Psychosis Flashcards
Knowledge of the epidemiology, aetiology and prognosis of psychosis
Epidemiology
- 15 cases per 100,000
- Equal prevalence in females and males
- Earlier onset in males (23, compared to 26)
- Peak incidence in the 20’s and then 30s-40s
Aetiology
- Organic causes: Lesions, dementia
- Substance misuse
- Especially cannabis use in adolescence
- Secondary to medication
- Steroids, antihistamines, sympathomimetics
- Psychiatric conditions: Schizophrenia, schizoaffective, first episode of psychosis
Prognosis
- Variable
Knowledge of the clinical presentation, including an understanding of the ICD-10 diagnostic criteria, of psychosis
Clinical presentation:
- Presence of psychotic symptoms: hallucinations and/or delusions
ICD-10 diagnostic criteria:
Knowledge of the physical conditions that present with psychiatric sympotms, including appropriate investigations for psychosis
Psychical conditions presenting with psychosis:
- Organic causes:
- Neurological: Head injury, CNS infection, tumour, temporal lobe epilepsy
- Metabolic: Hypernatraemia, hypocalcaemia
- Endocrine: Hypo/hyperthyroidism, Cushing’s syndrome
- Substance misuse
- Iatrogenic: Prescribed medications
Appropriate investigations:
See table
Knowledge of the common comorbidity of psychosis
- Suicide
- CVD, T2DM, stroke
- PTSD/Hx of trauma or adverse life events
-
Substance dependence
- Cannabis - Schizophrenia
- Intellectual disability
- Neurological
- Depression
Knowledge of the physical, psychiatric and social consequences of psychosis, including stigma
Knowledge of the indications, mechanism of action and side effects of antipsychotics
(NOTE: Name 4 EPSE)
Indications: Psychosis, mood disorders, anxiety disorders, rapid transquilisation
Mechanism of action: D2 receptor antagonism
- Also, antagonise muscarinic and histamine receptors - providing explanation for their commonly associated side effects
Common side effects:
- EPSE: Acute dystonia, Parkinsonism, Akathisia, tardive dyskinesia
- Sedation
- Weight gain
- Hyperprolactinaemia
- QTc prolongation
- Antimuscarinic side effects
Psychiatric emergencies:
- NMS
Antipsychotic features: Most associated with EPSE, most sedating, most weight gain, least side effects
Most EPSE: FGAs
Most sedating: Olanzapine, quetiapine, clozapine
Most weight gain: Olanzapine, cloazapine
Least side effects: Aripiprazole
Knowledge of the indications for psychological interventions in psychosis
* 3 approaches to name *
CBT
- Should be offered to all patients with psychosis
Family intervention
- For those who live with or are in close contact with others
Art therapies
- Should be offered to all patients with psychosis
- Particuarly effective for the treatment of negative symptoms of psychosis
DO NOT routinely offer counselling and supportive psychotherapy
Knowledge of the indications and practical implementation of social interventions in psychosis
Indications:
- All patients
- Accommodation, culture and ethnicity, leisure activities and recreation, responsibilities for children/as a carer
Practical implementation:
- Patient must engage
- Limited resources within the community
Recognise the common psychopathology of psychosis in clinical interview
Give a list of relevent differential diagnoses in patients with psychotic symptoms
-
Organic causes
- Neurological: TLE, tumour, dementia
- Endocrine: Hypo/hyperthyroid, cortisol
- Metabolic: Hypernatraemia, hypocalcaemia
- Iatrogenic: Medications (steroids, sympathomimetics)
- Substance misuse
-
Psychosis
- Schizophrenia
- Schizoaffective
- 1st episode of psychosis
-
Other psychiatric conditions
- Depression
- Anxiety
Carry out a clinical risk assessment on a patient with psychosis
FIRST, assess the patients risk factors (male gender, middle age, unemployed, chronic pain, poor social support, substance misuse, extensive forensic history, previously known to mental health services and displayed poor engagement/concordance - indicate increased risk).
Short summary of risk factors and any past involvement with mental health services
Risk to self
- Self harm
-
Suicide
- Thoughts towards suicide
- Previous attempts: Planning, precautions, preparation (last acts)
- Access to means: Still have tablets?
- Response to suicide attempt not being successful: Are they glad that they’re alive? Intentions to attempt again?
-
Self care
- Currently eating/drinking and capable of maintaining hygiene?
- Compliance to treatment
-
Harm through misadventure
- Delusions/hallucinations that may cause them to harm themself
Risk to others
- Intention/thoughts about harming others
Risk to children
- Any caring reponsibilties?
- Any contact with children?
Risk to property
Driving
Forensic Hx
Risk from others
- Worries/concerns that someone else may harm them
- Do they feel that they are being taken advantage of?
Compliance
- Taking medications as directed?
- Engaging with therapies?
Develop a structured targeted management plan for an individual patient with psychosis
- Setting: Inpatient or community
- Assess risk
- Biopsychosocial approach:
- Biological
- Antipsychotic medication
- Short term use of benzodiazepines for the treatment of behavioural disturbance, insomnia etc
- Antidepressants and lithium may be used to augment antipsychotics in treatment resistant schizophrenia
- Psychological
- CBT
- Family therapy
- Art therapy
- Social
Explain the aetiology, bio-psycho-social management plan and prognosis of psychosis to a patient/carer/colleague
Aetiology
- Lots of contributing factors
- Genetics, environment, substance misuse
Management plan
- Biological:
- Explain side effects
- Psychological
- CBT - explain what this is
- Social
Prognosis
- Variable prognosis
- 15% have only a single episode
- Generally a chronic relapsing and remitting pattern
- Increased risk of suicide
