Psychosis Flashcards
Define psychosis
Distorted reality (delusions, hallucinations and thought disorder) - and also psychomotor abnormalities, mood/affect disturbance, cognitive deficiencies etc
5 parametres
- perception
- abnormal beliefs
- thought disorder
- negative symptoms
- psychomotor function
Perception disturbance
hallucination - perception with no external stimulus
illusions - misrepresentations of external stimuli (think inattention or intense emotional experience)
pseudohallucinations = inner space of the mind (some say its recognising delusions as false)
auditor hallucinations
- Most common in psychosis
- Elementary (acute organic states)
- first person and thought echo
- second person (persecutory or complimentary depending on state as associated with mood disorders) -command hallucinations
- third person
visual hallucinations
- acute organic state (delirium , occipital lobe tumours, epilepsy, dementia)
- psychoactive substances - LSD, mescaline, inhalents, alcohol withdrawl) - Lilliputian
- Charles Bonnet - Loss of vision
Somatic hallucinations
- superficial (just below skin eg cocain and alc withdrawl) + thermal and hygric (fluid)
- Visceral - organs throbbing stretching, distending
- kinaesthetic - limbs moving twisting vibrating joints
Olfactory/gustatory hallucinations
- often together and mood congruent
- rule out epilepsy and organic brain disturbances
special hallucinaitons
- Hypnagoic and hypnopompic - auditory or visual when going to sleep and waking up
- extracampine hallucinations - outside sensory fields
- Functional hallucinnations = normal stimulus precipitates hallucinations in same modality
- Reflex hallucination = different modality
Abnormal beliefs
Primary delusions - autochthonous (not caused by psychological stat) but often presceded by delusional atmosphere
Secondary delusions - pre-existing psychological mood
Overvalued ideas - plausible belief that pt preoccupied with to an unreasonable extent (often personality disorder)
Delusions definition
Fixed false belief . . .. work out if
1) primary or secondary
2) Mood congruent or incongruent
3) bizarre or non bizarre
4) according to content of delusions
Delusions by content
- paranoid
- persecutory
- grandiose
- delusions of reference
- religious
- delusions of love
- delusions of infidelity
- delusions of misidentification (capgras =familiar replaced and fregoli = stranger is familiar)
- Nihilistic
- somatic
- delusion of infestation
- delusion of control
Thought disorder
- Disorganised and hard to understand speech (important to note verbatum)
- Circumstantiality - mirial . . . long route
- Tagentiallity - jumping from one to another
- flight of ideas
- loosening of association
- word salad
special forms of thought disorder:
- thought blocking
- neologisms
- preservation - repeating relevant answer
- echolailia - repetition of words/phrases
- irrelevant answers
Negative symptoms
- marked apathy
- poverty of thought and speech
- blunting affect
- social isolation
- poor self care
- cognitive impairment
this can appear same time or after initial schizophrenic episode . . . must be different from mood disorder
psychomotor function
- can’t be due to meds . . . its rare
- Catatonic rigidity
- Catatonic posture
- Catatonic negativity
- Catatonic waxy
- Catatonic stupor
- echopraxia
- mannerisms - innapropriate timing/ situation
- tics
Schizophrenia ICD-10
One or more of:
a)thought echo, insertion, withdrawal or broadcast
b) delusions of control or passivity (delusional perception
c) hallucinatory voices in third person or from body part
d) bizarre delusions
]two or more of:
e)other hallucinations that occur every day for weeks or associated with flwwting delusions
f) thought disorganisation (loosening incoherenc, neologisms)
g) catatonic symptoms
h) negative symptoms
I)change in personal behaviour ( loss of interest, amimlessness or social withdrawl)
Rule out organic brain disorder, substance use or withdrawl
Schneider’s first rank symptoms
1) delusional perception
2) Delusions of thought control
3) delusions of control
4) hallucinations in 1st person, echo or third person
add in bizzare dwlusions and hallucination of body part and you get the ICD-10?
