Psychosis Flashcards
Define Psychosis
A loss of contact with reality
Define Delusions
Strongly held false beliefs that are not part of the patient’s cultural or religious backgrounds
Types of Delusions
Persecutory Grandiose Erotomanic Somatic Delusions of reference Delusions of control
Define Hallucinations
Wakeful experiences of content that is not actually present
Auditory most common
Thought Disorganization
Alogia/poverty of content
Thought blocking
Loosening of association
Tangentiality
Clanging or clang association: rhyming words
Word salad: words linked incoherently
Perseravation: repeating words phrases no matter the topic
Differential Diagnosis of Psychotic Disorders
Schizophrenia Bipolar disorder + psychotic features Major depression + psychotic features Schizoaffective disorder Schizophreniform disorder Brief psychotic disorder Substance induced psychotic disorder Delusional disorder Psychosis secondary to medical condition
Define Schizoaffective Disorder
Affective disorder but have psychotic features at a separate time than the affective disorder
Define Schizophreniform Disorder
Schizophrenia that doesn’t quite meet the criteria for Schizophrenia
Labs for Psychosis Work-up
CBC CMP RPR/VDRL TSH HIV UA Urine drug screen
What is the peak age of schizophrenia?
Men: 12-25
Women: 25-35
Items that make schizophrenia difficult to deal with
Highly disabling
Persists throughout patient’s life
Poor care & social ostracism
Only 1/2 obtain treatment
DSM-5 Criteria: 2 of the following characteristics during a 1 month period
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms
Social or occupational dysfunction
Continuous signs of disturbance persisting for at least 6 months within 1 month of “active-phase” symptoms
Positive Symptoms of Schizophrenia
Delusions
Hallucinations
Negative Symptoms of Schizophrenia
Affective flattening Poverty of speech (Alogia) Blocking Poor grooming Lack of motivation Anhedonia Social withdrawal
Which types of symptoms have better responses to treatment?
Positive symptoms
Subtypes of Schizophrenia
Paranoid type
Disorganized type
Catatonic type
Define Paranoid Schizophrenia
Preoccupation with one or more delusions or frequent auditory hallucinations
No disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect
Characteristics of Disorganized Schizophrenia
Disorganized speech
Disorganized behavior
Flat or inappropriate affect
Characteristics of Catatonic Schizophrenia
Motoric immobility Excessive purposeless motor activity Extreme negativism or mutism Peculiarities of voluntary movement Echolalia or echopraxia
Define Echolalia & Echopraxia
Mimic your movements or your speech
Four Components of Delusions
False belief
Based on incorrect inference about external reality
Not consistent with patient’s intelligence & cultural background
Cannot be corrected by reasoning
Name this type of Delusion: “I can’t believe that they’ve now sabotaged my car! Last week they stole my mail and I know they are following me overtime I leave the house”
Delusion of Persecution
Name this type of Delusion: “God has chosen me to be the world’s representative at the universal meeting at Mars next month”
Delusion of Grandeur
Name this type of delusion: “Invaders from space have infiltrated my testicles so I wouldn’t be allowed to father any children.”
Bizarre Delusion
Name this type of delusion: “It doesn’t matter anyway with how my thoughts are controlled by the government.”
Delusion of Control
Name this type of delusion: “The DJ is really giving me instructions on what to do. He just disguises it so no one will pick up on it.”
Delusion of Reference
Different Thought Form & Process’s
Flight of ideas Thought blocking Incoherence Poverty of content Poor abstraction abilities Verbigeration Tangentiality Circumstantiality Loose associations Derailment Neologisms
Parts of a Mental Status Examination
General description Mood, feelings, affect Perception Thought: content, form & process Sensorium & cognition: oriented x3, memory intact, poor insight Impulsiveness
Neurotransmitters Associated with Schizophrenia
Dopamine Glutamate Gamma-amino-butyric-acid (GABA) Acetylcholine Serotonin
Dopamine in Schizophrenia
Decreased dopamine: cognitive & negative symptoms
Glutamate in Schizophrenia
Major CNS excitatory neurotransmitter
Hypofunction of glutamate receptor may contribute to pathology
Gamma-amino-butyric-acid (GABA) in Schizophrenia
Major CNS inhibitory neurotransmitter
Important for regulation of the prefrontal cortical function
Interneurons are dysfunction in schizophrenia
Acetylcholine in Schizophrenia
Nicotine can normalize some eye-tracking & EEG abnormalities
Serotonin in Schizophrenia
Antagonism at 5-HT2 receptors reduces psychotic symptoms
Pattern of Symptoms in Schizophrenia
Quiet, passive, & introverted personality
Few friends growing up
Adolescents may have no close friends, dates, & may avoid team sports
Enjoy movies & TV or listening to music instead of social activities
Poor Outcomes of Schizophrenic Patients
Repeated hospitalizations
Exacerbation of symptoms
Episodes of major mood disorders
Suicide attempts
What is common among untreated schizophrenic patients?
