Psychosis Flashcards
1
Q
What is the prevalence of schizophrenia in the UK?
A
1%
2
Q
What is the life time risk of schizophrenia in the UK?
A
1%
3
Q
What age range is the normal time for onset of schizophrenia for men?
A
18-25
4
Q
What age range is the normal time for onset of schizophrenia for women?
A
25-35
5
Q
Which has an increased prevalence of schizophrenia ; a high or low socioeconomic class? (For extra keenness name the classes + explain why)
A
Lower socioeconomic class (class IV and V) (A theory to explain this may be that psychosis leads to a ‘drift’ down the social economic scale)
6
Q
Is schizophrenia more prevalent in rural or urban areas?
A
Urban areas
7
Q
Immigrants have a higher prevalence of schizophrenia, but which immigrant group have the highest?
A
Afro-Caribbean’s
8
Q
What % concordance is there for schizophrenia between monozygotic twins? (what backs this up?)
A
50% (adoption studies)
9
Q
What % concordance is there for schizophrenia between dizygotic twins? (what backs this up?)
A
10% (adoption studies)
10
Q
Schizophrenia can be related to developmental factors during which two specific periods?
A
Pregnancy and Birth
11
Q
Which two periods of the year are more schizophrenics born? (Why is this the case)
A
Late winter and spring (as second trimester influenza may play a role)
12
Q
Do imaging studies show functional or structural changes in the brain due to psychosis?
A
Haha trick question! Both functional and structural changes can be demonstrated
13
Q
What are the changes in the brain (shown via imaging) in psychosis caused by?
A
It can be 2ry to the condition or in fact due to the treatment
14
Q
Name the 2 main structural changes seen on brain imaging in psychosis? (extra marks for naming the 5 specific areas involved).
A
Ventricles become enlarged and brain size is reduced (frontal lobes, temporal lobes, hippocampus, amygdala and parahippocampal gyrus)
15
Q
What are the negative symptoms of psychosis associated with on neuroimaging?
A
An increase in size of the ventricles
16
Q
Which pathway in the brain is schizophrenia thought to be related to? (is it over or under active?)
A
Mesolimbic dopamine pathway. (it is over active)
17
Q
Which drugs potentiate the brain pathway involved in schizophrenia and therefore can produce psychotic symptoms?
A
Amphetamines and antiparkinsonian drugs
18
Q
Name three attitudes family members can have that may precipitate a psychotic patient to relapse
A
Over involvement, over critical and hostility. (essentially high expressed emotion)
19
Q
Is schizophrenia generally chronic or acute?
A
Chronic
20
Q
Is schizophrenia generally relapsing and remitting or constant?
A
Relapsing and remitting
21
Q
What % of schizophrenics have a single episode without relapse?
A
20%
22
Q
What % of schizophrenics have a poor outcome characterised by repeated psychotic episodes with hospitalizations, depression and suicide attempts?
A
50%`
23
Q
What % of schizophrenics successfully commit suicide?
A
10%
24
Q
Describe the most at risk group of schizophrenics that are likely to commit suicide. (there are 4 factors)
A
Young, well educated men who have good insight into their disease
25
Are schizophrenics most likely to commit suicide before, during or after a hospital stay?
After
26
How many years less do schizophrenics live on average?
10 years
27
Is the prognosis of schizophrenia better in developed or developing countries?
Developing
28
Which are more likely to have a better prognosis in schizophrenia: males or females?
Females
29
Which groups are more likely to have a better prognosis in schizophrenia: divorced, single or married individuals?
Married
30
Which are more likely to have a better prognosis in schizophrenia: younger or older age of onset?
Older age of onset
31
Which are more likely to have a worse prognosis in schizophrenia: onset without stress or onset precipitated by life stress?
Onset not precipitated by life stress
32
Which are more likely to have a better prognosis in schizophrenia: long or short duration of illness?
Short duration of illness
33
Which subtype of schizophrenia has a better prognosis?
Paranoid subtype
34
Which are more likely to have a worse prognosis in schizophrenia: those with negative symptoms or those where negative symptoms are abscent?
Those with negative symptoms
∴ negative symptoms = poor prognosis
35
Which are more likely to have a better prognosis in schizophrenia: those without prominent mood symptoms or those with prominent mood symptoms
Those with prominent mood symptoms
∴ mood symptoms = better prognosis
36
Does a family history of mood disorder translate to a poor prognosis in schizophrenia?
