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3a psychiatry > Psychosis > Flashcards

Psychosis Flashcards

1
Q

Define phenomenology

A

study of symptoms and signs of objectively describing abnormal states of mind

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2
Q

When is a hallucination non pathological?

A 
when tired
when vigilance high 
hypnosis
hypnagogic = experience on going to sleep
hypnapompic = experience on waking up
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3
Q

What is a pseudo-hallucination?

A

a perceptual experience which differs from a hallucination in that it appears in subjective inner space of mind

  1. vivid mental images but not perceived in external stimulus/ space but within the mind
  2. person recognises that experience does not correlate with real world
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4
Q

What are the 8 different types of hallucination

A 
auditory 
visual
olfactory 
tactile
somatic 
gustatory 
autoscopic 
reflex
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5
Q

Describe auditory hallucinations

A

2nd person = talking to the individual “you are worthless” , telling them to do things (= command) e.g. depressive psychosis, mania, personality disorder

3rd person= running commentary, several voices “she is” , e.g. 1st rank Schneider symptom

echo “de la pense” = voice speaks persons thoughts
commands = “hit her”
voices talking to each other e..g schizophrenia
gedankenlautwerden = voice anticipates what person thinks moments later

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6
Q

Define delusions

A

a firmly held, false belief which is out of keeping of their culture, intelligence and social background and held with great conviction

(vs over valued idea which is held with less rigidity than a delusion)

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7
Q

How are delusions described?

A
  1. fixity = complete or partial
  2. onset = primary autochthonous or secondary delusion
  3. other delusional experiences
  4. theme/ content
  5. other features
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8
Q

Define disorders of thinking

A

broader category involving delusions and obsessions

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9
Q

What are the types of disorders of thinking?

A

formal thought disorder e.g. flight of ideas, perseveration, loosening of association

abnormal thought content e.g. passivity phenomena, concrete thinking, circumstantiality, confabulation

abnormal beliefs about possession of thought e.g. thought broadcast, thought withdrawal, thought insertion

disorders of stream of thought e.g. pressure of speech, poverty of thought, blocking

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10
Q

Describe “flight of ideas”

A

rapid skipping from one thought to another distantly related ideas
jumps between topics
logical sequence of ideas

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11
Q

Describe “perseveration”

A

persistent and inappropriate repetition of the same thoughts
associated with dementia , organic disorder, wernickes encephalopathy

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12
Q

Describe “loosening of association”

A

loss of normal / logical structure of thinking

answers muddled and illogical attempts to clarify results

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13
Q

What are the types of loosening of association?

A
  1. knights moves/ derailment = jumps between sentences with no logical connection and no evidence of links
  2. word salad = extreme derailment, grammatical structure of speech lost
  3. talking past the point = never gets to the point of the conversation
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14
Q

Describe “pressure of speech”

A

lots of thoughts passing through mind rapidly
unusual associations , use of rhymes and puns
wander off the point of conversation

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15
Q

Describe “poverty of thought”

A

few thoughts
thoughts slow through mind
a negative symptom

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16
Q

Describe “thought blocking”

A

sudden interruption in train of thought, leaving a blank
patient may believe thoughts are blocked by someone
(negative symptom)

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17
Q

Describe the abnormal beliefs about the possession of thought (thought alienation)

A

thought broadcast= own thoughts are made available by others
thought withdrawal= somebody is removing thoughts from head
thought insertion = somebody is putting thoughts in their head

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18
Q

Describe “concrete thinking”

A

lack of abstract thinking (e.g. inability to understand metaphors)
normal in childhood aspergers and autism , frontal lobe disorders, learning disability

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19
Q

Define obsessions (the thought)

A

recurrent, persistent thoughts, impulses or images that enter the mind despite patients efforts to resist/ exclude them

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20
Q

define compulsions (the act)

A

repetitive and seeming purposeless behaviour performed in a stereotyped way accompanied by subjective sense they must be carried out and urge to resist

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21
Q

List the types of obsessions

A 
obsessional thoughts
obsessional ruminations
obsessional doubts 
obsessional impulses
obsessional phobias
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22
Q

What is the proposed cause of schizophrenia?

