psychosis + confusion Flashcards
classic characteristics of psychosis
hallucinations
delusions
disorder of form of thought
lack of insight
primary vs secondary delusions
Primary = arrive fully formed in the consciousness without need for explanation
Secondary = are often attempts to explain anomalous experiences – hallucinations, passivity experiences, depression
thought interferences
Clanging + punning – ding dong bell, go to hell
Loosening of associations
Knight’s move thinking – came here in dads car, he’s got a blue car, the sea is blue
Neologisms
Tangentiality
Word salad/verbigeration
thought insertion
there are thoughts being put into my head that don’t belong to me – I haven’t thought them
thought withdrawal
= they can extract the information from me using the internet, they take my thoughts out of my head
thought broadcasting
it’s like everyone can know what I am thinking – my sky dish is beaming
thought blocking
it’s like I get halfway through thinking something + the thoughts jut dry up and I cant think of anything for a while
what do 3rd person auditory hallucinations suggest?
schizophrenia
(depression sometimes 2nd person hallucinations but never 3rd)
management of psychosis
1 - 4-6weeks trial of atypical
2 - 4-6weeks trial of second atypical or typical
3 - 6month trial of clozapine titrated up to 900mh/day (best efficacy but super bad side effects)
4 - adjuvant medication/ECT (in addition to clozapine)
drug induced psychosis
May be acute symptoms or more insidious + chronic
o Tend to be short is access to psychoactive substance is removed
Not the same as intoxication + withdrawal effects
Beware of comorbidity with schizophrenia + bipolar disorder
depressive psychosis
Characterised by mood congruent content of psychotic symptoms
Delusions - worthlessness/guilt/hypochondriasis/poverty
Hallucination - accusing/insulting/threatening voices
o Typically 2nd person
mania with psychosis
Delusions – grandeur, special ability, persecution, religiosity
Hallucinations – tend to be 2nd person + auditory
- hearing God’s voice telling you you’re great
Flight of ideas
delirium
Acute transient confusion state – last from hrs to weeks
Assoc with physical insult or injury or environmental factors
Rapid in onset, 1-2days from precipitating insult
Duration varies but often continues beyond resolution of original insult – often by weeks or months
Medical emergency
o 35-40% patients die within one year
o Barriers to treatment – too agitated for IV lines etc
types of delirium
hypoactive - quiet, confused drowsy, fearful patient
hyperactive - driven, wandering, agitated, shouting out, aggressive
mixed - some periods of both of above
risk factors for delirium
older age
previous history of delirium
underlying cognitive deficits
delirium presentation
Clouding of consciousness
o Subtle drowsiness to unresponsiveness
o Disorientation in time, place + person
o Fluctuating severity over time – lucid intervals
o Worse at night
Impaired concentration/memory, especially for new information
Visual hallucinations/illusions +/- auditory – often threatening
Persecutory delusions
Agitation OR retardation
Insomnia
causes of delirium
I WATCH DEATH
- Infections
- Withdrawal
- Acute – electrolyte probs, acidosis
- Toxins – drugs, opiates
- CNS - Encephalitis, Stroke
- Hypoxia
- Deficiencies – thiamine, B12
- Endocrine – thyroid, adrenal, glycaemia
- acute vascular shock
- trauma - head injury, hypothermia
- heavy metals - lead, mercury
delirium investigations
4AT
1 - alertness - normal/mild sleepiness
2 - AMT-4 = age, DOB, place, current tear
3` - attention = name months backwards
4 - acute or fluctuating course
delirium treatment
treat underlying cause
reassurance + reorientation
low stimulus environment
use of appropriate legal measure to allow for treatment
pharma - assist with distress, agitation (supportive)
- consider low dose antipsychotic - haloperidol, quetiapine
–> NOT in PARKINSONS
post-ictal confusion
abnormal condition following a seizure
- begins when seizure ends + ends when patient has returned to baseline
- usually resolves within 30 mins
post-ictal confusion presentation + management
drowsiness, nausea, confusion, exhaustion
Mx = supportive, seizure prevention
chronic illnesses which cause confusion
- Encephalitis
- Hypoglycaemia
- Hypothyroidism/hyperthyroidism
- Vit B12 deficiency
- Anaemia
- Electrolyte disturbances
schizophrenia
self-disorder due to perceptual incoherence
genetically determined neurodevelopmental vulnerability later triggered by environmental stressors
78% heritability, polygenic inheritance
onset of schizophrenia
young adults
men - 12-25yrs
women - 25-35yrs
schizophrenia risk factors
stress
drugs - heavy regular cannabis, cocaine
social adversity
neuro - enlarged ventricles, thinner cortices
neurochemical - altered dopamine signalling
genetics
birthcomplications
which gene alterations are risk factors for schizophrenia?
