Psychosis Flashcards
1
Q
Psychosis—Definition
A
Broadly defined as a loss of contact with reality
2
Q
Psychotic states are high risk periods of? 4
A
- Agitation
- Aggression
- Impulsivity (suicide)
- Other forms of behavioral dysfunction.
3
Q
- What are Delusions?
- They may be what?
A
- Strongly held false beliefs that are not part of the patient’s cultural or religious backgrounds
- They may be bizarre or non-bizzare
4
Q
Types of delusions? 6
A
- Persecutory
- Grandiose
- Erotomanic
- Somatic
- Delusions of reference
- Delusions of control
5
Q
- What are Hallucinations?
- Can involve what?
- What is the most common?
- Then in order of prevalence? 4
A
- Wakeful experiences of content that is not actually present
- Any of the 5 senses
- Auditory most common
- Followed by
- visual,
- tactile,
- olfactory
- gustatory
6
Q
Thought disorganization—Speech:
Manifests how?
7
A
- Alogia/poverty of content
- Thought blocking—suddenly loosing train of thought
- Loosening of association—sequences not well connected
- Tangentiality—answers to questions veering off topic
- Clanging or clang association—using rhyming words
- Word salad—real words linked incoherently
- Perseravation—repeating words or ideas even when topic is changed
7
Q
Psychotic Disorders–Differential
9
A
- Schizophrenia
- Bipolar disorder w/ psychotic features
- Major depression w/ psychotic features
- Schizoaffective disorder
- Schizophreniform disorder
- Brief psychotic disorder
- Substance induced psychotic disorder
- Delusional disorder
- Psychosis secondary to a medical condition
8
Q
Workup for Psychotic disorders:
First two things you do?
A
- Thorough mental status exam—note grooming, mannerisms, reactions
- PE
9
Q
Labs for workup of Psychotic disorders?
7
A
- CBC
- CMP
- RPR/VDRL
- TSH
- HIV
- UA
- Urine drug screen
More as indicated by history
10
Q
What labs are in the Complete metabolic panal?
14
A
Complete Metabolic Panel (14):
- Electrolytes
1. Sodium
2. Potassium
3. Chloride
4. Carbon Dioxide (CO2) - Proteins
5. Albumin
6. Total protein - Kidney Tests
7. Blood urea nitrogen (BUN)
8. Creatinine (Cr) - Liver Tests
9. Alkaline phosphatase (ALP)
10. ALT (SGPT)
11. AST (SGOT)
12. Total bilirubin - Other
13. Glucose
14. Calcium
11
Q
Basic Metabolic panal? 8
A
Basic Metabolic Panel (8):
- Electrolytes
1. Sodium
2. Potassium
3. Chloride
4. Carbon Dioxide (CO2) - Kidney Tests
5. Blood urea nitrogen (BUN)
6. Creatinine (Cr) - Other
7. Glucose
8. Calcium
12
Q
Electrolyte Panel (4):
A
Electrolytes
- Sodium
- Potassium
- Chloride
- Carbon Dioxide (CO2)
13
Q
The diagnosis of schizophrenia is based entirely on what?
A
the psychiatric history and mental status examination.
14
Q
Peak ages of onset for Schizophrenia:
- Men?
- Women?
A
- Men: 12-25yo
- Women: 25-35yo
***Onset of schizophrenia before
age 10 and after age 60
is EXTREMELY rare!
15
Q
Several things make schizophrenia a very difficult issue to deal with:
4
A
- For most patients it is highly disabling
- Generally persists throughout patient’s life
- Patients and their families often suffer from poor care and social ostracism
- Only approximately half of all patients with schizophrenia obtain treatment, in spite of the severity of the disorder
16
Q
Diagnosis (DSM-5)
for Schizophrenia?
5
These are considered __________ symptoms
A
Two (or more) of the following, each present for a significant portion of time during a 1 month period (or less if successfully treated):
- Delusions
- Hallucinations
- Disorganized speech (e.g., frequent derailment or incoherence)
- Grossly disorganized or catatonic behavior
- Negative symptoms (e.g., affective flattening or poverty of speech)
“active-phase”
17
Q
Schizophrenia
Only one of these criterion are
necessary if:
3
A
-Delusions are bizarre
-Hallucinations consist of a voice
keeping up a running commentary,
or
-two or more voices conversing
18
Q
Schizophrenia: Diagnosis (DSM-5)
A couple of other keys?
2
A
- Social or occupational dysfunction
- Continuous signs of the disturbance persisting for at least 6 months and within this at least 1 month of “active-phase” symptoms (see previous slide)
19
Q
Schizophrenia: May include prodromal or residual periods where signs of disturbance may be manifested by only what?
