Psychosis Flashcards
Psychosis
A state in which there is a loss of contact with reality Includes: Delusions Hallucinations Formal thought disorder
Prevlance psychosis
1/100
When is the peak incidence of psychosis in males?
23 y/o
When is the peak incidence of psychosis in females?
26
2nd peak 30-40
Biological aetiology schizophrenia (2)
FHx
Idenitcal twins - 46%
Obstetric complication
Psychological aetiology schizophrenia
Congitive errors
Premorbid personality - schizotypal disorder
Social aetiology schizophrenia (4)
Urban living
Migration
Life events incl physical + sexual abuse
Ethnicity - Afro-Caribbean
Prodrome
Period of time when the individual = gradually developing Sx but has not yet met criteria for diagnosis
What is the average DUP?
> 1
Good prognostic factors psychosis (8)
Female Married FHx affective disorder Acute onset Good premorbid personality Early Tx prominent mood Sx good response to Tx
Poor prognostic factors psychosis (6)
FHx schizophrenia High expressed emotion Substance misuse Prominent negative Sx Early onset Lack of insight/non-compliance
What are the 3 groups of schizophrenia symptoms?
Positive
Negative
Motor/catatonic
E.g.s of positive schizophrenia Sx (3)
Formal thought disorder
Hallucination
Delusion
E.g.s of negative schizophrenia sx (7)
Anhedonia Blunting of affect Apathy Lack of volition - under control Poverty of thought Poor self-care Cognitive deficits
E.g.s of motor/catatonic schziophrenia Sx (7)
Rigidity Posturing Mutism Waxy flexibility Negativism Stereotypies Tics
What is rigidity
Maintaining a fixed position and rigidly resisting all attempts to be moved
What is posturing
Adopting an unusual position that is then maintained for some time
What is waxy flexibility
patients can be moulded like wax into a position that is then maintained
What is negativisim
A seemingly motiveless resistance to all instructions/attempts to be moved
What is stereotypies
A complex movement that does not appear to be goal-directed e.g. rocking
Perception
The process of making sense of the physical information we receive from our 5 sensory modalities
Illusions
Misperceptions of real external stimuli
Delusion
A fixed, usually false unshakable belief which is out of keeping with patients educational, cultural and background + held despite all evidence to contrary
Persecutory delusion
Delusional belief that one’s life is being interfered with in a harmful way
Delusion of reference
Delusional belief that external events have been arranged so that a messaged is conveyed
Grandiose delusions
Delusional belief that the patient has special powers
Primary delusions
Do not occur in response to any previous psychopathologies state
Mood congruent delusions
Contents are appropriate to patients mood
De-Clerambault’s syndrome
Delusion where the patient believes another individual is in love with them and they are destined to be together
Capgras syndrome
Patient is replaced by an identical double’ who is not the real person
Cotard syndrome
Psychotic depressive presentation with nihilistic delusions and hypochondriacal disorder
Fergoli syndrome
Strangers have been replaced by one familiar person who changes appearance or takes on disguises
Nihilistic delusion
Patient believes they have died or no longer exists or the world has ended
Delusion perception
A real percept that leads immediately to a delusional belief - the traffic lights turned red and I knew I was the King of England’
Overvalued ideas
Ideas that are understandable and reasonable in themselves come to dominate the patients life
Typical disorders that feature overvalued ideas (5)
Anorexia nervosa Hypochondriacal disorder Dysmorphophobia Paranoid personality disorder Morbid jealous
The more simple the auditory hallucination…
The more likely the cause is to be organic
When does a Hypnopomic hallucination occur?
Upon waking
When does a hypnagogic hallucination occur?
Upon falling asleep
Conditions where visual hallucinations are more common (5)
Dx withdrawal Some dementias Encephalitis Epilepsies Occipital lobe tumours
What is a visceral tactile delusion
False perception of inner organns
What is Ekbom’s syndrome
False belief that one = infested with small but visible organisms
Auditory pseudohallucinations
A perceptual experience which differs from hallucination in that it appears to arise in the subjective inner space of the mind
How can auditory pseudohallucinations be explained?
Internalisation of past aggressor/abuser
E.g. in EUPD
Features of formal thought disorder (5)
Loosening of association Flight of ideas Circumstantial thoughts Tangential thoughts Thought block
What is Knight’s move thinking
Patients train of thought shifts suddenly from 1 v loosely unrelated idea –> next
–> ‘word salad’
Thought block
Pt experience a sudden cessation to their flow of thought, often mid sentance.
