Psychosis Flashcards
Which questions should you ask regarding a suspected psychosis?
- When did the patient last feel themselves?
- How have things changed recently?
- Ask about normal life, friends/family, hobbies and interests
- Auditory halluncations
- Strange or frightening experiences
- Hearing things when nobody else is present
- TV/radio speaking TO them
- Feeling others are against them/want to harm them
- Ideas of special powers
What are some differential diagnoses for psychosis?
- Brain tumours: accompanied by disorientation, memory loss, neurological features
- High-dose steroids
- Temporal lobe epilepsy
- Thyroid disease
- Encephalitis
- Acute confusion
- Dementia
- Metabolic disorders
Which mental disorders can cause psychotic symptoms?
- Severe depression
- Drug-induced psychosis
- Manic phase of a bipolar disorder
- Dementia
What is the first line treatment for psychosis?
- CBT
- Antipsychotics:
Nice guidance says patients should be offered antipsychotics + CBT
What are the common side-effects of antipsychotic medication?
- Sedation
- Diabetes
- Raised prolactin
Which baseline investigations should be performed before starting an anti-psychotic medication?
- Weight (on chart)
- Waist circumference
- Pulse and BP
- Fasting BMs, HbA1c, blood lipid profile and prolactin levels
- Assessment of movement disorders
- Assessment of nutritional status, diet, and physical activity
- ECG
What are the criteria for a section 2 of the MHA?
- The patient is suffering from a mental disorder of a nature/degree which warrants hospital detention for assessment +/- treatment
- The patient ought to be detained in the interests of their own health/safety, or to protect others
- The patient will not agree to other forms of appropriate treatment/cannot consent
What is a section 135?
Section 135:
- Can be used once
- Allows access to a premises to remove a patient to place of safety
- Does not allow for treatment
- Requires one doctor, AMHP and police
- Allows for further assessment
What is a section 136?
Section 136:
- Can be used once
- Allows police to remove person from public place to safety
- Does not allow treatment
- Requires police
What is a section 2?
Section 2:
- Lasts up to 28 days
- Admission for assessment
- Treatment can be given for mental disorder itself or condition directly as a result of it
- Requires application of AMHP or nearest relative, and 2 doctors
- Patient can appeal and be discharged
- Application is made for a section 3 if more detention needed
What is a section 3?
Section 3:
- Lasts for 6 months
- Admission for treatment
- Treatment can be given for the first 3 months, then consent/second opinion needed
- Requires application by AMHP/nearest relative, and 2 doctors
- Patient can appeal and be discharged
What is a section 4?
Section 4:
- Emergency admission for assessment
- Treatment can only be given under common law
- Requires application by AMHP/nearest relative, and any doctor
- Patient cannot appeal, only be discharged by responsible clinician
What is a section 5(2)?
Section 5(2)
- Lasts for 72 hours
- Emergency holding order (patient already admitted on an informal basis)
- Treatment can only be given under common law
- Requires recommendation from doctor or approved clinician
- Cannot appeal
What is a section 5(4)?
Section 5(4):
- 6 hours
- Emergency holding order when patient already admitted informally
- Treatment can only be given under common law
- Requires recommendation from a registered nurse
- Patient cannot appeal
When are anti-psychotics indicated?
- Schizophrenia
- Schizoaffective disorder
- Severe depression with psychosis
- Augmenting agent in treatment resistant depression/anxiety
- Dementia
What are typical antipsychotics?
Examples:
- Haloperidol
- Sulpiride
- Pimozide
- Chlorpromazine
- D2 dopamine receptor antagonists, and therefore have extrapyramidal side effects (Parkinsonian symptoms)
What are atypical antispsychotics?
- Serotonin-dopamine 2 antagonsists (SDAs)
- Affect dopamine AND serotonin transmission
Examples:
- Risperidone (tablets, IM and immediate release)
- Olanzapine (tablets, IM and immediate release)
- Quetiapine (tablets), commonly causes orthostatic hypotension and weight gain
- Apiprazole (tablets and IM), D2 partial agonist, noQT prolongation
SE: weight gain and prolactinaemia, hyperglycaemia, hypercholesterolaemia, hypertrigyceridaemia
How does Clozapine work?
- Atypical antipsychotic
- Regular tablets only
- Reserved for treatment resistant patients
- Associated with agranulocytosis
- Weekly bloods for first 6 months, then every fortnight for 6 months
- Increased risk of seizures (especially with lithium) Side effects: - Sedation - Weight gain - Deranged LFTs - Hypertriglyceridaemia - hypercholesterolaemia - Hyperglycaemia
What is neuroleptic malignant syndrome?
Potentially life-threatening
Presents with autonomic dysfunction:
- Hyperthermia
- Hypertension
- Hyperreflexia
- Tachycardia
- Tremor
- Agitation
- Irritability
- Sweating
Complications:
- Rhabdomyolysis
- Hyperkalaemia
- Renal failure
- Seizures
Treatment:
- Discontinue medication
- ICU, ventilatory and circulatory support
- Treat hyperthermia with cooling
- Dantrolene/Bromocriptine/Amantadine for rigidity
- Benzodiazepines for agitation
- IV hydration for diuresis
Following discharge from hospital, what should be done for the patient?
They should be managed in the community, with a Care Programme Approach:
Liaise early intervention in psychosis team
- Should include details of how to get help in a crisis
- Patients should receive a written care plan
- Updated and reviewed every 6-12 months
