Psychosis Flashcards
What is the ICD-10 Dx criteria of psychosis (3)
= mental state where reality grossly distorted
→ Delusions
→ Hallucinations
→ Formal thought disorder
What is the age of peak incidence age of schizophrenia in males + females?
M 23Y
F 26Y
What are the ICD-10 Dx criteria for schizophrenia? (4)
No organic cause
Symptoms present >28d (+ before mood Sx)
≥1 of: 1st rank symptoms
OR ≥2 of: Sustained hallucinations Overvalued ideas/delusions Disorganised thought Catatonic symptoms -ve symptoms
What is the difference b/wn psychosis + schizoaffective/mood disorder?
Depends on whether psychotic or mood symptoms predominate
What are some other psychotic disorders that could be a DDx for schizophrenia? (6)
Schizoaffective disorder (1st ranks + mood) Delusional disorder (>hallucinations) Schizotypal disorder (psychotic personality disorder) Substance use e.g. alc withdrawal, stimulant intoxication Mood disorders (mania, severe depression) Acute/transient psychotic disorder (<28d)
What are the RFs for schizophrenia? (bio (4) -psycho (2) -social (4))
Biological: Genetic Obstetric complications Dopamine theory Neurodevelopmental theory
Psychological: Cognitive errors (jumping to conclusions - esp delusions/paranoia) Premorbid personality (schizotypal)
Social:
Urban living
Adverse life events (e.g. physical, sexual abuse)
Immigrants
Ethnicity (Afro-Caribbean + South Asians)
In Schizophrenia, list some good prognostic factors (8)
Female
Married (or good support network)
FH affective disorder
Mood symptoms predominate
Good premorbid personality
Rapid onset
Early treatment
Good response to treatment
In Schizophrenia, list some poor prognostic factors (7)
Opposite of good prognostic factors High expressed emotion (family critical/non-tolerant) FH schizophrenia Prominent negative symptoms Substance misuse Early/insidious onset Lack of insight / non-compliance
What are the general prognostic outcomes in schizophrenia/psychosis (1/3rds)
What factors can increase risk of premature death (3)
1/3rd → will never have another episode
1/3rd → manageable but recurrent episodes (req extensive support network)
1/3rd → continuous illness not free of symptoms
Risk early death: suicide (10-15%), CV disease + T2DM
What is a delusion defined as? / what criteria must something meet to be classed as delusion (4)
= pathological belief
Cannot be rationalised in any way
No external proof (even w. contradictory evidence)
Of personal significance
Not part of individuals cultural/religious background
List some phenomena that are examples of formal thought disorder (4)
Loosening of association (derailment)
Flight of ideas
Tangential thoughts
Thought block
List the positive symptoms of schizophrenia (4)
List the negative symptoms (5)(PARBS)
List any psychomotor symptoms (3)
Hallucinations
Delusions
Thought disorder
Disorganised behaviour
Reduced attention Avolition (no motivation) Social withdrawal Blunted affect Poverty of speech
Stupor/tics/rigors
Describe the First Rank symptoms (ABCD)
Auditory hallucinations
Broadcasting of thought / thought insertion/withdrawal
Controlled thought (delusion of mind/body controlled by external force)
Delusional perception (normal sensory perception links to bizarre perception e.g. saw bird + thought was president
What is the prodrome phase of schizophrenia + what do the symptoms consist of? (3)
= the period of time when pt gradually developing symptoms but not yet met criteria for Dx
→ Non-specific -ve symptoms
→ Emotional distress/ agitation for no reason
→ Transient psychotic symptoms
Outline the general management of a patient first presenting with psychotic symptoms (5)
1. Establish a Dx: Hx / MSE Ix (physical/psychosocial) 2. Manage Where to manage? (in-pt/community) (dep on risk) Who to manage? (which service) Bio-psycho-social management Support for carer Follow-up
What are some organic causes for psychosis (MENDS)
Medication-induced (steroids, stimulants, DA agonists)
Endocrine e.g. Cushing, hyper/hypothyroid
Neuro disorder (temp lobe epilepsy, MS, Huntingtons)
Delirium
Systemic disease (SLE, porphyria)
Why are physical investigations done in psychosis? (2)
What Ix done (6) (BUMPER)
To rule out organic cause
Preparing for antipsychotics
Bloods: LFTs/TFTs/FBC/gluc/lipids/cholesterol *Urine drug screen MRI/EEG (if indicated) *Physical Ex (neuro, BMI) ECG *Review all medications
What psychosocial Ix can be done in psychosis? (4)
Collateral Hx from other informant
OT assessment of daily functioning
Social assessment of housing/benefits etc
Carer assessment
What lifestyle factors contribute to poor co-morbidities in schizophrenia (5) (NARPS)
Smoking Poor diet Reduced physical activity Not engaging with physical health monitoring Antipsychotics metabolic SEs
What physical health monitoring must be done in SCZ? (5) + how often
Baseline Ix + yearly
PMH/FH of CHD/DM (in initial) Smoking/drinking status BP/BMI FBC/RFT/LFT/Gluc/Lipid ECG
List some psychiatric (7) + non-psychiatric (4) indications for anti-psychotics
SCZ Mood disorders with psychotic features Organic psychosis Delirium Behavioural disturbance in dementia Insomnia Anxiety disorders
Motor tics (e.g. Tourette’s)
N+V
Incontractable hiccups / pruritis
Rapid tranquilisation
What are the main dopaminergic pathways (3) that anti-psychotics work on?
