Psychosis Flashcards
Psychosis
A grossly distorted sense of reality, resulting in delusions, hallucinations and thought disorder
Perception
Process of making sense of the physical information we receive from the 5 senses
Hallucination
A perception occurring in the absence of an external physical stimulus
Illusion
A misperception of real external stimuli - can occur in healthy people, associated with inattention or strong emotion
Pseudohallucination
Perceptual experience that the patient recognises as having coming from within their own mind, yet beyond conscious control
Elementary auditory hallucinations
Simple, unstructured sounds e.g. whirring, buzzing, whistling or single words
Commonly occur in acute organic states
Complex auditory hallucinations
Spoken phrases, sentences or dialogue in 1st, 2nd or 3rd person
Audible thoughts
1st person auditory hallucination
Person hears their thoughts spoken aloud as they think them
Thought echo
1st person auditory hallucination
Person hears their own thoughts as an echoed by a voice after they have thought them
Second person auditory hallucinations
Patients hear a voice/voices speaking directly to them
Often persecutory, critical, complimentary or issue commands (command hallucinations)
Often associated with mood disorders with psychotic features, where they are mood congruent
Third person auditory hallucinations
Patients hear voices speaking about them or referring to them
Autoscopic hallucination
The experience of seeing an image of oneself in an external space
Charles Bonnet syndrome
Complex visual hallucinations associated with no other psychiatric symptoms or impairment in consciousness - usually in older adults, associated with a loss of vision
Lilliputian hallucinations
Seeing miniature people or animals
Somatic hallucinatons
Hallucinations of bodily sensations
Tactile (haptic) hallucinations
Experience of the skin being touched, pricked or pinched
Formication
Unpleasant sensation of insects crawling on or just below the skin
Associated with long-term cocaine use and alcohol withdrawal
Hygric hallucinations
False perception of fluid e.g. ‘I can feel water sloshing in my brain’
Visceral hallucinations
False perceptions of internal organs - include deep sensations of organs throbbing, stretching, distending or vibrating
Kinaesthetic hallucinations
False perception of joint or muscle sense
Includes feeling sensation of free-falling as you are about to fall asleep
Olfactory hallucinations
Often occur with gustatory hallucinations, as the two senses are closely related
Important to rule out epilepsy (especially temporal lobe) and other organic brain diseases
Hypnagogic hallucinations
False perceptions in any modality (often auditory or visual) that occur as a person goes to sleep
Not indicative of psychopathology
Hypnopompic hallucinations
False perceptions in any modality (often auditory or visual) that occur as a person wakes up
Not indicative of psychopathology
Extracampine hallucinations
False perceptions that occur outside of the limits of a person’s normal sensory field e.g. hearing voices from 100 miles away
Functional hallucination
When a normal sensory stimulus is required to precipitate a hallucination in the same sensory modality e.g. voices that are only heard when the doorbell rings
Reflex hallucination
When a normal sensory stimulates in one modality precipitates a hallucination in another e.g. voices that are only heard when the lights are on
Delusion
An unshakeable false belief, not in keeping with the patient’s social and cultural background
A delusion is to ideation what a hallucination is to perception
Delusional atmosphere
Where the world seems subtly altered, uncanny, portentous or sinister. This resolves into a delusion, usually in a revelatory fashion, which seems to explain the unusual feeling of anticipation
Delusional intuition
Where delusions arrive ‘out of the blue’, without external cause
Delusional perception
Where a normal percept is interpreted with delusional meaning. For example, a person sees a red car and knows that this means their food is being poisoned by the police
Secondary delusions
Secondary delusions (sometimes called delusion-like ideas) are considered to be, at least in principle, understandable in the context of a person’s life history, personality, mood state or presence of other psychopathology. For example, a person becomes depressed, suffers very low mood and self-esteem, and subsequently believes they are responsible for some terrible crime which they did not commit.
Primary delusions
Do not occur in response to any previous psychopathological state - their genesis is un-understandable
Partial delusion
Beliefs that were previously held with delusional intensity, but then become held with less conviction.