neuregulin
dysbindin
DISC-1
genetic risk in schizophrenia
o MZ twins 40-60%
o Both parents 50%
o One parent 15%
o Some mutations – 22q11
o Higher in African-Caribbean
birth complications that increase risk of schizophrenia
Prenatal exposure to viral infections – 2nd trimester
o Maternal stress, malnutrition
o Higher rates of perinatal complications than controls – prematurity, prolonged labour., fetal hypoxia, pre-eclampsia
o Winter/spring births – due to viral illness
o Risk increases by 50% by childhood viral CNS infection
pathophysio of schizophrenia
drugs which release dopamine in brain (amphetamine) or D2 receptor agonists (apomorphine) produce a psychotic state
-> it is assumed schizophrenia is related to overactivity of dopamine pathways in the brain
(dop receptor antagonist used to treat symptoms of schiz)
amphetamine can make symptoms of schizophrenia worse
physical pathology of schizophrenia
enlarged lateral ventricles - non-progressive
reduced frontal-temporal lobe volume
reduced frontal lobe grey matter
reduced activation of prefontal areas on specific tasks - impairment of executive function (Stroop test - can only read words)
first rank/Schneider’s symptoms of schizophrenia
delusions
auditory hallucinations - thoughts, voices
thought interference - passivity of thought, withdrawal, insertion, broadcasting
passivity phenomena - affect, impulse, volition, somatic
schizophrenia presentation
positive -
hallucinations
delusions
passivity phenomena
disorder of form of thought
negative -
reduced speech
reduced motivation/drive (avolition)
reduced interest/pleasure (anhedonia)
apathy
blunting of affect
sub-types of schizophrenia
paranoid
hebephrenic
catatonic
persistent delusional disorder
most common type of schizophrenia
paranoid
- 80% of diagnoses
- first rank symptoms dominate
hebephrenic schizophrenia
shallow + inappropriate emotional responses
bizarre behaviour
catatonic schizophrenia
movement disorder predominates
management of schizophrenia
1st = Risperidone, olanzapine -> 2nd gen oral (atypical) antipsychotics – 6-8weeks
2nd = haloperidol -> 1st or 2nd gen – 6-8weeks
3rd line – check diagnosis, optimise social supports, check compliance
o Compliance -> depot (long term) – IM weekly to 3 monthly -> haloperidol
o Consider clozapine – weekly blood tests tho
o Consider combining 2 antipsychotics
CBT to all
treatment of schizophrenia side effect considerations
- Medication induced weight gain -> cardiac problems
- Falls due to EPSE
- Cognitive effects of anticholinergic
- Osteoporosis due to raised prolactin
- Sedation leading to immobility
cardio risk modification - linked to antiosychotics + high smoking rates
indicators of poor prognosis in schizophrenia
poor premorbid adjustment - prodromal phase of social withdrawal
insidious (slow, not obvious) onset
early onset - child/teen
long duration of untreated psychosis
cognitive impairment
enlarged ventricles
strong fam Hx, low IQ
indicators of good prognosis in schizophrenia
females
marked mood disturbance especially elation
fam Hx of mood disorders
older age onset
shorter time of untreated psychosis
schizophrenia prognosis
Suicide
o 10-15% suicide rate
o May occur following recovery of insight
o High risk time = first week of discharge from hospital
o Need to ensure adequate medical follow up as well as psychological + social support
Homicide by people with schizophrenia is rare
o Note in command hallucinations + delusions of jealousy
