Psychosis

Question 1

What are psychosis?

Answer 1

The presence of hallucinations or delusions.

It describes symptoms and is not a diagnosis in itself.

Question 2

What are delusions?

Answer 2

Abnormal beliefs, outside of cultural norms, unshakeable.

Question 3

When could you get psychosis?

Answer 3

Schizophrenia
Drug induced psychosis
Affective psychosis
Post-partum psychosis

Question 4

Organic psychosis

Answer 4

Delirium caused by infection 
Delirium tremors - Alcohol withdrawal
Acute drug / alcohol intoxicating 
Post -ictal psychosis -after a seizure 
Hyperthyroidism 
Encephalitis (including anti-NMDA receptors)
Hypercalcaemia 
Cerebral Lupus 

Iatrogenic:
Steroids
L-DOPA

Question 5

What are hallucinations?

Answer 5

Perception without a stimulus.
Can be in any sensory modality.
Viral hallucinations are usually organic (caused by a problem with brain or eyes)

Question 6

What are first rank symptoms?

Answer 6

Auditory hallucinations - hearing thought outloud. Running commentary. Voices refer to the patient in third person a conversing with each other about the patient.
“respond” so stop and listen as overwhelming

Passive experiences - Patient believes an action or feeling is caused by an external force.

Thought withdrawal, broadcast or insertion - Thoughts being taken out, known to others or implanted into the mind

Delusional perception - Attribution of new meaning usually in the sense of self-reference, to a normal perceived object. This new meaning cannot be understood as arising from patient’s affective state or previous attributes.

Somatic hallucinations - Mimics feelings from inside the body

Lack of insight - not believe they are unwell

Question 7

What are positive symptoms?

Answer 7

Delusions, hallucinations, thought disorder, lack of insight

Added symptoms

Question 8

What are the positive symptoms?

Answer 8

Underactivity, low motivation, socal withdrawal, emotional flattening, self neglect

Symptoms taken away from the patient.

Question 9

What is the ICD10 diagnosis of Schizopherenia?

Answer 9

At least one of the following:

• Thought echo, insertion, withdrawal or broadcast
• Delusions
• Hallucinatory voices

Or at least of the following:

• Hallucinations
• Catatonic behaviour
• Neologisms, breaks or interpolations in triangle of thought
• Negative symptoms

Question 10

What are the types of scizophrenia

Answer 10

Paranoid schizophrenia
Simple schizophrenia
Hebephrenic schizophrenia
Undifferentiated schizophrenia

Question 11

What is paranoid schizophrenia>

Answer 11

Delusions or hallucinations prominent -This is what most people associated with the word ‘schizophrenia’

Question 12

What is simple schizophrenia

Answer 12

Loss of drive and interest, aimlessness, idleness, self absorbed attitude and social withdrawal.
Marked decline in social, academic or work performance.
No hallucinations / delusions.

Question 13

What is hebephrenic schizophrenia?

Answer 13

Definite and sustained flattening or shallowness of effect or incongruity / appropriateness of affect, aimless and disjointed behaviour or thought disorder affecting speech.
Hallucinations / delusions must not dominate.

Question 14

Undifferentiated

Answer 14

Insufficient symptoms to meet criteria of any subtypes or so many symptoms that they fit more than one criteria

Question 15

Catatonic Schoziphrenia

Answer 15

Catatonia is a state of psycho-motor immobility and behavioral abnormality manifested by stupor.

Question 16

Describe the pathophysiology of schizophrenia

Answer 16

Dopamine pathways - Mesolimbic and mesocortical pathway

Brain changes

Limbic system

Question 17

What is the mesolimbic pathway?

Answer 17

From ventral tegmental area to the limbic structures and nucleus accumbens.

Overactive in Schizophrenia, causing the positive symptoms.

Question 18

What is the mesocortical pathway?

Answer 18

From ventral segmental area to frontal cortex and cingulate cortex.

