Psychotic Disorders Flashcards
Hallucination vs Imagery vs Illusion vs Pseudohallucination
Hallucination: perception occurring in absence of external stimuli (when patient is fully conscious, not hypnagogic or hypnopompic)
- SAME AS NORMAL SENSORY experience
Imagery: experience within mind without sense of reality, clearly known to be in the mind
Illusion: misperception of real external stimuli; associated with inattention or strong emotion
Pseudohallucination: perceptual experience arising in subjective inner space of the mind and not through external sensory organs
Classification of Auditory Hallucinations
Elementary = simple unstructured sounds
Complex = phrases, sentences or dialogue
- -> first person: thought echo
- -> second person: clarify content, any commands; often a/w mood disorders with psychotic features and are mood-congruent e.g. MDD –> derogatory
- -> third person: discussing, running commentary
Visual Hallucinations: common causes, Charles Bonnet syndrome, Lilliputian hallucinations
Commonly in organic brain disturbances e.g. delirium, dementia, epilepsy, occipital lobe tumours
or
psychoactive substance abuse e.g. LSD, flu-sniffing, alcoholic hallucinosis
Charles Bonnet syndrome = complex VH a/w no other symptoms
Lilliputian hallucinations = miniature people
Somatic Hallucinations: types
Superficial = on or below skin
e.g. tactile (formication in cocaine use, alcohol withdrawal), thermal, hygric (fluid), visceral, kinaesthetic
Olfactory and Gustatory hallucinations: important DDx
Need to r/o epilepsy and other organic brain diseases
Special forms of Hallucinations: Hypnagogic, hypnopompic, extracampine, functional, reflex
Hypnagogic = going to sleep Hypnopompic = awakening Extracampine = occurring outside of person's normal sensory field e.g. hearing 100 miles away Functional = normal stimulus required to precipitate hallucination in the same modality Reflex = normal stimulus in one modality precipitates hallucination in another
Delusion vs Overvalued Idea vs Obsession
Delusion = UNSHAKEABLE false belief despite the lack of evidence and FAULTY REASONING, that is out of keeping with the person’s social and cultural background
- EGOSYNTONIC (no doubt about thought, no resistance)
Overvalued Idea = shakeable, derived through LOGICAL reasoning, strong preoccupation
Obsession = recurrent INTRUSIVE and UNWANTED thoughts
- EGODYSTONIC (know its not reasonable but can’t help it)
Classification of Delusions: primary vs secondary, mood congruence, bizarre or not, content
Primary vs Secondary
- primary = does not occur in response to any previous psychopathological state
- -> TYPICALLY SCHIZOPHRENIA (seldom in other disorders)
- -> delusional perception = out of the blue, delusional meaning attached to a normal perception (first rank symptom), usually in self reference
- secondary = response to pre-existing psychopathological states, usually mood disorders
- -> preceded by delusional mood (SCHIZOPHRENIA)
Mood congruent or incongruent
- appropriate to patient’s mood – commonly in depression or mania with psychotic features
Bizarre or non-bizarre
- bizarre = completely impossible –> **CHARACTERISTIC OF SCHIZ
Content of delusions
- MC: persecutory, grandiose, referential
- religious
- love (de Clerambault syndrome - older + higher status man is in love with woman)
- infidelity/morbid jealousy/Othello syndrome
- misidentification (Capgras syndrome - familiar person replaced by imposter; Fregoli syndrome - complete stranger is a familiar person)
- nihilistic (emptiness, oneself/world about to end)
- hypochondriacal
- infestation (small but visible org., Ekbom’s syndrome)
- passivity (thoughts, feelings, actions are controlled by external agency; thought alienation e.g. insertion, withdrawal, broadcasting)
Thought disorder: types of disorganised thinking - circumstantiality, tangentiality, flight of ideas, loosening of association, thought blocking, neologisms, idiosyncratic word use, perseveration, echolalia, irrelevance, incongruous affect
Circumstantiality = overinclusion of details but eventually connects to desired destination
Tangentiality = unnecessary asides and diversions, doesn’t connect to desired destination
Flight of ideas = accelerated thinking (manic)
Loosening of association = train of thoughts shifts suddenly from one loosely for unrelated idea to the next; **characteristic of schizophrenia
Thought blocking = sudden cessation of flow of thought, no recall of what they were saying; **CHARACTERISTIC OF SCHIZ
Neologisms = new word created by patient
Idiosyncratic word use = Use recognised words randomly by attributing them to non-recognised meaning
Perseveration = initially correct response is inappropriately repeated – palilalia (repeat last word of sentence), logoclonia (repeat last syllable of word)
Echolalia = senselessly repeat words or phrases spoken around them by others
Irrelevant answers
Incongruous affect - SCHIZOPHRENIA
Negative symptoms (5)
APATHY
