psychosis Flashcards
define psychosis
set of Sx - “losing contact w reality”
realitu is greatly distorted
lack of insight is a key component
Sx of psychosis
-> hallucinations
-> delusions
thought interference
passivity
formal thought disorder
other Sx
what are hallucinations
“a perception in the absence of a stimulus”
- most commonly auditory (2nd - voices talking diorectly to them or 3rd person - voices speaking about them, command, thought echo, running commentary)
M/F
voices outside from the head
- visual more likely ot be delirium
- olfactory indicates possible frontal lobe pathology
- true hallucinations are perceived as real and we may be able to observe behaviour that confirms or refutes this
- pseudo-hallucinations - hearing voices in my head
- illusions and distortions
what are delusions
‘a fixed, false belief that is maintained despite contradictory evidence and which is not explained by the person’s culture or religion
- persecutory, grandiose, nilhillistic, religious
- person is 100% sure of belief and will behave as if it is real
- stable over time
- ask “how did u come to this conclusion
- overvalued ideas - person pursues past the point of reason
Types of delusion
.
what is thought interference/thought alienation
- SIGNIFICANT IN DIAGNOSIS OF SCHIZO
1. thought insertion - thoughts being put into the mind
2. thought withdrawal - thought being taken/ “stolen” from the mind
3. thought broadcasting - thoughts are available to others in the vicinity
OBJECTIVE Sx
thought blocking - thought just top, nothing there, will stop talking (often considered as part of formal thought disorder.
what are passivity Sx
SIGNIFICANT IN SCHIZO
- made Action - actions/movements are being controlled externally “like a puppet”
- made Affect - emotions are being controlled externally
- made Impulse - urges are being controolled externally
what is formal thought disorder
disorganised thought which manifest as speech which is hard to follow or in severe forms make no sense at all
types
- knight’s move thinking - no discernible links
- circumstantially - explain something so excessively
- derailment
- thought blocking
Sx of catatonic schizo
- stupor
- excitement
- negativism
- mutism
- posturing
- wavy flexibility
stereotypy - echolalia
- verbigeration
DD for psychosis
drug intoxication delirium epilepsy brain injury thyrotoxicosis hyper PTH encephalitis huntingtons demnetia cushings Wilson
Ix for psychosis, schizo
physical esp neuro exam
FBC, U&Es, Ca, TFTs, LFTs, ESR
urine drug screen
consider CT head EEG ANA STI testing
baseline Ix for antipsychotic
BMI ECG U&Es LFTs HbA1c Lipid profile Prolcatin
What is functional psychosis
- brief psychotic episode <1 month
- schizophrenia
- schizoaffective disorder
- depression or mania w psychotic Sx
- Drug induced psychosis
- persistent delusional disorder
attenuated “borderline” or psuedopsychotic conditions
- Schizotypal disorder
- borderline (or emotionally unstable) personality disorder
- paranoid personality disorder
- treated psychotic conditions
non-organic causes of psychosis
schizophrenia schizotypical disorder schizoaffective disorder acute psychotic episode mood disorders w psychosis drug induced psychosis delusional disorder induced delusional disorder puerperal psychosis
organic causes of psychosis
drug induced psychosis iatrogen (medication) complex partial epilepsy delirium dementia Huntington's disease SLE Syphillis Endocrine disturbances ie cushing Metabolic disorders - vit B12 deficiency and porphyria
what is shizotypal disorder
characteristics
Another name latent schizophrenia
chracterised by
- eccentric behaviour
- suspiciousness
- unusual speech
- deviations of thinking
DO NOT SUFFER FROM HALLUCINATIONS/DELUSIONS
increased risk if they have first-degree relatives w schizophrenia
what is acute and transient psychotic disorders
a psychotic episode presenting very similaryly to schizophrenia <1 months
characteristics of schizoaffective disorder
criteria
