Psychosis Flashcards
Define psychosis
A mental disorder in which thoughts, affective response, or ability to recognise reality and the ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality
The characteristics are hallucinations, delusions and disorder of the form of thought
4 categories of cause of psychosis?
1) organic conditions (delirium, dementia, brain injury, stroke)
2) substance use (acute alcohol intoxication, drug intoxication, withdrawal)
3) schizophrenia and other paranoid illnesses
4) manic depressive psychosis (unipolar or bipolar)
List seven psychotic symptoms
1) hallucinations
2) ideas of reference
3) delusions
4) thought disorder
5) thought interference
6) passivity
7) loss of insight
Define hallucination
a perception which occurs in the absence of an external stimulus
it is experienced in real space and has the same qualities as normal perception ie is vivid, solid and compelling, it is not subject to conscious manipulation (you cant turn it off)
can occur in any sensory modality but most common are auditory or visual
Define ideas of reference
innocuous or coincidental events will be ascribed significant meaning by the person
e. g. a news report is really commenting about them and talking directly to them
e. g. radiostation is braodcasting songs in a certain way to tell them something
Define a delusion
a fixed falsely held belief held with unshakeable conviction, impervious to logical argument or evidence to the contrary
it is held out with the usual social, cultural and educational background of the patient
may be bizarre or impossible but doesn’t have to be > it is delusion due to how they arrived at the belief > does why the believe it make sense?
Explain the difference between primary and secondary delusions?
primary delusions arrive fully formed in the consciousness without the need for explanation
secondary delusions are often attempts to explain other psychotic experiences .eg. hallucinations, passivity phenomena, thought insertion
List some themes of delusions? (12)
- Paranoid > out to get you
- Persecutory > out to get others
- Grandiose
- Religious
- Misidentification (capgrass- people replaced by imposters fregoli- everyone is the same person changing outfits)
- Guilt
- Sin
- Poverty
- Nihilistic (cottard- believed you have died already)
- Erotomanic (de clerambault - believe a public figure is in love with you)
- Jealousy (othello syndrome- can believe spouse is being unfaithful- red flag, cases of homicides due to these delusions )
- Of reference
Describe how the specific content of a delusion is influenced?
Content of delusions are usually culturally defined, a persecutor is often recognised by society/ culture as a danger or threat, hence in the past control was by ghosts or spirits but now patients more likely complain of x-rays, transmitters, satellites or the internet. Delusions around illness shifts to fear of the time e.g. was the plague, now COVID 19
Thoughts cannot be directly observed so much be inferred from __________
the patients pattern of speech
List some things that may suggest thought disorder?
clanging punning loosening of associations neologisms word salad/ verbigeration circumfrentiality tangentiality
Define clanging
associating words on sound for example rain on the brain, i took a train today
Define punning
association of words that sound the same for example how soulful, i like sole
Define loosening of associations
aka knights move thinking
person is moving to loosely related ideas that are getting increasingly more fragmented as they talk
Define neologisms
making up new words or expressions
Define word salad and verbigeration
saying words fluently but the actual sentences dont make sense
verbigeration is obsessive repetition of random words
Explain the difference between circumfrentiality and tangentiality ?
circumfrentiality the patient is asked a question and talks about something else but then comes back round the question
tangentiality the patient goes off on a tangent and never actually returns to the point
List 4 types of thought interference?
thought insertion
thought withdrawal
thought broadcasting
thought blocking
Define thought insertion
think that someone else is putting thoughts in their head
Define thought withdrawal
someone is stealing their thoughts
Define thought broadcasting
think everyone can hear their thoughts
Define thought blocking
half way through a thought the patient just stops, usually person stops talking in the middle of a sentence, when asked they usually describe their head just going blank
3 types of passivity?
passivity of volition
passivity of affect
passivity of urges
Explain what passivity of volition is?
made actions “someone moved my legs and i couldn’t stop them”
Explain what passivity of affect is?
someone is controlling my emotions
Explain what passivity of urges is?
made urges “someone made me jump out into traffic”
Describe loss of insight in psychosis?
the patient perceives everything is fine apart from people are saying they are unwell
the psychiatrist has to ask enough questions to confirm the beliefs are in fact psychotic but also keep a good relationship
What is delirium?
acute, transient disturbance from the person’s normal cognitive function
insult to the brain leads to neuropsychotic symptoms
List some causes of delirium
infection, post surgery, post op hypoxia, organ failure, drugs (digoxin, steroids, diuretics, anticholinergics) list is basically endless!
