Psychosis and schizophrenia | Flashcards
What is the definition of psychosis?
State in which there is loss of contact with reality and includes:
- Delusions
- Hallucinations
- Formal thought disorder
What are 3 components of psychosis?
- Delusions
- Hallucinations
- Formal thought disorder
What is a hallucination?
A percept without object - i.e. a sensory experience without an external stimulus
What is a delusion?
A pathological belief where there is:
- absolute subjective certainty and cannot be rationalised away
- no external proof - held even with contradictory evidence
- personal significance
- cannot be understood as part of the subjects cultural or religious background
What is formal thought disorder?
A pattern of disordered language use that reflects disordered thought form
- Can sometimes be difficult to describe
- loosening of association (derailment), flight of ideas, circumstantial thoughts, tangential thoughts, thought block
What are Schneider’s first rank symptoms for schizophrenia?
ABCD:
- Auditory hallucinations:
- thought echo
- hearing voices referring to himself / herself, made in the third person (not in 2nd person)
- auditory hallucinations in the form of a commentary - Broadcasting of thought
- Controlled thought (delusions of control)
- Thought withdrawal, insertion and interruption
- Passivity of affect/impulses/voilition
- Somatic passivity - Delusional perception
What is delusional perception?
What is an example?
The patient who takes a precept and ascribes an delusional idiosyncratic value to it, e.g. “I heard the church bells and knew I would win Wimbledon”
What is thought echo?
Hearing thoughts spoken aloud
What is passivity of affect/impulses/ made volition?
The patient reports his will/sensation of feelings, impulses or acts to be under the control of an external force as if they have been hyponotised or had become a robot
What is somatic hallucinations/passivity?
Patient reports experiencing sensations on their body and believed being controlled by an external force e.g. an electric current though legs
What is broadcasting of thought?
The patient believes that their thoughts are being made known to other agencies. This may be via telepathy, the radio broadcasting his thoughts, the newspaper telling about his thoughts etc.
What is thought withdrawal?
the delusion that thoughts have been taken out of the patient’s mind
What are 5 organic causes of psychosis?
- Delirium - is another syndrome and there are many causes of delirium (e.g. sepsis)
- Medication-induced (e.g. corticosteroids, stimulants, dopamine agonists)
- Endocrine disorders (e.g. Cushings, hypothyroidism, hyperthyroidism)
- Neurological disorder (e.g. temporal lobe epilepsy, multiple sclerosis, movement disorders, Wilson’s disease, Huntington’s disease)
- Other systemic diseases (e.g porphyria, SLE)
What are other psychiatric disorders apart from schizophrenia that can cause psychosis?
- Schizoaffective disorder (a mixture of first rank symptoms and mood symptoms)
- Delusional disorder (the main symptom is non-first rank delusional belief with minimal hallucination)
- Schizotypal Disorder
- Acute and transient psychotic disorder (symptoms less than 28 days)
- Mood disorder (Mania, Severe depression)
- Substance misuse - e.g. alcohol withdrawal, intoxication with stimulants, cannabis
What is the lifetime risk of schizophrenia?
1 in 100
Is schizophrenia more common in M or F?
M=F
What is the peak incidence of schizophrenia in M and F?
M = 23 years F = 26 years (2nd peak between 30-40)
What are the 3 groups of causes of schizophrenia?
- Biological
- Psychological
- Social
What are the biological causes of schizophrenia?
- Genetic - Family history (possible multiple genes)
- Obstetric complication - increased risk
- Dopamine theory - dopaminergic overactivity
- Neurodevelopmental theory
What are psychological causes of schizophrenia?
- Cognitive errors - jumping to conclusions (especially in delusions and paranoia)
- Premorbid personality - schizotypal disorder
What are social causes of schizophrenia?
- Urban living (x2 to x3 - consistent research finding)
- Migration (x3)
- Life events (including physical and sexual abuse)
- Ethnicity (x4 in Afro-Caribbeans in the UK; higher incidence also in South Asians)
What is the course of schizophrenia?
