Psychosis Flashcards
Define psychosis
Impaired assessment of reality with significant alterations in perceptions, thoughts, moods andbehaviours.
What are some abnormal psychomotor behaviours?
Catatonia
Abnormal movements
Abnormal postures
What is the key course of psychostic disorders?
Prodromal period - common but not always - lasts a few days to months
Acute episode - often followed by a relapsing and remitting courses of extended time period (years)
What is the relevant epidemiology of schizophrenia?
Most common onset 2nd or 3rd decade
1% of population
What is meant by positive symptoms of psychosis?
Add to patients experience of illness
Hallucinations - sensory stimuli in absence of real
Delusions - unusual or bizarre fixed beliefs (persecutatory)
Abnormal thinking processes and though experiences
Passivity experience - external control of bodily movements
Disorganisation of thought and behaviour
What are the key features to understand of auditory hallucinations of voices?
Internally or externally
How many? Any recongisable?
Content: derogatory, neutral, affirming
Commanding - does patient want to act on this?
Third person - ‘running commentary’ of what the patient is doing
What are the different types of hallucinations?
Visual
Auditory
Olfactory
Gustatory
Tactile
Any felt stimulus in the absence of real stimuli.
What is pareidolia?
Seeing faces in objects
What is apophenia?
Tendency to perceive meaningful connections between unrelated things.
Predispose to hallucinations or delusions
‘very gullible’ - is a normal trait but can be overactive in developing psychosis.
What is the key difference between a hallucination and a delusion?
Hallucination - percieved stimuli that does not exist
Delusion - misinterpretation of a real stimuli - tends to be belief patterns
Define delusion
A false (not always wrong)
Fixed and unshakeable
Out of keeping with personals normal social and religious context
Tend to be beliefs or thought processes
What is the key difference between an overvalued idea and a delusion?
Overvalued - comprehensible idea, pursued beyond the bounds of reason -> may be believable under social/religious norms but is exaggerated, is shakeable
Delusion - false and unshakeable belief generated by internal processes -> more personalised
What are the difference types of delusions?
Persecutory (paranoid)
Grandiose (being a superhero)
Jealousy - partner cheating
Erotomanic - in love with you
Somatic - hypochondria
Nihilistic - severe depression
What is meant by a mood congruence and mood incongruence delusion?
Congruence - feature of delusion suits patients mood - typically nihilistic in depression
Incongruence - does not align with mood typically seen in schizophrenia
What is passivity phenomena/delusion of control?
Commonly in schizophrenia - loss of boundary between self and others
Belief that an external entity is interfering with thoughts/movements/ previously voluntary actions.
What are the different types of delusions people experience relating to their thoughts?
Though insertion - someone putting thoughts into my head
Thought withdrawal - taking thoughts out of the head
Thought broadcasting - other people able to read our thoughts
What are the different disorganisations of throughts present in patients with psychosis?
Thought block - patient might interpret as thought withdrawal
Derailment - jumping or lack of logical connection
Formal thought disorder - affects form not content
What is meant by a negative symptom of schizophrenia?
Detract from a patients ability to function
Flattened or restricted (“blunted”) affect - unreactive to situations/events
Cognitive impairements - attention and executive function
Decreased volition/apathy (not goal driven)
Deterioration in social function and activities of daily living.
What is catatonia?
Changes in mental state and physical behaviour
Appear to act unmotivated to outsiders
What are the signs of catatonia?
LIMP MEN
Lethargy - no activity, comatosed despite being awake
Immobility - physical lack of activity
Mutism
Positioning - catalepsy (rigidity hard to change to position), posturing (maintain same posture for long period of time - waxy flexibility)
Motor - grimacing, mannerism, sterotypy (repeating pointless movements again)
Echolalia - repeating phrases - echopraxia - movements - typically of people around them
Negativism - no response to external stimuli
What conditions if catatonia most common in?
Bipolar - 50%
Psychosis - 15%
Depression - 35%
What are the complications of catatonia?
DVT
PE
Failure to follow ADLs - often hospitalised
<50% would recover if left untreated
What is malignant catatonia?
Catatonia with autonomic dysfunction
including sweating, fevers, changes in heart/resp rate and BP
Up to 10% mortality rate with treatment
What is the typical treatment for catatonia?
BED
Benzodiazepines at high doses- affect within minutes
ECT if treatment-resistant
D/c antipsychotics - can worsen catatonic once developed and inc risk of neuroleptic malignant syndromes
What are the risk factors for schizophrenia?
Genetics - vulnerability 10 genes with stong inc
Childhood psychological trauma - modify genetic expression
Pregnancy and birth complications - low bw, premature, neonatal asphyxia
What are common triggers for schizophrenia?