A
negative symptoms or other symptoms from previous slide in an attenuated form
20
Q
Schizophrenia
- Positive symptoms? 2
- Negative symptoms? 7
A
- Positive Symptoms
- Delusions
- Hallucinations - Negative Symptoms
- Affective flattening
- Poverty of speech (alogia)
- Blocking
- Poor grooming
- Lack of motivation
- Anhedonia
- Social withdrawal
21
Q
Treatment: Why do we care about positive or negative symptoms?
- Patients that predominantly have positive symptoms?
- Patients that predominantly have negative symptoms?
A
- Patients that predominantly have positive symptoms?
- Relatively good responses to treatments - Patients that predominantly have negative symptoms?
- Poor responses to treatments
22
Q
What are the subtypes of Schizophrenia? 3
A
- Paranoid type
- Disorganized type
- Catatonic type
23
Q
Schizophrenia: Paranoid type
- Characterized by what? 2
- Lacks what symptoms? 3
A
- Preoccupation with one or more delusions or
- frequent auditory hallucinations
- No
- disorganized speech,
- disorganized or catatonic behavior, or
- flat or inappropriate affect
24
Q
Schizophrenia: Disorganized type. Characterized how?
3
A
- Disorganized speech,
- disorganized behavior,
- flat or inappropriate affect
25
Schizophrenia: Catatonic type. Characterized how?
| 5
1. Motoric immobility
2. Excessive purposeless motor activity
3. Extreme negativism or mutism
4. Peculiarities of voluntary movement (e.g. bizarre posturing, stereotyped movements)
5. Echolalia or echopraxia
26
Schizophrenia: Mental Status Examination
1. General Description would include?
- Ranges from?
- Behavior? 3
1. Range from completely disheveled, screaming, and agitated to obsessively groomed, completely silent, and immobile
Behavior?
- May be talkative and exhibit bizarre postures;
- may become agitated or violent in an unprovoked manner or in response to hallucinations;
- may be in a catatonic stupor; tics, echopraxia, etc.
27
Schizophrenia: Mental Status Examination
Mood, feelings, affect:
-Ranges from? 2
1. Reduced emotional responsiveness to
| 2. overly active and inappropriate emotions such as extremes of rage, happiness, and anxiety
28
Schizophrenia: Mental Status Examination
Perception?
1. All five senses may be affected by what?
2. May have illusions. How are these differentiated from hallucinations?
1. hallucinatory experiences (most common are auditory and visual)
2. Illusions? Differentiated from hallucinations in that illusions are distortions of REAL images
29
Schizophrenia: Mental Status Examination
| What is the core symptoms of schizophrenia?
Thought:
The most difficult symptoms to understand
Also… likely the CORE symptoms of schizophrenia
Thought Content
Thought Form and Process
30
Schizophrenia: Thought content includes?
What is the person thinking? (ideas, beliefs, and interpretations of stimuli)
31
What are the four components of delusion?
1. False belief
2. Based on incorrect inference about external reality
3. Not consistent with patient’s intelligence and cultural background
4. Cannot be corrected by reasoning
32
Match That Delusion!!
1. “I can’t believe that they’ve now sabotaged my car! Last week they stole my mail and I know they are following me every time I leave the house.”
2. “God has chosen me to be the world’s representative at the universal meeting at Mars next month.”
3. “Invaders from space have infiltrated my testicles so I wouldn’t be allowed to father any children.”
4. “It doesn’t matter anyway with how my thoughts are controlled by the government.”
5. “The DJ is really giving me instructions on what to do. He just disguises it so no one will pick up on it.”
1. Delusion of persecution
2. Delusion of Grandeur
3. Bizarre Delusion
4. Delusion of control
5. Delusion of Reference
33
```
Thought
Thought Form and Process
How is the person thinking what they’re thinking
Patterns?
