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psychosis Flashcards

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1
Q

define psychosis?

A

umbrella term used in psychiatry to define a group of disorders characterised by a particular symptom set:

  1. delusions or hallucinations
  2. disorder of thought/ behaviour
  3. core feature = prob with reality testing - what is real and what isn’t
  4. schizophrenia is the main illness but not the only
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2
Q

what are the disorders for which psychosis is the primary feature?

A
  1. schizophrenia
  2. schizotypal disorder (personality disorder in DSM)
  3. persistent delusional disorder
  4. acute and transient psychotic disorders
  5. induced delusional disorder
  6. schizoaffective disorder
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3
Q

what are the disorders where psychosis occurs but not as the 1y feature?

A
  1. affective disorders
  2. dementia/delirium
  3. other organic brain problems
  4. substance misuse/intoxication
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4
Q

definition of schizophrenia?

A

clinical syndrome - a collection of signs and symptoms of unknown aetiology, predominantly defined by signs of psychosis

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5
Q

most common form of schizophrenia?

A

paranoid delusions
auditory hallucinations
late teens/early adult

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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

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7
Q

evidence for neurodevelopmental hypothesis of schizophrenia, rather than demence precoce

A
  1. copenhagen birth cohort - patients had hx of delayed developmental milestones in 1st year
  2. dunedin birth cohort - IQ reduced early and persistently in kids who develop it
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8
Q

structural brain changes in SCZ

A
  1. enlarged 3rd ventricles
  2. cortical volume reduction
  3. median temporal structures less grey matter
  4. PM - lighter and smaller brains
  5. functional imaging disconnectivity btween frontal and temporal lobes
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9
Q

NTs in SCZ

A

dopamine - antipsychotics
glutamine - a la ketamine
serotonin - a la LSD
NA - more metabolites in CSF

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10
Q

correlations/associations of SCZ

A
  1. obstetric complications
  2. maternal flu in pregnancy/winter
  3. delayed milestones
  4. disturbed childhood behaviour
  5. urbanisation at birth
  6. presence of birth defects: curved pinky, high palate, low set ears
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11
Q

genetics and SCZ

A

48% concordance in MZ
polygenetic likely
high heritability

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12
Q

general population risk SCZ

A

1%

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13
Q

children risk SCZ

A

13%

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14
Q

siblings risk SCZ

A

9%

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15
Q

What are the FRS for schizophrenia?

A
  1. auditory hallucinations: thought echo, discussing in 3rd person, running commentary
  2. thought interference: insertion, withdrawal, broadcasting (delusion)
  3. passivity
  4. delusional perception
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16
Q

are FRS pathognomonic for SCZ?

A

nope

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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

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18
Q

major SCZ criteria ICD10

A
  1. thought echo, insertion, withdrawal, broadcast
  2. delusions of control/passivity, delusional perception
  3. 3rd person auditory hallucinations
  4. persistent delusions (culturally INAPPROPRIATE)
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19
Q

minor criteria ICD 10 SCZ

A
  1. persistent hallucinations in any mode + half-formed delusions
  2. breaks in thought fluency
  3. catatonia - stupor, posturing, waxy flex, mutism
  4. negative symptoms
  5. deterioration in personal behaviour
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20
Q

ICD SCZ subtypes

A
  1. paranoid
  2. hebephrenic
  3. catatonic
  4. undifferentiated
  5. simple
  6. residual
  7. post-SCZ depression
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21
Q

paranoid SCZ?

A

most common

delusions + hallucinations, not necessarily paranoid

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22
Q

hebephrenic SCZ

A

disorganised speech and behaviour
flat affect/inappropriate affect
earlier onset, worse px

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23
Q

catatonic schizophrenia

A

psychomotor prob

rare

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24
Q

undifferentiated SCZ

A

not fitting any subtype

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25
Q

simple SCZ

A

insidious development of -ve symptoms

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26
Q

residual SCZ

A

started +ve, now mainly -ve

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27
Q

post SCZ depression

A

increased risk of suicide

depressive episode after SCZ illness

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28
Q

-ve symptoms of SCZ

A

anhedonia
alogia
affective blunting
avolition

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29
Q

psych ix for SCZ

A
  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
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30
Q

what is DUP?

A

duration of untreated psychosis

from symptoms to tx

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31
Q

what is the detect programme?

A

pilot early intervention for psychosis service - south dublin + wicklow

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32
Q

tx of SCZ?

A
  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
Q

why no polypharmacy in SCZ>

A

LQT, SCD

only if refractory

34
Q

monitoring tests for those on antipsychotics?