A 
mixture of genetics and environment 
neurochemical imbalance:
dopamine overactivity
glutamate overactivity 
serotonin overactivity 
GABA under activity
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23
Q

List the risk factors for schizophrenia

A 
genetics 
traumatic life events
drug abuse 
pregnancy and birth complications 
disturbed childhood behaviour
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24
Q

What are schneiders first rank symptoms?

A
  1. thought alienation - thought withdrawal, insertion and broadcast
  2. delusional perception
  3. passivity phenomena = someone else controlling thoughts and actions , includes somatic
  4. 3rd person auditory hallucinations - arguing voices or commenting on persons actions “he is rubbish”
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25
Q

What are schneiders second rank symptoms?

A 
delusions of reference 
paranoid and persecutory delusions
2nd person auditory hallucinations
thought disorders
catatonic behaviours
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26
Q

What is the difference between positive and negative symptoms?

A

positive symptoms= excess or a distortion of normal functioning (respond well to medications), often acute, mesolimbic dopamine pathway

negative symptoms= a decrease or loss of functioning (respond less well to medications) , often chronic , mesocortical dopamine pathway

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27
Q

What are positive symptoms?

A

delusions e.g. persecutory, passivity, thought interference
hallucinations e.g. auditory, visual, olfactory
formal thought disorder
incongruent = bursts out laughing for no reason or very angry (mismatch between emotional expression and content)
speech disorders
disturbance in mood
lack of insight
catatonia

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28
Q

What are negative symptoms?

A

flattening of affect (= reduced range of emotional expression)
blunting
decreased motivation
poverty of speech or thought
deterioration in functioning
psychomotor retardation (slowing of thoughts and movement)

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29
Q

What are the 3 presentations of schizophrenia?

A
  1. prodromal schizophrenia = premorbid change in individual who later develop disease, non specific negative symptoms followed by positive symptoms
  2. 1st schizophrenic episode = usually in late adolescence or early adult years e.g. withdrawal, onset of personality change
  3. subsequent disorders = relapse of psychotic symptoms after remission, deterioration or crisis in life
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30
Q

What are the types of schizophrenia?

A 
paranoid schizophrenia 
hebephrenic schizophrenia 
catatonic schizophrenia 
post schizophrenic depression
residual schizophrenia 
simple schizophrenia
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31
Q

Describe paranoid schizophrenia

A

key symptoms= delusions and hallucinations
leads more normal life and functional
auditory hallucinations and persecutory delusions revolve around them and consistent

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32
Q

Describe hebephrenic schizophrenia

A

key symptoms= disorganised thoughts and flat inappropriate thoughts
impaired emotional process (unstable, blunted, flattened), difficulty in daily living

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33
Q

Describe catatonic schizophrenia

A

key symptoms= psychomotor disturbance

dramatic reduction in motor activity, waxy flexibility, unusual body positions/ facial contortions/ posturing

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34
Q

What investigations are necessary to rule out other causes of schizophrenia?

A

urine drug screening - rule out amphetamines and cannabis as cause
FBC, LFTs - indicative of alcohol abuse
EEG - rule out epilepsy
serological tests - for syphilis or AIDs

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35
Q

How is schizophrenia diagnosed?

A

ICD-10 CRITERIA:

  1. duration of over 1 month
  2. social or occupational dysfunction
  3. 1st first rank symptom or 2 2nd rank symptoms
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36
Q

How do you assess the risk in psychotic patients?

A
  1. assess risk of suicide
  2. assess risk of unintentional harm to themselves
  3. assess risk from others e.g. safeguarding, vulnerability
  4. assess risk of harm to others e.g. history of violence, emotions, victims of delusions
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37
Q

How is schizophrenia managed?

A
  1. treat acute episodes e.g. intervene early, antipsychotics, psychosocial therapy
  2. reduce risk of relapse e.g. maintenance therapy, family therapy, support
  3. promote long term recovery e.g. maintenance therapy, CBT, support employment
38
Q

how are acute episodes of schizophrenia treated?

