psychosis Flashcards
define psychosis?
umbrella term used in psychiatry to define a group of disorders characterised by a particular symptom set:
- delusions or hallucinations
- disorder of thought/ behaviour
- core feature = prob with reality testing - what is real and what isn’t
- schizophrenia is the main illness but not the only
what are the disorders for which psychosis is the primary feature?
- schizophrenia
- schizotypal disorder (personality disorder in DSM)
- persistent delusional disorder
- acute and transient psychotic disorders
- induced delusional disorder
- schizoaffective disorder
what are the disorders where psychosis occurs but not as the 1y feature?
- affective disorders
- dementia/delirium
- other organic brain problems
- substance misuse/intoxication
definition of schizophrenia?
clinical syndrome - a collection of signs and symptoms of unknown aetiology, predominantly defined by signs of psychosis
most common form of schizophrenia?
paranoid delusions
auditory hallucinations
late teens/early adult
what causes schizophrenia?
NO IDEA
theory of it being a collection of related but separate conditions
theory of altered brain circuitry
neurodevelopmental disorder - symptoms start in late teens/20s when prefrontal cortical matter still maturing
evidence for neurodevelopmental hypothesis of schizophrenia, rather than demence precoce
- copenhagen birth cohort - patients had hx of delayed developmental milestones in 1st year
- dunedin birth cohort - IQ reduced early and persistently in kids who develop it
structural brain changes in SCZ
- enlarged 3rd ventricles
- cortical volume reduction
- median temporal structures less grey matter
- PM - lighter and smaller brains
- functional imaging disconnectivity btween frontal and temporal lobes
NTs in SCZ
dopamine - antipsychotics
glutamine - a la ketamine
serotonin - a la LSD
NA - more metabolites in CSF
correlations/associations of SCZ
- obstetric complications
- maternal flu in pregnancy/winter
- delayed milestones
- disturbed childhood behaviour
- urbanisation at birth
- presence of birth defects: curved pinky, high palate, low set ears
genetics and SCZ
48% concordance in MZ
polygenetic likely
high heritability
general population risk SCZ
1%
children risk SCZ
13%
siblings risk SCZ
9%
What are the FRS for schizophrenia?
- auditory hallucinations: thought echo, discussing in 3rd person, running commentary
- thought interference: insertion, withdrawal, broadcasting (delusion)
- passivity
- delusional perception
are FRS pathognomonic for SCZ?
nope
what is the ICD 10 approach to SCZ?
major and minor criteria
need any major for >1 month
need any 2 minor for >1 month
major SCZ criteria ICD10
- thought echo, insertion, withdrawal, broadcast
- delusions of control/passivity, delusional perception
- 3rd person auditory hallucinations
- persistent delusions (culturally INAPPROPRIATE)
minor criteria ICD 10 SCZ
- persistent hallucinations in any mode + half-formed delusions
- breaks in thought fluency
- catatonia - stupor, posturing, waxy flex, mutism
- negative symptoms
- deterioration in personal behaviour
ICD SCZ subtypes
- paranoid
- hebephrenic
- catatonic
- undifferentiated
- simple
- residual
- post-SCZ depression
paranoid SCZ?
most common
delusions + hallucinations, not necessarily paranoid
hebephrenic SCZ
disorganised speech and behaviour
flat affect/inappropriate affect
earlier onset, worse px
catatonic schizophrenia
psychomotor prob
rare
undifferentiated SCZ
not fitting any subtype
simple SCZ
insidious development of -ve symptoms
residual SCZ
started +ve, now mainly -ve
post SCZ depression
increased risk of suicide
depressive episode after SCZ illness
-ve symptoms of SCZ
anhedonia
alogia
affective blunting
avolition
psych ix for SCZ
- earlier = better outcomes
- collateral history
- establish timeline
- premorbid function
- understand social circumstances
- rule out physical causes
- assess insight
what is DUP?
duration of untreated psychosis
from symptoms to tx
what is the detect programme?
pilot early intervention for psychosis service - south dublin + wicklow
tx of SCZ?
- 2nd gen antipsychotic or agreed agent with patient/carer
- titrate to minimum effective dose
- adjust according to tolerability and response
- assess over 6-8 weeks
- change drug if ineffective - SGA/FGA - if still not effective - clozapine
- if drug works leave it
- if not taking then figure out why
why no polypharmacy in SCZ>
LQT, SCD
only if refractory
monitoring tests for those on antipsychotics?