No a family history of mood disorder is a good predictor of disease outcome
37
Is good premorbid functioning related to a good prognosis in schizophrenia?
Yes, yes it is
38
Name 5 potential presenting symptoms in psychosis.
1) Abnormal perceptions (hallucination, pseudohallucination, illusion)
2) Abnormal beliefs (delusions (1ry and 2ry) and overvalued ideas)
3) Thought disorder (PET FACT)
4) Negative symptoms (- generally only once patient develops full on schizophrenia)
5) Psychomotor functioning (- generally only once patient develops full on schizophrenia)
Delusions, hallucinations, psychomotor abnormalities, mood/affect disturbance, cognitive deficits, disorganised thoughts and disorganised behaviour
39
Name the 3 types of abnormal perception.
Hallucination, pseudohallucination, illusion
40
Do hallucinations or illusions occur in the presence of physical symptoms?
Illusions
41
Do patients have a lot or only a little insight into hallucinations? (Explain why)
Patients have little insight as the hallucinations appear as if real to the patient
42
Which of the senses do hallucinations occur in?
Haha trick --> all of them
43
Are illusions possible in healthy adults?
Err Yees
44
Define an illusion.
A distortion of a real external stimulus.
45
Define a pseudohallucination.
A hallucination that arises from the patients ‘inner eye’ (or 'minds eye' or 'minds ear) and not through a sensory organ. (also described as arising from the subjective inner space of the mind)
Examples include:
1) distressing flashbacks in post-traumatic stress disorder
or
2) someone hearing a voice inside their own head telling them to harm themselves.
46
What is the most common sense to have a hallucination in?
Auditory
47
What type of auditory hallucination is indicative of an acute organic state?
Simple unstructured sounds or single words
48
What type of pathology are second person auditory hallucinations often associated with?
Mood disorders with psychotic features (thus are often persecutory)
49
Name the two common causes of visual hallucinations.
Organic disorders, psychoactive substance abuse.
50
Which is more common visual or auditory hallucinations?
Auditory
51
Define a somatic hallucination and name its subtypes.
Hallucinations of bodily sensation. The subtypes are superficial, visceral and kinaesthetic hallucinations.
52
Describe the difference between a hypnogogic and a hypnopompic hallucination
A hypnogogic hallucination occur as a person is falling asleep. A hypnopompic hallucination occurs as a person is waking up.
53
What is an extracampine hallucination?
One that occur outside the patients body. (Latin extra=outside campaneus=field)
54
What is a delusion?
An unshakeable false belief that is not accepted by other members of the patients culture
55
What are the four categories used to classify a delusion?
1ry vs 2ry.
Mood congruent vs incongruent.
Bizarre vs non-bizarre.
Classified according to the content of the delusion.
56
What is a 1ry delusion? (which conditions do they typically occur in?)
Delusions that do not occur in response to any other psychopathology. (They typically occur in schizophrenia and other primary psychotic disorders)
57
What is a 2ry delusion? (which conditions do they typically occur in?)
A delusion that is a consequence of a pre-existing psychopathological state. (usually occur with mood disorders)
58
Explain what a mood congruent delusion is and give and example.
Where the patients emotion matches the emotions they are expressing (aka affect display). Example: depressive person expressing suicidal ideation.
59
Explain what a mood incongruent delusion is and give and example.
Where the patients emotion does not match the emotions they are expressing (aka affect display). Example: depressive person expressing delusions of grandeur.
60
Explain what a bizarre delusion is and give and example.
Where the delusion is clearly implausible. Example: the pt's organs have been removed but there is no scar visible.
61
Explain what a non-bizarre delusion is and give and example.
Where the delusion, though false, is at least plausible. Example: the pt's believes they are under constant police surveillance.
62
Name 7 types different types of delusion (using content to differentiate them)?
1) Persecutory delusion
2) Grandiose delusion
3) Delusions of reference
4) Erotomania (delusion of love)
5) Nihilistic delusion
6) Somatic delusion
7) Delusion of control
PRES GM(N)C
63
Explain what a delusion of reference is and give an example.
Thinking objects, people or events have intense personal meaning. Example: the news reader is referring to you.
64
Explain what a nihilistic delusion is by giving a couple of examples.
False beliefs that the world is about to end or they do not exist.
65
Explain what a somatic delusion is and give an example.
A delusion that a part of one's body has been injured or altered in some manner. Example: your bowels are rotting away.