Preceded by a prodrome before they meet the criteria for diagnosis
What is the prodrome of schizophrenia?
The period of time when the individual is gradually developing symptoms but has not yet met the criteria for diagnosis. These symptoms include:
- Non-specific negative symptoms
- Emotional distress/ agitation without reason
- Transient psychotic symptoms
How does a longer duration of untreated psychosis affect the outcome of schizophrenia?
Worse outcome
What % of people with an episode of psychosis never have another episode?
20%
What % of people have continuous illness, and are not free of symptoms, after their episode of psychosis?
30%
What % of people improve, but require extensive support network, after an episode of psychosis?
25%
What are 6 positive prognostic factors for schizophrenia?
- Marked mood disturbance, especially elation during initial presentation
- FH of affective disorder
- female
- Living in a developing country
- Good premorbid personality
- Early treatment
What are 6 poor prognostic factors of schizophrenia?
- Poor premorbid adjustment
- Insidious onset
- Early onset in childhood/adolscence
- Cognitive impairment
- Enlarged ventricles
- Substance misuse
What is the ICD-10 diagnostic criteria for schizophrenia?
- At least one of the following:
a. Thought echo, insertion, withdrawal or broadcasting
b. Delusions of control, influence or passivity, clearly referred to body or limb movements or specific thoughts, actions, or sensations and delusional perception
c. Hallucinatory voices giving a running commentary on patient’s behaviour or discussing them between themselves or other types of voices coming from some part of body
d. Persistent delusions of other kinds that are culturally inappropriate or implausible - OR at least 2 of of the following:
a. Persistent hallucinations in any modality, when accompanied by fleeting or half-formed delusions without clear affective content, persistent over-valued ideas, or occurring everyday fr weeks/months on end
b. Breaks of interpolations in the train of thought, resulting in incoherence or irrelevant speech or neologisms
c. Catatonic behaviour such as excitement, posturing, or waxy flexibility, negativism, mutism and stupor
d. Negative symptoms such as marked apathy, paucity of speech and blunting or incongruity of emotional responses
e. A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude and social withdrawal - Duration of over 1 month
What is waxy flexibility?
When you move their arm, it stays there until you move it again, like a wax figure
What is mutism?
Severe anxiety, stopping people speaking to certain people or in certain social situations
What is the DSM-IV diagnostic criteria for schizophrenia?
A. Characteristics of symptoms: 2 or more of the following, each present for a significant portion of time during a 1 month period
- Delusions
- Hallucinations
- Disorganised speech
- Grossly disorganised or catatonic behaviour
- Negative symptoms (i.e. affective flattening or avolition)
NB. only 1 symptom is required if delusions are bizarre or hallucinations consist of a voice eeping up a running commentary on the person’s behaviour or thoughts, or 2 more voices conversing with each other.
B. Social/occupational dysfunction
C. Duration - continuous signs of the disturbance persist for at least 6 months, during which much include at least 1 month of symptoms meeting critera A
What are physical conditions that can occur with psychosis?
- Catatonia
- Water intoxication
- Risk of suicide
- Increased risk of CVD
- Increased risk of T2 DM
- Increased risk of stroke
What symptoms can occur with catatonia?
- Excitement
- Posturing
- Waxy flexibility
- Negativism
- Mutism
- Stupor
- Autonomic obedience - mechanically following instruction
etc
What are clinical features of water intoxication with psychosis?
- Polyuria
- Hyponatraemia
- Polydipsoa
May cause: - Confusion
- Seizures
- Cerebral and peripheral oedema
- Death
What investigations should be done for someone with psychosis?
- Bloods: U+E, LFT, calcium, FBC, glucose
- When suggested by history/examination: VDRLs, TFTs, PTH, cortisol, tumour markers - Radiological: CT/MRI if there is suggested neurological abnormality or persistent cognitive impairment
- CXR if examination/history suggests comorbid respiratory/cardiovascular condition - Urine: Urine drugs screen (stimulants and cannabis) - important
- Other:
- EEG only if history of seizure of symptoms suggest TLE
- ECG - Psychosocial
- Collateral hx from others
- OT assessment of functioning
- Social assessment for housing, benefits, financies
- Carer assessment
What physical examinations would you do for someone with psychosis?