ALOGIA (poverty of speech)
AFFECTIVE BLUNTING (implies schizophrenia if say this)
AVOLITION (poor motivation to initiate and perform activities)
ANHEDONIA (inability to feel pleasure in normally pleasurable activities)
Social isolation and poor self care
Psychomotor function: Catatonia definition and types, echopraxia, mannerisms, stereotypes, tics
Catatonia = extreme muscular tone or rigidity, commonly describes excessive or decreased motor activity that is apparently purposeless
Catatonic rigidity, posturing (maintaining unusual position), negativism (motiveless resistance to all attempts to be moved), wavy flexibility (moulded like wax), excitement, stupor (akinesis, mutism and extreme unresponsiveness in otherwise alert patient)
Echopraxia (senselessly repeat actions of those around them, a/w echolalia)
Mannerisms (goal directed movements that are performed repeatedly)
Stereotypes (complex movements that are not goal directed)
Tics (sudden involuntary rapid recurrent non-rhythmic motor movements or vocalisations)
Differential Diagnosis for Psychosis
Psychotic disorders
- schizophrenia
- schizophrenia-like disorders (acute and transient psychotic disorders <1 month)
- schizoaffective
- delusional disorder
Mood disorders
- manic or severe depressive episode with psychotic features
Secondary to general medical condition
**Secondary to psychoactive substance use (always primary Ddx if have use)
Dementia/Delirium
Personality disorder (schizotypal, borderline, schizoid, paranoid)
Neurodevelopmental (ASD)
Investigations for Psychosis
Exclude other possible medical or substance related causes
- LRFT for baseline, CBC, TFT, Urine drug screen, Ca, BG, ESR
- ECG as antipsychotics may prolong QTc
Routine EEG/MRI or CT brain to rule out organic psychosis
Schizophrenia (精神分裂症) Diagnostic criteria
- TWO OR MORE of the following for a significant time during a ONE MONTH period:
- delusions
- hallucinations
- disorganised speech/thought
- grossly disorganised or catatonic behaviour
- negative symptoms - Level of functioning is markedly below the level achieved before onset (social and occupational)
- Continuous signs of disturbance persist for AT LEAST 6 MONTHS (with one month of symptoms)
- R/O schizoaffective, MDD or BAD with psychotic features – no prominent mood symptoms concurrently
- Not attributable to substance or medical condition or prolongation of ASD
Classical symptoms of schizophrenia
Schneider’s first rank symptoms - highly specific for schizophrenia (in around 70% patients that meet full dx criteria)
- delusional perception
- thought alienation
- delusion of passivity
- AH – thought echo, 3rd person, running commentary
Schizophrenia epidemiology - lifetime prevalence, age of onset, M:F ratio
1% lifetime prevalence
Incidence: 0.2/1000/yr
Point prevalence: 4/1000/yr
Age of onset: late teens to 18-25; men 15-35; women 25-35 yrs then around 50
Men have higher incidence but equal prevalence
Increased prevalence in lower socioeconomic classes, 10% prevalence in homeless people
Schizophrenia aetiology and risk factors
GENETICS 70%-80%
- making a person more vulnerable to schizophrenia when under stress
(family studies: 10-15% risk in siblings/one parent, 40% if both parents
twin studies: monozygotic concordance 40%, dizygotic 15%
adoption studies)
Environment 30% predisposing: - complications during pregnancy and birth - winter births, fetal malnutrition, (high parental age), urban birth, maternal influenza in 2nd trimester - low social class precipitating: - life events (family, LD, stress) - early cannabis use perpetuating: - high EE
(under stimulation increases negative symptoms, overstimulation increases positive symptoms)
Pathophysiology of Schizophrenia - brain changes, neurotransmitters
Brain: (neurodevelopmental problem)
- cortical tissue loss, lateral and 3rd ventricle enlarged
- smaller thalamus
- enlarged caudate nucleus
- smaller temporal lobes
- smaller hippocampus/amygdala and parahippocampus
Neurotransmitter:
- overactivity of mesolimbic pathway (dopamine hypothesis) in the basal ganglia and diminished transmission in the prefrontal cortex
Schizophrenia subtypes and significance
Significance - different prognosis and treatment response
Paranoid: prominent positive symptoms, less disorganised thought and negative symptoms
- later onset, better prognosis
Hebephrenic: thought disorganisation, disturbed behaviour and inappropriate/flat affect, perceptual disturbance not prominent
- earlier onset (15-25 yrs), poorer prognosis
Catatonic: rare, >1 catatonic symptoms
Residual: 1 yr of predominantly CHRONIC negative symptoms preceded by one clear psychotic episode in the past
Cognitive deficits associated with schizophrenia
Neurocognition
- attention, processing, working memory, verbally learning, reasoning and problem solving (executive functioning)
Social cognition
- emotional processing, social perception, social knowledge, attributional bias
Schizophrenia: course and prognosis