A 
BP/pulse
ECG
glucose, lipids 
BMI
U+E, LFTs
FBC
prolactin
35
Q

side effects of antipsychotics?

A

dystonia
pseudo-parkinsonism
akathisia
tardive dyskinesia

36
Q

what is dystonia?

A

involuntary muscle spasms
oculogyric crises
torticollis
painful

37
Q

what is pseudo parkinsonism?

A

tremor +/- rigidity
bradykinesia
bradyphrenia
can confuse with -ve sx

38
Q

akathisia? what is it?

A

state of inner restlessness
strong compulsion to move
can be mistaken for agitation

39
Q

what is tardive dyskinesia

A

involuntary repetitive movements eg lip smacking, tongue protrusion, choreiform hand movements

40
Q

most common side effect of antipsychotics?

A

akathisia

41
Q

timeline of antipsychotic side effects

A

dystonia - within hrs, mins if IV
parkinsonism - days to weeks
akathisia - hours to weeks
tardive dyskinesia -months to years - 50% reversible

42
Q

tx of dystonia?

A

anticholinergics

43
Q

tx of parkinsonism?

A

reduce dose
change to atypical
anticholinergics

44
Q

tx for akithisia?

A 
reduce dose
change to atypical
propnalol - poor evidence
low dose clonazepam
mirtazapine
NO ANTICHOLINERGICS
45
Q

tx tardive dyskinesia

A

NO ANTICHOLINERGICS
reduce dose
change to atypical
trial clozapine

46
Q

tx for relapse or acute exacerbation of schizophrenia?

A
  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
Q

depot frequency

A

2-4 wks

48
Q

examples of depots

A

typical: fluphenazine, haloperidol

atypical - risperidone, olanzapine

49
Q

withdrawal of tx for SCZ

A 
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
Q

psychological tx for schizophrenia

A
  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
Q

social tx of schizophrenia

A
  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
Q

what is tx resistant schizophrenia?

A

lack of improvement despite use of therapeutic dose for 6-8 weeks of at least 2 antipsychotics, with at least one being atypical

53
Q

how to tx tx resistant schizophrenia?

A

clozapine

54
Q

features of clozapine?

A
  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
Q

side effects of clozapine?

A
  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
Q

px psychosis?

A

after 1st episode psychosis 85% remission, median time is 9 months to remission - 16% recover completely

57
Q

px SCZ?

A

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
Q

poor prognostic factors SCZ?

A
  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
Q

what are persistent delusional disorders

A

single delusion (or set of related)which are persistent

no hallucinations/thought disorder

preserved personality

usually middle age

need 3 months of sx

60
Q

associations of persistent delusional disorder?

A

social isolation

deafness

61
Q

tx persistent delusional?

A

varies
antipsychotics
antidepressants

62
Q

othello syndrome?

A

delusional jealousy

63
Q

de clerambault syndrome

A

erotomania

64
Q

capgras syndrome

A

people known to the individual have been replaced with imposters

65
Q

fregoli syndrome

A

persecutor is masquerading as different people and can assume their identities and appearances

66
Q

what is schizoaffective disorder?

A
  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
Q

what is schizotypal disorder?

A
  1. abnormal behaviour and thinking that resemble schizophrenia but no definite SCZ symptoms at any stage
68
Q

possible symptoms of schizotypal disorder

A
  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
Q

typical antipsychotic features

A
  1. more blocking dopamine receptors
  2. cause more EPSEs
  3. more hyperprolactinaemia
70
Q

atypical antipsychotic features?

A

better at -ve symptoms

71
Q

typical antipsychotics

A

phenthiazines: chlorpromazine
thioxanthines: fluphenthixol
butyrophenones: haloperidol
substituted benzamide: sulpride

72
Q

atypical antipsychotics?

A 
olanzapine
quetiapine
risperidone
amisulpride
aripiprazole
clozapine
73
Q

s/e of chlorpromazine?

A

photosensitivity

use sunblock

74
Q

non EPSE s/e of antipsychotics

A
  1. anticholinergic
  2. pituitary - lactation, menstrual probs/infertility, gynaecomastia, osteoporosis
  3. photosensitivity
  4. poor glucose tolerance, wt gain - DM, metabolic syndrome
  5. LQTS
75
Q

pre clozapine work up

A 
FBC
LFTs
Fasting lipid profile
fasting glucose
ECG
76
Q

clozapine dosing

A

start low go slow
12.5mg OD

max 300-450mg/ day

monitor BP hourly for 6 hrs - hypotensive

77
Q

when to stop clozapine?

A

WCC

78
Q

if miss dose of clozapine?

A

must start from scratch again

Psych (23 decks)

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