66
Define an overvalued idea.
A plausible belief that the patient is preoccupied with to an unreasonable extent.
67
Give an example of a condition which typically features overvalued ideas.
Anorexia nervosa.
68
Give 6 important signs of thought disorder (disorganised thinking).
1) Circumstantiality and tangentiality.
2) Flight of ideas
3) Loosening of association
4) Thought blocking
5) Perseveration
6) Echolalia
PET FACT
69
Describe circumstantiality.
Speech that is delayed in reaching its final goal because of the over inclusion of detail but does eventually get to the point.
70
Describe tangentiality.
Similar to circumstantiality as pt's include excessive detail in their speech, but unlike circumstantiality, in tangentiality the patient never returns to the point and thus it is pathological.
71
Define flight of ideas.
When thinking is markedly accelerated resulting in a stream of connected concepts through words, puns or clang association.
72
Define clanging.
A mode of speech characterized by association of words based upon sound rather than concepts.
73
Define loosening of association (give two other names for this and what is it characteristic for).
When speech moves from one loosely or unrelated topic to the next (derailment or knight's move thinking, characteristic for schizophernia)
74
Define thought blocking.
Stopping mid-sentence and then having no recall of what one was saying and talking about a new topic.
75
Define perseveration
When an intially correct response is inappropriately repeated.
E.g. "whats your name?"
"Ben"
"What is your date of birth?"
"Ben"
It is highly suggestive of organic brain disease (e.g. dementia)
76
Define palilalia (what is this highly indicative of).
Repeating of the last word of the sentence (indicative of an organic brain disorder)
77
Define echolalia.
Meaningless repetition of another person's spoken words as a symptom of psychiatric disorder - like a parrot
78
Give 7 examples of negative symptoms?
1) Marked apathy
2) Poverty of thought
3) Poverty of speech
4) Blunting of affect
5) Social isolation
6) Poor self-care
7) Cognitive deficits
PAID
79
Define apathy.
A lack of interest, enthusiasm, or concern
80
Define blunting of affect
A lack of emotional reactivity
81
Give the 5 main groups of psychotic/schizophrenic psychopathology.
1) Abnormal perceptions
2) Thought disorder
3) Abnormal beliefs
4) Negative symptoms
5) Psychomotor function
PANT
82
Abnormal beliefs in psychosis include what 3/2 main categories.
Delusions (1ry and 2ry) and overvalued ideas
83
What are the two main causes of reduced motor function in psychiatric patients?
Medication and organic brain disorder
84
Give three symptoms which are examples of abnormal psychomotor function.
Rigidity, stupor, tics
85
What is stupor?
A level of consciousness wherein a sufferer is almost entirely unresponsive.
86
Name four ICD-10 symptoms, of which you only need one to diagnose schizophrenia.
1) Thought interference (insertion, withdrawal or broadcast)
2) Delusions of passivity (/control)
3) Auditory hallucinations (voices giving a running commentary, discussing the patient in the third person, thought echo)
4) Bizarre delusions
87
Name five ICD-10 symptoms, of which you only need two of to diagnose schizophrenia.
1) Hallucinations that either occur every day for weeks or that are associated with fleeting delusions or sustained overvalued ideas
2) Thought disorder (loosening of association, incoherence or neologism)
3) Catatonic symptoms
4) Negative symptoms
5) Change in personal behaviour (loss of interest, aimlessness or social withdrawal)
88
Define neologism (give an example).
A new word or phrase of the patient's own making (headshoe to mean hat)
89
Generally how long should symptoms be present for before they can be used to diagnose schizophrenia?
Symptoms should be present most of the time for at least 1 MONTH.
90
Give two occasions when a patient should not be diagnosed with schizophrenia.
1) Organic brain disease
| 2) Drug intoxication/withdrawal
91
Name 5 first rank symptoms of schizophrenia?
1) Delusional perception
2) Delusions of passivity (/control)
3) Thought interference (insertion, withdrawal or broadcast)
4) Auditory hallucinations (voices giving a running commentary, discussing the patient in the third person, thought echo)
92
Name 6 subtypes of schizophrenia.
1) Paranoid
2) Hebephrenic
3) Catatonic
4) Residual
5) Post-schizophrenia depression
6) Simple
93
What psychopathology is paranoid schizophrenia denominated by?
Delusions and hallucinations
94
What psychopathology is hebephrenic schizophrenia denominated by?