schizophrenia and a mood disorder in the same episode of illness
mood Sx should meet the criteria for either a depressive illness or a manic episode
AND
one or two typical Sx of schizophrenia
what is persistent delusional disorder
development of a single or set of delusions for a period of at least 3 months
content of delusion is often persecutory, grandiose or hypochondriacal
Sx respond well to antipsychotics
what is puerperal psychosis
acute onset of a manic or psychotic episode shortly after childbirth (first 2 weeks following birth)
what is late paraphrenia
late onset schizophreia
delusion of reference
perceive things have special meaning. referring to you
there is a connection between them
ie. personal messages from television and newspapers
delusional percepetion
see a red car outside but now u think thats gonna kill their mum
theres no connection between them
negative Sx of schizo
Avolition (reduced motivation)
Asocial behaviour - loss of drive for any social engagements
Anhedonia
Alogia (poverty of speech)
Affect blunted - diminished or absent capacity to express feelings
Attention - cognitiv deficits
poverty of speech
apathy- lack of motivation
What is schizophrenia and the phases
most common psychotic condition characterised by - hallucinations - deusions - thought disorders
leading to functional impairment
- prodromal
- acute psychotic
- maintenance
RFs of schizo
increased likelihood
- positive family history
dopamine hypothesis - secondary to over-activity of mesolimbic dopamine pathways
obstetric complications
fetal inuury
low birth weight
adverse life events
psychological stress
predisposing biological RFs of schizo
precipitating
perpetuating
PREDISPOSING
Genetic
Neurochemical - increased dopamine, reduced glutamate, serotonin, GABA
Neurodevelopmental: intrauterine infection
premature birth
fetal brain injury
obstetric complications
Age 15-35
extremes of parental age
<20 or >35
cannabis
PRECIPITATING
- smoking cannabis or psychostimulants
PERPETUATING
- substance misuse
- poor compliance to medication
predisposing PSYHCOLOGICAL RFs of schizo
precipitating
perpetuating
PREDISPOSING
closer the family member is the higher the risk
childhood abuse
PRECIPITATING
- adverse life events
- poor coping style
PERPETUATING
- adverse life events
predisposing
precipitating
perpetuating
SOCIAL RFs of schizo
substance misuse
low socioeconomic status
migrants
PRECIPITATING
- adverse life events
PERPETUATING
- decreased social support
- expressed emotion
peak onset age of schizophrenia
15-35 years
define what is meant by positive symptoms
acute syndrome when there is the appearance of hallucinations and delusions
define what is meant by negative symptoms
chronic syndrome refers to loss of function
what are the positive Sx of schizo
Delusions Held - Hallucinations Firmly - formal thought disorder Think - Thought interference Psychosis - passivity phenomenon
classification of schizophrenia
Paranoid - Paranoid schizophrenia Psychotic - Postschizophrenic depression Humans - Hebephrenic schizophrenia Can't - catatonic schizophrenia Supply - Simple schizophrenia Understandable - Undifferentiated schizophrenia Reasoning - residual schizophrenia
what is parnaoid schizophrenia
most common
dominated by positive symptoms (hallucinations and delusions)
what is postschizophrenic depression
depression predominates with schizophrenic illness in the past 12 months with some schizophrenia Sx present
what is hebephrenic schizophrenia
thought disorganisation predominates
onset of illness is earlier (15-25) and has poorer prognosis
what is catatonic schizophrenia
one or more catatonic symptoms
what is simple schizophrenia
rare form where negative symptoms develop without psychotic symptoms
what is Undifferentiated schizophrenia
meets diagnostic criteria for schizophrenia but does not conform to any of the other subtypes
what is residual schizo
1 year of chronic negative symptoms preceded by.a clear-cut psychotic episode
ICD-10 criteria for schizophrenia
