Psychosis

Question 1

How does psychosis present?

Answer 1

hallucinations
psychomotor
thought disorder - eg. word salad, flight of ideas
delusions
negative symptoms

Question 2

Psychosis differentials

Answer 2

schizophrenia
schizoaffective disorder
bipolar disorder
organic disorders (delirium, dementia, temporal lobe epilepsy, brain injury)
psychotic depression
post-partum psychosis
delusional disorder
substance-induced psychosis

Question 3

What medical conditions should be ruled out in psychosis?

Answer 3

delirium
dementia
malignancy
epilepsy
head trauma
cerebrovascular accident
HIV/AIDS encephalitis
CJD
syphilis
metabolic (Ca, Na, glucose)
vitamin deficiencies (B1, B3, B12, folate)
medications
substances

Question 4

What are the ICD-11 criteria for delusional disorder?

Answer 4

presence of a delusion or set of related delusions
persists for at least 3 months
absence of a depressive, manic or mixed episode
common forms of delusion = grandiose, somatic, persecutory, jealousy, erotomania
affect, speech and behaviour typically unaffected
symptoms not due to another disorder

Question 5

Common delusions

Answer 5

persecutory
somatic
grandiose
jealousy
erotomania

Question 6

What is capgras syndrome?

Answer 6

belief that a person closely related to the patient has been replaced by a double

Question 7

What is Fregoli syndrome?

Answer 7

identifies familiar people in strangers

Question 8

What is De Clerambault’s syndrome?

Answer 8

erotomania
often believe that someone of a higher social class is in love with them
commoner in women
they may pester the victim with letters/stalking behaviour

Question 9

What is Othello syndrome?

Answer 9

also known as morbid jealousy
delusional belief that partner is having an affair without any evidence
occurs in alcoholism, organic states, affective psychosis
leads to domestic violence

Question 10

What is Cotard’s syndrome?

Answer 10

nihilistic delusion
false belief that part of the body is dead, dying or doesn’t exist
typically seen in psychotic depression

Question 11

What is Ekbom syndrome?

Answer 11

delusional parasitosis
describes the delusion of infestation
often associated with tactile hallucination (formication) in cocaine misuse, dementia and alcohol withdrawal
occurs in affective psychosis, delusional disorder, paranoid schizophrenia, organic brain syndromes

Question 12

What is Foli-a-deux?

Answer 12

delusion disorder that occurs at the same time in 2 people that have a strong emotional or situational link
one person adopts the delusional belief of the other
delusions may remit in the less dominant person when the 2 individuals are separated

Question 13

Causes of substance-induced psychosis

Answer 13

alcohol
cannabis
legal highs
amphetamines
cocaine
hallucinogens
inhalants/solvents
prescribed medications (anti-parkinsonian drugs, corticosteroids, anticholinergics)

Question 14

Management of substance-induced psychosis

Answer 14

setting - do they need acute physical care? detention?
antipsychotics
abstinence from the substance

Question 15

What is puerperal psychosis?

Answer 15

psychosis post-partum

Question 16

Puerperal psychosis presentation

Answer 16

positive psychotic symptoms
depressive/manic symptoms also typically present

Question 17

Puerperal psychosis risk factors

Answer 17

history of puerperal psychosis
pre-existing psychotic illness of severity requiring inpatient admission
family history of affective psychosis in 1st or 2nd degree relatives

Question 18

Management of puerperal psychosis

Answer 18

as per psychosis in general
need to consider if mother is breastfeeding: olanzapine + quetiapine have lowest levels in breastmilk, mothers on clozapine should not breastfeed

Question 19

Lewy body dementia pathology

Answer 19

alpha-synuclein cytoplasmic inclusions (Lewy bodies) in the substantia nigra, paralimbic and neocortical areas

Question 20

Features of Lewy body dementia

Answer 20

progressive cognitive impairment
parkinsonism
visual hallucinations
fluctuating cognition
repeated falls, syncope
neuroleptic sensitivity

Question 21

Lewy body dementia medical management

Answer 21

donepezil
rivastigmine
galantamine
antipsychotics - clozapine, quetiapine (typical antipsychotics will significantly worsen parkinsonism)

Question 22

Behaviours and psychological symptoms of dementia

Answer 22

agitation, aggression, distress, psychosis
wandering + hoarding
depression + anxiety
sexual disinhibition
sleep problems
apathy + shouting

Question 23

When should antipsychotics be given in dementia?

Answer 23

serious risk of harm to self or others
experiencing agitation, hallucination or delusions causing severe distress

Question 24

What antipsychotics are preferred in dementia?

Answer 24

risperidone first choice (except in lewy body dementia)
haloperidol second choice

Question 25

Delirium management

Answer 25

non-pharmacological:
- calm environment, consistent caregivers
- regular family visits
- optimise sensory acuity - glasses, well-lit room, hearing aids
- orientation aids - clock, calendar

pharmacological:
- haloperidol
- quetiapine
- avoid benzodiazepines unless substance withdrawal