Psychosis Flashcards
Causes of psychosis
Drug induced, steroid induced, temporal lobe epilepsy, delirium, dementia, schizophrenia, depression, mania
Schizophrenia risk factors + symptoms (Schneiders, positive + negative)
Risk factors: adverse life events, cannabis, obstetric complications, encephalitis, males Schneiders first rank symptoms: Auditory hallucinations (3rd person, running commentary) Thought interference (insertion, withdrawal, broadcasting) Delusions of control/ passivity Schizophrenia usually has an insidious prodromal phase with subtle problems in language, cognitive ability + behaviour Positive symptoms: hallucinations, delusions Negative symptoms: flattened affect, apathy, anergy, anhedonia, alogia (decreased speech)
Dopamine hypothesis + dopamine pathways
Dopamine agonists (levodopa, amphetamines) cause schizophrenia like symptoms Dopamine antagonists (antipsychotics) can help treat schizophrenia +ve symptoms = due to dopamine overactivity in mesolimbic system -ve symptoms = dopamine underactivity in mesocortical system Nigrostriatal pathway = when dopamine is reduced by antipsychotics in this pathway, you get Parkinson like symptoms + EPSEs Tuberoinfundibular pathway = when dopamine is reduced by antipsychotics in this pathway, you get prolactinaemia (dopamine has negative feedback with prolactin)
ICD 10 criteria for schizophrenia
Symptoms present for most of the time for at least 1 month 1) Thought interference 2) Delusions of control, passivity, delusional perception 3) Auditory hallucinations 4) Persistent delusions
Types of schizophrenia
Paranoid - common, paranoid delusions, hallucinations + perceptual disturbances Hebephrenic - prominent affective changes, inappropriate mood, thought disorder, negative symptoms Catatonic - psychomotor disturbances, stupor
Physical investigations for schizophrenia
FBC, U+E, LFT, TFT, HbA1c, lipids Drug screen
Treatment for schizophrenia
1st: antipsychotic (usually atypical) 2nd: try another AP, then combine 3rd: clozapine 4th: add benzo, lithium or anticonvulsant Continue on drug for 12-24 months
Antidopaminergic drug effects
Improves +ve symptoms SE: EPSEs, hyperprolactinaemia, NMS, weight gain
Serotonergic drug effects
Improves -ve + affective symptoms SE: anxiety, insomnia, weight gain, DM
Antihistaminergic drug effects
Sedation, weight gain
Antiadrenergic drug effects
Postural hypotension, tachycardia, sexual dysfunction
Anticholinergic drug effects
Dry mouth, blurred vision, urinary retention, constipation
Extrapyramidal SE
Acute dystonia Akathisia Parkinson like symptoms Tardive dyskinesia
Acute dystonia - S+S, high risk groups, treatment
Acute reaction to AP Painful spastic contractions of muscles Tongue protrusion, torticollis, oculogyric crisis Common with haloperidol Common in young males Give anticholinergics (procyclidine)
Akathisia S+S, treatment
Acute reaction to AP Restlessness Give anticholinergics (procyclidine) or propranolol
Parkinson like symptoms S+S, high risk groups, treatment
Acute reaction to AP Tremor, rigidity, bradykinesia Common in elderly females Give anticholinergics (procyclidine)
Tardive dyskinesia - S+S, high risk groups, treatment
Long term reaction to AP Involuntary repetitive movements (tongue, lips, face, extremeties, chorieform hand movements) Worse with stress More common in elderly women DON’T give anticholinergics Switch to clozapine/ quetiapine
NMS - S+S, pathology, complications
Neuroleptic malignant syndrome Reaction to AP due to blockage of hypothalamospinal tracts Hyperthermia, muscle rigidity, altered mental state and autonomic instability (labile BP, tachycardia) Rhabdomyolysis - high CPK Can cause respiratory, CV + renal failure, seizures + DIC
Schizoaffective disorder
Schizophrenia + affective symptoms in same episode
Persistant delusional disorder
Single delusion - may be hallucinations
Orthello, de Clerambaults + Ekboms syndrome
Orthello = partner is cheating de Clerambaults = being loved by someone inaccessible (celebrity, famous) Ekboms = skin is infected by parasite
Cortards, Capgras + Fregoli syndrome
Cortards = delusion you no longer exist/ dead/ rotting Capgras = familiar person replaced by imposter Fregoli = familiar person is disguising themself as strangers
Folie impose/ communique
Impose = only A suffers from primary psychotic disorder, B’s delusions disappear if separated Communique = B maintains delusions when separated from A
Folie simultanee/ induite
Simultanee = both A+B suffer from primary psychosis but share same delusion Induite = both A+B suffer from primary psychosis but transfer their delusions to each other
Typical antipsychotics - names, action
Older gen - haloperidol, chlorpromazine Increase prolactin, EPSEs Block all 4 dopamine pathways Dopamine receptor antagonists at D2
Atypical antipsychotics - action, effect
Only block mesolimbic + mesocortical Effective against positive and negative symptoms Anticholinergic + antihistaminergic side effects Also good mood stabilisers
Haloperidol - SE, uses
High risk of EPSE + high prolactin High risk of NMS Sexual dysfunction QTC prolongation - must have ECG before starting Good antiemetic Good for rapid tranquilisation
