psychosis Flashcards
1
Q
define psychosis?
A
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
2
Q
what are the disorders for which psychosis is the primary feature?
A
- schizophrenia
- schizotypal disorder (personality disorder in DSM)
- persistent delusional disorder
- acute and transient psychotic disorders
- induced delusional disorder
- schizoaffective disorder
3
Q
what are the disorders where psychosis occurs but not as the 1y feature?
A
- affective disorders
- dementia/delirium
- other organic brain problems
- substance misuse/intoxication
4
Q
definition of schizophrenia?
A
clinical syndrome - a collection of signs and symptoms of unknown aetiology, predominantly defined by signs of psychosis
5
Q
most common form of schizophrenia?
A
paranoid delusions
auditory hallucinations
late teens/early adult
6
Q
what causes schizophrenia?
A
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
7
Q
evidence for neurodevelopmental hypothesis of schizophrenia, rather than demence precoce
A
- 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
8
Q
structural brain changes in SCZ
A
- 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
9
Q
NTs in SCZ
A
dopamine - antipsychotics
glutamine - a la ketamine
serotonin - a la LSD
NA - more metabolites in CSF
10
Q
correlations/associations of SCZ
A
- 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
11
Q
genetics and SCZ
A
48% concordance in MZ
polygenetic likely
high heritability
12
Q
general population risk SCZ
A
1%
13
Q
children risk SCZ
A
13%
14
Q
siblings risk SCZ
A
9%
15
Q
What are the FRS for schizophrenia?
A
- auditory hallucinations: thought echo, discussing in 3rd person, running commentary
- thought interference: insertion, withdrawal, broadcasting (delusion)
- passivity
- delusional perception
16
Q
are FRS pathognomonic for SCZ?
A
nope
17
Q
what is the ICD 10 approach to SCZ?
A
major and minor criteria
need any major for >1 month
need any 2 minor for >1 month
18
Q
major SCZ criteria ICD10
A
- thought echo, insertion, withdrawal, broadcast
- delusions of control/passivity, delusional perception
- 3rd person auditory hallucinations
- persistent delusions (culturally INAPPROPRIATE)
19
Q
minor criteria ICD 10 SCZ
A
- persistent hallucinations in any mode + half-formed delusions
- breaks in thought fluency
- catatonia - stupor, posturing, waxy flex, mutism
- negative symptoms
- deterioration in personal behaviour
20
Q
ICD SCZ subtypes
A
- paranoid
- hebephrenic
- catatonic
- undifferentiated
- simple
- residual
- post-SCZ depression
21
Q
paranoid SCZ?
A
most common
delusions + hallucinations, not necessarily paranoid
22
Q
hebephrenic SCZ
A
disorganised speech and behaviour
flat affect/inappropriate affect
earlier onset, worse px
23
Q
catatonic schizophrenia
A
psychomotor prob
rare
24
Q
undifferentiated SCZ
A
not fitting any subtype
25
simple SCZ
insidious development of -ve symptoms
26
residual SCZ
started +ve, now mainly -ve
27
post SCZ depression
increased risk of suicide
| depressive episode after SCZ illness
28
-ve symptoms of SCZ
anhedonia
alogia
affective blunting
avolition
29
psych ix for SCZ
1. earlier = better outcomes
2. collateral history
3. establish timeline
4. premorbid function
5. understand social circumstances
6. rule out physical causes
7. assess insight
30
what is DUP?
duration of untreated psychosis
| from symptoms to tx
31
what is the detect programme?
pilot early intervention for psychosis service - south dublin + wicklow
32
tx of SCZ?
1. 2nd gen antipsychotic or agreed agent with patient/carer
2. titrate to minimum effective dose
3. adjust according to tolerability and response
4. assess over 6-8 weeks
5. change drug if ineffective - SGA/FGA - if still not effective - clozapine
6. if drug works leave it
7. if not taking then figure out why
33
why no polypharmacy in SCZ>
LQT, SCD
| only if refractory
34
monitoring tests for those on antipsychotics?
```
BP/pulse
ECG
glucose, lipids
BMI
U+E, LFTs
FBC
prolactin
```
35
side effects of antipsychotics?
dystonia
pseudo-parkinsonism
akathisia
tardive dyskinesia
36
what is dystonia?
involuntary muscle spasms
oculogyric crises
torticollis
painful
37
what is pseudo parkinsonism?
tremor +/- rigidity
bradykinesia
bradyphrenia
can confuse with -ve sx
38
akathisia? what is it?
state of inner restlessness
strong compulsion to move
can be mistaken for agitation
39
what is tardive dyskinesia
involuntary repetitive movements eg lip smacking, tongue protrusion, choreiform hand movements
40
most common side effect of antipsychotics?
akathisia
41
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
42
tx of dystonia?
anticholinergics
43
tx of parkinsonism?
reduce dose
change to atypical
anticholinergics
44
tx for akithisia?
