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RC Nuggets > Psychosis > Flashcards

Psychosis Flashcards

1
Q

What percentage refractory?

A

25%

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2
Q

What percentage functional remission?

A

12-15%

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3
Q

Most common delusion?

A

Persecutory

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4
Q

How long for delusional disorder?

A

1 month

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5
Q

Other name for erotomania delusion?

A

Clérambeault

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6
Q

Other name for jealousy delusion?

A

Othello

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7
Q

Delusional disorder specifiers?

A

With bizarre content
Severity (0-4, 5-point scale)
Course (after 1 year, first episode, multiple episodes, continuous, unspecified)

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8
Q

Delusional disorder epidemiology?

A

Prevalence 0.2%
M=F for most part
Onset around 40yo

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9
Q

What is NOT a risk factor for delusional disorder?

A

DEPRESSION

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10
Q

Delusional disorder is not a risk for developing what?

A

SCHIZOPHRENIA

Stable diagnosis, 50% remission, 30% no change

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11
Q

How long for brief psychotic disorder?

A

24 hours to 1 month

Only need ONE symptom (at least delusion, hallucination or disorganized speech)

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12
Q

Brief psychotic disorder specifiers?

A

With marked stressors
Without marked stressors
With postpartum onset (max 4 weeks PP)
With catatonia

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13
Q

Brief psychotic disorder epidemiology?

A

Prevalence 9% of first episode psychosis
2F : 1M
More in developing countries
Onset in mid 30s

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14
Q

Brief psychotic disorder prognosis?

A

50% will have a final diagnosis of something chronic (like schizophrenia or mood d/o)

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15
Q

How long for schizophreniform?

A

1 month at least but less than 6 months
At least TWO symptoms
No need for functional decline

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16
Q

Schizophreniform specifiers?

A

With good prognostic features = at least TWO of

  • prominent psychotic symptoms within 4 weeks of first noticeable change in behaviour
  • confusion or perplexity
  • good pre-morbid functioning
  • absence of blunted or flat affect

Without good prognostic features
With catatonia

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17
Q

Schizophreniform epidemiology?

A

Prevalence 0.3-0.7% similar to schizophrenia
Common in DEVELOPING countries
5M : 1F
Higher likelihood of a family history of mood disorder vs. schizophrenia

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18
Q

Schizophreniform prognosis?

A

1/3 remain with schizophreniform
2/3 eventually schizophrenia or schizoaffective
RESPOND QUICKER TO RX than schizophrenia
Higher risk of schizophrenia in relatives if dx

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19
Q

How long for schizophrenia?

A

At least 1 month and more than 6 months (including prodromal and residual phases)
At least TWO symptoms
Marked decrease level of functioning

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20
Q

Most common predictor of non-adherence to treatment?

A

Anosognosia (symptoms NOT coping strategy)

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21
Q

Schizophrenia specifiers?

A

Course (after 1 year)
With catatonia

Early onset = 18 years old
Very early onset = 13 years old

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22
Q

Schizophrenia epidemiology?

A 
Prevalence 0.3-0.7%
Higher INCIDENCE in men
Prevalence M = F
Mid to late 20s for FEP
Late teens and mid-30s for symptom emergence
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23
Q

Which symptoms are more closely related to prognosis in schizophrenia?

A

Negative symptoms

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24
Q

Schizophrenia risk factors?

A

Male gender
Winter birth
Urban environment
Hypoxia at birth, perinatal complications
Advanced paternal age (>60yo in K&S)
Migration (2nd generation > 1st generation)
** MOST INDIVIDUALS WITH SCHIZOPHRENIA HAVE NO FAMILY HISTORY**

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25
Q

Suicide in schizophrenia?

A 
5-6% complete
20% attempt
Young males with substance use
Following discharge from hospital
Depression MOST SIGNIFICANT
Unemployed
NEGATIVE SYMPTOMS ARE PROTECTIVE
CLOZAPINE IS PROTECTIVE
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26
Q

Criteria for schizoaffective disorder?

A

Major mood episode concurrent with criterion A of schizophrenia.
Psychotic sx in absence of mood episode for at least 2 WEEKS.
Mood sx present for majority of total duration of illness
No need for functional decline or to r/o ASD

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27
Q

Schizoaffective disorder specifiers?

A

Depressive type
Bipolar type
With catatonia
Course (after 1 year)

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28
Q

Schizoaffective disorder symptoms compared to schizophrenia?