Occurs when patients start recovering after receiving treatment
Overvalued idea
A plausible belief that a patient becomes preoccupied with to an unreasonable extent . The pursuit of the idea causes considerable distress to the patient or those living around them
Persecutory delusion
False belief that one is being harmed, threatened, cheated, harassed or is a victim of a conspiracy
Grandiose delusion
False belief that one is exceptionally powerful (including having ‘mystical powers’), talented or important
Delusions of reference
False belief that certain objects, people or events have intense personal significance and refer specifically to oneself, e.g. believing that a television
newsreader is talking directly about one
Religious delusions
False belief pertaining to a religious theme, often grandiose in nature, e.g. believing that one is a special messenger from God
Delusions of love (erotomania)
False belief that another person is in love with one (commoner in women).
de Clerambault syndrome
A woman (usually) believes that a man, frequently older and of higher status, is in love with her
Delusions of infidelity (morbid jealousy, Othello syndrome)
False belief that one’s lover has been unfaithful. Note that morbid jealousy may also take the form of an overvalued idea, that is, non-psychotic jealousy
Capgras syndrome
Belief that a familiar person has been replaced by an exact double – an impostor
Fregoli syndrome
Belief that a complete stranger is actually a familiar person already known to one
Nihilistic delusions
False belief that oneself, others or the world is non-existent or about to end. In severe cases, negation is carried to the extreme with patients claiming that
nothing, including themselves, exists
Somatic delusions
False belief concerning one’s body and its functioning, e.g. that one’s bowels are rotting. Also called hypochondriacal delusions (to be distinguished
from the overvalued ideas seen in hypochondriacal disorder)
Ekbom’s syndrome
False belief that one is infested with small but visible organisms. May also occur secondary to tactile hallucinations, e.g. formication
Delusions of control (passivity or ‘made’ experiences)
False belief that one’s thoughts, feelings, actions or impulses are controlled or ‘made’ by an external agency, e.g. believing that one was made to break a window by demons
Thought insertion
Belief that thoughts or ideas are being implanted in one’s head by an external agency
Thought withdrawal
Belief that one’s thoughts or ideas are being extracted from one’s head by an external agency
Thought broadcasting
Belief that one’s thoughts are being diffused or broadcast to others such that they know what one is thinking
Loosening of association (derailment/knight’s move thinking)
When the patient’s train of thought shifts sud- denly from one very loosely or unrelated idea to the next
Characteristic of schizophrenia
Word salad
Most extreme form of loosening of association. Speech becomes a mixture of incoherent words and phrases
Thought blocking
A sudden cessation to the flow of thought, often in mid-sentence. Patients have no recall of what they were saying or thinking
Neologisms
New words created by the patient
Perseveration
When an initially correct response is inappropriately repeated
Highly suggestive of organic brain disease
Echolalia
When patients senselessly repeat words or phrases spoken around them by others
Negative symptoms
Indicate a clinical deficit
Include marked apathy, poverty of thought and speech, blunting of affect, social isolation, poor self-care and cognitive deficits
Catatonic rigidity
Maintaining a fixed position and rigidly resisting all attempts to be moved
Catatonic posturing
Adopting an unusual or bizarre position that is then maintained for some time
Catatonic negativism
A seemingly motiveless resistance to all instructions or attempts to be moved; patients may do the opposite of what is asked
Catatonic waxy flexibility (flexibilitas cerea)
Patients can be ‘moulded’ like wax into a position that is then maintained
Catatonic excitement
Agitated, excited and seemingly purposeless motor activity, not influenced by external stimuli
Catatonic stupor
A presentation of akinesis (lack of voluntary movement), mutism and extreme unresponsiveness in an otherwise alert patient (there may be slight clouding of
consciousness)
