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Psychiatry > Psychosis > Flashcards

Psychosis Flashcards

1
Q

Define psychosis

A

The thoughts, affective response or ability to recognise reality and the ability to communicate and relate to others is grossly impaired with the capacity to deal with reality

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2
Q

What are the classic characteristics of psychosis?

A

Hallucinations
Delusions
Disorders of form of thought
Lack of insight

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3
Q

When can psychosis occur?

A
  • Organic conditions
  • Manic depressive
  • Substance use
  • Dementia praecox
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4
Q

What signs are involved in psychotic experiences?

A
  • Hallucinations
  • Ideas of reference
  • Delusions
  • Passivity
  • Loosening of associations
  • Neologisms
  • Circumstantiality
  • Changing and punning
  • Thought interference
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5
Q

What are hallucinations?

A

Occurs in the absence of stimuli but has the same qualities as normal perception

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6
Q

What is meant by ideas of reference?

A

Innocuous, day to day events that a person with psychosis will think are significant to them

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7
Q

Give an example of ideas of reference

A

Message in the news

Number plates

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8
Q

What are delusions?

A

Abnormal belief held to absolute conviction, usually false and not amenable to social or cultural beliefs

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9
Q

What is the difference between primary and secondary delusions?

A

Primary - no preceding event

Secondary - derived from a preceding event e.g hallucination

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10
Q

Describe passivity phenomena

A

Behaviour is experienced as being controlled by an external agency rather than the individual

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11
Q

Describe loosening of associations

A

Speech is muddled and difficult to follow, cannot be clarified with no logical connection

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12
Q

What are neologisms?

A

Patient makes up a new work/phrase with no accepted meaning

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13
Q

What is another name for loosening of associations?

A

Knights move thinking

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14
Q

Name four types of thought interference

A
  • insertion
  • withdrawal
  • broadcasting
  • blocking
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15
Q

What illicit substances can cause psychosis?

A

Legal highs , amphetamine, cannabis

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16
Q

Which prescription drugs can cause psychosis?

A

Levodopa, steroids, anti-malarial, anti-psychotic, anti-convulsants, anti-depressants

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17
Q

What causes psychosis on withdrawal?

A

Alcohol

Benzodiazepines

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18
Q

How does a drug induced psychosis present?

A

Florid symptoms - visual or tactile hallucinations which should resolve on cessation of the drug (takes up to 4 weeks)

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19
Q

How will depressive psychosis present?

A

Delusions of worthlessness, guilt, nihilism, derogatory hallucinations usually auditory

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20
Q

Describe manic psychosis

A

Delusions of grandeur and auditory hallucinations

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21
Q

What is delirium?

A

Acute disorder of the mental processes whereby mental confusion is accompanied by a physical condition

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22
Q

What are the symptoms of delirium?

A
  • Disorientation in time and place
  • Delusions
  • Hallucinations
  • Insomnia
  • Agitation
  • Worse at night
  • May have lucid periods
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23
Q

What are the three types of passivity?

A

of volition - made actions
of affect - made feelings
of impulse - made urges

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24
Q

What is your lifetime risk of schizophrenia?

A

1%

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25
Q

Which gender and class are more at risk of schizophrenia?

A

Men and those of lower socioeconomic class

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26
Q

What is the average age of onset of schizophrenia?

A

Males - 15-25 years old

Females 25-35 years old

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27
Q

What percentage of cases of schizophrenia are inherited?

A

80%

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28
Q

What environmental factors can contribute to schizophrenia?

A 
Obstetric complications (2nd trimester virus, pre-eclampsia, hypoxia?
Childhood CNS infection 
Early Cannabis use 
Urban upbringing 
Psychological stress
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29
Q

What neurochemical changes can be seen in schizophrenia?

A

Changes in dopamine signalling

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30
Q

What histological changes can be seen in schizophrenia?

A

Lack of gliosis

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31
Q

What structural changes can be seen in schizophrenia?

A

Ventricular enlargement and altered CSF flow
Decrease in healthy white matter associated with cognitive decline
Reduced frontal lobe volume (and grey matter) Reduced grey matter in the temporal cortex.

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32
Q

State the first rank symptoms

A
  • 3rd person auditory hallucinations that give a running commentary
  • Thought insertion, broadcast, removal
  • Passivity phenomena
  • Delusional perception
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33
Q

What is delusional perception?

A

Belief attached to a real perception

34
Q

State the symptoms in ICD10 that only require one for diagnosis

A 
Thought interference 
Delusional perception 
Hallucinatory voices 
Persistent delusions 
One for at least one month
35
Q

State the symptoms in ICD10 that require two for diagnosis

A

Persistent hallucinations occurring everyday
Incoherent/irrelevant speech due to neologisms/breaks/interpolations
Catatonic behaviour
Negative symptoms

36
Q

What are the positive symptoms?

A
  • hallucinations
  • delusions
  • passivity phenomena
  • disorder of form of thought
37
Q

What are the negative symptoms?

A
  • reduced speech
  • reduced motivation
  • reduced interest/pleasure
  • reduced social interaction
  • blunting affect
38
Q

Describe paranoid schizophrenia

A

Most common type (80%)

Mainly first rank symptoms (hallucinations and delusions of self)

39
Q

Describe hebephrenic schizophrenia

A

Disorganised, thought disorder with odd behaviour and bizarre delusions, intellectual disorientation

40
Q

Describe catatonic schizophrenia

A

Predominant mood disorders (odd postures), mutism, stupor, resistance to command/attempts to be moved = negativism or automatic command

41
Q

Name four other types of paranoid psychoses

A
  • persistent delusional disorder
  • schizotypal disorder
  • acute and transient psychotic disorder (<1month)
  • schizoaffective disorder (first rank +depression or mania)
42
Q

Name the poor prognostic indicators

A 
Poor pre-morbid adjustment 
Insidious onset 
Early onset 
Long duration of untreated psychosis 
Cognitive impairment 
Enlarged ventricles
43
Q

Name good prognostic indicators

A 
Shorter time of untreated psychosis 
Older onset 
Female 
Marked mood disturbance
Family history of mood disorders
44
Q

How are antipsychotic drugs classified?