A

Less negative symptoms
Less anosognosia
Better prognosis overall, but not as good as pure mood disorder

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29
Q

Schizoaffective disorder gene?

A

DISC1 gene on 1q42

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30
Q

Schizoaffective disorder epidemiology?

A

Prevalence 0.3% (1/3 as likely as schizophrenia)
F > M
Early adulthood age of onset

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31
Q

Suicide in schizoaffective disorder?

A

5%

Higher risk with depressed type and North Americans

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32
Q

What percentage of FEP is substance-induced?

A

7-25%

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33
Q

Alcohol-induced hallucinations are generally what kind?

A

Auditory

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34
Q

What to rule out if olfactory hallucinations?

A

Temporal lobe epilepsy

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35
Q

Most common psychosis due to medical condition?

A

Post-ictal psychosis in 2%-7.8% epilepsy patients

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36
Q

What are the other-specified schizophrenia spectrum disorders?

A

Persistent auditory hallucinations
Delusions with significant overlapping mood episodes
Attenuated psychosis syndrome
Delusional symptoms in partner of individual with delusional disorder

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37
Q

Catatonia most common with?

A

Mood disorders (25-50%, bipolar especially)
Less with schizophrenia (10%)
Need to r/o NMS

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38
Q

How many patients with schizophrenia have catatonia?

A

35%

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39
Q

Types of catatonia?

A
  1. Malignant
  2. Stuperous
  3. Excited

NMS presents with malignant and stuperous
Mania presents with excited
Periodic catatonia presents with stuperous and excited

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40
Q

Cannabis and psychosis

A

Association ++ at younger than 15yo
Earlier disease onset by 2.7-6.9 years
2-3x increased risk for schizophrenia but inverse NOT TRUE (adolescent psychosis does not increase cannabis use risk)

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41
Q

Schizophrenia and physical co-morbidities

A

Cigarettes, CAD, DM2, HIV, Hep C
Life expectancy decreased by 10-20 years!
LOWER RISK OF RHEUMATOID ARTHRITIS

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42
Q

Schizophrenia and psychiatric co-morbidities

A

Substance use 44-47%
Anxiety 50%
Mood disorder 50%
PTSD

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43
Q

Schizophrenia and elderly

A

Less positive symptoms
20% have no active symptoms over 65yo
Respond WELL to antipsychotics
Need smaller doses

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44
Q

Bleuler

A

Associational disturbances
Affective disturbance
Autism
Ambivalence

Secondary symptoms of hallucinations, mood changes, delusions and perplexity

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45
Q

Schneider first rank symptoms?

A

Auditory hallucinations (audible thoughts, arguing voice, commentating voice)
Broadcasting of thoughts (insertion, withdrawal)
Control of thoughts (forced feelings/impulses, forced actions, passivity experiences)
Delusional perception

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46
Q

Negative symptoms?

A 
Anhedonia
Asociability
Alogia
Avolition
Decreased emotional expression

NOT APATHY (don’t have loss of concern)

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47
Q

Hallucination outside normal perceptual field (such as seeing behind your back)

A

Extracampine hallucination

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48
Q

Fantom mirror

A

Autoscopic

in depression

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49
Q

Don’t see self in mirror

A

Negative autoscopic

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50
Q

Image persists despite stimulus gone

A

Palinopsia

in LSD, trauma, migraine, epilepsy

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51
Q

Seeing small people or animals

A

Lilliputian

delirium tremens, LBD

52
Q

Perceiving shapes (such as in clouds)

A

Pareidolia

53
Q

Mixed up sense (seeing doors)

A

Synesthesia

54
Q

Altered internal state (such as “brain on fire”)

A

Cenesthetic hallucination

55
Q

Imposter syndrome (hypo identification)

A

Capgras

56
Q

Stranger is a loved one (hyper identification)

A

Fregoli

57
Q

Other created physically similar

A

Subjective double

58
Q

Inanimated double

A

Doppleganger

59
Q

Others interchange physically and psychologically

A

Intermetamorphosis

60
Q

Places have been duplicated

A

Reduplicative paramnesia

61
Q

People living in house

A

Phantom boarder syndrome

62
Q

Nihilistic delusion

A

Cottard

63
Q

Schizophrenia heritability?

