Psychosis and Schizophrenia Flashcards
What is a hallucination and list its key features
a hallucination is perception occurring in the absence of external stimulation
To the patient, they appear real, with all of the characteristic of a normal stimulus.
They are experienced as sensations from one of the 5 sensory modalities
They are not misinterpretations of external stimuli, they occur in the absence of an external stimulus
what are first person auditory hallucinations? (audible thoughts)
These are where the person hears their thoughts spoke out loud as they think them.
what are second and third person auditory hallucinations
Secondary - where the voices address the person experiencing the hallucination
Third- where the voices are speaking about the person who is having the hallucination
what is Charles Bonnet syndrome?
Charles Bonnet syndrome describes the condition where patients experience complex visual hallucinations associated with no other psychiatric symptoms or impairment in consciousness; it usually occurs in older adults and is associated with loss of vision.
what sort of aetiology for the psychosis would visual hallucinations indicate ?
organic disorders - delirium, dementia, epilepsy, occipital lobe tumour
Drug-induced psychosis
what is a delusion?
o A belief that is firmly held on inadequate and irrational grounds. It is not a conventional belief to that person given their educational, cultural and religious background. They significantly affect the way a person behaves and how they feel.
name some types of delusions
Several types of delusions including persecutory, grandiose, guilt, bizarre or reference.
how may you classify delusions?
Primary or secondary.
Mood congruent or mood incongruent.
Bizarre or non-bizarre.
According to the content of the delusion
name some types of thought control
Thought insertion: belief that thoughts or ideas are being implanted in one’s head by an external agency
Thought withdrawal: belief that one’s thoughts or ideas are being extracted from one’s head by an external agency
Thought broadcasting: belief that one’s thoughts are being diffused or broadcast to others such that they know what one is thinking
name some types of thought disorder
circumstantial/over-inclusive thinking
tangential thinking/ flights of ideas
loosening of associations
what does positive and negative symptoms in psychosis refer to?
Positive symptoms include things such as delusions and hallucinations
Negative symptoms indicate a clinical deficit and include things such as a lack of apathy, poverty of thought and speech, blunting of affect, social isolation and poor self-care
what are Schneider’s first rank symptoms in schizophrenia
- Delusional perception
- Delusions of thought control: insertion, withdrawal, broadcast
- Delusions of control: passivity experiences of affect (feelings), impulse, volition and somatic passivity (influence controlling the body)
- Hallucinations: audible thoughts (first person or thought echo), voices arguing or discussing the patient, voices giving a running commentary
what are the ICD-10 guidelines for diagnosing schizophrenia?
- One or more of the following symptoms:
o a. Thought echo, insertion, withdrawal or broadcast
o b. Delusions of control or passivity; delusional perception
o c. Hallucinatory voices giving a running commentary; discussing the patient among themselves or ‘originating’ from some part of the body
o d. Bizarre delusions
o OR - Two or more of the following symptoms:
o e. Other hallucinations that either occur every day for weeks or that are associated with fleeting delusions or sustained overvalued ideas
o f. Thought disorganization (loosening of association, incoherence, neologisms)
o g. Catatonic symptoms
o h. Negative symptoms
o i. Change in personal behaviour (loss of interest, aimlessness, social withdrawal) - Symptoms should be present for most of the time during at least 1 month
- Schizophrenia should not be diagnosed in the presence of organic brain disease or during drug intoxication or withdrawal
how is schizophrenia usually managed?
Aim is to manage in the community but they may require an initial period of hospitalisation.
Combination of long-term medication and psychological treatment.
The atypicals are preferred to the typicals as they may leads to a lower relapse rate
The main factor affecting drug choice is tolerability
What is treatment resistant schizophrenia ?
Treatment-resistant schizophrenia is defined as a lack of satisfactory clinical improvement despite the sequential use of at least two antipsychotics for 6–8 weeks, one of which should be a second-generation antipsychotic.
name three typical anti-psychotics
haloperidol
- Chlorpromazine
- Fluphenazine
- Zuclopenthixol
- Flupenthixol
name three atypical anti-psychotics (second-generation)
- Risperidone
- Olanzapine
- Aripiprazole
- Quetiapine
- Clozapine
what is a drug-specific side effect of clozapine that you must be aware of?
How does smoking affect clozapine?
What is clozapine usually used to treat?
agranulocytosis
Can activate enzymes in the liver leading to reduced levels in the blood - may need to increase the dose
Treatment resistant schizophrenia
name some factors predictive of a good outcome
- Sudden onset
- Short episode
- No previous psych history
- Prominent affective
- Paranoid
- Old age onset
- Married
- Good social relationships
- Compliance
name some factors predictive of a bad outcome
- Insidious onset
- Long episode
- Prev psych history
- Negative symptoms
- Enlarged lateral ventricles
- Male
- Young at onset
- Single, separated, widowed, divorced
- Social isolation
- Poor compliance
what is delusional disorder?
In this disorder, the development of a single or set of delusions for the period of at least 3 months is the most prominent or only symptom
how do most anti-pyschotics work?
They work through antagonism of dopamine (D2) receptors in the mesolimbic pathway of the brain, reducing positive symptoms
name some extra-pyramidal side effects of anti-psychotics
These are more prominent with the typical anti-psychotics
- Acute dystonia ( <10%)
a. Involuntary contraction of skeletal muscle. e.g. torticollis or oculogyric crisis. More commonly younger males, neuroleptic naïve. - Pseudo-parkinsonism (<40%)
a. Tremor, rigidity and hypokinesia. Dopamine blockade of nigro-striatal pathways implicated aetiologically - Akathisia(<30%)
a. Characterised by motor restlessness , a subjective feeling of tension and an inability to tolerate inactivity which gives rise to restless movement. - Tardive dyskinesia<30%
a. Late onset hyperkinetic, involuntary movements. Involves face, lips, tongue, jaw and neck, but which involve the trunk, arms and hands. Most common syndrome is the BLM syndrome(Bucco-linguo-masticatory Triad). Most importantly may be irreversible in 30% cases. Aetiology appears to be the increase in sensitivity of Dopamine receptors through up regulation from chronic blockade.
what effect may anti-psychotics have on those with epilepsy?
They can lower the seizure threshold, need to be careful when deciding on the management of these patients
what autonomic side effects can anti-psychotics have ?
- Anti-adrenergic
o Postural Hypotension
o ECG changes (QTC prolongation) with subsequent cardiac dysrythmias such as Torsade des pointes.
o Sexual dysfunction – ejaculatory failure. - Anti-cholinergic Effects-
o Dry mouth, blurring of vision, constipation, difficulty with micturition and urinary retention.
what parameters would you typically monitor in a patient on anti-psychotics?
Weight, BP, ECG, glucose/HbA1c, lipids
