Psychosis Flashcards
What is psychosis?
Involves inability to distinguish between subjective experience and reality
Characterised by lack of insight
Harmful to individuals functioning of interpersonal relationships
What are some psychotic experiences?
Hallucinations Delusions Passivity Formal thought disorder Emotional disturbance Physical symptoms
What are some of Schneider’s first rank symptoms?
Auditory hallucinations: voices arguing, thought echo, running commentary
Delusions of thought interference: thought insertion/withdrawal/broadcasting
Delusions of control: passivity of affect/impulse/volitions, somatic
What is in the ddx of psychotic symptoms?
Schizophrenia Psychoactive Substance Use Mania Depression Schizoaffective Disorder Delirium Dementia Other organic cause
Define simple schizophrenia
A disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance. The characteristic negative features of residual schizophrenia (e.g. blunting of affect and loss of volition) develop without being preceded by any overt psychotic symptoms.
What are self referential experiences?
The belief that external events are related to oneself
Can vary in intensity from a brief thought, to frequent & intrusive thoughts to delusional intensity (self-referential delusions or delusions of reference)
Describe the symptoms in drug induced psychosis
May be florid symptoms or chronic symptoms but tend to be short lasting if access to the psychoactive substance is removed.
Describe depressive psychosis
Psychosis is a marker of severity in depression
Typified by mood congruent content of psychotic symptoms
Delusions of worthlessness / guilt / hypochondriasis / poverty
Hallucinations of accusing / insulting / threatening voices – typically 2nd person
Describe mania with psychosis
Typified by mood congruent content of psychotic symptoms
Delusions of grandeur / special ability / persecution / religiosity
Hallucinations: auditory (e.g. God’s voice)
Flight of ideas
How commonly is a symptom of first rank present in a manic episode?
About 20%
How is schizoaffective disorder characterised?
Presence of both symptoms typical of schizophrenia and affective disorder
Any specific episode may be schizo-manic or schizo-depressed
What is delirium?
Acute confusion-transient global disturbance, common and related to many underlying conditions
What conditions are related to delirium?
Alcohol Withdrawal Infection-septicaemia Medical/surgical in-patients Organ failure-cardiac, renal, hepatic Hypoglycaemia Post-op hypoxia Post-ictal Encephalitis SOL Drug intoxication- steroids, digoxin, diuretics, anticholinergics Drug withdrawal- benzos
What happens in delirium?
Clouding of consciousness
-Ranges from subtle drowsiness to unresponsive
-Disorientation in time, place & person
-Fluctuating severity over time (lucid intervals)
-Worse at night
Impaired concentration / memory
-Especially for new information
What symptoms occur in delirium?
Visual hallucinations/illusions +- auditory (often threatening)
Persecutory delusions
Psychomotor disturbance-agitation or retardation
Irritability
Insomnia
How is the ddx of psychosis decided on?
Nature of psychotic experiences
3rd person auditory hallucinations suggest schizophrenia
Mood related delusions suggest affective disorder
Associated psychiatric symptoms
Natural history of the symptoms – presentation over time
Other features of history - FH, PH, DH etc
What is the definition of violence?
The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation
What does the immediate treatment of aggression include?
Management of substance withdrawal phenomena and management of acutely disturbed or aggressive behaviour
Under the Scottish Mental Health act, what is the definition of a patient?
A person who has or appears to have a mental disorder
What is covered by the term ‘mental disorder’?
Any mental illness
Personality Disorder
Learning Disability
‘However caused or manifested’
When should emergency detention be used, and who can use it?
‘Where it is necessary as a matter of urgency to detain the patient in hospital for the purpose of permitting a full assessment of the person’s mental state; and where if the patient were not detained in hospital there would be a significant risk to either themselves or others’
Any registered medical practioner
How long does an emergency detention last?
Max 72 hrs
What treatment is allowed under an emergency detention?
None-except emergency care
Must be reported to MWC on form T4
Who can apply a short term detention?
Approved Medical Practitioner
Must have MHO consent
Does a short term detention allow treatment?
Yes-treatment authorised
How long does a short term detention last?
Max 28 days
When should a STD be used?
The patient has mental disorder
The patient’s ability to make decisions about the provision of medical treatment is significantly impaired as a result of that mental disorder (Significantly Impaired Decision Making Ability)
It is necessary to detain the patient in hospital for the purpose of determining what medical treatment should be given to the patient or of giving them medical treatment
There would be a significant risk to the health, safety or welfare of the patient or to the safety of any other person if the patient were not detained in hospital
Who can apply for a compulsory treatment order?
MHO- supported by two medical reports
One must be AHP
Other usually patient’s GP
Does a CTO authorise treatment?
Yes
Is a tribunal hearing required in a CTO?
Yes
How long can a CTO last?
Up to 6 months
What is the rapid tranquilisation policy for a patient with either/some of: history unknown, cardiac history, no history of typical antipsychotics, current illicit drug use?
Consider oral therapy- Lorazepam 1-2mg
If unsuccessful/need effect within 30 mins
Lorazepam 1-2mg IM (1:1 in water or 0.9% NaCl)
Wait 30 mins
Repeat injection once if necessary
What is the rapid tranquilisation policy for a patient with confirmed history of significant typical antipsychotic exposure (not just PRN)?
Consider oral therapy- Lorazepam 1-2mg and/or haloperidol 5mg
If unsuccessful/need effect within 30 mins
Lorazepam 1-2mg IM (1:1 in water or 0.9% NaCl)
In extreme cases, combination of lorazepam and haloperidol 5mg IM (not in same syringe)
Monitor RR, HR, BP every 5/10mins for 1hr
Wait 30 mins
Repeat injections once if necessary
What should be used for sedation in psychosis?
Use BDZ rather than increase antipsychotics, or use sedating antipsychotics
How do you decide which antipsychotic to use?
Patient and carer preference (Advance statements if available)
Patient characteristics (age, weight, physical health etc)
Usually Atypical is first line
Depot – issues with compliance, patient preference
Clozapine – treatment resistant illness
What is available for use in psychosis with mood disorder?
Mood stabilisers e.g. lithium, sodium valproate, carbamazepine, lamotrigine
Antidepressants
ECT
