Psychosis - Group Teaching Flashcards
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
What else would you like to know about Andy? What sources of information could you use?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
Perform a mental state examination (MSE) on Andy, using the following structure:
* Appearance and behaviour
* Speech
* Mood and Affect
* Thoughts
* Perceptions
* Cognition
* Insight
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
History of presenting complaint
* 6 month history of social withdrawal
* 8 month history of poorer functioning at university
Past psychiatric history
* Problems with anxiety as a teenager but no diagnosis
* No previous psychotic symptoms
Risk factors for psychosis
* Family history of schizophrenia (grandfather)
* Cannabis use starting ~ a year ago
* Early life stress - separation from dad (though good relationship with mum)
What is our working diagnosis?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
Acute and transient psychotic episode
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
History of presenting complaint
* 6 month history of social withdrawal
* 8 month history of poorer functioning at university
Past psychiatric history
* Problems with anxiety as a teenager but no diagnosis
* No previous psychotic symptoms
Risk factors for psychosis
* Family history of schizophrenia (grandfather)
* Cannabis use starting ~ a year ago
* Early life stress - separation from dad (though good relationship with mum)
Would you diagnose schizophrenia?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
Not on the basis of a single consultation
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
History of presenting complaint
* 6 month history of social withdrawal
* 8 month history of poorer functioning at university
Past psychiatric history
* Problems with anxiety as a teenager but no diagnosis
* No previous psychotic symptoms
Risk factors for psychosis
* Family history of schizophrenia (grandfather)
* Cannabis use starting ~ a year ago
* Early life stress - separation from dad (though good relationship with mum)
At the end of the consultation, Andy agrees that he may benefit from treatment. What are his treatment options?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
-
Pharmacological:
- Antipsychotic medications
- Often mainstay of treatment
-
Psychological:
- CBT for psychosis
- Newer therapies like avatar therapy
-
Social support:
- Supportive environments, structures and routines
- Housing, benefits
- Support with budgeting /employment
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
History of presenting complaint
* 6 month history of social withdrawal
* 8 month history of poorer functioning at university
Past psychiatric history
* Problems with anxiety as a teenager but no diagnosis
* No previous psychotic symptoms
Risk factors for psychosis
* Family history of schizophrenia (grandfather)
* Cannabis use starting ~ a year ago
* Early life stress - separation from dad (though good relationship with mum)
What neurotransmitter system is most implicated in the mechanism of antipsychotics?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
- Dopamine… but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
History of presenting complaint
* 6 month history of social withdrawal
* 8 month history of poorer functioning at university
Past psychiatric history
* Problems with anxiety as a teenager but no diagnosis
* No previous psychotic symptoms
Risk factors for psychosis
* Family history of schizophrenia (grandfather)
* Cannabis use starting ~ a year ago
* Early life stress - separation from dad (though good relationship with mum)
Which drug actions on dopamine receptors would be most likely to improve psychotic symptoms?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
Most antipsychotics are dopamine antagonists. Newer agents (e.g. aripiprazole) are partial agonists
Dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
History of presenting complaint
* 6 month history of social withdrawal
* 8 month history of poorer functioning at university
Past psychiatric history
* Problems with anxiety as a teenager but no diagnosis
* No previous psychotic symptoms
Risk factors for psychosis
* Family history of schizophrenia (grandfather)
* Cannabis use starting ~ a year ago
* Early life stress - separation from dad (though good relationship with mum)
Andy agrees to take an antipsychotic medication (Risperidone) and go to psychological therapy. A few weeks later, Andy’s symptoms improved but he develops some movement symptoms:
* Parkinsonism
* Acute dystonic reactions
* Tardive dyskinesia
* Akathisia
What makes something a ‘typical’ versus an ‘atypical’ antipsychotic?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
Typical antipsychotics are older agents and have an increased risk of causing EPSE
Newer, atypical antipsychotics (e.g. olanzapine) - less likely to cause EPSEs due to 5HT-2A antagonism
But can be caused by all antipsychotics
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
History of presenting complaint
* 6 month history of social withdrawal
* 8 month history of poorer functioning at university
Past psychiatric history
* Problems with anxiety as a teenager but no diagnosis
* No previous psychotic symptoms
Risk factors for psychosis
* Family history of schizophrenia (grandfather)
* Cannabis use starting ~ a year ago
* Early life stress - separation from dad (though good relationship with mum)
Andy agrees to take an antipsychotic medication (Risperidone) and go to psychological therapy. A few weeks later, Andy’s symptoms improved but he develops some movement symptoms:
* Parkinsonism
* Acute dystonic reactions
* Tardive dyskinesia
* Akathisia
How are these symptoms managed?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
- Consider lowest therapeutic dose
- Use atypical as first line
- Change medication
- Anticholinergic medications can help e.g. procyclidine
Andy is a 21 year old university student who is seeing a psychiatrist due to concerns raised by his GP.
He is in the final year of his degree and lives in a shared house with friends.
History of presenting complaint
* 6 month history of social withdrawal
* 8 month history of poorer functioning at university
Past psychiatric history
* Problems with anxiety as a teenager but no diagnosis
* No previous psychotic symptoms
Risk factors for psychosis
* Family history of schizophrenia (grandfather)
* Cannabis use starting ~ a year ago
* Early life stress - separation from dad (though good relationship with mum)
Andy agrees to take an antipsychotic medication (Risperidone) and go to psychological therapy. A few weeks later, Andy’s symptoms improved but he develops some movement symptoms:
* Parkinsonism
* Acute dystonic reactions
* Tardive dyskinesia
* Akathisia
Andy is switched to a different antipsychotic (Aripiprazole) and his movement symptoms improve. He remains stable on this new medication and does not experience any residual symptoms.
What is the long term management plan?
https://youtu.be/ZB28gfSmz1Y [00:00 - 05:30]
- Community follow-up
- Managing antipsychotic side effects e.g. weight, diabetes
- Health promotion: reducing risk factors e.g. smoking, diet
All cause mortality 2.5x higher in schizophrenia: ~15 years lost