A

80%
Multi loci gene with incomplete penetrance

22q11 = PRODH (Di George) 1-2% of schizophrenia but 25x increased risk in those with Di George
22q1 = COMT

9 linkage sites: 1q, 5p, 6p, 8p, 10p, 13p, 15q, 22q

Pyknic type (short, stalky) = good
Aesthenic/athletic types = bad
64
Q

Genetic risk if MZ twin

A

47%

65
Q

Genetic risk if both parents

A

40%

66
Q

Genetic risk if DZ twin

A

12%

67
Q

Genetic risk if 1 parent

A

12% (or 6% in KS)

68
Q

Genetic risk if sibling

A

8%

69
Q

Di George characteristics

A

22q11
Nasal voice, long narrow face, narrow palpebral fissures, flat cheeks, proeminent nose, small ears, small mouth, learning d/o, ++ otitis, cardiac malformation, hypocalcemia, platelet dysfunction

70
Q

Genetics of negative symptoms in schizophrenia?

A

Mutations in DTNBP1 + NEUREGLIN1

71
Q

Ultra high risk psychosis groups?

A
  1. 1st degree relative or significant decrease in functioning in last year
  2. Attenuated positive symptoms (MOST COMMON)
  3. Brief and intermittent positive symptoms
72
Q

Ultra high risk group conversion to psychosis?

A

10-18% / year
35% / 10 years

73% have co-morbidity
DEPRESSION most common

73
Q

What should be monitored at all check-ins (baseline, 1 month, 3 months, annually?)

A

BMI/weight

EPS

74
Q

What should be monitored only as clinically indicated?

A

Prolactin

75
Q

Dopamine signaling in schizophrenia?

A

Phasic INCREASES

Tonic DECREASES

76
Q

Neuropsychiatry and schizophrenia

A

White matter loss STABLE
Grey matter loss PROGRESSES
Cognitive deficits often precede diagnosis
Become more severe with 1st episode then stable
Decreased dendritic arborization and spines

77
Q

Neuropathology and schizophrenia

A

INCREASED lateral ventricles (80%)
INCREASED 3rd ventricle
INCREASED basal ganglion
INCREASED asymmetry

HYPOFRONTALITY on functional imaging (decreased frontal metabolism)

DECREASED thalamus
DECREASED cerebellum
DECREASED temporal, frontal, occipital lobes
DECREASED amygdala
DECREASED hippocampus

ATROPHY = poor prognostic sign

78
Q

Acute intermittent porphyria

A

Abdominal pain, psychosis, polyneuropathy
Increased urinary aminolevulinic acid (while symptomatic)
Treat with IV hemin

79
Q

Which neurotransmitter has a possible role in anhedonia?

A

Norepinephrine

80
Q

Positive symptom circuit?

A

Anterior cingulate basal ganglia thalami-cortical circuit

81
Q

Negative symptom circuit?

A

Dorsolateral-prefrontal

Correlate with decrease DA1 receptor concentration in prefrontal cortex

82
Q

EEG in psychosis

A

Abnormal in 15-25%
Worst prognosis if abnormal in FEP
Similar to complex partial epilepsy picture

83
Q

Eye movements in schizophrenia

A

Decreased smooth visual pursuit

Disinhibition of saccadic movements

84
Q

Endocrinology and schizophrenia

A

Abnormal dexamethasone suppression test which predicts poor outcome
Decreased concentrations of LH and FSH
luted release of prolactin and HG or GRH/TRH

85
Q

Percentage of post-psychotic depressive disorder?

A

25%

Increased suicide risk

86
Q

LAI trial?

A

6 weeks post achieving steady state

87
Q

Clozapine trial?

A

8-12 weeks

More than 400mg or Clozapine level more than 1100nm/L

88
Q

CATIE trial findings?

A

SGA = FGA except Zyprexa which was mildly superior but had high incidence of metabolic syndrome

89
Q

Relapse?

A

15-23% per year if treated vs. 79% if untreated

90
Q

Clozapine response rate?

A

30-60%

91
Q

Treatment resistance?

A

At least 2 moderate + symptoms OR at least 1 severe + symptom after trial of 2 different APs

92
Q

Clozapine resistance tx?

A 
NOT Tegretol (agranulocytosis risk)
NOT Gabapentin
93
Q

Metabolic syndrome?

A

Abdominal obesity (WC 80cm women or 94cm men) + 2 others

  • Trigs > 1.7mol/L
  • Hypertension >130/85mmHg
  • HDL <1.3 mol/L
  • Fasting glucose > 5.6mmol/L
94
Q

Mesocortical

A

Negative symptoms
Hypoactivity
D1 receptors
Motivation and cognition

95
Q

Mesolimbic

A

Positive symptoms
Memory, emotional behaviours
Reward pathway
D2 receptors

96
Q

Tuberoinfundibular

A

Decreased dopamine secretion by hypothalamus with decreased inhibition of prolactin aka indirect prolactin increase

DOPAMINE INHIBITS PROLACTIN

97
Q

Serotonin and dopamine?