- Neurological
- Full neurological exam inc fundoscopy, gait inspection, examination of 4 limbs for weakness/altered sensation, hand-eye coordination
- Cranial nerves - Cognitive examination
- inc orientation, attention/concentration and anterograde/retrograde memory as minimum
What are common comorbidities of schizophrenia?
Psychiatric:
- Inc depression, anxiety, personality disorders
- Substance abuse
- Suicide
Physical: 1. CVD 2. T2DM 3. Stroke (probably due to poor lifestyle habits, not seeking proper medical help when needed and medication) 4. Catatonia 5. Water intoxication
What should you ask about in risk assessment of someone with psychosis?
- Risk to self
- Intent on taking own life?
- Self-harm - Risk to others
- Violence, weapons etc
- Children
- Property - Self-neglect
- Appetite, health
What is the structure of a treatment plan for someone with schizophrenia following the bio-psycho-social model?
- Bio
- Medication
- Physical health monitoring at baseline and at least every year - Psycho
- CBT
- FIT - Social
- Daytime activities/ occupation/ employment/ education/ leisure hobbies
- Family
- Accommodation
- Benefits
- Relationships
- Cultural needs
- Safeguarding
Follow-up
Where are patients with schizophrenia followed-up depending on severity?
Usually need 2o mental health service follow up
- Community mental health team
- Assertive outreach
- Early intervention
Those with more stable illness can be monitored by GP
What are monitored during the follow-up?
- Monitor mental state
- Monitor treatment effectiveness and side effects
- Monitor risk
- Monitor support system
- Further psychoeducation
What should be checked in the physical health monitoring in schizophrenia patients (6)?
How often should they be monitored?
Baseline and at least every year:
- Smoking and drinking status
- Personal/ family history of diabetes/ coronary heart disease
- BP
- BMI
- Blood for FBC, RFT, LFT, glucose and lipid
- ECG
According to NICE guidelines, which patients with schizophrenia/psychosis should be offered CBTp (CBT for psychosis) and family intervention?
Everyone
How many sessions of CBTp is recommended for psychosis?
16
What are the aims of CBTp?
- Help people establish links between their thoughts, feelings or actions and their current or past symptoms, and/or functioning
- The re-evaluation of people’s perceptions, beliefs or reasoning related to the target symptoms
Also at least one of the following components:
- People monitoring their own thoughts, feelings or behaviours with respect to their symptoms or recurrence of symptoms
- Promoting alternative ways of coping with the target symptom
- Reducing distress
- Improving functioning
What are the aims of family intervention?
- Include the person with psychosis or schizophrenia if practical
- Be carried out for between 3 months and 1 year
- Include at least 10 planned sessions
- Take account of the whole family’s preference for either single-family intervention or multi-family group intervention
- Take account of the relationship between the main carer and the person with psychosis or schizophrenia
- Have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work
What is the mechanism of action of antipsychotics?
Postsynaptic competitive receptor antagonism at a dopaminergic synapse via the mesocortical/mesolimbic pathway
What are the 3 dopaminergic pathways?
- The tuberoinfundibular
- Mesocortical/mesolimbic
- Nigrostriatal pathways
What is the cause of side effects of antipsychotic medication?
- Antagonism of the tuberoinfundibular and nigrostriatal pathways responsible for most of the common side effects
- Blockade of the tuberoinfundibular pathway can result in hyperprolactinaemia
- Blockade of the nigrostriatal pathway can result in extrapyramidal side-effects
What are the 3 main treatment aims for the use of antipsychotics in psychosis?
- Alleviate positive symptoms of psychosis
- Alleviate negative symptoms of psychosis
- Minimise side-effects including metabolic disturbances
What are some baseline investigations you should do before starting someone on antipsychotics (9)?
- ECG
- Weight/height
- BP
- FBC
- U&Es
- LFT
- Prolactin
- Glucose/HbA1c
- Fasting lipids
What are the 2 broad categories of antipsychotics?
