Psychosis Tutorial Flashcards
What is psychosis?
broad descriptive term for difficulty interpreting and perceiving reality
What are the different symptom domains in psychosis?
- Positive symptoms
- Negative symptoms
- Disorganisation
What is the prevalence of psychotic disorders?
- prevalence ~3.5%, of which ~1% is schizophrenia
- Schizophrenia has taken a lot of focus both in terms of research and cultural perception of psychosis but this is changing
What is a hallucination?
Percepts in absence of a stimulus
What are positive hallucination symptoms?
- Auditory
- Voices commenting on you
- Voices talking to each other
- Visual
- Somatic/tactile
- Olfactory (rare)
What are delusions?
Fixed, false beliefs, out of keeping with social/cultural background
What are positive delusion symptoms?
- Persecutory
- Control
- Reference
- Mind reading
- Grandiosity
- Religious
- Guilt/sin
- Somatic
- Thought broadcasting
- Thought insertion
- Thought withdrawal
What are positive symptoms?
- Hallucinations
- Delusions
What are negative symptoms?
- Alogia
- Avolition/apathy
- Anhedonia/asociality
- Affective flattening
What are disorganisation symptoms?
- Bizarre behaviour
- Thought disorder
What is alogia?
-Poverty of speech
•Paucity of speech, little content
•Slow to respond
What is avolition/apathy?
- Poor self-care
- Lack of persistence at work/education
- Lack of motivation
What is anhedonia/asociality?
- Few close friends
- Few hobbies/interests
- Impaired social functioning
What is affective flattening?
- Unchanging facial expressions
- Few expressive gestures
- Poor eye contact
- Lack of vocal intonations
- Inappropriate affect
What is bizarre behaviour?
- Bizarre social behaviour
- Bizarre clothing/appearance
- Aggression/agitation
- Repetitive/sterotyped behaviours
What is thought disorder?
- Derailment
- Circumstantial speech
- Pressured speech
- Distractibility
- Incoherent/illogical speech
What is the onset of psychosis like?
- Can occur at any age
- Peak incidence in adolescence/early 20s
- Peak later in women
What is the course of psychosis like?
- Often chronic & episodic
* Very variable
What is morbidity of psychosis like?
- Substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
- Significant impact on education, employment and functioning
What is the mortality of psychosis like?
- Substantial
- All-cause mortality 2.5x higher, ~15 years life expectancy lost
- High risk of suicide in schizophrenia – 28% of excess mortality
What is the psychiatric history?
- History of Presenting Concern
- Past Psychiatric History
- Background History (Family, Personal, Social)
- Past Medical History and Medicines
- Corroborative History
- The patient’s description of the presenting problem – nature, severity, onset, course, worsening factors, treatment received
- Circumstances leading to arrival to hospital
What would you ask for past psychiatric history?
- Any known diagnosis?
- Any treatment?
- Known to a community team?
- Any previous admissions to hospital?
What would you ask for family history?
- Age of parents, siblings, relationship with them
- Atmosphere at home
- Mental disorder in the family, abuse, alcohol/drugs misuse, suicide
What would you ask for personal history?
- Mother’s pregnancy and birth
- Early development, separation, childhood illness
- Educational and occupational history
- Intimate relationships
What would you ask for social history?
- Living arrangements
- Financial issues
- Alcohol and illicit drug use
- Forensic History
What would you ask for past medical history and medicines?
Medical problems = a cause or consequence of
mental disorder or psychiatric treatment
•Regular medications?
•Compliance?
•Over the counter medications?
•Interactions?
What is a corroborative history?
-Need for consent
•Informants: relatives, friends, authority
•Confidentiality
What is in a mental state examination (MSE)?
- Appearance and Behaviour
- Speech
- Mood
- Thoughts
- Perceptions
- Cognition
- Insight
What are you looking for in appearance and behaviour?
- General appearance
- Facial expression
- Posture
- Movements
- Social behaviour
What are you looking for in general appearance?
- neglect: alcoholism, drug addiction, dementia, depression, schizophrenia
- weight loss: anorexia nervosa, depression, cancer, hyperthyroidism, financial issues/homelessness
What are you looking for in facial expression?
depressive, anxious,
“wooden” parkinsonian
What are you looking for in posture?
