Psychosis and schizophrenia 2 Flashcards
What are some of the other differentials for a patient presenting with psychosis ?
- Drug induced psychosis
- Depressive psychosis
- Mania with psychsosis
- Schizoaffective disorder - This is the presence of schizophrenic disorder and affective disorder (either manic or depressive) Can be schizo-manic or schizo-depressive or both
- Delirium
Describe the key features suggestive of drug induced psychosis
- Symptoms tend to be short lasting if access to the psychoactive substance is removed.
- Particularly in young people esp cannabis
- occur from taking too much of a certain drug, having an adverse reaction after mixing substances, during withdrawal from a drug, or if the individual has underlying mental health issues.
- Beware comorbidity of substance use in schizophrenia & bipolar disorder
What are the 3 typical features suggesting depressive psychosis ?
- Mood congruent - so their emotions match the type of delusion/ hallucinations they are experiencing i.e. depressive mood with delusions and hallucinations as below:
- Delusions of worthlessness / guilt / hypochondriasis / poverty
- Hallucinations of accusing / insulting / threatening voices – typically 2nd person
What are the typical features of mania with psychosis ?
- Typified by mood congruent (i.e. again there mood matches the delusions/ hallucinations they are having) content of psychotic symptoms
- Delusions of grandeur / special ability / persecution / religiosity
- Hallucinations: auditory (e.g. God’s voice)
- Flight of ideas
Define schizoaffective disorder
Schizoaffective disorder is a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.
What are the features suggestive more of delirium
- Acute onset e.g. in alcohol withdrawal, infection, medical / surgical in-patients,
- septicaemia, organ failure (cardiac, renal, hepatic), hypoglycaemia, post-op hypoxia, post-ictal, encephalitis, space occupying lesion, drug intoxication (e.g. steroids, digoxin, diuretics, anticholinergics), drug withdrawal (e.g. benzodiazepines)
- Often older patients
- inattention with fluctuating course
- disorganised thinking (impaired concentration/ memory)
- altered consciousness.
- visual hallucinations / illusions
- ± auditory hallucinations
- irritability
- insomnia
- psychomotor disturbance - agitation or retardation
What is the main mechanism of action of typical anti-psychotics and give some examples of them
- Main action is D2 inhibiton (dopamine antagonist)
- Chlorpromazine or haloperidol
What is the main mechanism of action of atypical anti-psychotics and give some examples of this class of drug
- Main mechanism of action is D2 and 5-HT2 antagonists
- Olanzapine, risperidone, quetiapine, clozapine
What is the main differences between typicals and atypical anti-psychotics ?
Atypicals are:
- Less likely to induce Extra-Pyramidal side-effects (EPSE) + less likely for dopamine blockade with hyperprolactinaemia/sexual dysfunction
- They are worse for metabolic syndrome and sedation
- High 5-HT2A to D2 ratio
- Better efficacy against negative symptoms (schizophrenia)
- Effective in patients unresponsive to typical drugs
What is metabolic syndrome ?
A cluster of conditions; Increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels
Describe the main side effects cause by typical anti-psychotics
EPSE and hyperprolactinaemia
EPSE symptoms:
- acute dyskinesias and dystonicreactions, - intermittent spasmodic or sustained involuntary contractions
- tardive dyskinesia, - stiff, jerky movements of your face and body that you can’t control
- Parkinsonism - signs similar to parkinsons (covered in neuro)
- akinesia, - loss or impairment of the power of voluntary movement.
- akathisia - feeling of inner restlessness and inability to stay still
- neuroleptic malignant syndrome. - life-threatening idiosyncratic reaction fever, altered mental status, muscle rigidity, and autonomic dysfunction.
Hyperprolactinaemia signs:
- sexual dysfunction
- galactorrhoea,
- amenorrhoea,
- infertility.
What drug should be used to treat EPSE in patients on typical anti-psychotics ?
procyclidine
What are the side effects of atypical anti-psychotics ?
Sedation, weight gain (mainly mediated through increased hunger), metabolic syndrome, EPSE (extra-pyramidal side effects), constipation, QTc prolongation, neuroleptic malignant syndrome.
Before starting an anti-psychotic medication what needs to be done ?
Record the following baseline investigations:
- Weight
- waist circumference
- Pulse and BP
- Fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile and prolactin levels
- Assessment of any movement disorders
- Assessment of nutritional status, diet and level of physical activity
- an ECG (if cardiac risk factors or personel history of CVD)
What is the treatment for psychosis and schizophrenia ?
1st line = Oral anti-psychotic + psychological intervention (CBT + family intervention)
Choice of anti-psychotic:
- 1st line = atypical anti-psychotics (olanzapine usually first
- 2nd line = typical
- 3rd line = clozapine if used at least 2 or more anti-psychotics (at least one being an atypical) and both failed