Echopraxia
Patients senselessly repeat or imitate the actions of those around them. Associated with echolalia – also occurs in patients with frontal lobe damage
Mannerisms
Apparently goal-directed movements (e.g. waving, saluting) that are performed repeatedly or at socially inappropriate times
Stereotypies
A complex movement that does not appear to be goal-directed (e.g. rocking to and fro, gyrating)
Tics
Sudden, involuntary, rapid, recurrent, non-rhythmic motor movements or vocalizations
Differential diagnosis for the psychotic patient
Psychotic disorders
• Schizophrenia
• Schizophrenia-like psychotic disorders
• Schizoaffective disorder
• Delusional disorder
Mood disorders
• Manic episode with psychotic features
• Depressive episode, severe, with psychotic features
Secondary to a general medical condition
Secondary to psychoactive substance use Dementia/delirium
Personality disorder (schizotypal, borderline, schizoid, paranoid)
Neurodevelopmental disorder (autistic spectrum)
ICD-10 diagnostic guidelines for schizophrenia (4,5)
One or more of the following symptoms:
a. Thought echo, insertion, withdrawal or broadcast
b. Delusions of control or passivity; delusional
perception
c. Hallucinatory voices giving a running commentary;
discussing the patient among themselves or ‘originating’ from some part of the body
d. Bizarre delusions
OR
Two or more of the following symptoms:
e. Other hallucinations that either occur every
day for weeks or that are associated with fleeting delusions or sustained overvalued ideas
f. Thought disorganization (loosening of association, incoherence, neologisms)
g. Catatonic symptoms
h. Negative symptoms
i. Change in personal behaviour (loss of interest,
aimlessness, social withdrawal)
How long do symptoms need to be present to diagnose schizophrenia?
Symptoms should be present for most of the time during at least 1 month
Schneider’s first rank symptoms of schizophrenia (3+3+3+2)
- Made phenomena
- Made affect (emotion)
- Made impulse (drive)
- Made volition (acts) - Disruptions of thought
- Thought insertion
- Thought withdrawal
- Thought broadcast - Types of auditory hallucinations
- Voices giving a running commentary on the patient
- Hearing thoughts spoken out loud
- Voices in the third person criticising or discussing the person - Somatic passivity
5 . Delusional perception
Paranoid schizophrenia
Dominated by the presence of delusions and hallucinations (positive symptoms). Negative and catatonic symptoms as well as thought disorganization are not prominent. The prognosis is usually better and the onset of illness later than the other subtypes.
Hebephrenic (disorganised) schizophrenia
Characterized by thought disorganization, disturbed behaviour and inappropriate or flat affect. Delusions and hallucination are fleeting or not prominent. Onset of illness is earlier (15 to 25 years of age) and the prognosis poorer than paranoid schizophrenia
Catatonic schizophrenia
A rare form characterized by one or more catatonic (psychomotor) symptoms
Residual schizophrenia
1 year of predominantly
chronic negative symptoms which must have been preceded by at least one clear cut psychotic episode in the past
Delusional disorder
The development of a single or set of delusions for the period of at least 3 months is the most prominent or only symptom
Folie a deux
When a non-psychotic patient with close emotional ties to another person suffering from delusions (usually a dominant figure) begins to share those delusional ideas themselves. The delusions in the non-psychotic patient tend to resolve when the two are separated
Medical conditions that can cause psychotic symptoms
-Cerebral: neoplasm, infarct, trauma, infection, inflammation
-Endocrinological: thyroid, parathyroid, adrenal
-Epilepsy (especially temporal lobe)
-Huntington’s disease
-SLE
-Vitamin B12, niacin (pellagra) and thiamine deficiency (Wernicke’s encephalopathy)
Acute intermittent porphyria
Substance-related causes of psychotic symptoms
- Alcohol
- Cannabis
- ‘Legal highs’
- Amphetamines
- Cocaine
- Hallucinogens
- Inhalants/solvents
Prescribed:
- Antiparkinsonian drugs
- Corticosteroids
- Anticholinergics
Schizophrenia-like psychotic disorder
ICD-10: acute and transient psychotic disorder
DSM-IV: schizophreniform disorder or brief psychotic disorder
If symptoms have been going on for