Pt - no recall of what they were saying + continue to talk about different topic
Neoglisms
New word created by the patient
Idiosyncratic word use
Using recognised words by attributing them with non-recognised meaning
Perseveration
When an initially correct response is inappropriately repeated
Echolalia
Patients senselessly repeat words or phrases spoken around them by others = parrot
What are Schnider’s 1st rank symptoms (ABCD)
Auditory hallucinations
Broadcasting of thought
Controlled thought - delusions of control
Delusional perception
Diagnostic criteria schizophrenia - ICD-10
>28 days No organic cause 1st rank symptoms present 1 or > of: thought sx, delusion control/passivity, delusional perception, hallucinatory voices running commentary, bizarre delusions May also have -ve and cognitive
Organic causes psychosis (6)
Delirium Medication induced Endocrine - Cushings, HypoT/hyperT Neuro Systemic - porphyria/SLE Substances
Medications that can induce psychosis (3)
Corticosteroids
Stimulants
Dopamine agonists
DDx psychotic patient (6)
Schizoaffective disorder Delusional disorder Schizotypal disorder Acute + transient psychotic disorder Mood disorder Substance misuse
Ix psychosis (7)
Neurological exam BMI Bloods Urine - Dx screen Syphillis screen ECG Collateral Hx
Common co-morbidity psychosis
Substance misuse
Reasons for non-compliance with antipsychotics (5)
Lack of insight SE of medication Delusions about medication/prescriber Patient feels 'better' when ill Pt gains remission + thinks meds no longer required
Physical health monitoring for psychosis patients (6)
Smoking/drinking status P/FHx of DM/Coronary heart disease BP BMI Bloods ECG
Define treatment resistance schizophrenia
Lack of response to adequate doses of 2 different antipsychotics
What should you double check if you are about to diagnose someone with TRS (Tx-resistant schizophrenia)
Review diagnosis
Rule out co-morbid substance misuse
Ensure dose/duration + compliance prev Tx
Med used for TRS
Clozapine
SE clozapine (7)
Neutropenia Fatal agranulocytosis Hypersalivation Cardiomyopathy Myocarditis DM Seizures
Monitoring clozapine
FBC weekly for 1st 18w
Then every 2w for 1year
Then every 4 weeks
Psychological Tx schizophrenia
CBT ***
FIT (Family intervention therapy)
Psychoeducation
Coping stratergies
What is involved in psychoeducation for schizophrenics (4)
Relapse signs
Crisis plans
Relapse prevention
WRAP - Wellness, recovery + Action Plans
Conditions antipsychotics can be used for (10)
Psychosis Delirium Behavioural disturbance - dementia Mood disorders Severe agitation, anxiety + violent/impulsive behaviour Insomnia Rapid tranquillisation N+V Hiccups Tics incl Tourette's
What are the 3 main aims of Tx in the use of antipsychotics in psychosis
Alleviate +ve Sx
Alleviate -ve Sx
minimise SE
1st gen antipsychotics (5)
Chlorpromazine Haloperidol Sulpiride Flupentixol Zuclopenthixol
2nd gen antipsychotics (5)
Clozapine Olanzapine Quetiapine Risperidone Amisulpride
SE 1st gen antipsychotics (12)
NMS Seizure threshold lowered Sedation EPSE BP/Temp changes Hypersensitivity reactions - liver, bone marrow, skin Raised prolactin Apathy Confusion Depression Arrhythmia Metabolic syndrome
What is Akathisia
Subjective feelings of restlessness
Parkinsonism
Tremor, rigidity, bradykinesia
What is Acute dystonia
Involuntary mm spasms which prod briefly sustained abnormal postures.
Within 48hrs initiation
What is Tardive Dyskinesia
Abnormal involuntary hyperkinetic chewing, head nodding, grimacing, rocking movements
Features of metabolic syndrome (6)
Central obesity Insulin resistance Impaired glucose regulation HTN Raised plasma TG Raised LDL cholesterol level
Mortality rate NMS
5-20%
Sx NMS (7)
Hyperthermia Confusion TachyC Hyper/HoTN Tremor Raised CK Low pH - metabolic acidosis
SE olanzapine
Sedation + W gain ++++ Raised TG Dizziness AntiC SE
SE risperidone
W gain +
EPSE ++
Sexual dysfunction +
Sedation +
Quetiapine SE
Sedation ++
Weight gain ++
Possible QT prolongation
Lowest risk EPSE
SE Aripiprazole
Nausea
Restlessness
Insomnia
Exacerbates psychosis initially
What’s great about Aripiprazole
Least W gain
Minimal metabolic effect
Depot Antipsychotics (7)
Haloperidol Flupentixol Zuclopenthixol Fluphenazine Risperidone Olanzapine Aripiprazole
How long should schizophrenics continue their meds after recovering from an acute episode?
1-2 years at least
What psychosocial interventions should not be offered to schizophrenics (2)
Adherence therapy
Social skills training