A

SEROTONIN INHIBITS DOPAMINE

98
Q

D2 blockade percentages?

A 
68% = efficacy
72% = prolactin increase
80% = EPS

Clozapine = 38-68%
Clozapine and Quetiapine most loose binding
Haldol, paliperidone and risperidone higher blockade

99
Q

Abilify

A 
5HT1a partial agonist
5HT2a antagonism
CYP 2D6 and 3A4
Least QT prolongation
No effect or even decreases prolactin
100
Q

Anticholinergic APs

A

Clozapine > Zyprexa > Seroquel > Abilify > Risperdal
Least risk NMS
Tx with Physostigmine

DOPAMINE INHIBITS CHOLINERGIC ACTIVITY
Low potency APs have higher anticholinergic activity

101
Q

EPS risk factors?

A

High potency APs
Women
Elderly

Symptoms can last 2 weeks to 3 months after stopping AP

102
Q

Akathisia

A

Middle aged women most at risk
Risk factors include iron deficiency, caffeine, SSRIs, anxiety, co-morbid mood d/o

Beta-blocker
ANTICHOLINERGIC NOT HELPFUL

103
Q

Indications for B-blocker use?

A 
Akathisia
Performance anxiety
Tremor due to Lithium
Alcohol withdrawal
Aggressive/violent especially secondary TBI
104
Q

Acute dystonia

A

Risk factors include young man, hypocalcemia, hypothyroidism, hypoparathyroidism, recent cocaine use

Treat with anticholinergic, benzo SL or Benadryl IM
BETA BLOCKERS NOT HELPFUL

105
Q

Most frequent TD symptom?

A

Peri-oral

106
Q

TD

A

Rarely in first 6 months of treatment
Decreased by sleep, movement of affected areas, voluntarily

ANTICHOLINERGIC MAY WORSEN

107
Q

Clozapine CBC monitoring?

A

CBC weekly x 6 months
every 2 weeks x 6 months
every month afterwards

108
Q

Which anticholinergic may cause depression?

A

Tetrabenazine

109
Q

Which meds can cause agranulocytosis?

A

Clozapine
Tegretol
Seroquel
Mirtazapine

110
Q

Predictor sign of seizures?

A

Myoclonus

111
Q

Missed Sustenna injection?

A

Less than 6 weeks, give dose
Less than 6 months, give loading dose again
More than 6 months, start over

112
Q

Missed Abilify Maintena?

A

More than 6 weeks, need to supplement with PO again (usually have to supplement with PO Abilify x 2 weeks when starting)

113
Q

Missed Risperdal Consta?

A

If missed 2nd dose or more than 6 weeks, need PO supplementation again (usually have to supplement with PO Risperdal x 3 weeks when starting)

114
Q

Side effect frequency?

A
  1. Parkinsonism
  2. Dystonia
  3. Akathisia (most common in another source??)
  4. TD
115
Q

NMS criteria

A 
0.01-0.02%
Fever
Rigidity
Tachycardia
Autonomic dysfunction
Altered mental state
Elevated CK, LFTs, WBC
116
Q

NMS risk factors

A 
Young male (compared to elderly women for almost all other side effects except for acute dystonia)
Neurological dysfunction
Dehydration
Exhaustion
Agitation
Fast administration/titration
117
Q

NMS treatment

A

Dantrolene
Bromocriptine
Amantadine

118
Q

Which receptors mediate weight gain?

A

5HT2C
H1
Alpha 1

119
Q

Black box warning for SGA?

A

Increased stroke risk in dementia-related psychosis

120
Q

Which antipsychotic can cause cataracts?

A

Quetiapine

121
Q

Which cognitive task is most affected in schizophrenia?

A

Processing speed

122
Q

Perseveration is common in which illnesses?

A 
SCHIZOPHRENIA
Organic causes (delirium)
123
Q

Genes of negative symptoms?

A

DTNBP1

Neureglin 1

124
Q

Who coined the term “schizophrenia”?

A

Bleuler

125
Q

Who coined the term “dementia praecox”?

A

Kraepelin

RC Nuggets (20 decks)

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