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Psychiatry > Psychosis > Flashcards

Psychosis Flashcards

1
Q

Psychiatric differential of psychosis

A

Schizophrenia

Schizoaffective disorder: Prominent mood symptoms

Schizotypal personality disorder: Chronic nature

Manic episode (e.g. of bipolar): Other features of mania

Postpartum psychosis: Acute postpartum onset

Delusional disorders: absence of other features of schizophrenia

Psychotic depression

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2
Q

Non-psychiatric differentials of psychosis

A

Iatrogenic: Anti-malarials, L-DOPA, steroids

Substance misuse: Esp. amphetamine

Complex partial epilepsy: other evidence of seizures (e.g. post-ictal grogginess)

Huntington’s: Family history, choreiform movements

Syphilis:

SLE: renal and skin involvement

Dementia: Age, cognitive impairment

Delirium: Acute onset, clouding of consciousness

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3
Q

Schneider’s first-rank symptoms of schizophrenia

A

Delusional perception (e.g. delusions of reference)

Auditory hallucinations: Third-person, running commentary, thought echo

Passivity: Thought, feeling, action

Thought interference: Withdrawal, insertion, broadcasting

Somatic hallucinations

Can occur in 10-20% of manic episodes

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4
Q

Difference between primary and secondary delusion

A

Secondary delusions arises understandably from aother mental state (e.g. guilt in depression)

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5
Q

Features of catatonic schizophrenia

A

Waxy flexibility

Posturing

Negativism

Echopraxia

Automatic obedience

Ambitendency

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6
Q

Appearance and behaviour in schizophrenia

A

Idiosyncratic dress

Mannerisms and stereotypies

EPSEs

Suspicious/distracted/uninterested behaviour

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7
Q

Mood in schizophrenia

A

Flattened affect

Incongruency between mood and thought content

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8
Q

Thought in schizophrenia

A

Formal thought disorder (e.g. loosening of associations)

Delusional beliefs

Thought block/echo/interference

Neologisms

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9
Q

Perceptions in schizophrenia

A

Hallucinations esp. auditory

Check for content (esp risk to self/others)

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10
Q

Duration criterion for schizophrenia

A

1 month

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11
Q

Negative symptoms of schizophrenia (particularly in chronic)

A

Flattened affect

Apathy and avolition

Social withdrawal

Poor self-care

Cognitive, attentional, and memory impairment

Poverty of speech

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12
Q

Short-term management of first-episode psychosis

A

Admission (and possible detention)

Antipsychotic (low-dose if first episode, may not have schizophrenia!)

Benzodiazepine if necessary for sedation

Establish context/precipitating factors for illness

Screen for autoantibodies causing autoimmune encephalitis/psychosis if first episode

Referral to EIS if first episode

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13
Q

Long-term management of schizophrenia

A

Bio:

  • Monitor drug levels/SEs (esp EPSEs, prolactin, ECG, clozapine FBC)
  • Regular medical review (esp weight, BP, glucose, HbA1c, lipids)

Psycho:

  • Involve family for therapy and psychoeducation
  • Post-schizophrenic depression –> antidepressants
  • CBT for persistent delusions
  • Regular monitoringof mental state

Social:

  • CPA planning: Assigned key worker/care coordinator
  • Accommodation, benefits, employment support
  • Address risks to self/others
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14
Q

Time to assess response to antipsychotic

A

6 weeks (although early response can be noted at 2-4 weeks)

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15
Q

When to administer clozapine

A

After failure of 2 antipsychotics at treatment dose for 6w each

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16
Q

Psychological treatments for schizophrenia

A

Family therapy: To lower expressed emotion and educate about early warning signs/management (difficult + modest effect)

CBT: for residual symptoms (modest effect + minimal engagement); ?VR trial

Cognitive remediation therapy: to improve memory deficits

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17
Q

Social interventions for schizophrenia

A

Supported accommodation

Employment support

Assertive outreach for patients with chaotic lifestyles

Regular f/u with named key worker/care coordinator

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18
Q

Poor prognostic factors: demographic

A

Onset <25y

Isolated, unmarried

Male

Poor work record

Substance misuse

Psychiatric Hx

Social isolation

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19
Q

Poor prognostic factors: illness

A

Insidious onset

Prolonged untreated psychosis

Hebephrenic subtype

Poor treatment compliance

Early negative symptoms

Poor insight into disease

No mood symptoms (schizoaffective better prognosis)

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20
Q

Main causes of mortality and morbidity

A

Life expectancy 12-15 years shorter

Cardiovascular illness and diabetes

Suicide (5-10%)

Exploitation/victims of violent crimes from others (40%)

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21
Q

Age of incidence of schizophrenia

A

20-28 for men

More equal distribution in females (26-32) with second peak post-menopause

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22
Q

ICD-10 diagnostic criteria for schizophrenia, at least one of:

A

Thought: insertion, withdrawal, broadcast, echo

Delusion: Of control, passivity, or persistent culturally inappropriate

Hallucinations: Auditory, third-person, giving running commentary or discussing among themselves

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23
Q

Features of delusional disorders

A

No hallucinations or other symptoms of schizophrenia

Persistent systematized, less bizarre delusions, MSE otherwise unremarkable

Acute self-limiting often in response to stressors

24
Q

Management of schizoaffective disorder

A

Manage mood and psychotic elements on their own merits

25
Q

Management of delusional disorders

A

Antipsychotics if peristent (>3 months), otherwise spontaneous recovery

26
Q

Heritability of schizophrenia

A

80%

27
Q

Risk of developing schizophrenia if one parent affected

A

12%

28
Q

Risk of schizophrenia if identical twin affected

A

48%

29
Q

Biological risk factors for schizophrenia

A

Family history

Obstetric complications - incl. fetal malnutrition, maternal influenza

Early cannabis use

Advancing paternal age

30
Q

Social/psychological risk factors for schizophrenia

A

Urban living

Life stressors (may be precipitating)

Migrant population

Family with high expressed emotion

Poverty

Cannabis use (esp <15)

31
Q

Most common structural abnormality in schizophrenia

A

Enlargement of lateral ventricles (but not diagnostically useful)

32
Q

Most common first-gen antipsychotics

A

Haloperidol

Chlorpromazine

33
Q

Extrapyramidal side effects of first-gen antipsychotics (in order of appearance)

A

Dystonia

Akathisia

Parkinosnism

Tremors

Tardive dyskinesia

34
Q

Emergency treatment of acute dystonia

A

Anticholinergic procyclidine

35
Q

Life-threatening adverse events of typical antipsychotics

A

Neuroleptic malignant syndrome

Torsade de pointes following Q-T prolongation

36
Q

Features of neuroleptic malignant syndrome

A

Increased stiffness

Autonomic instability, sweating

Raised creatine kinase, white cell count, metabolic acidosis

37
Q

Side effects of atypical antipsychotics

A

sedation (anti-histamine effect)

weight gain

T2DM

Possible increased risk of stroke

Neutropenia (esp pines)

38
Q

Non-EPSEs of typical antipsychotics

A

Hyperprolactinaemia

Constipation, urinary retention (anti-muscarinic)

Postural hypotension (anti-alpha 1)

Sedation, weight gain (but usually not T2DM)

39
Q

Most common atypical antipsychotics

A

Risperidone

Olanzipine

Quetiapine

Amisulpride

Clozapine

40
Q

Side effects of clozapine

A

Agranulocytosis (weekly blood tests)

Myocarditis/cardiomyopathy

Seizures

Metabolic syndrome

Hypersalivation

!!constipation (clozapine-induce gut hypomotility, most fatal)!!

41
Q

Drug that is affected by smoking

A

Clozapine, olanzapine - cessation reduces plasma levels

42
Q

Antipsychotics available as depots

A

Haloperidol

apriprazole

olanzapine

risperidone

43
Q

Mechanism of action of typical antipsychotics

A

D2 antagonism –> reduce +ve symptoms

44
Q

Mechanism of action of atypical antipsychotics

A

D2 antagonism + 5-HT2a antagonism –> increase DA slightly in nigrostriatal pathway –> reduced EPSEs In mesocortical pathway –> reduced-ve symptoms

45
Q

Advantages of risperidone

A

Most tolerable SE profile

46
Q

Advantages of olanzapine

A

Sedative effect

47
Q

Other condition for quetiapine

A

Bipolar depression

48
Q

Benefits of clozapine

A

Most efficacy + anti-suicide drug –> for Rx-resistant

49
Q

Antipsychotics by propensity for weight gain

A

Olanzipine > clozapine > quetiapine > risperidone

50
Q

Antipsychotics by sedative effect

A

Clozapine > olanzipine > quetiapine > haloperidol > risperidone

51
Q

ICD-10 diagnostic criteria for schizophrenia, at least two of:

A

Negative symptoms

Persistent hallucinations of any modality

Catatonic behaviour

Neologisms or breaks in thought –> incoherent speech

52
Q

Differentiating schizophrenia from mood disorder

A

In mood disorder mood symtpoms precede psychosis + psychosis is mood congruent

53
Q

Indications for antipsychotics in bipolar

A

For mania

If presenting euthymic, use mood stabiliser

54
Q

Physical health monitoring for antipsychotics

A

Weight, BP, ECG, HbA1c, blood glucose/lipids, smoking cessation advice

Weekly for first 3/12

Monthly for 6/12

55
Q

Prognosis for schizophrenia

A

Acute illness, complete recovery: 20%

Recurrent illness, some persistent deficit: 50%

Chronic illness, severe functional disability: 20%

Suicide: 10% (esp if younger, more insight)

Psychiatry (20 decks)

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