```
reduce dose
change to atypical
propnalol - poor evidence
low dose clonazepam
mirtazapine
NO ANTICHOLINERGICS
```
45
tx tardive dyskinesia
NO ANTICHOLINERGICS
reduce dose
change to atypical
trial clozapine
46
tx for relapse or acute exacerbation of schizophrenia?
1. investigate precipitants - provide support and continue normal tx
2. acutely - add sedative and reassess
3. can change to alternative antipsych
4. depot if adherance prob
5. clozapine if tx resistant
47
depot frequency
2-4 wks
48
examples of depots
typical: fluphenazine, haloperidol
| atypical - risperidone, olanzapine
49
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
```
50
psychological tx for schizophrenia
1. psychoeducation
2. family tx - less hospitalisation and impact of a high EE environment
3. CBT - not strong evidence for tx of symptoms but improves adherance and engagement
4. complicane therapy
5. rehabilitation/day centre/training programmes
6. art therapy
51
social tx of schizophrenia
1. addiction services
2. accommodation - housing needs, supported housing, SW + OT
3. employment schemes
4. patient advocacy groups
5. voluntary organisations eg shine
6. social skills training
52
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
53
how to tx tx resistant schizophrenia?
clozapine
54
features of clozapine?
1. good for +ve and -ve symptoms
2. less suicidality
3. improves tardive dyskinesia
4. 1% risk agranulocytosis
5. must monitor FBC - weekly 18/52 then every two weeks for a year, then monthly
55
side effects of clozapine?
1. sedation
2. wt gain
3. tachycardia
4. hypotension/HTN
5. agranulocytosis
6. fever
7. hypersalivation
8. seizures
9. VTE
10. myocarditis
11. cardiomyopathy
56
px psychosis?
after 1st episode psychosis 85% remission, median time is 9 months to remission - 16% recover completely
57
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%
58
poor prognostic factors SCZ?
1. insidious onset
2. young AOO
3. no precipitating factors
4. -ve symptoms
5. male
6. substances
7. poor premorbid
8. poor supports
9. unmarried
10. delayed tx
11. poor tx response
59
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
60
associations of persistent delusional disorder?
social isolation
| deafness
61
tx persistent delusional?
varies
antipsychotics
antidepressants
62
othello syndrome?
delusional jealousy
63
de clerambault syndrome
erotomania
64
capgras syndrome
people known to the individual have been replaced with imposters
65
fregoli syndrome
persecutor is masquerading as different people and can assume their identities and appearances
66
what is schizoaffective disorder?
1. affective and SCZ symptoms
2. possible spectrum between BPAD + SCZ
3. manic type has best px
4. tx as for main symptoms - usually combo of antipsychotic and mood stabiliser +/- antiD
67
what is schizotypal disorder?
1. abnormal behaviour and thinking that resemble schizophrenia but no definite SCZ symptoms at any stage
68
possible symptoms of schizotypal disorder
1. inappropriate affect/cold
2. anhedonia
3. odd behaviour
4. social withdrawal, paranoia
5. obsessive ruminations
6. thought disorder
7. perception probs
8. intense illusions
9. delusion like ideas
69
typical antipsychotic features
1. more blocking dopamine receptors
2. cause more EPSEs
3. more hyperprolactinaemia
70
atypical antipsychotic features?
better at -ve symptoms
71
typical antipsychotics
phenthiazines: chlorpromazine
thioxanthines: fluphenthixol
butyrophenones: haloperidol
substituted benzamide: sulpride
72
atypical antipsychotics?
```
olanzapine
quetiapine
risperidone
amisulpride
aripiprazole
clozapine
```
73
s/e of chlorpromazine?
photosensitivity
| use sunblock
74
non EPSE s/e of antipsychotics
1. anticholinergic
2. pituitary - lactation, menstrual probs/infertility, gynaecomastia, osteoporosis
3. photosensitivity
4. poor glucose tolerance, wt gain - DM, metabolic syndrome
5. LQTS
75
pre clozapine work up
```
FBC
LFTs
Fasting lipid profile
fasting glucose
ECG
```
76
clozapine dosing
start low go slow
12.5mg OD
max 300-450mg/ day
monitor BP hourly for 6 hrs - hypotensive
77
when to stop clozapine?
WCC
78
if miss dose of clozapine?
must start from scratch again