- hunched shoulders, downcast head and eyes – depressive
2 sitting upright, head erect, hands gripping the chair – anxious
What are you looking for in movements?
- overactive, restless – manic
- inactive, slow - depressive
- immobile, mute – stupor
tremors, tics, choreiform movements, dystonia, tardive dyskinesia
mannerisms, stereotypies
What are you looking for in social behaviour?
disinhibited, overfamiliar
withdrawn, preoccupied
signs of impending violence: raised voice, clenching fists, pointed fingers, intrusion into personal space
What are you looking for in speech?
1. Quantity: less, more, mutism 2. Rate: slow, fast, pressure of speech 3. Spontaneity: latency 4. Volume: quiet, loud
What are you looking for in mood?
Subjective Objective Predominant mood Constancy Congruity
What is constancy?
emotional lability/incontinence
reduced reactivity/blunting/flattening
irritability
What is congruity?
cheerful while describing sad events
What are you looking for in thoughts?
- Stream: pressure, poverty, blocking
- Form: flight of ideas, loosening of associations, perseveration
- Content:
What type of content are you looking for?
- Preoccupations
- Morbid thoughts, suicidality
- Delusions, overvalued ideas
- Obsessional symptoms
What are some delusions/overvalued ideas?
1. primary – occurs suddenly secondary – arises from previous abnormal idea/experience (hallucination/mood/delusion) 2. delusional mood/perception/memory shared delusion = folie à deux 3. paranoid of reference grandiose/ expansive of guilt/ worthlessness hypochondriacal of jealousy sexual/ amorous religious of control concerning the possession of thought (insertion, withdrawal, broadcast)
What are some obsessional symptoms?
- obsessional thoughts: dirt and contamination, aggressive actions, orderliness, disease, sex, religion
- compulsions: checking, cleaning, counting, dressing rituals
What are you looking for in perceptions?
- Illusions
- hallucinations
- Distortions
What is an illusion?
= misperception of a real external stimulus
Hallucinations
What is a hallucination?
= perception in the absence of external stimulus
1. true perception + 2) coming from outside the head
pseudohallucination = 1) OR 2)
1. hypnagogic, hypnopompic
2. auditory – second person, third person
3. visual – Charles Bonnet syndrome
4. olfactory
5. gustatory
6. tactile, of deep sensation
What are you looking for in cognition?
- Consciousness
- Orientation
- Attention and concentration
- Memory
- Language functioning
- Visuospatial functioning
What are you looking for in insight?
- Awareness of oneself as presenting phenomena that other people consider abnormal
- Recognition that these phenomena are abnormal
- Acceptance that these abnormal phenomena are caused by mental illness
- Awareness that treatment is required
- Acceptance of the specific treatment recommendations
What is psychosis often preceded by?
- ‘prodromal’ symptoms
- Changes in social behaviour, like social withdrawal, and impairments in functioning, often precede onset
What did people at high-risk of developing psychosis usually have?
psychosis often have/had another mental disorder like affective disorders earlier in life
What are genetic risk factors for psychosis?
- Schizophrenia is highly heritable: ~46% concordance in MZ twins
- Highly polygenic – lots of genes of small effect sizes, but ones found so far account for ~20% of known genetic risk
What are environmental risk factors for psychosis?
- Drug use, especially cannabis
- Prenatal/birth complications
- Maternal infections
- Migrant status
- Socioeconomic deprivation
- Childhood trauma
What are additional sources of information?
- Collateral history
1. Family
2. Friends
3. Work/education - Healthcare records
1. GP
2. Mental health services
What else might you look for in appearance and behaviour in someone with psychosis?
- Bizarre or inappropriate clothing e.g. no shoes
- Agitation/aggression
- Poor personal hygiene or neglect of self-care – negative symptoms
- Injuries/wounds – people with psychosis are far more likely to be victims of violence
Why is it important to assess for mood in people with psychosis
- Some affective disorders can cause psychosis (e.g. bipolar disorder, depression) with implications for treatment
- Depression comorbid with schizophrenia in ~30% of cases (Li et al, 2020)
- People at high-risk of psychosis often have another mental disorder
- Lifetime risk of suicide 5% in schizophrenia
What is derailement?