Tuberoinfundibular (→ hyperprolactinaemia)
Nigrostriatal (→ EPSEs)
Mesocortical/mesolimbic
What type of drugs are typical (1st Gen) anti-psychotics?
List some examples (8)
D2-R antagonists
Chlorpromazine Fluphenazine Pipothiazine Trifluoperizine Haloperidol Zuclopenthixol Flupentixol Sulpiride
What are the categories of diff SEs of antipsychotics (PEN CHAP)
Psychiatric (worsen -ve symps): depression, apathy, confusion
Endocrine (hyperprolactinaemia): galactorrhoea, amenn, sexual dysfunc
Neurological: NMS, seizures (threshold lowered), sedation, EPSEs
Cardiac: arrhythmia, QT prolongation, myocarditis
Hypersensitivity reactions: skin/liver/marrow
Autonomic: BP, Temp
Peripheral autonomic: muscarinic SEs, alpha antag (post hypo)
What are the Extra-Pyramidal Side Effects? (ADAPT)
Acute Dystonia (invol musc spasms → brief abnorm postures)
Akathisia (subj feelings of restlessness - obj signs e.g. pacing, rocking)
Parkinsonism (tremor, rigidity, bradykinesia)
Tardive dyskinesia (abnormal invol hyperkinetic movements e.g. gurn-type, head-nod, grimacing)
What are the features of metabolic syndrome with anti-psychotics? (6)
Which antipsychotics have the highest risk (2)
Central obesity Impaired glucose regulation Insulin resistance Hypertension Raised triglycerides Raised LDL:HDL
Olanzapine + Clozapine have biggest risk (therefore physical monitor more freq)
Which typicals (4) /atypicals (5) can be given as a depot injection?
Fluphenazine
Flupentixol
Zuclopenthixol
Haloperidol
Olanzapine Risperidone Quetiapine Arirpiprazole Amisulpride
List the symptoms of neuroleptic malignant syndrome (8) HMCT HMCT
Hyperthermia
Muscle Rigidity
CK (creatine kinase) raised
Metabolic acidosis
Tremor
Confusion
Tachycardia
Hypo/hypertension
What are some reasons for poor compliance with antipsychotic Tx (5)
Lack of insight Side effects Delusions about medication/prescriber Pt feels better when 'ill' Pt in remission sees medication no longer required
What is treatment-resistant SCZ defined as?
What 3 things must be checked before making Dx
= lack of response to adequate (high) doses of 2 different antipsychotics
- Review Dx
- Rule out co-morbid substance misuse
- Ensure dose, duration + compliance with prev Tx
What are the SEs of clozapine? (6)
Neutropenia / agranulocytosis (v rare)
Metabolic syndrome
Seizures/epilepsy (lowers threshold)
Cardiomyopathy / myocarditis
Hypersalivation
Hunger/wt gain
What are the contraindications of clozapine? (6)
Severely reduced consciousness (v sedating) Epilepsy Parkinsons Pheochromocytoma Cardiac disease (esp arrhythmias) H/o agranulocytosis
What other things should be considered when prescribing an anti-psychotic? (5)
PMH/FH of DM or metabolic syndrome Current obesity Concerns about wt gain Potential impact of sedation Child-bearing age (ideally use typicals)
What is the general guideline advice when prescribing / titrating dose of anti-psychotic (5)
Use lowest effective dose
Start low go slow (can take weeks for response)
Precribe 1 psychotic at a time
Monitor SEs
Assess concordance before making any changes
What psychological therapies are available for psychosis? (2+4)
CBT (NICE guidelines - CBTp)
Family Intervention Therapy (FIT) (NICE guidelines)
Psychotherapy (crisis plans, relapse prevention)
Coping strategies
Maastricht therapy
Concordance therapy
What are the benefits of CBT in psychosis (3)
How does FIT help in psychosis (3)
Helps with symptoms
Helps improve insight
Helps improve compliance with meds
(in reality cannot be used in acute psychosis)
Helps change relative behaviour/beliefs
Reduces relapse + admission
Builds alliances / sets approp expectations + limits
What things should be considered in the social side of management for psychosis? (7)
Daily activities + hobbies/ employment/ education Family Relationships Safeguarding Housing Benefits Cultural needs
What things need to be considered in follow-up of psychosis management? (5)
Monitor treatment effectiveness / SEs Monitor mental state Monitor risk Monitor support system Further psychoeducation
What are some risks of using anti-psychotics in delirium?
+ in dementia?
Anti-psychotics in delirium: reduces seizure threshold in alc withdrawal
Anti-psychotics in dementia: increased risk CVA
Describe any psychotic symptoms that may appear with mania
What % manic pts experience 1st rank Sx?
Delusions*: mood congruent, grandiose beliefs, persecutory (with irritability)
Hallucinations: rare, mood congruent, 2nd person auditory
10% manic pts have 1st rank Sx