11
```
1. Flight of ideas
2. Thought blocking
3. Incoherence
4. Poverty of content
5. Poor abstraction abilities
6. Verbigeration
7. Tangentiality
8. Circumstantiality
9. Loose associations
10. Derailment
11. Neologisms
34
Mental Status Examination:
Sensorium and Cognition:
3 characteristics
1. Usually oriented to person, time, and place (lack of such orientation should prompt clinicians to investigate the possibility of medical or neurological brain disorder)
2. Memory usually intact (may be difficult however to get patient to attend closely enough to the memory tests for adequate assessment)
3. Classically described as having poor insight into the nature and severity of the disorder (why is this a problem- wont allow treatment)
35
Schizophrenia
Mental Status Examination:
Impulsiveness:
2 descriptions
1. May be agitated and have little impulse control when ill
2. Along with this, may have decreased social sensitivity
Examples: May grab another person’s cigarettes, change television channels abruptly, or throw food on the floor (often response is to a auditory command hallucination)
36
Schizophrenia
| Etiology Theories
1. Stress-Diathesis Model
2. Neurobiology
3. Dopamine Hypothesis (Dominating theory)
37
Describe each theory for Schizophrenia
1. Stress-Diathesis Model
2. Neurobiology
3. Dopamine Hypothesis (Dominating theory)
1. A person may have a specific vulnerability (diatheses) that, when acted on by a stressful influence, allows the symptoms of schizophrenia to develop
2. Brain imaging in living people and neuropathological examination of postmortem brain tissue have implicated the limbic system as potential site for primary pathological process in at least some, and perhaps most, schizophrenic patients
3. Simplest formulation? Too much dopaminergic activity (evolved from efficacy of most antipsychotic drugs and drugs that increase dopaminergic activity cause symptoms)
Mesocortical and mesolimbic tracts are most often implicated (association with limbic system)
38
Neurotransmitter roles.
We already know the significance of dopamine, but what about Serotonin?
2
1. Antagonism at the serotonin 5-HT2 receptor has been emphasized as important in reducing psychotic symptoms
2. Serotonin-dopamine antagonists have a high affinity for serotonin 5-HT2 receptors (even higher than for D2 receptors)
39
Schizophrenia
Course:
What may be the first evidence of illness?
Premorbid pattern of symptoms may be the first evidence of illness (this is usually only discovered in hindsight however)
40
Schizophrenia: Premorbid pattern of symptoms may be the first evidence of illness (this is usually only discovered in hindsight however): Which symptoms?
4
1. Quiet, passive, and introverted personality
2. Usually few friends growing up
3. Adolescents may have no close friends, no dates, and may avoid team sports
4. Often enjoy movies and TV or listening to music to the exclusion of social activities
41
Schizophrenia Prognosis?
Over the 5 – 10 year period after 1st psychiatric hospitalization, only approxamately10 – 20 % of patients can be described as having a good outcome
42
Schizophrenia: More than 50% of patients can be described as having a poor outcome? This includes?
4
1. Repeated hospitalizations
2. Exacerbations of symptoms
3. Episodes of major mood disorders
4. Suicide attempts
Schizophrenia does not always run a deteriorating course; estimated that 20 – 30% of all schizophrenic patients are able to lead somewhat normal lives
43
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Violent behavior (excluding homicide) is common among untreated schizophrenic patients:
Emergency treatment may include restraints and seclusion
-What kind of sedation would we use?
```
Acute sedation with lorazepam (Ativan), 1 to 2 mg IM, may be repeated every hour as needed to prevent patient from doing harm to others
44
Schizoaffective disorder prominently features both affective and psychotic symptoms (MUST be a period of what?
-In the absense of what?
1. delusions or hallucinations in
| 2. the ABSENCE of mood disorder
45
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Antipsychotic Medicaitons
First generation antipsychotics (FGAs)
1. Which drugs are these? 2
2. MOA?
3. Protein binding abilities?
4. Interactions?
```
1. Examples:
- Haloperidol (Haldol),
- chlorpromazine (Thorazine)
2. Strong antagonism of D2 receptors in both cortical & striatal areas
3. Highly protein & tissue bound
4. All are subject to extensive metabolism via cytochrome P450 & can interact w/ drugs that effect that system
46
First generation antipsychotics (FGAs)
Examples: Haloperidol (Haldol), chlorpromazine (Thorazine)
-SE?
7
1. Extra-pyramidal symtoms (EPS)
2. Tardive dyskinesia (TD)
3. Hyperprolactinemia (?)
4. Neuroleptic malignant syndrome (NMS)
5. QT prolongation
6. Sudden death
7. Increased risk of mortality when treating elderly patients w/ dementia
47
First Generation Antipsychotics
Drug class: phenothiazines
three drugs?
1. Chlorpromazine (Thorazine)
2. Haloperidol (Haldol)
3. Thioridazine (Melllaril)
48
First Generation Antipsychotics: Drug class: phenothiazines
SE?
