Psychosis Flashcards
Define psychosis
Individual experiencing a reality different to everyone else
Symptoms of psychosis
Hallucinations
Delusions
Formal thought disorder
Fragmentation of boundaries of self
Define hallucinations
Perception of an object in the absence of external stimulus
- can be any of 5 modalities
- auditory most common
Define delusions
Fixed, firmly held belief than is usually false
Cannot be reasoned away
That is held despite evidence to the contrary
Out of keeping with person’s sociocultural norms
Types of delusions
Persecutory - someone/thing is after you Grandiose - you are powerful Reference - everything is about you Erotomanic - someone loves you Hypochondrial - have x illness
Define formal though disorder
Problem of speech which means that each word/sentence does not follow on from next
Define disorders of the self
Individual can no longer distinguish between oneself and the world
- broadcast - everyone can hear your thoughts
- passivity phenomena - physical movement controlled by someone/thing else
- thought insertion - someone places thought in your head
Define schizophrenia
Group of disorders characterised by psychotic episodes (positive symptoms) and negative symptoms
Features of general schizophrenia
At least one
- thought echo, ingestion, broadcasting or withdrawal
- delusions of control, influence of passivity
- hallucinatory voices
- persistent delusions
Or at least 2 of
- persistent hallucinations of any modalities
- neologisms or breaks in train of thought
- catatonic behaviour
- negative symptoms
Define neologisms
A new word or phrase of patients own making
Define catatonic behaviour
Significant decrease in reactivity to environment
- negativism
- mutism
- stupor
Diseases associated with psychosis
Schizophrenia - most common
Bipolar disorder
Severe depression
Severe anxiety
Incidence of psychosis
31.7 per 100 000
Causes of psychosis
Non-organic - schizophrenia - acute psychotic episode - mood disorders with psychosis - drug-induced psychosis - puerperal psychosis Organic causes - drug-induced psychosis - iatrogenic - levodopa, methyldopa, steroids, antimalarials - delirium - dementia - Huntington's - SLE - syphilis - Cushing's - vit B12 deficiency
Define schizophrenia
Most common psychotic condition
Characterised by hallucinations, delusions and thought disorders -> functional impairment
Predisposing factors for schizophrenia
Biological - genetic - positive family history - neurochemical - increased dopamine, decreased glutamate, serotonin and GABA - neurodevelopmental - obstetric complications, foetal injury and low birth weight - age 15-35 Psychological - FH - childhood abuse Social - substance misuse - low socioeconomic status - migrants
Features of dopamine hypothesis for schizophrenia
Schizophrenia is secondary to over-activity of mesolimbic dopamine pathways in the brain
- antipsychotics block dopamine receptors
Features of expressed emotion theory for schizophrenia
Those with relatives that are over involved or that make hostile or excessive critical comments are more likely to relapse
Features of stress-vulnerability model for schizophrenia
Predicts that schizophrenia occurs due to environmental factors interacting with a genetic predisposition
- patients have different vulnerabilities and so different individuals need to be exposed to different levels of environmental factors to become psychotic
Precipitating factors for schizophrenia
Biological - smoking cannabis or using psychostimulants Psychological - adverse life events - poor coping skills Social - adverse life events
Perpetuating factors for schizophrenia
Biological - substance misuse - poor compliance to medication Psychological - adverse life events Social - reduced social support - expressed emotion
Define first rank symptoms of schizophrenia
Symptoms which is one or more is present are strongly suggestive of schizophrenia
- alternative tool to ICD-10 for diagnosis
What are the first rank symptoms of schizophrenia
Delusional perception - new delusion that forms in response to a real perception without any logical sense
Third person auditory hallucinations - usually a running commentary
Thought interference - thought insertion, withdrawal or broadcast
Passivity phenomenon
Positive symptoms of schizophrenia
Delusions Firmly Held Think Psychosis - Delusions - Hallucinations Formal thought disorder Thought interference Passivity phenomenon
Define passivity phenomenon
Actions, feelings or emotions being controlled by an external force
Negative symptoms of schizophrenia
Avolition - reduced motivation
Asocial behaviour - loss of drive for social engagements
Anhedonia - loss of enjoyment
Alogia - decrease in speech
Affect blunted - diminished or absent capacity to express feelings
Attention deficits
Features of a schizophrenic prodrome
Reserved Anxious Suspicious Irritable Disturbance in normal everyday functioning
Features of paranoid schizophrenia
Most common
Dominated by positive symptoms - hallucinations and delusions
Features of postschizophrenic depression
Depression predominates with schizophrenic illness in past 12 months with some schizophrenia symptoms still present
Features of hebephrenic schizophrenia
Thought disorganisation predominates
Onset of illness earlier - 15-25
Prognosis poorer
Features of catatonic schizophrenia
Rare
Characterised by one or more catatonic symptoms
Features of simple schizophrenia
Rare
Negative symptoms develop without psychotic symptoms
Features of undifferentiated schizophrenia
Meets diagnostic criteria for schizophrenia but does not conform to any other subtypes
Features of residual schizophrenia
1 year of chronic negative symptoms preceded by a clear cut psychotic episode
ICD-10 criteria for schizophrenia
At least one very clear symptom from group A or 2 or more from group B for at least 1 month
Without presence of organic brain disease
Group A
- thought echo/insertion/withdrawal/broadcast
- delusions of control, influence or passivity phenomenon
- running commentary auditory hallucinations
- bizarre persistent delusions
Group B
- hallucinations in other modalities that are persistent
- thought disorganisation
- loosening of associations, neologisms, incoherence
- catatonic symptoms
- negative symptoms
Questions to help identify schizophrenia
Have you ever had the experience of hearing voices/noises when there is nobody else around?
How many voices are there?
Do they speak directly to you?
Do they make comments on what you are doing?
Are you afraid someone is trying to harm you?
Do you have any special abilities?
Have you ever felt that thoughts are being taken out of your mind?
Has anyone ever put thoughts into your head?
Have you felt under the control of an outside force?
Investigations for schizophrenia
Bloods - FBC, TFT, glucose/HbA1c, serum calcium, U+Es, LFTs, cholesterol, vitamin B12 and folate Urine drug test ECG - antipsychotics can prolong QT interval CT - rule out organic causes EEG - rule out temporal lobe epilepsy
Management of schizophrenia
Risk assessment and use of mental health act if refuse informal admission
For 1st presentation of psychosis early intervention in psychosis team should be involved
Assess social circumstances and involve family
Poor prognostic factors for schizophrenia
Strong family history Gradual onset Reduced QI Premorbid history of social withdrawal No obvious precipitant
Biological management of schizophrenia
Antipsychotics
- atypical first line - risperidone and olanzapine
- depot formulation if prefer or refusing oral
- clozapine - most effective and used for treatment-resistant schizophrenia
Adjuvants
- benzodiazepines provide short term relief of behavioural disturbance, insomnia, aggression and agitation
- antidepressant and lithium
ECT
- patients who are resistant to pharmacological agents
- effective for catatonic schizophrenia
Psychological management of schizophrenia
CBT
- strongly recommended by NICE
- reduces residual symptoms
Family intervention
- psychoeducation helps families reduce high levels of expressed emotion - reduced relapse
Art therapy
- alleviation of negative symptoms in young people
Social skills training
- behavioural approach to help patients improve interpersonal, self-care and coping skills
Social management of schizophrenia
Support groups - national groups - rethink and SANE Peer support - delivered by peer support worker who has recovered form psychosis or schizophrenia Supported employment programmes