- Typical/1st generation
2. Atypical/2nd generation
Which category of antipsychotic is more likely to be prescribed?
Atypical
What are 6 atypical antipsychotics?
- Aripiprazole
- Amisupride
- Clozapine
- Olanzapine
- Quetiapine
- Risperidone
What are 5 typical antipsychotics?
- Flupentixol
- Haloperidol
- Pipothiazine
- Sulpiride
- Trifluoperazine
What are the side effects of typical antipsychotics?
- Neurological
- Autonomic
- Hypersensitivity reactions
- Endocrine
- Psychiatric
- Peripheral autonomic nervous system
- Cardiac
- Neurological
- Neuroleptic malignant syndrome
- Seizure threshold lowered -> fits
- Sedation
- Extrapyramidal side-effects - Autonomic
- BP
- Temp - Hypersensitivity reactions
- Liver
- Bone marrow
- Skin - Endocrine
- Raised prolactin
- Metabolic syndrome - Psychiatric
- Apathy
- Confusion
- Depression - Peripheral autonomic nervous system
- Muscarinic receptor blockade
- Alpha-1-adrenoceptor blockade - Cardiac
- Arrhythmia
What are the most widely reported side-effect of typical antipsychotics?
EPSE
What is the biggest concern with EPSE?
Tardive dyskinesia - may be irreversible
What are 4 EPSE?
- Akathisia - subjective feelings of restlessness, often associated with objective signs (pacing, rocking, repeatedly crossing legs).
- Parkinsonism - antipsychotic and idiopathic parkinsonism are clinically identical (tremor, rigidity and bradykinesia). Usually develops after several days to weeks.
- Acute Dystonia - involuntary muscle spasms which produce briefly sustained abnormal postures. Usually occurs within 48hrs of initiation.
- Tardive dyskinesia (TD) - abnormal involuntary hyperkinetic movements. TD is potentially irreversible. Abnormal movements include abnormal tongue movements (fly catching sign, bon-bon sign), pouting/smacking of lips, chewing, head nodding, grimacing, rocking movements
Which 2 antipsychotics are most likely to increase the risk of metabolic syndrome?
Clozapine
Olanzapine
What is neuroleptic malignant syndrome?
When does it usually occur?
How dangerous is it?
Potentially fatal side effect of all antipsychotics, an idiosyncratic reaction
Most frequently occurs when initiating treatment
Medical emergency - all antipsychotics should be stopped immediately
What are the symptoms of neuroleptic malignant syndrome (8)?
- Hyperthermia
- Muscle rigidity
- Confusion
- Tachycardia
- Hyper/hypotension
- Tremor
- Raised Creatine Kinase (CK)
- Low pH – metabolic acidosis
When are antipsychotics given in an im depot form?
Non-concordance with treatment/patient choice
What are the side effects of the typical antipsychotic aripripazole?
- Nausea
- Restlessness
- Insomnia
- may initial exacerbation of psychosis
- least weight gain
- minimal metabolic effect
What is the mechanism of action of the typical antipsychotic aripripazole?
Is the half life long or short?
Partial dopamine agonist
Long half life
What are 2 indications for the atypical antipsychotic olanzapine?
- Treating psychosis
2. Rapid tranquilisation - im
What are the 6 side effects of the atypical antipsychotic olanzapine?
- Sedation +++
- Weight gain ++++
- Raised triglycerides
- Proglycaemic
- Dizziness
- Anticholinergic side-effects
What are the 2. indications for the atypical antipsychotic quetiapine?
- Psychosis
2. Bipolar depression
What are 4 side effects of the atypical antipsychotic quetiapine?
- Sedation ++
- Weight gain ++
- Less metabolic disturbance than olanzapine
- Possible QT prolongation
What are 5 side effects of the atypicalantipsychotic Risperidone?
- Sedation +
- Weight gain ++
- Hyperprolactinaemia
- Sexual dysfunction ++
- EPSE ++
What is the mode of action of the atypical antipsychotic Clozapine?