A
  1. second generation anti psychotic (atypical) e.g. olanzapine, risperidonem quetiapine
  2. benzodiazepine long acting e.g. diazepam IM or oral
39
Q

Which medications are used to treat schizophrenia maintenance?

A

1st line = 2nd gen atypical antipsychotic
start at lowest dose possible
taken for 4-6 weeks before deciding if ineffective
continue drug for 5 years to prevent relapse

40
Q

Which psychological therapy is used to treat schizophrenia?

A

CBT** +/- family therapy

41
Q

What is acute psychosis?

A

brief psychotic disorder with sudden onset and resolves in less than 3 months.
Usually caused by an acute stressor e.g. bereavement, divorce, childbirth, trauma within 2 weeks
often don’t need treatment

42
Q

What are the main clinical symptoms of post partum psychosis?

A

= an acute psychotic episode following post partum (peak at 2 weeks post partum)

  1. prominent affective = mania +/- depression and psychosis
  2. schizophreniform disorder
  3. acute organic psychosis
43
Q

What are the risk factors for post partum psychosis?

A

previous history of psychosis
family history of psychosis
first time mothers
lack of social support and single parent hood

44
Q

Describe persistent delusional disorder

A

a fixed delusion or delusional system with other areas of thinking and function well preserved (no hallucinations) - often in elderly

45
Q

What are the clinical features of persistent delusional disorder?

A

presence of delusions for >3 months (non bizarre delusions that could happen in real life) - associated with smell/ contamination/ food
thought process unimpaired
cognition and memory intact
irritable, angry and low mood

46
Q

What is schizoaffective disorder?

A

features of both affective (mania or depression) and schizophrenia in equal proportions

must have periods of uninterrupted illness and episode of mania/depression whilst psychotic

47
Q

How is schizoaffective disorder managed?

A

antipsychotic (paliperidone) + anti depressant/ mood stabiliser + psychotherapy

48
Q

Which medication is used to treat “treatment resistant schizophrenia”?

A

clozapine

SE: agranulocytosis

49
Q

What are the features of “acute dystonic reaction”?

A

facial grimacing
oculogyric crisis
torticollis
opisthotonos (muscle spasm causing head to arch back)
dystonia of the laryngeal/pharyngeal muscles

50
Q

What is the management options for acute dystonic reaction?

A

stop antipsychotic

anti-cholinergic medication e.g. procyclidine

51
Q

What is neuroleptic malignant syndrome?

A

life threatening emergency reaction in response to anti psychotics

52
Q

What are the symptoms in neuroleptic malignant syndrome?

A 
Hyperthermia
labile BP
 sweating
tachycardia
muscle rigidity
raised CK
53
Q

What are the management options for neuroleptic malignant syndrome?

A

supportive: fluids, benzodiazepines

bromocriptine

54
Q

What other adverse events do you need to look out for in a patient on anti psychotics?

A 
extrapyramidal symptoms
anti-muscarinic symptoms
increased prolactin
reduced seizure threshold
prolonged QT interval (esp haloperidol)
55
Q

What are “extra pyramidal symptoms”?

A

acute dystonia
akathisia (restlessness) (Rx - propanolol, benzodiazepines)
Parkinsonism
tardive dyskinesia (chewing, jaw movements)

56
Q

What are “anti-muscarinic” symptoms?

A

dry mouth
blurred vision
urinary retention
constipation

57
Q

What are the different sections of the mental health act?

A

Section 4 is used to admit a patient when only one doctor can be found - this doctor may be the GP (72 hr detention)

Section 2 – Requires 2 doctors (one section 12 approved) and AMP to make recommendation. Allows for assessment up to 28 days.

Section 3 – As above. For patients under section 2 or who are known to the service. Allows for 6 months of treatment and can be renewed.