BP/pulse ECG glucose, lipids BMI U+E, LFTs FBC prolactin
side effects of antipsychotics?
dystonia
pseudo-parkinsonism
akathisia
tardive dyskinesia
what is dystonia?
involuntary muscle spasms
oculogyric crises
torticollis
painful
what is pseudo parkinsonism?
tremor +/- rigidity
bradykinesia
bradyphrenia
can confuse with -ve sx
akathisia? what is it?
state of inner restlessness
strong compulsion to move
can be mistaken for agitation
what is tardive dyskinesia
involuntary repetitive movements eg lip smacking, tongue protrusion, choreiform hand movements
most common side effect of antipsychotics?
akathisia
timeline of antipsychotic side effects
dystonia - within hrs, mins if IV
parkinsonism - days to weeks
akathisia - hours to weeks
tardive dyskinesia -months to years - 50% reversible
tx of dystonia?
anticholinergics
tx of parkinsonism?
reduce dose
change to atypical
anticholinergics
tx for akithisia?
reduce dose change to atypical propnalol - poor evidence low dose clonazepam mirtazapine NO ANTICHOLINERGICS
tx tardive dyskinesia
NO ANTICHOLINERGICS
reduce dose
change to atypical
trial clozapine
tx for relapse or acute exacerbation of schizophrenia?
- investigate precipitants - provide support and continue normal tx
- acutely - add sedative and reassess
- can change to alternative antipsych
- depot if adherance prob
- clozapine if tx resistant
depot frequency
2-4 wks
examples of depots
typical: fluphenazine, haloperidol
atypical - risperidone, olanzapine
withdrawal of tx for SCZ
no consensus usually 1-5yrs after episode don't cure need long term to stop relapse need family and CBT to stay well need to be stopped gradually over 6 months
psychological tx for schizophrenia
- psychoeducation
- family tx - less hospitalisation and impact of a high EE environment
- CBT - not strong evidence for tx of symptoms but improves adherance and engagement
- complicane therapy
- rehabilitation/day centre/training programmes
- art therapy
social tx of schizophrenia
- addiction services
- accommodation - housing needs, supported housing, SW + OT
- employment schemes
- patient advocacy groups
- voluntary organisations eg shine
- social skills training
what is tx resistant schizophrenia?
lack of improvement despite use of therapeutic dose for 6-8 weeks of at least 2 antipsychotics, with at least one being atypical
how to tx tx resistant schizophrenia?
clozapine
features of clozapine?
- good for +ve and -ve symptoms
- less suicidality
- improves tardive dyskinesia
- 1% risk agranulocytosis
- must monitor FBC - weekly 18/52 then every two weeks for a year, then monthly
side effects of clozapine?
- sedation
- wt gain
- tachycardia
- hypotension/HTN
- agranulocytosis
- fever
- hypersalivation
- seizures
- VTE
- myocarditis
- cardiomyopathy
px psychosis?
after 1st episode psychosis 85% remission, median time is 9 months to remission - 16% recover completely
px SCZ?
20-25% have partial remission between episodes with persistent disability
33% good social outcome
5-10% severe persistent
mortality 1.6 increase over general pop
suicide: 10x, lifetime risk 7%
poor prognostic factors SCZ?
- insidious onset
- young AOO
- no precipitating factors
- -ve symptoms
- male
- substances
- poor premorbid
- poor supports
- unmarried
- delayed tx
- poor tx response
what are persistent delusional disorders
single delusion (or set of related)which are persistent
no hallucinations/thought disorder
preserved personality
usually middle age
need 3 months of sx
associations of persistent delusional disorder?
social isolation
deafness
tx persistent delusional?
varies
antipsychotics
antidepressants
othello syndrome?
delusional jealousy
de clerambault syndrome
erotomania
capgras syndrome
people known to the individual have been replaced with imposters
fregoli syndrome
persecutor is masquerading as different people and can assume their identities and appearances
what is schizoaffective disorder?
- affective and SCZ symptoms
- possible spectrum between BPAD + SCZ
- manic type has best px
- tx as for main symptoms - usually combo of antipsychotic and mood stabiliser +/- antiD
what is schizotypal disorder?
- abnormal behaviour and thinking that resemble schizophrenia but no definite SCZ symptoms at any stage
possible symptoms of schizotypal disorder
- inappropriate affect/cold
- anhedonia
- odd behaviour
- social withdrawal, paranoia
- obsessive ruminations
- thought disorder
- perception probs
- intense illusions
- delusion like ideas
typical antipsychotic features
- more blocking dopamine receptors
- cause more EPSEs
- more hyperprolactinaemia
atypical antipsychotic features?
better at -ve symptoms
typical antipsychotics
phenthiazines: chlorpromazine
thioxanthines: fluphenthixol
butyrophenones: haloperidol
substituted benzamide: sulpride
atypical antipsychotics?
olanzapine quetiapine risperidone amisulpride aripiprazole clozapine
s/e of chlorpromazine?
photosensitivity
use sunblock
non EPSE s/e of antipsychotics
- anticholinergic
- pituitary - lactation, menstrual probs/infertility, gynaecomastia, osteoporosis
- photosensitivity
- poor glucose tolerance, wt gain - DM, metabolic syndrome
- LQTS
pre clozapine work up
FBC LFTs Fasting lipid profile fasting glucose ECG
clozapine dosing
start low go slow
12.5mg OD
max 300-450mg/ day
monitor BP hourly for 6 hrs - hypotensive
when to stop clozapine?
WCC
if miss dose of clozapine?
must start from scratch again