1) Disturbed/chaotic/disorganised behaviour
2) Thought disorder
3) Inappropriate/flat affect
95
Which has an earlier onset hebephrenic schizophrenia or paranoid schizophrenia (and which has a better prognosis)?
Hebephrenic schizophrenia (paranoid schizophrenia)
96
Explain the course of residual schizophrenia.
1 year of predominantly chronic negative symptoms preceded by one clear cut psychotic episode
97
Does an episode of post-schizophrenia depression have many, a few or no schizophrenic symptoms?
Post schizophrenia depression has A FEW schizophrenic symptoms
98
Describe the course of simple schizophrenia.
Mainly negative symptoms, with signs of residual depression. Insidious onset with NO preceding psychotic episode.
99
Define insidious.
Proceeding in a gradual, subtle way, but with harmful effects
100
What sets schizoaffective disorder apart from schizophrenia?
Schizoaffective disorder is schizophrenia plus mood symptoms depression or mania) that present in the same episode of illness (within a few days)
101
What 3 symptom types should be present for schizoaffective disorder to be diagnosed?
1) Mood symptoms that meet the criteria for depression/mania
2+3) The patient should have one or preferably two core symptoms of schizophrenia.
102
What must be present to diagnose delusional disorder (how long must it be present for)?
A set or single delusion for at least 3 months where it is the predominant symptom
103
What type of delusions would bypass a diagnosis of delusional disorder and point straight to a diagnosis of schizophrenia?
Delusions of passivity (/control) will point straight to a diagnosis of schizophrenia
104
Do pts with delusional disorder function well socially and personally?
Yes they do
105
Describe the nature of hallucinations and depressive episodes in delusional disorder.
Delusional disorder has BRIEF depressive episodes and FLEETING hallucinations
106
What do typical antipsychotics pharmacologically target and where effect do they have their effect?
D2 dopamine receptor and cause its blockage (ie antagonists) in the mesolimbic pathway
107
What group of symptoms are side effects of the typical antipsychotics (and why does this happen)?
Extra-pyramidal symptoms (due to dopamine blockage in other areas of the brain)
108
Which receptors do atypical antipsychotics act on and are they antagonists or agonists at these receptors?
They have relatively little antagonistic action at D2 receptors and have the ability to antagonise serotonin 2A (5-HT2a) receptors.
109
Name three typical antipsychotics.
Chlorpromazine, haloperidol and flupentixol
110
Name five atypical antipsychotics.
Clozapine, olanzapine, risperidone, quetiapine, amisulpride.
111
Define psychosis.
A mental state in which reality is grossly distorted.
112
What symptoms occur in psychosis?
1) delusions
2) hallucinations
3) thought disorder
113
What makes schizophrenia different from psychosis? (list the symptoms)
It has extra symptoms:
1) Psychomotor abnormalities
2) Mood/affect disturbance
3) Cognitive defects
4) Disorganised behaviour
114
What conditions should you ask a patient about before they start on antipsychotics?
1) Diabetes
2) HTN
3) CVS disease
Note: you should ask about Fx of these things too.
115
What advice should you give to pt's when starting antipsychotics about lifestyle?
1) diet
2) weight control
3) exercise
116
What baseline tests should you include before starting antipsychotics (APs)? (for extra marks can you explain why?)
1) BMI (as you can get weight gain)
2) Blood tests --> fasting blood glucose (as APs are diabetogenic), lipid profile (as APs can alter this), FBC (due to risk of agranulocytosis)
3) ECG (due to risk of QT interval elongation from APs and schizophrenics are at increased risk of CVS disease)
117
What should be monitored every 6 months with pts on antipsychotics?
1) LFT's
2) U+E's
3) Prolactin
4) BMI
5) HBa1c
118
What type of antipsychotics are 1st line in new patients?
The atypicals (Clozapine, olanzapine, risperidone, quetiapine, amisulpride.)
119
What makes typical antipsychotics less desirable than atypicals?
1) They fail to treat or worsen negative symptoms.
2) Increased risk of EPSE (e.g. tardive dyskinesia)
3) Risk of neuroleptic malignant syndrome
4) Hyperprolactinaemia (Dopamine inhibits prolactin release)
120
What effect does dopamine have on prolactin release?
Dopamine inhibits prolactin release.
121
Which are more effective at treating positive symptoms, typical or atypical antipsychotics?