20-22% have single lifetime episode
50% have repeated psychotic episode with hospitalisations, depression and suicide attempts
**More severe in males
Avg 15 yrs shorter lifespan than general pop
- *Prone to CVS disease and metabolic syndrome
- smoking prevalence higher (nicotine arousal)
- medication S/E
- poor diet due to cognition
- lack of motivation
Good prognostic factors:
- female
- older age of onset (more common in females, usually have preserved affect, no thought disorder, mainly positive symptoms)
- abrupt onset with shorter duration prior to Tx
- PRECIPITATED BY ACUTE STRESS
- paranoid type
- absence of negative symptoms, or cognitive impairment
- no FHx
- good response to med
- have prominent mood symptoms
- good pre-morbid functioning
- normal pre-psychotic personality
Overall prognosis:
- 20% remit after Tx
- 50% relapse, recurrence with persistent deficits (gradual deterioration)
- 20% chronic/residual (persistent functional impairment)
- 10% suicide (young patients, intact insight in early disease)
Schizophrenia management
Outpatient preferred unless severe risk
- assess severity, risk, social support, insight
Health screening and ECG due to increased CVS risk
Bio
- antipsychotics to reduce positive symptoms (little effect on negative symptoms)
- —> clozapine most effective but not first line due to S/E – only for treatment resistant cases (no improvement despite sequential use of at least 2 antipsychotics for 6-8 wks, one of which is SGA)
- —> main factor in choice is tolerability
- —> IM depots available for specific drugs if poor compliance
- —> effect on psychotic symptoms may take up to 3 wks to develop; 70% response
- BZD (lorazepam) to relief behavioural disturbance/agitation/insomia in ACUTE psychosis but no antipsychotic effect
(- antidepressants/Li sometimes for augmentation in treatment resistant cases)
Psychosocial (reduce long term disability)
- CBT (to ameliorate positive symptoms but modifying misinterpretations or irrational beliefs)
- family therapy/daycare to DECREASE HIGH EXPRESSED EMOTION (hostile, critical comments, over-involved emotionally) which predicts higher risk of relapse
- psychoeducation to patients and carers (compliance, carer stress)
- social skill training
- vocational* rehab (skills, supported employment, sheltered work)
- assess needs for housing*
- if long course of illness, incomplete recovery
Case management by CPN, OT, Social worker to ensure continuity of care and patient’s needs are met (monitoring, compliance, therapies, family work, liaison)
“Critical period” of Schizophrenia, implications, benefits of early intervention
First 2-3 years after 1st episode
- prophylactic treatment recommended using antipsychotics (at least >6 months after symptom free)
Longer duration of untreated psychosis and more relapses = higher neurotoxicity
–> NEED EARLY DETECTION AND INTERVENTION
–> MORE INTENSIVE CARE FOR FIRST EPISODE PSYCHOSIS
(>75% response to treatment, family therapy, easier to engage)
Schizophrenia-like psychotic disorders
Abrupt onset
Precipitated by acute life stress
Duration of symptoms less than usually observed in schizophrenia (<1 month)
ICD10 = acute and transient psychotic disorders DSM = schizophreniform disorder (<6 months) and brief psychotic disorder
Schizoaffective disorder main characteristics, diagnostic criteria, tx
BOTH schizophrenic and mood symptoms that present in the same episode of illness with equal prominence
- Major mood episode concurrent with criterion A of schizophrenia
- Delusions or hallucinations for >2 wks in the absence of major mood episode during lifetime duration of illness
- Mood symptoms meet criteria for depressive or manic episode and are present for the majority of the total duration of illness
- Not attributable to substance, other medical conditions
Tx: both antipsychotics and antidepressants (+/- Li if manic)
Schizoaffective vs Severe depression with psychosis
TEMPORAL RELATION TO DIFFERENTIATE
Others:
- schizophrenia has incongruent affect
- depression has mood congruent delusions whereas schizophrenia may have bizarre delusions
Acute Schizophrenia - main symptoms, MSE
Acute syndrome (positive symptoms) - hallucinations (MC auditory), persecutory delusions, delusion of reference, social withdrawal, impaired work performance
- appearance and behaviour can be entirely normal (or slightly awkward, preoccupied, withdrawn, confused)
- mood: mood change
- affect: blunted, incongruous
- speech: vague, loosening of association, word salad (totally incoherent thought and speech), formal thought disorder
- thought: difficulty in dealing with abstract ideas, poverty of thought, thought blocking, pressure of thought
- -> content of thought: delusions (occasionally primary, mostly secondary) - may be preceded by delusional mood
- ——–> persecutory common but not specific
- ——–> referential, passivity, thought alienation more specific for schizophrenia
- insight: impaired