Stressful life events - loss, bereavement, redundancy, divorce, abuse
Drug misuse - two way associations - cannabis, cocaine, LSD, amphetamines
What is the gold standard for treatment of schizophrenia?
Antipsychotic medication combined with psychological intervention
Therapy - supportive, education, stress-vulnerability model
May take form of CBT or family therapy
What is the main proposed theory behind the cause of psychosis?
The dopamine theory
Imbalances in dopamine pathways/function in the brain leads to psychosis
What are the four main dopamine pathways affected in psychosis?
Mesolimbic
Mesocortical
Nigrostriatal
Tuberoinfundibular
How is mesolimbic pathway affected in Schizoprehnia?
Typically inc dopamine activity -> VTA to nucleus accumbens (Limbic system) -> emotion and reward
This leads to positive signs - hallucinations, delusions
How is the mesocortical pathways typically affected in schizophrenia?
Typically dec dopamine activity -> VTA to the prefrontalcortex -> cognitive and executive function
leads to negative signs - socially withdrawn, decline in ability to perform ADLS, apathy
How is the nigrostriatal pathway affected in schizophrenia?
Increased dopamine activity
This leads to hyperkinesia + dyskinesia + tics
How is the tuberofundibular pathway affected in anti-psychotics?
Atypicals have a limited affect
Typicals - reduced dopamine activity - lead to unsuppressed prolactin release - prolactinaemia
= galactorrhoea, gynaecomastia, sexual dysfunction
How is the nigrostriatal pathway affected by anti-psychotics?
Atypicals have a limited affect
Typicals - reduce dopamine activity -> leads to Parkinsonian like symptoms and extrapyramidal side effects
What are the key side effects of typical anti-psychotics?
Extrapyramidal side effects = parkinsonian, dystonia, dyskinesia (often in the face = lip smacking)
Hyperprolactinaemia = galactorrhea, sexual dysfunction, gynaecomastia
May cause worsening negative signs of schixo = dec dopamine in mesocortical pathway
What is the basic mechanism of action of typical/1st gen antipsychotics?
Block Dopamine receptors - mainly D2
Are NOT selective of the dopamine pathway
What are some common high potency typical anti-psychotics?
Haloperidol
Fluphenazine
Prochloroperazine
Trifluperazine
What are some common low potency typical anti-psychotics?
Chloropromazine
What are the typicall side effects of chloropomazine?
Low potency typical anti-psychotic - extra-pyramidal and hyperPL are less common
Affects:
Alpha adrenergic receptors - postural hypos
Cholinergic - AC - confusion, dry mouth, constipation, urinary retention
Histamine - sedation and weight gain
What is the basic mechanism of action of atypical/2nd generation antipsychotic drugs?
Block D2 receptors - more transiently
Block seratonin receptors (5-HT2A) - blockage leads to increased dopamine production - reduce affect of above in certain dopamine pathways - reduce risk of extrapyramidal side effects
What are some examples of 2nd generation antipsychotics?
Aripiprazole
Clozapine
Lurasidone
Olanzapine
Quetiapine
Risporidone
Ziprasidone
What atypicals anti-psychotics have side effects at seratonin recepotors?
What are these efects
Clozapine
Olanzapine
Hyperlipidaemia
Hyperglycemia
Weight gain
What atypical anti-psychotics have side effects at histamine receptors?
What are these effects?
Clozapine
Quetiapine
Olanzapine
Drowsiness
Weight gain
What atypical anti-psychotics have side effects at alpha-1 receptors?
Clozapine
Risperidone
Postural drops = orthostatic hypotension
What atypical antipsychtoic can have side effects at dopamine receptors?
What are these effects?
Risperidone
Extra-pyramidal and hyperprolactinemia
What are the key side effects of typical antipsychotics?
Hyperprolactinaemia - galactorrhea, amenorrhea, sexual dysfunction
Extra-pyramidal -> parkinsonism, dystonia (Sustained muscle contraction), dyskinesia (involuntary movements often in the jaw), akathisia (severe restlessness)
What are the key side effects of atypical antipsychostics?
Metabolic syndrome -> commonly requires monitoring for hypercholesterolemia and hyperglycemia
Rispiridone -> may also cause hyperprolactinemia.
What side effect is common for both typical and atypical antipsychotics?
Sedation
What is the defining feature of aripriprazole?
Atypical antipsychotic
Tends to have less side effects but is also less effective
What is important to know about clozapine?
Risk of agranulocytosis -> vulnerable to infection -> requires weekly then monthly bloods for course of duration
Also hypersalivation -> risk of aspiration pneumonia
Constipation -> risk of bowel obstruction