Schizophrenia sybtypes
paranoid schizophrenia - 18-25 typical onset with del and hal prominent and neg + catatonic not
hebephrenic (disorganised) schizophrenia - 15-25 typical onset with thought disorganisation and
disturbed behaviour and inappropriate or flat affect prominent and del/ hal not
catatonic - rare with one or more catatonic
residual schizophrenia - 1 year of predominantly negative symptoms after clear psychotic episode
DDx of delusions
Psychotic disorders
- schizophrenia
- acute or transient psychotic disorders (no prodromal and triggered by life stress) . . . often leads to schizophrenia
- schizoaffective disorder - depression or mania happening with one the ICD-10 a-d together
- delusional disorder - single or set of delusions for at least 3 months and no other sx . .. usually middle aged and cannot be control or passivity
- mood (affective disorders) … dep ep or manic ep
- secondary to general medical condition or psychoactive substances
- delirium or dementia
- personality disorder - no clear baseline . . schizotypal;
- neurodevelopmentl disorder - social difficulties and rigid thinking common in autistic spectrum
Secondary to medical or psychoactive substances
medical:
- cerebral neoplasm, infarct, trauma, infection, inflammation
- endicrinological (thyroid, parathyroid or adrenal)
- Epilepsy (especially temporal lobe)
- huntington disease
- SLE
- Vit B12, niacin or thiamine deficiency
Substances:
-alcohol, cannabis, novel psychoactive substances, amphetamine, cocaine hallucinogens, inhalents. solvents
prescribed
- antiparkinson drugs
- corticosteroids
- anticolinergics
Assessment general
- rule out medical/ psychoactive substances
- Hx . . don’t forget collateral
- examination - neurological and endocrine sx
- investigations
Psychosis Hx questions
Hallucination
- strange noises or voices which no one else can hear?
-hear your own thoughts spoken outload?
-ever hear your thoughts echoed?
-does a voice talk directly to you or give commands?
do voices talke about you or make comments on what you are doing?
delusions
- afraid someone with harm or imprison you?
- noticed thatpeople are doing or saying things that have special meaning to you?
- do you have special abilities or powers?
- does it seem like you are being controlled by an external force?
- do you feel you have thoughts that don’t belong to you?’
Investigations
Bloods
- exclude medical or substance abuse
- baseline for antipsychotics or psychotropic drugs
- asses renal and liver function (important for depot)
- infection markers
urine analysis for recreational drugs
ECG for Q-T prolongation risk
electroencephalogram, CT and MRI for organic brain disease
psychosis thought process
psychotic sx?
secondary to m condition or psychoactive substance?
duration < month? (acute/transient)
del sx only for > 3 months?
typical schiz in absence of mood did?
Typical schiz in presence of mood?
psychotic sx (congruent usually) preceeded by mood disorder)?
schizophrenia epidemiology
15/100,000 per year 1% orevelence onset usually 18-25 (M) and 25-35 (f) m:f 1.4:1 incidence increased prevalence with decreased socioeconomic background
schizophrenia aeitiology
Genetics
- 50% congruent in monozygotic
- genes ax with neurodevelopment , immune, glutamaterigic and dopaminergic neurotransmission
- rare high penetrance with deletion of chromosome 22 (30% prevalence)
developmental - possible perinatal amalnutrition or 2nd trimester influenza
brain abdnormalities
- enlarged ventricles and reduced brain size
- abnormalities of cognition/memory and sensory integreation
neurotransmitter abnormalities
- glutamate hypothesis = NMDAr hypofunction contributes to schizophrenia pathogenesis
- dopamine hypothesis = sxhizophrenia secondary to overactivity of mesolimbic dopamine pathways (antipsychotics acting on D2rs)
adverse life events
- childhood trauma increase risk threefold
- stressful life events precede psychosis
cannabis
-link but could be self medicating