Both the same
122
What symptoms can atypical APs treat that typicals cannot?
1) negative symptoms
2) mood symptoms
(also maybe cognition)
123
Define tardive dyskinesia.
Involuntary movements of the face and jaw.
124
What is the extrapyramidal system?
Part of the motor system causing involuntary movements.
125
Which APs are prolactin sparing?
Mainly clozapine and quetiapine. To some extent olanzapine.
126
What is the most serious side-effects of clozapine?
Agranulocytosis (and is thus not 1st line)
127
Some of the AP's can cause metabolic side-effects. What are these side-effects and which AP cause them?
1) Diabetes
2) Weight gain
3) Lipid abnormalities
Caused by clozapine, olanzapine and quetiapine.
128
Which AP's specifically are related to increased prolactin levels?
Risperidone and amisulpride.
129
What effect can APs have on the CVS?
Can induce arrthmias due to cardiac disease. e.g. fatal QT interval prologation
130
What effect can APs have on the consciousness?
Can induce sedation
131
What is the relationship of APs and Parkinsons?
APs decrease dopamine levels exacerbating Parkinsons.
132
All APs are equally effective except one, which is?
Clozapine
133
In what case is clozapine reserved for?
Treatment resistant schizophrenia.
134
Define treatment resistant schizophrenia.
A lack of satisfactory clinical improvement despite the sequential use of at least two antipsychotics for 6-8 weeks, one of which should be an atypical
135
Compliance in schizophrenia is poor, so what can be used to administer treatment?
Depot injections.
136
If schizophrenic patients respond well, over how long should treatment be withdrawn?
6-8 months.
137
Roughly how many schizophrenic patients require lifelong treatment (none, a few, 50:50, most, or all)
Most pts require lifelong treatment.
138
Why should olanzapine and risperidone not be used to treat behavioural problems in pts with dementia?
They increase the risk of CV events when used in dementia pts.
139
What effect on ECG can APs have?
Fatal QT interval prolongation.
140
Which APs especially should pts BMI be monitored?
olanzapine and clozapine.
141
What is the most popular drug used to treat psychosis?
Respiradone.
142
What are benzodiazepines used to treat in schizophrenia? (and what are they not used to treat?)
1) Behavioural disturbances
2) Insomnia
3) Aggression
4) Agitation
(they have no antipsychotic effects)
143
What is used to augment antipsychotics in treatment resistant schizophrenia?
Antidepressants such as lithium (especially when there are affective symptoms)
144
How often is ECT used in schizophrenia?
Rarely
145
What 4 non-psychiatric issues can APs be used for?
1) Motor tics
2) N+V (prochloperazine)
3) Intractable hiccups
4) Pruritus
146
In dementia what can APs be used for?
Behavioural problems.
147
Other than schizophrenia name 2 other psychotic conditions where APs are used as treatment.
Schizoaffective disorder + delusional disorder.
148
Why should APs be used with caution in delirium due to alcohol withdawal?
As the combination of alcohol withdawal and APs lowers the seizure threshold.
149
Which categories of receptor are blocked by typical APs that lead to some of their side-effects?
1) Muscarinic ACh receptors
2) Histaminergic receptors
3) Alpha-adrenergic receptors.
150
Why do atypical APs have varied side-effect profiles?
As they have differing affinities to other receptors (such as muscarinic receptors)
151
Name 4 types of psychological intervention used in pyschosis/schizophrenia?
1) CBT
2) Family psychological interventions (family therapy)
3) Psychoeducation
4) Social-skills training
152
What method is used to coordinate the delivery of services to schizophrenic pts?
The care program approach (CPA).
153
What is the role of a care coordinator in schizophrenic patients? (any professional in the MDT can be the care coordinator)
1) To coordinate the multifaceted aspects of patients’ care
2) To monitor mental state
3) To monitor compliance with medication.
154
What is a delusional perception and give an example.
A two-stage process whereby a real perception is then interpreted in a delusional way
e.g. The traffic lights changed to green and I knew I was Queen of Ireland
155
Give some examples of EPSEs.
1) dystonia (sustained muscle contractions cause twisting and repetitive movements or abnormal postures)
2) akathisia (feeling of inner restlessness and a compelling need to be in constant motion)
3) parkinsonism (tremor, bradykinesia, rigidity, and postural instability)
4) tardive dyskinesia
156
What effect does serotonin have on prolactin levels?
Serotonin increases prolactin levels