- Spontaneous speech that tends to slip off track
- Ideas are loosely related or unrelated
What. is loosening of association?
A patient identifies his family as ‘mother, father, son, Holy Ghost’ (Bleuler, 1911/1950)
What cognitive impairments are associated with schizophrenia?
- Working memory impairments
- Lower scores on cognitive testing (from childhood)
- Poorer educational attainment (from childhood)
What difficulties might you have treating someone with very poor insight into their psychosis?
- Concordance with treatment
- Attendance at follow-up
- Would not stay in hospital
What are some differentials?
- Delirium
- Schizophrenia
- Encephalopathy, acquired brain injury, stroke etc
- Dementia (Alzheimer’s, vascular, Parksinons/Lewy body, Huntingtons)
- Personality disorder
- Mania depression / Schizoaffective disorder / peurperal psychosis / other psychotic disorders
- Drugs: Cocaine, LSD, Cannabis, Alcohol
L-Dopa, Steroids, Anticholinergics - Metabolic: Ca2+, MG2+, Cu2+, Vit B12
- Endo: thyroid, Cushings , Addisons
- Infections: Encephalitis, syphilis,
any
What is pharmacological management?
- Antipsychotic medications
2. Often mainstay of treatment
What is psychological management?
- CBT for psychosis
2. Newer therapies like avatar therapy
What is social. support management?
- Supportive environments, structures and routines
- Housing, benefits
- Support with budgeting /employment
What neurotransmitter system is most implicated in the mechanism of antipsychotics?
- Dopamine
- but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine
What elevated level is implicated in causing reality distortion in psychosis?
- Dopamine
- Evidence from imaging + drug models + post-mortem studies -> elevated presynaptic dopamine in striatum
What type of drugs are antipsychotics?
- Most antipsychotics are dopamine antagonists
- Aripirazole is a partial agonist
- Dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms
What are extrapyramidal side effects (EPSEs)?
Antipsychotics can cause post-synaptic dopamine blockade in the extrapyramidal system (parts of the brain that enable us to maintain posture and tone)
What are examples of ESPEs?
- Parkinsonism
- Acute Dystonia
- Tardive Dyskinesia
- Akathisia
What is parkinsonism?
- rigidity - characteristic‘cog-wheeling’
- slow and shuffling gait
- Lack of arm swingin gait – early sign
- ‘pill-rolling’ tremor- slow (4-6Hz) movement of the thumb across the other fingers:
What is dystonia?
- Increased motor tone -> sustained abnormal posture
- Can occur shortly after taking dopamine antagonist
- Can be acute, frightening, painful, even fatal (laryngeal dystonia)
What is tardive dyskinesia?
- repeated oral/ facial/ buccal/ lingual movements
- Initially subtle – can progress to tongue involvement, lip smacking
- Increased risk: long-term antipsychotics, female
What is akathisia?
- Inner restlessness
- Feel compelled to move, but does little to alleviate
- Can lead to overt, relentless movement
- Legs most commonly affected
What makes something a ‘typical’ versus an ‘atypical’ antipsychotic?
- ‘Typical’ antipsychotics commonly cause extrapyramidal side effects at therapeutic doses
- Definition is NOT based on pharmacology/drug target
Can newer antipsychotics cause EPEEs?
- Newer, atypical antipsychotics (e.g. olanzapine) – less likely to cause EPSEs
- But can be caused by all antipsychotics
What is the management of EPSEs?
- Avoid them in the first place: atypical antipsychotics usually first-line
- Change medication
- Anticholinergic medications can help e.g. procyclidine
- Patients need to be fully-informed about risks
What are other side effects of antipsychotics?
- CNS: EPSEs, sedation
- Haematolgoical: Agranulocytosis, neutropenia
- GI: constipation
- Pituitary: increase prolactin (release suppressed by dopamine)
- Metabolic: increase appetite, weight gain, diabetes
- Cardiac: dysrhythmia, long QTc
What is the long term management in psychosis?
- 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: ~14 years lost
Do people have another psychotic episode?
- Some people after an episode of psychosis recover completely and remain well
- Majority follow an episodic course, with periods of wellness and relapses