Under active in schizophrenia casing the negative symptoms

Question 19

What Brian changes occur in schizophrenia?

Answer 19

Enlarged ventricles

Reduced hippocampal formation, amygdala, parahippocampal gyrus and prefrontal cortex.

Question 20

What is anti-NMDA encephalitis?

Answer 20

Psychotic for first time with no family history - check not missing.

Only discovered in 2007

Underlying ovarian teratoma

Antibodies bind to NMDA teratoma - hyperfunction.

Present:
Viral prodome
Neuropsychiatric symptoms
Prolonged symptoms

Question 21

What other theories for causes of schizophrenia?

Answer 21

Limbic structures involved - role in regulating emotional behaviour

Basal ganglia -even untreated patients can present with motor symptoms.

Question 22

How can you treat schizophrenia?

Answer 22

Typical anti-psychotics (Haloperidol - got side effects)
Block D2 receptor in all CNS dopaminergic pathways.
Main action as antipsychotic is on mesolimbic and mesocortical pathways.

Atypical antipsychotics
Low affinity fo D2 receptors
Milder side effects as dissociate rapidly from D2 receptors
Gi coupled receptors.

Avatar therapy - confront voices as make an aviator of what the voices look like.

Also CBT

Question 23

What are the side effects of anti-psychotics?

Answer 23

Parkinsonian symptoms:

Tremor
Muscle rigidity
Pill rolling tremor 
Stooped posture 
Mask like, blank expression 

Acute distonia - head stuck on one side - treat with IM precyclodine as not swallow

Get Parkinsonian treatment as less movement

Question 24

What is acute encephalitis Lethargica?

Answer 24

Also called “sleepy sickness”

The disease attacks the brain, leaving some victims in a statue-like condition, speechless and motionless

Dopamine used to treat but, go back to state after a while.

Question 25

What is Catalonia?

Answer 25

More than two weeks, one or more of:
Stupor / Mutism 
Excitement 
Posturing 
Negativism
Rigidity 
Waxy flexability - move around and will stay in that posture 
Command automatism - psychological pillow (head stay up if take pillow away) 

Probably due to less GABA biding so loss of inhibitory effect.

Give them lorazepam
Can also used ECT

Question 26

What is the prognosis of schizophrenia?

Answer 26

Focus on early intervention and better treatment available means prognosis is better.

Moderately good long term global outcome is about 50%.

Good prognostic factors:
Absence of family history
Good premorbid function
Acute onset
Mood disturbance
Prompt treatment
Maintenance of initiative and motivation

Question 27

What is the prognosis of severe mental illness?

Answer 27

Mortality is twice as high as in general population

Shorter life expectancy

Higher incidence of CVS disease, respiratory disease and cancer - due to smoking as nicotine can reduce auditory hallucinations.

Suicide risk os 9x higher than in general population.

Death from violent incidents is 2x as high

About 50% have a substance misuse problem

Higher rate of cigarette smoking

Question 28

What is drug induced psychosis?

Answer 28

Psychosis induced by a psychoactive substance.

“Onset of psychotic symptoms during or within two weeks of substance use.
Persistence of the psychotic symptoms for more than 48 hours
Duration of the disorder does not exceed 6 months”

Question 29

What is affective psychosis?

Answer 29

Psychotic experiences are normally congruent with mood.

For example, manic patients may have grandiose delusions, hear the voice of God talking to then ect.

Depressed patients may have delusions of guilt or nihilism, unpleasant auditory hallucinations

Question 30

What is post partum psychosis?

Answer 30

Affects 1 in 1000 women

Very severe so needs to be recognised quickly to avoid harm to mother or baby.

Can present in patient with no previous psychiatric history

More common if previous bipolar disorder or psychotic illness, or mother or sister suffered.

Onset within days to weeks of delivery.

Can develop over hours to days.

Question 31

What types of hallucinations can occur in the normal population?

Answer 31

Hypnogogic - going to sleep

Hypnopompic - waking up