6
```
1. Akinesia
Extrapyramidal symptoms
2. Akathisia
3. Parkinsonian syndrome
4. Acute dystonias
5. Tardive dyskinesia
6. Weight gain/hyperprolactinemia
```
49
Second generation antipsychotics (SGAs)
1. Drugs in this category? 2
2. MOA?
3. SE? 8
4. Cost?
1. Examples:
- respirdone (Resperdol),
- aripiprazole (Abilify)
2. MOA: post-synaptic blockade D2 receptors PLUS 5HT2 receptor binding (which may explain the lower risk of EPS
3. SE:
- weight gain,
- hyperglycemia,
- hyperlipidemia,
- EPS,
- TD,
- NMS,
- hyperprolactinemia, and
- increased mortality in elderly patient w/ dementia
4. Cost: much higher unless generic available
50
Why would we not use Clzapine for first line therapy?
Clozapine: can cause agranulocytosis; NOT first line therapy
51
Indications for FGAs: Primarily used for?
2
Metabolized where?
1. IV for emergent situations (with careful cardiac monitoring because they can prolong QT interval)
2. Haloperidol and fluphenazine (Prolixin) are available as depot preparations for ease of administration for long term use and more cost effective then the atypical antipsychotics
All are metabolized in the liver
52
Risperidone (Risperdal)
1. Advantages of the drug?
2. SE? 5
3. Forms of administration? 3
1. No anticholinergic effects
2. SE:
- sedation,
- hypotension,
- akathisia,
- prolactin elevation and
- weight gain
3. Forms:
- disintegrating tablet,
- liquid and
- depot formulations
53
Olanzapine (Zyprexa)
1. Levels of this can be decreased by what?
2. SE? 6
3. Forms? 3
4. Cost?
1. Levels decreased some by cigarette smoking***
2. SE:
- *weight gain,
- sedation,
- akathisia,
- hypotension,
- dry mouth and
- constipation
3. Forms:
- coated tablets,
- disintegrating tablets,
- injectable solution
4. More expensive then other SGAs
54
Quetiapine (Seroquel)
1. Also used to treat what? 3
2. SE? 5
3. Disadvantage?
4. Low incidence of what?
1. Also used to treat mood and anxiety disorders, PTSD, and Parkinson disease
2. BID dosing recommended, often given qday—comes only as tablets
3. SE:
- sedation (improves over time),
- orthostatic hypotension,
- akathisia,
- dry mouth,
- weight gain (moderate)
4. Low incidence of EPS
55
Aripipraole (Abilify)
1. Unique pharmacokinetics such as? 3
2. SE? 6
3. Forms 2
4. Disadvantage?
1. Unique pharmacokinetics:
- Agonist at D2 receptors
- Partial agonist at 5HT1a receptors
- Antagonist at 5HT2a, H1 and alpha-1-adrenergics
2. SE:
- HA,
- N/V,
- akathisia,
- tremor,
- constipation and
- minimal weight gain
3. Forms:
- standard and
- disintegrating tablets and IM solution
4. Disadvantage: unpredictable effect on activity of other antipsychotics
56
Clozapine (Clozaril)
1. What is it known for?
2. Why is it only reccommended for those resistant to treatment?
- What do we need to monitor?
3. SE?
1. Unique for its efficacy in otherwise treatment-resistant patients
2. Has high risk of agranulocytosis (1-2%) therefore only recommended for those resistant to treatment (must monitor?)CBC
3. SE:
- orthostatic hypotension,
- tachycardia,
- weight gain,
- metabolic syndrome,
- sialorrhea,
- sedation,
- constipation and
- seizure risk that increases with dose
57
Side Effect Management
| EPS? 3
1. Akathisia—most common
2. Parkinsonian syndrome:
3. Dystonias:
58
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Side Effect Management
EPS: How can we treat the following?
1. Akathisia—most common 2
2. Parkinsonian syndrome 2
3. Dystonias 2
```
1.
- Cautious antipsychotic dose reduction
- Treatment w/ benzodiazepine, beta-blocker, benztropine
2.
- Benztropine
- Amantadine: can cause hypotension and mild agitation
3.
- Preferred to change to antipsychotic w/ lower EPS
- Benztropine, diphenhydramine
59
Tardive Dyskinesia:
| Movements such as? 5
1. Sucking/smacking of lips
2. Choreaoathetoid movement of the tongue
3. Facial grimacing
4. Lateral jaw movements/clenching
5. Choreiform or athetoid movements of the body
60
Risk factors for developing tardive dyskinesia?
4
Treatment?
1. long use,
2. EPS,
3. elderly,
4. use of other meds
NO pharmacologic treatment available
61
For those who responded well, but are habitually nonadherent they should be considered for ______ medication?
depot
62
Although SGAs have been considered first-line, because of their lower risk for EPS compared to FGAs, what is their downside?
2
they are more expensive and several cause more metabolic SE and weight gain than FGAs
