Psychosis Flashcards
epidemiology
life time risk 1%; prevalence 0.2-0.7%; M=F; incidence: 5-50/100,000 (20/100,00o per year) peaks 23M, 26F; mostly late teens and mid 30s (M 18-25, F 25-35); rare rural; social class IV/V and immigrants (esp. Afro-Carro)
aetiology
biological: genetics (multi), obstetrics/infection, ethnicity (Afro-Carro 4x, S. Asian)
- dopamine theory: increased ML decreased MC pathways;
- neurodevelopmental theory: birth/antenatal complications; brain abn (large ventricles, smaller frontal/temporal lobes, hippoC, amygdala, parahipp gyrus)
psychological: cognitive errors (conclusion, misinterpretation), premorbid personality (schizotypal)
social: urban (2-3x), migration (3x), life events ( ?trigger), expressed motion (involved, critical, hostile carers), substances (cocaine, meth, cannnabis)
prognosis
20% only one episode; 50% have repeated episode (Ax, SI, depp)
30% continuous Sx, 25% improve but need support, 30% don’t respond to APDs
premature death (ave. 10y): med SE (CVS, DM), neglect (neg Sx), physical illness ignored, fear of Dr, post d/c most vulnerable (SI) -10% successfully commit suicide
diagnostic criteria (ICD-10)
duration >1/12, no organic
one major:
- auditory hallucinations: 3rd person/running commentary/body part
- delusions of control/passivity
- bizarre delusions, persecutory delusions, delusional perception
- thought alienation: echo, insertion, withdrawal, broadcast
or two minor: persistent hallucination/fleeting delusions/overvalued ideas; negative symptoms/catatonia, behaviour (aimless, w/d, no interest), thought disorganisation
-thought: loose association/flight, incoherent, neologism
clinical features
often gradually develop (average DUP >1y)
non-specific negative Sx, emotional distress/agitation, transient psychosis
FRS: audio hallucination (3rd/running), thought alienation (w/d, insert, broadcast, echo), control/passivity delusion, delusional perception
positive (‘added’): hallucinations, delusions, thought disorder, disorganised behaviour
negative (‘taken away’): blunted affect, avolition, speech poverty/blocking, social withdrawal, self-neglect, attention
-As: ambivalent, affect, attention, asocial
antipsychotics - indication and mechanism
APDs: first/second gen; new Dx, acute episodes; wait 24-48h (rule out DDx); 3/6/9 month courses
BZD: behaviour, insomnia, aggressive, agitated
?ADD/Lithium: schizoaffective, depression, TRS augmentation
TRS: 2 APD (at least 6-8 weeks proper dose); clozapine
-confirm Dx, ?substances, ?concordance
treat co-morbidities
beware NMS: excess NS; ANS, rigidity, BP, CK, WCC; dantroline
psychological interventions
psychoeducation: relapse signs, relapse prevention, crisis plan
CBT: Sx (less for adherence/social function),
FIT: adherence, relapse, Ax, burden (less for Sx and Fx)
CRT: cognitive function (less for Sx and social function)
other: coping skills, concordance, rehab (skills), group therapy, self-help/responsibility
social interventions
acute environment: calm, remove weapons, trained staff, don’t turn back, stand between exit, slow soft speech, distract/rapport
education/employment; finances; housing; relationships; safeguarding; carers; activities/hobbies/skills
risk assessment
command, passivity, persecutory
chronic issues/risks: compliance, ongoing psychosis, substances, vulnerable/neglect, TRS, SE, physical health, wrong Dx, high EE/relapse, stressors
antipsychotics - benefits and SE
benefits: reduced relapse/Sx, 80% effective, not addictive
SE (most short/minor): sedation, EPSE (stiff/restless), DM and weight gain, sexual dysfunction, antiCh (blurry, dry)
antipsychotics - regimes
PO (daily) before IM (1-4/52); low and slow dosing
2-4 weeks until effect; 6-8 weeks before ‘failure’
3/6/9 month courses common
monitoring: yearly blood tests
Types of psychosis
paranoid schizophrenia: delusions/halls prominent; >1/12
hebephrenic: thoughts, affect, behaviour; dels/halls fleeting
catatonic
residual: psychotic episode then 1y of mostly negative Sx
simple schiz: insidious, depression, no psychosis, mostly negative
delusional disorder: delusions >3/12
acute transient/schizo-like: psychotic
family history and risk
MZ twin 46%;
sibling/DZ/one parent 15%; two parents 40%;
child/grandparent 6%
autn/uncle/nephew/niece/cousin 3%
differential diagnosis
organic: delirium/dementia, medication (DA, CST), endocrine (Cushing, thyroid), neurological (TLE, HD, SOL), systemic (porphyria, SLE)
psychiatric: shizophrenia, schizoaffective, delusional disorder, schizotypal PD, acute/transient psychosis, severe mood disorders (mania, depression, anxiety), factitious/malingering
substances, alcohol: intoxication or withdrawal; cannabis, cocaine, meth
culturally appropriate or religious belief
Prognostic factors
good: female, married, acute onset, older age onset, low DUP (most important), FHx (affective), mood >psychosis, good premorbid, triggered (stressors), Rx response
bad: opposites of good; FHx (schiz), high EE (relapse risk), substances, prominent negative Sx, poor insight and compliance