Chronic Schizophrenia - main symptoms, daily living skills, MSE
Chronic syndrome (negative symptoms) - disorganised behaviour, lack of drive (AVOLITION), social withdrawal, emotional apathy, thought disorder, cognitive impairment
- impaired daily living skills: neglect personal hygiene and appearance, social withdrawal, hoarding, odd behaviours e.g. shouting obscenities, disinhibition
- movement: catatonic e.g. stupor, excitement, stereotypes, mannerisms, wavy flexibility
- speech: thought disorder as in acute syndrome
- affect: blunted, incongruous
- perception: hallucinations common
- thought: delusions common and systematised, may be held with little emotional reaction, but may be “encapsulated”
- cognitive impairment (executive function, working and semantic memory)
- insight: impaired
Drug induced psychosis - main agents (SA and prescribed)
Amphetamines
Phencyclidine, cocaine, LSD, ecstasy
Cannabis precipitates relapse
Alcohol
Prescribed drugs: steroids and dopamine agonists in treatment of parkinson’s, (anticholinergics)
Other disorders to rule out before diagnosing schizophrenia (4 categories)
Organic syndromes:
- younger patients: Drug induced states, Temporal lobe epilepsy (when brief and have evidence of clouding of consciousness)
- older patients: delirium (acute, clouding of consciousness), dementia (memory disorder), neurosyphilis (general paralysis of the insane)
- —> cognitive impairment more severe than schiz
others e.g. SOL, trauma, infarcts, infection, endocrine (thyroid, adrenal), Vit deficiency (B12, thiamine - wernicke’s encephalopathy)
Psychotic mood disorder
- degree and persistence of mood disorder
- congruence of perceptual disturbance with mood
- nature of previous episodes
Personality disorders (can be difficult to dx, need prolonged observation)
Schizoaffective disorder
Indications for ECT in Schizophrenia/Psychosis
Severe depressive symptoms
Rare catatonic stupor
Postpartum psychosis
Delusional Disorder Diagnostic Criteria
- Presence of delusion for >1 MONTH (usually systematised)
- Criterion A for schizophrenia has never been met
- hallucinations, if present, are not prominent and are related to the delusional theme - Apart from impact of the delusions, FUNCTIONING IS NOT MARKEDLY IMPAIRED, and behaviour is not obviously bizarre or odd
- If manic or depressive episode has occurred, they have been brief relative to duration of delusion
- Not attributable to substance or another medical condition or mental disorder
Delusional Disorder common features, changes in affect/speech/behaviour, difference with schizophrenia
Persecutory delusion common (also pathological jealousy, grandiose, reference)
Hallucinations not prominent but may occur
(rarely induced delusion)
Affect, speech, behaviour normal, well preserved social skills
Poor insight
TYPICAL SCHIZOPHRENIC DELUSIONS OF PASSIVITY, THOUGHT ALIENATION EXCLUDES DELUSIONAL DISORDER
Differentiating delusional disorder from other disorders
Normal affect
Normal function
Poor insight
Usually 40s
Delusional Disorder epidemiology
Onset: middle age, insidious
F>M
Delusional Disorder aetiology, risk factors, prognosis
Genetic
- a/w FHx of schizophrenia but less sig than young onset schiz
Deafness Late onset (high pre-morbid IQ)
Personality - suspicious, sensitive, hostile, jealous
Prognosis - similar factors for schizophrenia
Pathological Jealousy aka morbid jealousy, Othello syndrome - M:F ratio, risk, aetiology, prognosis, treatment
M>F
Abnormal belief of partner’s infidelity
Intensive seeking for evidence
Repeated questioning of partner which may lead to VIOLENT quarrelling, rage, dangerous assault or murder
May be secondary to other psychiatric disorders e.g. schiz, MDD, alcoholism, organic disorder –> important to screen in determining treatment
Can also arise from personality disorder (sense of inadequacy)
Prognosis generally poor
Tx:
- inpatient care if high risk
- underlying disorder if present
- if none, give antipsychotic in the dose used for schiz
- open discussion of problem
- encourage partner not to response aggressively and avoid argument
Induced Psychosis (Folie a deux) - definition, F:M ratio, risk factors
Paranoid delusional system develops in a healthy person who is in a close relationship with another person (primary) who has an established delusion
- usually persecutory
- F>M
- secondary is usually dependent and suggestible
- living in close intimacy, often isolated from outside world
- persists until the 2 people are separated –> then improves gradually (may or may not require tx)
Paraphrenia - main features, functional impairment, epidemiology, risk factors, prognosis
Paranoid delusions (6 mths) +/- AH without severe functional/cognitive deterioration, preserved affect
Usually late onset (60s), 0.1-4% prevalence in elderly
Many have significant auditory/visual loss, socially isolated, maladaptive personality traits (paranoid, schizoid)
Life expectancy same as normal population but recovery from symptoms is rare
