Psychosis Flashcards
Psychiatric differential of psychosis
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
Non-psychiatric differentials of psychosis
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
Schneider’s first-rank symptoms of schizophrenia
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
Difference between primary and secondary delusion
Secondary delusions arises understandably from aother mental state (e.g. guilt in depression)
Features of catatonic schizophrenia
Waxy flexibility
Posturing
Negativism
Echopraxia
Automatic obedience
Ambitendency
Appearance and behaviour in schizophrenia
Idiosyncratic dress
Mannerisms and stereotypies
EPSEs
Suspicious/distracted/uninterested behaviour
Mood in schizophrenia
Flattened affect
Incongruency between mood and thought content
Thought in schizophrenia
Formal thought disorder (e.g. loosening of associations)
Delusional beliefs
Thought block/echo/interference
Neologisms
Perceptions in schizophrenia
Hallucinations esp. auditory
Check for content (esp risk to self/others)
Duration criterion for schizophrenia
1 month
Negative symptoms of schizophrenia (particularly in chronic)
Flattened affect
Apathy and avolition
Social withdrawal
Poor self-care
Cognitive, attentional, and memory impairment
Poverty of speech
Short-term management of first-episode psychosis
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
Long-term management of schizophrenia
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
Time to assess response to antipsychotic
6 weeks (although early response can be noted at 2-4 weeks)
When to administer clozapine
After failure of 2 antipsychotics at treatment dose for 6w each
Psychological treatments for schizophrenia
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
Social interventions for schizophrenia
Supported accommodation
Employment support
Assertive outreach for patients with chaotic lifestyles
Regular f/u with named key worker/care coordinator
Poor prognostic factors: demographic
Onset <25y
Isolated, unmarried
Male
Poor work record
Substance misuse
Psychiatric Hx
Social isolation
Poor prognostic factors: illness
Insidious onset
Prolonged untreated psychosis
Hebephrenic subtype
Poor treatment compliance
Early negative symptoms
Poor insight into disease
No mood symptoms (schizoaffective better prognosis)
Main causes of mortality and morbidity
Life expectancy 12-15 years shorter
Cardiovascular illness and diabetes
Suicide (5-10%)
Exploitation/victims of violent crimes from others (40%)
Age of incidence of schizophrenia
20-28 for men
More equal distribution in females (26-32) with second peak post-menopause
ICD-10 diagnostic criteria for schizophrenia, at least one of:
Thought: insertion, withdrawal, broadcast, echo
Delusion: Of control, passivity, or persistent culturally inappropriate
Hallucinations: Auditory, third-person, giving running commentary or discussing among themselves
Features of delusional disorders
No hallucinations or other symptoms of schizophrenia
Persistent systematized, less bizarre delusions, MSE otherwise unremarkable
Acute self-limiting often in response to stressors
Management of schizoaffective disorder
Manage mood and psychotic elements on their own merits
Management of delusional disorders
Antipsychotics if peristent (>3 months), otherwise spontaneous recovery
Heritability of schizophrenia
80%
Risk of developing schizophrenia if one parent affected
12%
Risk of schizophrenia if identical twin affected
48%
Biological risk factors for schizophrenia
Family history
Obstetric complications - incl. fetal malnutrition, maternal influenza
Early cannabis use
Advancing paternal age
Social/psychological risk factors for schizophrenia
Urban living
Life stressors (may be precipitating)
Migrant population
Family with high expressed emotion
Poverty
Cannabis use (esp <15)
Most common structural abnormality in schizophrenia
Enlargement of lateral ventricles (but not diagnostically useful)
Most common first-gen antipsychotics
Haloperidol
Chlorpromazine
Extrapyramidal side effects of first-gen antipsychotics (in order of appearance)
Dystonia
Akathisia
Parkinosnism
Tremors
Tardive dyskinesia
Emergency treatment of acute dystonia
Anticholinergic procyclidine
Life-threatening adverse events of typical antipsychotics
Neuroleptic malignant syndrome
Torsade de pointes following Q-T prolongation
Features of neuroleptic malignant syndrome
Increased stiffness
Autonomic instability, sweating
Raised creatine kinase, white cell count, metabolic acidosis
Side effects of atypical antipsychotics
sedation (anti-histamine effect)
weight gain
T2DM
Possible increased risk of stroke
Neutropenia (esp pines)
Non-EPSEs of typical antipsychotics
Hyperprolactinaemia
Constipation, urinary retention (anti-muscarinic)
Postural hypotension (anti-alpha 1)
Sedation, weight gain (but usually not T2DM)
Most common atypical antipsychotics
Risperidone
Olanzipine
Quetiapine
Amisulpride
Clozapine
Side effects of clozapine
Agranulocytosis (weekly blood tests)
Myocarditis/cardiomyopathy
Seizures
Metabolic syndrome
Hypersalivation
!!constipation (clozapine-induce gut hypomotility, most fatal)!!
Drug that is affected by smoking
Clozapine, olanzapine - cessation reduces plasma levels
Antipsychotics available as depots
Haloperidol
apriprazole
olanzapine
risperidone
Mechanism of action of typical antipsychotics
D2 antagonism –> reduce +ve symptoms
Mechanism of action of atypical antipsychotics
D2 antagonism + 5-HT2a antagonism –> increase DA slightly in nigrostriatal pathway –> reduced EPSEs In mesocortical pathway –> reduced-ve symptoms
Advantages of risperidone
Most tolerable SE profile
Advantages of olanzapine
Sedative effect
Other condition for quetiapine
Bipolar depression
Benefits of clozapine
Most efficacy + anti-suicide drug –> for Rx-resistant
Antipsychotics by propensity for weight gain
Olanzipine > clozapine > quetiapine > risperidone
Antipsychotics by sedative effect
Clozapine > olanzipine > quetiapine > haloperidol > risperidone
ICD-10 diagnostic criteria for schizophrenia, at least two of:
Negative symptoms
Persistent hallucinations of any modality
Catatonic behaviour
Neologisms or breaks in thought –> incoherent speech
Differentiating schizophrenia from mood disorder
In mood disorder mood symtpoms precede psychosis + psychosis is mood congruent
Indications for antipsychotics in bipolar
For mania
If presenting euthymic, use mood stabiliser
Physical health monitoring for antipsychotics
Weight, BP, ECG, HbA1c, blood glucose/lipids, smoking cessation advice
Weekly for first 3/12
Monthly for 6/12
Prognosis for schizophrenia
Acute illness, complete recovery: 20%
Recurrent illness, some persistent deficit: 50%
Chronic illness, severe functional disability: 20%
Suicide: 10% (esp if younger, more insight)
