Psychosis Flashcards
What is Psychosis?
Mental state in which reality is greatly distorted. Typically presents with delusions, hallucinations and thought disorder
What are delusions?
A fixed false belief which is firmly held despite contradictory evidence and which is not explained by the individual’s culture or religion
Person is 100% sure of belief and behave as if it is true. Delusions are somewhat stable over time. Worth asking “ how did you come to this conclusion”
How does delusions differ from overvalued ideas or obsessions?
Overvalued ideas: A belief that does not meet threshold for a delusion but which a person pursues past the point of reason
Obsessions: Difference is that the person knows belief is irrational
What are hallucinations?
Definition: Perception in the absence of an external stimulus
- Most commonly auditory (2nd or 3rd person command, thought echo, running commentary) however can be in any sensory modality. Other modalities suggest organic aetiology.
- True hallucinations are perceived as real.
- Attenuated hallucinations are usually called pseudo-hallucinations. Other similar symptoms are illusions & distortions
What is the definition of Thought Disorder?
Definition: Impairment in ability to form thoughts from logically connected ideas. Presents as thought insertion, thought broadcasting, thought blocking and though withdrawal
How can thought disorder present?
- Circumstantiality: The inability to answer a question without giving excessive, unnecessary detail. However, this differs from tangentiality in that the person does eventually return the original point.
- Tangentiality: Answers diverge from topic
- Neologisms: New word formations, which might include the combining of two words.
- Clang Associations: When ideas are related to each other only by the fact they sound similar or rhyme.
- Word salad: Completely incoherent speech where real words are strung together into nonsense sentences.
- Knight’s move thinking: Severe type of loosening of associations, where there are unexpected and illogical leaps from one idea to another. It is a feature of schizophrenia.
- Flight of ideas: A feature of mania, is thought disorder where there are leaps from one topic to another but with discernible links between them.
- Perseveration: Repetition of ideas or words despite an attempt to change the topic.
- Echolalia: The repetition of someone else’s speech, including the question that was asked.
- Alogia: Little information conveyed by speech
What are associated features of Psychosis?
- Agitation/aggression
- Neurocognitive impairment (e.g. in memory, attention or executive function)
- Depression
- Thoughts of self-harm
What are some non-organic causes of Psychosis?
- Schizophrenia
- Schizotypal disorder
- Schizoaffective disorder
- Mood disorders with psychosis
- Persistent delusional disorder
- Puerperal psychosis
- Induced delusional disorder
- Acute and transient (brief) psychotic disorder
- Late paraphrenia
- Borderline personality disorder
- Paranoid personality disorder
What are organic causes of Psychosis?
- Drug induced psychosis (alcohol, cocaine, amphetamine, methamphetamine, MDMA, mephedrone, cannabis, LSD, ketamine)
- Iatrogenic (levodopa, methyldopa, steroids, antimalarials)
- Delirium
- Dementia
- Neurological conditions (e.g. Parkinson’s disease, Huntington’s disease_
- Systemic Lupus Erythematous
- Endocrine such as Cushing’s syndrome
- Metabolic disorder: Vitamin b12 deficiency, Porphyria’s
What is Schizophrenia?
Most common psychotic condition characterised by hallucination, delusions and thought disorders which lead to functional impairment. Occurs in absence of organic disease, alcohol or drug-related disorder and not secondary to elevation or depression of mood
What are aetiological factors for Schizophrenia?
- Genetic: positive family history, monozygotic twin studies show 48% concordance rate
- Dopamine hypothesis: over-activity in mesolimbic dopamine pathways in brain. Supported by conventional antipsychotics which work by blocking dopamine receptor and by drugs that potentiate pathway causing psychotic symptoms
- Neurodevelopmental: factors interfering with early neurodevelopment such as obstetric complication, foetal injury and low birth weight lead to abnormalities expressed in mature brain
- Adverse life events and psychological stress increase likelihood of development. Childhood abuse is implicated.
- Social factors: substance misuse, low socioeconomic status, living in an urban area and migrants. Use of cannabis or psychostimulants can also precipitate.
What is the ICD-10 Criteria for Schizophrenia?