Explain how long delirium can last for?
can actually last for a long time even after correcting the underlying cause
What are the hallmarks of delirium?
clouding of consciousness (fluctuating severity over time with lucid intervals), impaired concentration, hallucinations, persecutory delusions, psychomotor disturbance, agitation, irritability and insomnia
Describe presentation of drug induce psychosis
may be florid acute symptoms or more insidious and chronic, the symptoms tend to be short lasting if the psychoactive substance is removed
Describe the importance of understanding co-morbidity and substance misuse?
should beware of co-morbidity of substance use and schizophrenia ie just because someone has taken drugs that isn’t necessarily the cause of their psychosis
may need to actually admit someone to hospital and have them off the drugs to determine the cause of their psychosis
Describe the presentation of depressive psychosis
This is typified by mood congruent content of psychotic symptoms
e.g. delusions of worthlessness, guilt, hypochondriasis, poverty, sin, nihilism
may have hallucinations of accusing, insulting, threatening voices, usually second person
Describe the presentation of mania with psychosis?
This is typified by mood congruent content of psychotic symptoms
Delusions of grandeur/ special ability/ persecution/ religiosity
hallucinations tend to be second person, auditory e.g. gods voice telling you that you’re great
tend to have flight of ideas
Age of onset of schizophrenia?
illness can begin at any age but is rare after puberty
Overview of schizophrenia criteria?
Either at least one of the syndromes, symptoms and signs listed as first rank symptoms or at least 2 of the symptoms and signs listed listed as second rank symptoms should be present for most of the time during an episode of psychotic illness lasting for at least one month (or at some time during most of the days)
First rank symptoms of schizophrenia? How many needed for diagnosis?
At least one of following
A) Thought echo, thought insertion or withdrawal or thought broadcasting
B) Delusions of control, influence or passivity, clearly referred to body or limb movements or specific thoughts, action or sensations, delusional perception
C) Hallucinatory voices giving a running commentary on the patients behaviour or discussing him between themselves or other types of hallucinatory voices coming from some part of the body
D) Persistent delusions of other kinds that are culturally inappropriate and completely impossible (e.g. being able to control the weather, or being in communication with aliens from another world )
Second rank symptoms of schizophrenia? How many are needed for diagnosis?
At least two of the following
E) Persistent hallucinations in any modality when occurring every day for at least one month when accompanied by delusions (which may be fleeting or half-formed) without clear affective content or when accompanied by persistent overvalued ideas F) Neologisms, breaks or interpolatations in the train of thought, resulting in incoherence or irrelevant speech G) Catatonic behaviour such as excitement posturing or waxy felxibility negativisim mutism and stupor H) Negative symptoms such as marked apathy, paucity or speech and blunting or incongruity of emotional responses (it must be clear that these are not due to depression or to neuroleptic medication)
Negative schizophrenic symptoms?
reduced amount of speech, reduced motivation/ drive, reduced interest/ pleasure, reduced social interaction, blunting of affect
Positive schizophrenic symptoms?
hallucinations, delusions, passivity phenomena, disorder of thought form
80% of schizophrenics have the _______ subtype which is characterised by ______ and _______ symptoms
paranoid
first rank
positive
Describe the characteristics of hebephrenic schizophrenia?
Affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common, the mood is shallow and inappropriate, thought is disorganised, and speech is incoherent, there is a tendency to social isolation and negative symptoms
Describe the characteristics of catatonic schizophrenia?
Movement disorder predominates, alternating between stupor and hyperkinesis, automatic obedience, posturing and waxy flexibility may be seen
List some other paranoid psychoses apart from schizophrenia?
persistent delusional disorder schizotypal disorder acute and transient psychotic disorder induced delusional disorder schizoaffective disorder
Describe persistent delusional disorder?
there is systematised fixed delusions, dont tend to have hallucinations
Describe schizotypal disorder?
DSM classes this as a personality disorder, ICD says it is a paranoid psychoses
Describe acute and transient psychotic disorder?
similar symptoms to schizophrenia but lasting less than a month
Described induced delusional disorder?
Induced delusional disorder (or shared paranoid disorder), also known as folie à deux, is a fairly uncommon disturbance characterized by the presence of similar psychotic symptoms in two or more individuals. Most often the symptoms are delusional.
Describe schizoaffective disorder?
episodic disorder in which both affective and schizophrenic symptoms are present but criteria for neither is met
Best results in managing schizophrenia are obtained when?
when drug and social treatments are combined
antipsychotics reduce symptoms and prevent relapses but antipsychotics won’t treat all the other problems that go along with schizophrenia
Explain simply what is thought to cause schizophrenia and how therefore antipsychotics work?
schizophrenia is thought to be partially due to the firing of aberrant dopaminergic neurons
so if you can back the receptors are reduce the effect of firing you will treat the symptoms (there are other factors causing schizophrenia but this is just a pathway we know about and can manipulate)
Describe an ideal antipsychotic? What actually happens?