A

1st, 2nd and 3rd generation

45
Q

Give examples of first generation anti-psychotics

A

Haloperidol and flupenticol

46
Q

Give examples of second generation anti-psychotics

A

Clozapine, risperiodone, olanzapine, quetiapine

47
Q

Give examples of third generation anti-psychotics

A

Aripiprazole (dopamine partial agonist)

48
Q

What pathology in relation to dopamine is present in schizophrenia?

A

Excess and aberrant firing of dopaminergic neutrons in schizophrenia

49
Q

Name the five dopamine pathways

A
  • mesolimbic (leads to first rank symptoms)
  • mesocortical (links to higher brain function)
  • nigrostriatal (voluntary movements)
  • tuberoinfundibular (hypothalamus and pituitary)
  • hypothalamospinal (into PNS)
50
Q

How many dopamine receptors are there and which do you want to target?

A

5

Aim to affect D2- limbic and mesolimbic pathways

51
Q

What other receptors are involved?

A

ACh, 5HT, Histamine, NAdr

52
Q

What percentage of dopamine blockage is the target?

A

60-80% for minimal side effects and maximal clinical effects

53
Q

What are the four key classes of side effects?

A
  • extra-pyramidal
  • neuroleptic malignant syndrome
  • hyperprolactinaemia
  • akathesia/restless legs
54
Q

What extra-pyramidal side effects can occur?

A

Acute dystonia
Parkinsonism
Tardive Dyskinesia

55
Q

Describe acute dystonia

A

Onset in minutes, presents with energetic increased tone, tongue protrusion, torticolis and oculogyric crisis (all eye muscles contract at the same time)

56
Q

Describe tardive dyskinesia

A

Long term, often permanent involuntary repetitive pro-facial movements (blinking, grimacing, pouting), may involve limbs or trunk and occurs after decades of treatment

57
Q

How are extra-pyramidal side effects treated?

A

Aim to balance ACh and dopamine by anti-cholinergic drugs such as procyclidine

58
Q

What is neuroleptic malignant syndrome?

A

Rare, onset over hours and fatal if untreated in 20-30%

Gradually increasing tone, pyrexia and autonomic instability - pulse/BP leads to rhabdomyolysis and acute renal failure

59
Q

How is neuroleptic malignant syndrome investigated?

A

CK - elevated

60
Q

How is neuroleptic malignant syndrome treated?

A

Stop drug, rapid cooling and renal support, muscle relaxant and dopamine agonist - may need induced coma
dantrolene, bromocriptine

61
Q

How does hyperprolactinaemia present in women?

A

Galactorrhoea, reduced libido, arousalm organism, amenorrhoea and anovulation

62
Q

How will hyperprolactinaemia present in men?

A

Gynaecomastia, ED, oligospermia, reduced libido

63
Q

How will hyperprolactinaemia present in both sexes?

A

Reduced bone density leading to osteoporosis

64
Q

Describe akathesia

A

Affects 20% of patients within days to weeks of treatment

Pacing, rocking from foot to foot, unable to sit/stand, restless legs, agitation and high risk of suicide

65
Q

What is the treatment for akathesia?

A

Beta blocker or benzodiazepine

66
Q

Other than dopaminergic what other side effects can occur with anti-psychotics?

A

Anti-cholinergic
Serotonergic
Anti-adrenergic
Others - long QT, hepatotoxicity, photosensitivity

67
Q

What is the best anti-psychotic?

A

Clozapine particularly for negative symptoms it also has antisuicidal properties

68
Q

What are the side effects of clozapine?

A 
Agranulocytosis 
Myocarditis 
Constipation leading to perforation
Weight gain (10kg in 3 months)
Sedation 
Sialorrhoea
69
Q

How often does a patient with clozapine need monitored?

A

Weekly for first 6 months
Biweekly for next 6 months
Monthly thereafter

70
Q

How long should an anti-psychotic be tried before it is deemed unsuccessful?

A

6-8 weeks

71
Q

What alternative administration can be considered in some patients?

A

Long acting depot - IM, deltoid or gluteal weekly to 3 months gives better stability

72
Q

What generation of drugs should be tried first?

A

2nd generation

73
Q

What is the function of the D1 receptor family?

A

Stimulates cAMP

74
Q

What is the function of the D2 receptor family?

A

Inhibit adenylyl cyclase
Inhibit voltage gates calcium channels
Open potassium channels

75
Q

Which set of dopamine receptors are present in the pituitary?

A

D2 important for pharmacology

76
Q

What is the difference between the effect of subcortical and mesocortical dopamine?

A

Subcortical hyperactivity causes psychosis

Mesocortical hyperactivity causes negative/cognitive symptoms

77
Q

What three proteins are involved in schizophrenia?

A

Neuregulin
Dysbindin
DISC-1

78
Q

What does neuregulin do?

A

Signalling protein that mediates cell-cell interactions and plays critical roles in the growth and development of multiple organ systems

79
Q

What does dysbindin do?

A

Essential for adaptive neural plasticity

80
Q

What is the function of DISC-1?

A

Neuritic outgrowth and cortical development through its interaction with other proteins

Psychiatry (18 decks)

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