Chlorpromazine - uses, SE
Antiemetic properties SE: photosensitivity, hepatotoxicity, weight gain, antiadrenergic (bradycardia, hypotension), sedation, hyperprolactinaemia
Clozapine - uses, SE, complications, OD, effect of smoking
Effect on D4 - used for treatment resistant schizophrenia or psychosis in Parkinsons Complications: agranulocytosis, GI hypomotility (constipation, bowel obstruction) SE: hypersalivation, weight gain, anticholinergic + adrenergic, sedation, diabetes, urinary incontinence Can cause myocarditis (flu symptoms, chest pain, tachycardia) + cardiac myopathy Causes hypotension OD causes seizures Smoking reduces plasma levels of clozapine - levels rise when stopping smoking
Amisulpride SE
Increases prolactin - avoid in women No sedation or anticholinergic SE
Risperidone action, SE
Acts on tuberoinfundibular pathway - biggest increase in prolactin - avoid in women Also causes postural hypotension + sexual dysfunction
Aripiprazole uses, SE, action
Small dose decreases prolactin - use with other APs Causes akathisia Doesn’t prolong QTC interval No metabolic SE Good antidepressant Partial dopamine agonist
Olanzapine SE
Most sedative + weight gain Diabetes risk
Quetiapine SE, uses
Less EPSEs, more metabolic SEs Good mood stabiliser Good for psychosis in dementia
Hyperprolactinaemia cause, S+S
DA inhibits prolactin release S+S: sexual dysfunction, reductions in bone mineral density, menstrual disturbances, breast growth, increase in risk of breast ca
Weight gain with antipsychotics - why, which APs are high + moderate risk
Due to serotonin antagonism + hyperprolactinaemia High risk: clozapine + olanzapine Moderate risk: risperidone, quetiapine, paliperidone, chlorpromazine
QT prolongation - why, which drugs
Block cardiac K+ channels Risk factor for ventricular arrhythmia + torsades de pointes High risk: TCAs, SSRIs, haloperidol
APs with high risk of sexual dysfunction
Haloperidol, risperidone, chlorpromazine
APs with high risk of diabetes
Olanzapine, clozapine
APs causing anti-adrenergic SE
Clozapine, chlorpromazine
TCAs - action, SE
Serotonin + noradrenaline reuptake inhibition Anticholinergic + antihistaminergic effects QT prolongation, ST elevation Postural hypotension + sedation (due to alpha adrenergic blockage)
MAOis - action, SE, complications
Inhibit MAO-A (noradrenaline, serotonin + tyramine) + B (dopamine, tyramine) Postural hypotension, restlessness, oedema, nausea, sexual dysfunction Risk of hypertensive crisis
MAOis cheese reaction - what happens, S+S, tyramine foods
Tyramine causes catecholamine release = tachycardia, sweating, HTN, arrhythmias, stroke Tyramine foods = cheese, yeast, hung game, red wine, pickled herring
Mirtazapine - type, action, SE
NASSA Enhances NA transmission Causes weight gain + sedation No CV + anticholinergic side effects
Antidepressant discontinuation symptoms
Flu like, insomnia, agitation, irritability, shock-like sensations, vivid dreams
Carbamazepine - action, SE
Blocks sodium channels - reduces glutamate release + decreases turnover of DA + NA Hepatic enzyme inducer SE: dizziness, diplopia, drowsiness, ataxia, blood dyscrasias
First line for partial seizures
Sodium valproate - action, SE, contraindications
Inhibits catabolism of GABA Can reduce aggression SE: blood dyscrasias, weight gain, hair loss, pancreatitis, sedation Major human teratogen - strong caution in women of child bearing age
Benzodiazepine receptors (+ effects)
omega 1 = hypnotic omega 2 = anxiolytic omega 3 = myorelaxant
Benzo withdrawal effects
Anxiety, tremor, pain, fatigue, psychosis, seizures, abnormal sensations
Z drug action
Zopiclone = anxiolytic + hypnotic Zolpidem + zaleplon = only hypnotic
Types of visual hallucination
Lilliputian = hallucination where subjects appear smaller (micropsia) = common in delirium Elementary = flashes of light Extracampine = seeing things outside your visual field ie someone standing behind you Reflex = sensory stimulus causes a hallucination in another modality (bright lights cause auditory hallucinations)
Charles Bonnet syndrome
Intact cognition Ocular pathology Visual hallucinations Affects people with visual loss (usually due to macular degeneration) - often see animals in the corner of the room
Auditory illusion
When auditory stimulus is misheard or misinterpreted
Schneiders first rank symptoms
Delusions Auditory hallucinations Thought disorder Passivity experience
Opisthotonus
Excessive spine extension
Oculogyric crisis
Painful superolateral deviation of the eyes
Buccolingual crisis
Bizarre grimacing/ facial expressions
Autochthonous delusion
Delusion that comes out of nowhere ‘light bulb’
De Clerambault delusion
Delusion that a famous person is in love with you
Delusional mood
When someone feels like something around them is going on but not sure what
Risk of developing schizophrenia (general population, twin, sibling or parent with schizophrenia)
Monozygotic twin has schizophrenia = 50% Parent has schizophrenia = 10-15% Sibling has schizophrenia = 10% No relatives with schizophrenia = 1%
Hypnogogic + Hypnopompic hallucinations
Hypnogogic = occur as falling to sleep Hypnopompic = occurs as you wake up, continues as you open your eyes