An ideal antipsychotic would be a pure D2 antagonist only active in the mesolimbic pathway. However unfortunately all brain receptors are very similar so there is lots of additional receptor activity.
Describe additional receptor activity with anti-psychotics?
other dopamine receptors Ach histamine 5HT NA potentially other receptors we haven't even discovered yet!
List some categories of side effects from antipsychotics?
Extrapyramidal side effects neuroleptic malignant syndrome prolactin akathisia other side effects
What causes extrapyramidal side effects with antipsychotics?
to do with disruption of the substantia nigra
3 extrapyramidal side effects from antipsychotics?
acute dystonia
parkinsonism
tardive dyskinesia
Describe acute dystonia as a antipsychotic side effect?
starts with in minutes of taking the drug, results in increasing muscle tone, uses a lot of energy, there is torticollis (head tilted down), oculogyric crisis (prolonged upwards gaze of eyes), tongue protrusion
Describe parkinsonism as an antipsychotic side effect?
due to dopamine antagonism
comes on within weeks to months of starting the drugs and presents like parkinsons disease
Describe tardive dyskinesia as an antipsychotic side effect?
comes on within weeks to months and lasts a long time even if treated, it involves involuntary, repetitive, oro-facial movement, blinking, grimacing, pouting, lip smacking and may involves limbs and/ or trunk
How can you treat extrapyramidal side effects of antipsychotics?
treated with anticholinergics which reduce Ach and balance the system, it’s fine to have less of dopamine and Ach as lots of redundancy within the system, its just that levels need to be balanced
e.g. procyclidine, trihexyphenidyl, orphenadine
What is neuroleptic malignant syndrome?
rare but important side effect of antipsychotics as fatal in 20-30% of cases
there is increasing muscle tone, pyrexia, changing pulse > rhabdomyolysis > AKI > coma and death
Key investigation for neuroleptic malignant syndrome?
CK will be high
Treatment of neuroleptic malignant syndrome?
stop antipsychotic (consider onwards management of schizophrenia), rapid cooling, renal support, skeletal muscle relaxants, may need to be put in a medically induced coma, dopamine agonists e.g. bromocriptine
Why do antipsychotics cause hyperprolactinaemia?
prolactin release is inhibited by dopamine, anti-psychotics reduce dopamine so there is an increase in prolactin
Presentation of hyperprolactinaemia?
in men: gynaecomastia, erectile dysfunction, oligospermia, decreased libido
In women: galactorrhea, decreased libido, decreased arousal, anorgasmia, amenorrhoea
in both: osteoporosis
Describe akathisia as a side effect of anti-psychotics?
restlessness/ inability to stand still
1/5 patients will report this
it comes on between days to weeks of starting the drug
pacing, rocking from foot to foot, unable to stand still, poor sleep
Treatment of akathisia as a side effect of anti-psychotics?
1st line =beta blocker e.g. propranolol
2nd line= benzodiazepines e.g. clonazepam
list some other side effects of antipsychotics?
anticholinergic 5HT > weight gain antiadrenergic > postural hypotension hepatotoxicity prolonged QT interval photosensitivity
Which antipsychotic works the best? Why is it not first line?
clozapine works the best by far but there are significant side effects including agranulocytosis, so needs strict monitoring
Describe pathway of choosing an antipsychotic?
start with second generation, titrate up to adequate dose over 6-8 weeks (e.g. amisulpiride, risperidone, olanzapine, quetiapine)
check if it works
if not add a 1st or 2nd generation, titrate up over 6-8 weeks again
if doesn’t work consider diagnosis, compliance, psychological input and then …
use clozapine
Describe 4 abnormalities that may be present in the brain someone with schizophrenia?
1.Robust finding of enlarged lateral ventricles - little progression over time
2.Reduced frontotemporal volume
? due to reduced size & arborisation of neurons
- Reduced activation of prefrontal areas on specific tasks - impairment of tasks that involve frontal areas (e.g. executive function)
- abnormalities in the neurotransmitters (dopamine, serotonin and increasing evidence that glutamate receptors are involved)
List some first and second generation anti-psychotics?
FIRST: haloperidol, chloropromazine
SECOND: quetiapine, risperidone, olanzapine, amisulpiride, clozapine