D4 blockade in addition to other sites
What is the indication of the atypical antipsychotic Clozapine?
Treatment resistant schizophrenia - improved efficacy over other antipsychotics
What are 3 serious side effects and 6 not serious side effects of the atypical antipsychotic Clozapine?
Serious:
- Myocarditis/Cardiomyopathy
- Orthostatic hypotension
- Agranulocytosis (this requires regular blood monitoring with initially weekly Full Blood Count)
Less serious:
- Sedation ++++
- Weight gain ++++
- Raised triglycerides
- Proglycaemic
- Hypersalivation
- Reduced seizure threshold
What antipsychotic do patients usually get started on?
Any atypical (not clozapine)
What should be considered when starting someone on antipsychotic medication (5)?
- Personal or family history of Type II diabetes
- Personal or family history of a metabolic syndrome
- Current obesity
- Concerns about weight gain
- Potential impact of sedation
What are the general guidelines when it comes to prescribing antipsychotics (5)?
- Use lowest effective dose
- Start low and go slow (it can take up to six weeks for a response)
- Prescribe one antipsychotic at a time
- Monitor for side-effects
- Assess concordance before making any changes
What are 2 important things to consider about the long-term efficacy of antipsychotic medication?
- Continue medication for at least 1-2 years following recovery from an acute episode
- Do not stop medication abruptly
What are factors to consider when starting an antipsychotic in a woman of child-bearing age?
- Remember women will often not realise they are pregnant until several weeks after conception
- Advice should be given about contraception, preferably long-acting reversible contraceptives (LARCs)
- Evidence base continues to change, current evidence favours typicals in pregnancy
- If uncertain seek advice
What social interventions are given to patients with psychosis?
- Social work and housing involvement, benefits etc
- CPNs to help provide info/education and monitor for early signs of relapse
- Drop-in community centres and other support provided by non-statutory or voluntary organisations helpful
- Interventions offered by other professions (e.g. OT, physiotherapy) when particular problems arise e.g. poor sleep/hygiene/anxiety management etc
How would you explain what psychosis is to a patient/carer or colleague?
Psychosis is a mental disorder where there is extreme impairment of ability to think clearly, respond with appropriate emotion, communicate effectively, understand reality and behave aprropriately. The 2 most debilitating symptoms are delusions and hallucinations.
Delusions are a false, fixed, strange or irrational belief that is firmly held.
An hallucination is sensory perception (seeing, hearing, feeling, smelling) without an appropriate stimulus, like hearing voices when no one is talking.
How do you explain the aetiology of psychosis to a patient/carer or colleague?
There are 3 main groups of causes of psychosis:
- Psychological - various mental disorders such as depression/bipolar/schizophrenia
- Physical - e.g. infections like sepsis etc
- Substance abuse i.e. alcohol and drugs
Mainly due to an imbalance of the chemical ‘dopamine’ in the brain, which is responsible for feelings of happiness/reward
Explain the bio-psycho-social management plan for psychosis to a patient/carer/colleague?
Bio
- Anti-psychotic medication - these stop the symptoms of delusion and hallucinations
- Physical health checks e.g. weight, bp, due to side effects of medication
Psycho
- CBT - type of talking therapy that helps you consider different ways of understanding what is happening to you
- Family intervention - help you and your family cope with your condition
Social
- Social workers etc can help with benefits, housing, employment etc
- We will also ask the OT to help you with activities
- Nurses in the community to help provide info/education and see how you get on
How do you explain the prognosis of psychosis to a pateint/carer/colleague?
The outlook for psychosis has improved a lot due to earlier intervention and improvements in drug treatment.
Prognosis depends on various factors such as gender, where you live and how early you are treated etc.
One of the things we need to look out for is the high rates of suicide among those with psychosis however.
What are 4 positive symptoms of schizophrenia and 5 negative symptoms?
Positive:
- Disorganised behaviour
- Thought disorder
- Delusions
- Hallucinations
Negative:
- Poverty of speech
- Blunted affect
- Reduced attention
- Social withdrawal
- Avoilition (decreased motivation to perform tasks)