Violent behavior
What percent of schizophrenic patients attempt suicide?
50%
How is Schizoaffective Disorder Different from Schizophrenia
Major depressive or manic episode
AND patient must have experienced delusions or hallucinations IN THE ABSENCE of the mood symptoms
How is Brief Psychotic Disorder Different from Schizophrenia
Symptoms of delusions, hallucinations, disorganized speech, or disorganized behavior that persist for more than 1 day but less than 1 month
How is Delusional Disorder Different from Schizophrenia?
Delusion WITHOUT other signs/symptoms of psychosis
Delusions are non bizarre
How is Schizophreniform Disorder Different from Schizophrenia?
Schizophrenia like symptoms for more than 1 month but less than 6 months
Examples of First Generation Antipsychotics (FGAs)
Haloperidol (Haldol)
Chlorpromazine (Thorazine)
Thioridazine (Mellaril)
MOA of First Generation Antipsychotics (FGAs)
Antagonism of D2 receptors in both cortical & stratal areas
SE of First Generation Antipsychotics (FGAs)
Extra-pyramidal symptoms (EPS) Tardive dyskinesia (TD) Hyperprolactinemia Neuroleptic malignant syndrome (NMS) QT prolongation Sudden death Increased risk of mortality when treating elderly patients with dementia Akinesia Weight gain
Extra-pyramidal Symptoms
Akathisia
Parkinsonian syndrome
Acute dystonias
Examples of Second Generation Antipsychotics (SGAs)
Respirdone (Resperdol)
Aripiprazole (Abilify)
MOA of Second Generation Antipsychotics (SGAs)
Post-synaptic blockade D2 receptors PLUS 5HT2 receptor binding
SE of Second Generation Antipsychotics (SGAs)
Weight gain Hyperglycemia Hyperlipidemia EPS TD NMS- neuromalignant syndrome Hyperprolactinemia Increased mortality in elderly patients with dementia
Primary Use of FGAs
IV for emergent situations
Depot preparations
SE of Risperidone (Risperdal)
Sedation Hypotension Akathisia Prolactin elevation Weight gain
SE of Olanzapine (Zyprexa)
Weight gain Sedation Akathisia Hypotension Dry mouth Constipation
What is quetiapine (Seroquel) used to treat?
Mood disorders
Anxiety disorders
PTSD
Parkinson disease
SE of Quetiapine (Seroquel)
Sedation Orthostatic hypotensions Akathisia Dry mouth Weight gain
Pharmacokinetics of Aripipraole (Abilify)
Agonist at D2 receptors
Partial agonist at 5HT1a receptors
Antagonist at 5HT2a, H1 & alpha-1-adrenergics
SE of Aripipraole (Abilify)
Headache N/V Akathisia Tremor Constipation Minimal weight gain
What does clozapine (Clozaril) have a high risk of?
Agranulocytosis
When do we use clozapine (Clozaril)?
Treatment-Resistant patients
SE of Clozapine (Clozaril)
Orthostatic hypotension Tachycardia Weight gain Metabolic syndrome Sialorrhea Sedation Constipation Seizure risk that increases with dose
How to treat akathisia as a SE of antipsychotics?
Benzodiazepine
Beta-blocker
Benztropine
How to treat parkinsonian syndrome as a SE of antipsychotics?
Benztropine
Amantadine: SE hypotension & mild agitation
How to treat dystonia as a SE of antipsychotics?
Change to antipsychotics with lower EPS
Benztropine
Diphenhydramine
Tardive Dyskinesia Movements
Sucking/smacking lips Choreaoathetoid movement of tongue Facial grimacing Lateral jaw movements/clenching Choreiform or athetoid movements of the body
Risk Factors for Tardive Dyskinesia
Long use of antipsychotics
EPS
Elderly
Use of other meds
Metabolic Effects of Antipsychotics
Weight gain
Hyperglycemia
Hyperlipidemia
NMS: fever, mental status changes, rigidity, autonomic instability
Treatment Options in Addition to Medication for Schizophrenia
Family psychoeducational intervention
Social skills training for the patient
Cognitive behavioral therapy
Family Psychoeducational Intervention
Educates family that schizophrenia is a disease, factors about the disease, how to help the person with the disease & fosters optimism
Monthly sessions for 6-9 months
Social Skills Training for the Patient
Uses behaviorally based instruction, role modeling, rehearsal, corrective feedback, & positive reinforcement
Helps with deficits in skills as a result of negative symptoms
Cognitive Behavioral Therapy
Used to treat medication-resistant psychosis