at least one very clear symptoms from Group A
- thought echo, control, withdrawal, broadcasting
- delusions
- hallucinatory voices giving a running commentary on pts behaviour or discussing the pt amongst themselves
- culturally inappropriate or implausible persistent delusions
or two or more from Group B for at least 1 month or more
- persistent hallucinations
- breaks of interpolations in the train of thought
- catatonic behaviour
- negative symptoms
Ix for schizophrenia
Blood tests
urine drug test: illicit drugs can cause and exacerbate psychosis
ECG: antipsychotics cause prolonged QT interval
CT scan: to rule out organic causes such as SOL
EEG: to rule out temporal lobe epilepsy as possible causes of psychosis
what blood tests are done schizophrenia
- FBC
- TFTs
- HbA1c -> atypical antipsychotics can cause metabolic syndrome
- serum calcium -> hypercalcaemia can present with psychosis
- U&Es
- LFTs - assess renal and liver function before giving antipsychotics
- cholestrol - atypical antipsychotics cause metabolic syndrome
- vitamin B12
- folate
Biological Mx of schizophrenia
FIRST LINE - Atypical
antipsychotics ie. risperidone + olanzapine 10mg nocte
aripiprazole 10 mg OD
Depot formulations
adjuvants - benzodiapezines, antidepressants and lithium can be used to augment antipsychotics
ECT - resistant to pharmacological agents. Effective catatonic schizophrenia
what is used for treatment-resistant schizophrenia (failure to respond to two other antipsychotics)
clozapine
when are benzodiazepines used for
Adjuvants
- benzodiazepines -> provide short-term relief of behavioural disturbance, insomnia, aggression and agitation
Psychological Mx of schizophrenia
REFER TO CPN
CBT - strongly recommended. Reduces residual symptoms
family intervention - psychoeducation helps families reduce
art therapy - alleviation of negative symptoms in young ppl.
social skills training - uses a behavioural approach to help pts improve interpersonal, self-care and coping skills needed in everyday life
Social Mx of schizophrenia
support groups - Rethink and SANE can help facilitate successul rehabilitation back into the community
peer support - delivered by a peer support worker who has recovered from psychosis or schizophrenia and remains stable
supported employment programmes
finance
Which risks are considered when assessing someone under the Mental Health Act
- Risk to themselves – malnutrition, poor personal hygiene leading to infection, suicide,vulnerability
- Risks to others – hurt others, unsafe driving
- Risks of further deterioration of mental health ie refusing treatment
signs seen on examination in NMS
Lead-pipe type muscular rigidity Hyperthermia (above 38degrees) Tachycardia Hypotension/Hypertension – Fluctuating BP usually. Incontinence.
bloods seen in NMS q
CK elevated. U&Es may show metabolic disturbance (due to AKI or acidosis). Bone profile may show hypercalcaemia. FBC may show leucocytosis. LFTs may be deranged and LDH raised. ABG may show metabolic acidosis.
Mx of NMS
Stop the medications Consider PRN benzodiazepines Transfer urgently to a medical ward for Aggressive hydration Treatment of hyperthermia Medications – bromocriptine mesylate (dopamine agonist) & dantrolene sodium, a muscle relaxant that works by inhibiting calium release, antipyretics
class of drug of olanzapine
SECOND GENERATION ANTIPSYCHOTIC Atypical antipsychotic
key side effects of olanzapine
Sedation, weight gain, metabolic changes such as insulin dysregulation.
Akathisia and parkinsonism are more associated with First Generation Antipsychotics (such as Haloperidol), although akathisia has been noted with Aripiprazole (which is a SGA).
What monitoring is required when prescribing olanzapine, both at baseline and ongoing?
Baseline bloods
- FBC
- U&E
- LFTs
- Lipid profile
- Glucose
- HbA1c
Metabolic baselines – as well as the blood tests mentioned above
- a baseline weight/BMI
- waist circumference should be performed. Repeat at 3 months, 6 months and yearly.
