed;
  • Tx: generally resistant. If parasitosis delusion, antipsych; therapeutic alignment with non-confrontational approach; focus on reducing the stress
37
Q

Psychosis NOS

A
  • No other criteria met

Psychiatry (5 decks)

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