Section 5 (2) – For patients in hospital (informal admission) gives doctors 72hrs holding power. (Section 5(4) for nurses)

58
Q

Define persecutory delusions

A

someone out to get them

59
Q

Define grandiose delusions

A

thoughts of self importance and super naturalness

60
Q

Define self-referential delusions

A

special significance to something

e.g. everyone in white tops are out to get me

61
Q

Define nihilistic delusions

A

pessimistic ideas about the world, about to die, world doomed

e.g. intestines disappeared

associated with depression

62
Q

define misidentification delusions “Cagras syndrome”

A

someone close to them has been replaced with an intruder

63
Q

define religious delusions

A

belive in communication with God

64
Q

Define hypochondriacal delusions

A

believe they have an illness or will die

65
Q

Define guilt delusions

A

thoughts of self worthlessness, depression

66
Q

Define sexual delusions

A

(de Clerambaults)

believe someone is in love

67
Q

Define eromatic delusions

A

believe someone of higher social standing is in love with them

68
Q

Define Morbid jealousy (othello syndrome) delusions

A

believe their sexual partner is being unfaithful

69
Q

Define delusions of reference

A

believe a message is about them in the media

70
Q

Define delusional perception

A

delusional belief resulting from a real perception
= attributing a new delusional meaning to a familiar concept
e.g. red traffic light means the FBI if after me

1st rank Schneider symptoms

71
Q

Define fregolis delusion

A

belive a number of different people are the same person

72
Q

describe olfactory hallucinations

A

rare
schizophrenia = smell gas
depression = rotting body

73
Q

describe tactile hallucinations

A

formacations (crawling over skin ) - e.g. cocaine abuse, schizophrenia or delusional parasitosis

74
Q

which signs are seen in depressive psychosis?

A 
olfactory hallucinations - rotting body
2nd person auditory hallucinations 
nihilistic delusions 
cotard delusions 
guilt delusions
75
Q

define neologism

A

abnormality of speech where patient uses own words/ phrases invented by themselves

76
Q

List the psychotic disorders that affect the elderly

A
  1. paraphrenia = late onset schizophrenia, persistent delusional disorder
  2. dementia = delusions, hallucinations
  3. cotards syndrome
  4. Charles bonnet
77
Q

what is cotards syndrome?

A

where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent
This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.
associated with severe depression and psychosis

78
Q

What is Charles bonnet syndrome?

A

complex visual or auditory hallucinations (‘little children’ colourful animals’) in clear consciousness + visual impairment (usually has insight)

79
Q

what are the risk factors for Charles bonnet syndrome?

A 
Advanced age
Peripheral visual impairment - cataract, glaucoma 
Social isolation
Sensory deprivation
Early cognitive impairment
80
Q

define illusion

A

misperception of real stimuli

81
Q

define hallucination

A

perception in the absence of an external stimulus (real to the person)

82
Q

who are visual hallucinations common in?

A

Lewy body dementia / organic causes

not common in pure psychiatric disorders

83
Q

define circumstantiality

A

talking at great length around the subject but returns to the topic

84
Q

define tangential

A

does not return to the topic

85
Q

define somatic passivity

A

delusional belief that patient is passive recipient of bodily sensation imposed from outside forces
(1st rank Schneider)

86
Q

define stupor

A

loss of activity with no response to stimuli, may mark a progression of motor retardation

87
Q

define depersonalisation

A

thoughts and feelings do not seem to belong to oneself

88
Q

define derealisation

A

feeling as if you are looking at yourself from the outside

89
Q

teams to help with psychosis presentation

A

CRISIS team

early intervention team/ 1st episode psychosis team

90
Q

define residual schizophrenia

A

chronic negative symptoms

91
Q

Describe the bio psycho social management plan for psychosis

A

BIO - antipsychotics

PSYCHO - family therapy, CBT

SOCIAL- family intervention/ carer support, employment, education, support with engagement/ benefits/ PSI

92
Q

how is post partum psychosis managed?

A

admitted to hospital
section under mental health act
high risk of recurrence
pscyh emergency

3a psychiatry (9 decks)

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