At least one very clear symptom from Group A or two or more from Group B for at least 1 month or more. Should not be diagnosed in presence of organic brain disease (rule out mood disorders and organic cause)
- Group A
- Thought echo/insertion/withdrawal/broadcast
- Delusions of control, influence or passivity phenomenon
- Running commentary auditory hallucinations (3rd person)
- Bizarre persistent delusions
- Group B
- Hallucinations in other modalities that are persistent/2nd person auditory hallucinations)
- Formal thought disorder (loosing of association, neologism, incoherence)
- Catatonic symptoms
- Negative symptoms
What are some positive symptoms of schizophrenia?
- Auditory hallucinations of a specific type (3rd person and 2nd person)
- Formal Thought disorder: abnormalities in how thoughts are linked together
- Thought Interference (Thought insertion, Thought withdrawal, Thought broadcasting, Thought blocking)
- Passivity phenomena
- Delusional perceptions
- Impaired insight
- Incongruity/blunting of affect (inappropriate emotion for circumstances)
- Decreased speech
- Neologisms: made-up words
- Catatonia
What are negative symptoms of Schizophrenia?
- Blunted affect: restricted emotional response
- Ambivalence/Avolition: holding conflicting attitude, lack of motivation
- Asocial behaviour/Autism: social withdrawal
- Loose associations: formal through disorder
- Anhedonia: inability to derive pleasure
- Alogia: poverty of speech
- Attention deficits
What are investigations for a patient with Schizophrenia?
- Blood tests: FBC (anaemia, infection), TFTs (thyroid dysfunction can present with psychosis), G_lucose or HbA1c_ (atypical antipsychotics can cause metabolic syndrome), serum calcium (hypercalcaemia can present with psychosis), U&Es and LFTs (assess renal and liver function before giving antipsychotics), C_holesterol, Vitamin B12 and Folate_ (deficiencies can cause psychosis
- Urine drug test: illicit drugs can cause and exacerbate psychosis
- CT head scan: rules out organic causes such as space occupying lesions
- EEG: rules out temporal lobe epilepsy as possible cause of psychosis
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ANA, STI Testing
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What are baseline tests needed before Antipsychotic treatment?
- ECG: antipsychotics can cause prolonged QT interval
- LFTs: assess liver function before giving antipsychotics
- U&Es: assess renal before treatment
- Glucose or HbA1c: atypical antipsychotics can cause metabolic syndrome so monitoring
- BMI
- Lipid profile
- Prolactin
What is the management of Schizophrenia?
Psychological
- Risk assessment and use of mental health act if required. For first presentation, early intervention in psychosis team should be involved. Essential to assess social circumstances and family
- Cognitive behavioural therapy should be offered to all patients. Other treatments are family intervention, art therapy, social skill training.
Social
- Support groups (SANE and Rethink), peer support and supported employment programmes
Biological
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1st line: Oral atypical antipsychotics
- Typical antipsychotics can also be used
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Adjuvants
- Benzodiazepine can provide short-term relief of behavioural disturbance, insomnia, aggression and agitation
- Antidepressant and lithium can be used for augmentation
- ECT: may be appropriate in patients resistant to pharmacological agents. Effective for catatonic schizophrenia
- CVD risk-factor modification monitoring due to the high rates of cardiovascular disease in schizophrenic patients (linked to antipsychotic medication and high smoking rates)
What are poor prognositic factors of Schizophrenia
- Strong family history
- Gradual onset
- Low IQ
- Prodromal phase of social withdrawal
- Lack of obvious precipitant
What is the ICD-10 Classification of Schizophrenia?
- Paranoid schizophrenia: dominated by positive symptoms
- Post-schizophrenic depression: depression predominates with schizophrenic in the past 12 months with some schizophrenia symptoms present
- _Hebephrenic Schizophrenia:_ though disorganization predominates. Earlier onset of illness and poorer prognosis
- Catatonic schizophrenia: rare form characterized by one or more catatonic symptoms
- Simple schizophrenia: rare form when negative symptoms develop without psychotic symptoms
- Undifferentiated schizophrenia: meets diagnostic criteria for schizophrenia but does not confirm to any other subtype
- Residual schizophrenia: 1 year of chronic negative symptoms preceded by clear-cut psychotic episode
What are passivity phenomena?
- Bodily sensations being controlled by external influence
- Actions/impulses/feelings: experiences which are imposed on the individual or influenced by others
- Made action: action/movement bring controlled externally.
- Made affect: emotions being controlled externally
- Made impulse: urges being controlled externally
What are delusional perceptions?
Two stage process where:
- First a normal object is perceived then secondly there is a sudden intense delusional insight into the objects meaning for the patient
- Example: ‘The traffic light is green therefore I am the King’.