Cardiac baselines – heart rate/blood pressure, and ECG (particularly to monitor QTc interval). Repeat at dose/drug changes and yearly.
what is the difference between section 2 and 3
Section 2 is for assessment whereas section 3 allows treatment for a known mental health condition
what type of drug is clozapine
second generation antipsychotic
when is clozapine prescribed
treatment resistant schizophrenia
It can be offered to patients who have not responded to two other antipsychotics, at least one of which should be a non-clozapine second generation antipsychotic, at adequate dosage. Due to it being an oral medication it requires agreement from the patient.
which blood test is carried out prior to starting clozapine and frequently after initiation
why is it done
FBC - leucocyte count -> agranulocytosis, thrombocytopenia
Timing
- weekly basis for 18 months
- fortnightly until one year
- monthly indefinitely
common side effects of clozapine
Constipation – this is important to be aware of as it can be fatal. Sedation Hypersalivation Changes in BP Tachycardia – usually benign, however be cautious and consider cardiology review as can be linked to Myocarditis (usually associated with fever, hypotension or chest pain). Clozapine has been linked to myocarditis and cardiomyopathy. ECG should be performed and consider echo/cardiology referral. Weight gain. Fever. Seizures. GORD. Nausea. Nocturnal Enuresis.
if pts refuse oral medication what can we administer
IM depot antipsychotic condition
What is paliperidone
how is it initated
- depot version of risperidone
- through loading doses of IM injection Day 1 and Day 8 of treatment then monthly after
pt remains stable for at least four months on the monthlu dose of IM paliperidone - every 3 months
what is CTO
This can be used to specify conditions to which the patient is subject to on discharge, and the patient may be recalled to hospital if the conditions are not met. For example, if the patient does not comply with their medication in the community, they can be recalled to hospital regardless of whether they would otherwise currently meet the required criteria for detention under a Section of the Mental Health Act – This means clinicians needn’t wait for the patient to relapse and become risky before re-admitting them to hospital, thus avoiding relapses and possible consequences of relapses.
Initial Mx of psychosis
take a detailed history perform an examination and Ix obtain collateral history refer to psychiatric team commence antipsychotic medication
lorazepam - acute agitation
which antipsychotic does not cause weight gain or has no clashes with cardiac problems
aripriprazole
biggest cause of death due to clozapine
constipation
DDx for schizophrenia
substance-induced psychotic disorder psychotic episode - mood disroders w psyhcotic features - delusional disorder - dementia/delirium - paranoid personality disorder - schizotypal PD
prevalence of schizophrenia
lifetime risk 15-19 per 1000 population
2 and 7 per 1000
the need for hospital admission schizo
• High risk of suicide or homicide.
• Other illness-related behaviour that endangers relationships, reputation, or assets.
• Severe psychotic, depressive, or catatonic symptoms.
• Lack of capacity to cooperate with treatment.
• Lack or loss of appropriate psychosocial supports.
• Failure of outpatient treatment.
• Non-compliance with treatment plan (e.g. depot medication) for patients detained under the MHA.
• Significant changes in medication for patient at high risk of relapse
• Need to address comorbid conditions (e.g. inpatient detoxication, physical problems, serious
medication side effects).
monitoring antipsychotic medication
- response to treatment,
- side effects of treatment, taking into account overlap between certain side effects and clinical features of schizophrenia (for example, the overlap between akathisia and agitation or anxiety) and impact on functioning
- the emergence of movement disorders
weight, weekly for the first 6 weeks, then at 12 weeks, at 1 year and then annually (plotted on a chart) - waist circumference annually (plotted on a chart)
- pulse and blood pressure at 12 weeks, at 1 year and then annually
- fasting blood glucose, HbA1c and blood lipid levels at 12 weeks, at 1 year and then annually
- adherence
- overall physical health.
in what conditions can hallucinations occur
illegal drugs/alcohol
schizophrenia
a progressive neurological condition, such as Alzheimer’s disease or Parkinson’s disease
charles bonnet
what to ask when someone mentions voices
- content - are they telling him to hurt himself or others
- 2nd or 3rd person
- running commentary
- does if feel like the voice is your own thoughts or a different person speaking
Poor prognostic factors of schizophrenia
strong family history gradual onset low IQ prodromal phase of social withdrawal lack of obvious precipitant
ariprazole
less hyperporlcat
less appetite craving
less sedative
give it in morning
risperidone
twice a day
shorter half life
higher protency given acutely
