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Y5 Psychiatry > Psychotic Disorders > Flashcards

Psychotic Disorders Flashcards

1
Q

What are Schneider’s 1st rank symptoms?

A
  • Delusions
  • Passivity (delusions of control)
  • Thought disorder:
    • Thought insertion - thoughts being placed into my mind
    • Thought withdrawal - thoughts being removed from my mind
    • Thought broadcasting - everyone knows what you are thinking
  • Auditory disorder:
    • Thought echo - hearing my thoughts out loud
    • 3rd person voice - ‘no one like’s her, she’s useless’
    • Running commentary - ‘now he’s falling asleep, and she’s calling a cab’
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2
Q

Define schizophrenia.

A

Severe mental illness characterised by disintegration of the process of thinking, contact with reality, and emotional responsiveness.

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3
Q

What is the ICD-10 definition of schizophrenia?

A
  • ≥1 Schneider’s 1st rank symptoms of a duration ≥1-month
    • (1) Delusions (false and fixed beliefs)
    • (2) Passivity (delusions of control)
    • (3) Thought disorder:
    • (4) Auditory disorder:

_______OR_______

  • ≥2 of the following; AND
    • Paranoid - persistent hallucinations in any modality
    • Hebephrenic - incoherent or irrelevant speech (i.e. neologisms, Knight’s move thinking)
    • Catatonic - catatonic behaviour – excitement, posturing, waxy flexibility, negativism, mutism, stupor
    • Simple - negative symptoms – apathy, paucity of speech, blunted/incongruent emotional response
  • Present, most of the time, ≥1 month; AND
  • Not caused by substance use or organic disease
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4
Q

Define hebephrenic.

A

Incoherent/Disorganised or irrelevant speech

  • neologisms
  • Knight’s move thinking
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5
Q

Describe the clinical pattern of schizophrenia?

A
  • Prodrome/At-Risk Mental State = -ve symptoms dominant
    • ​Teens to early 20s:
    • Social withdrawal
    • Loss of interest in work and relationships
  • Acute phase = +ve symptoms dominant
    • Delusions
    • Hallucinations
    • Thought interference (insertion, withdrawal, broadcast to public)
    • Passivity
  • Chronic phase = -ve symptoms dominant
    • Apathy
    • Anhedonia
    • Loosening of Association
    • Blunted affect
    • Poverty of thought/speech (devoid of thoughts/speech)
    • Social withdrawal
    • Loss of motivation
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6
Q

What are the sub-types of schizophrenia?

A
  • Paranoid - most common
  • Hebephrenic/Disorganised
  • Catatonia
  • Simple
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7
Q

What are the key features of paranoid schizophrenia?

A
  • Prominent delusions
  • Prominent hallucinations
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8
Q

What are the key features of hebephrenic schizophrenia?

A
  • Disorganised mood and speech
  • Neologisms
  • Knight’s move thinking
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9
Q

What are the key features of catatonic schizophrenia?

A
  • Psychomotor disturbance
  • Stupor
  • Waxy flexibility - retain any shape you put them into
  • Automatic obedience
  • Forced grasping - shaking a hand when specifically told not to
  • Opposition - same as above
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10
Q

What are the key features of simple schizophrenia?

A
  • Only negative symptoms
    • Apathy
    • Blunted affect
    • Social withdrawal
    • Anhedonia
    • Poverty of thought
    • Loss of motivation
    • Loosening of association
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11
Q

What is the average age of onset of schizophrenia?

A
  • 15-45
    • Late 20s for men
    • Early 30s for women
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12
Q

What is waxy flexibility?

A

A decreased response to stimuli and a tendency to remain in an immobile posture.

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13
Q

What are the biological risk factors for schizophrenia?

A
  • Genetics - mulitple susceptible genes
    • monozygotic twin concordance = 50%
  • Obstetric complications
    • Prenatal malnutrition
    • Prenatal viral infections
    • Pre-eclampsia
    • LBW
    • Emergency C-section
  • Substance misuse
    • Val allele = +ve symptoms (even more likely hallucination with cannabis)
    • Met allele = -ve symptoms
  • Neurodevelopmental
    • Enlarged ventricles = smaller brains, lower premorbid IQ
    • Early brain damage not obvious at first but becomes more obvious as brain matures
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14
Q

What are the psychosocial risk factors for schizophrenia?

A
  • Social disadvantage
  • Urban life and birth - 2x higher
  • Migration - 1st and 2nd generation
  • Black Caribbean or African - 4-6x higher
  • High expressed emotion/highly envolved relatives - increased relapse risk
  • Premorbid schizoid
  • Adverse life experiences - sexual or physical abuse
  • Fear of madness
  • Tendency to jump to conclusions
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15
Q

Name and breifly describe 3 biological hypothesis of schizophrenia?

A
  • DA hypothesis
    • +ve symptoms = increased DA in mesolimbic tract
    • -ve symptoms = decreased DA in mesocortical tract
  • 5-HT hypothesis- overactivity
  • Glutamate hypothesis - dysregulation
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16
Q

What investigations hsould be done for suspected schizophrenia?

A
  • Collateral History
  • Physical examination
  • Bloods (FBC, U&E, lipids, LFT, VDRL, 5-HIAA)
  • Urine (Drugs Screen, MSU)
  • MRI - hypofunction in the pre-frontal cortex
  • Rating Scale – Brief Psychiatric Rating Scale
  • ADL Assessment and Housing and Finance
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17
Q

What differences are found in an MRI of schizophrenic patient?

A

Hypofunction in the pre-frontal cortex

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18
Q

WHat differentials should be included for suspected schizophrenia?

A
  • Organic – substance misuse, dementia, delirium, epilepsy, steroids, tumours, medication withdrawal etc.
  • Acute/transient psychotic episodes – psychosis doesn’t mean you are schizophrenic
  • Mood disorder – depression and mania; check order of symptoms
  • Schizoaffective disorder – schizophrenic and affective symptoms develop together and are balanced
  • Persistent delusional disorder – only delusions
  • Schizotypal disorder – eccentricity with abnormal thoughts (not full schizophrenia)
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19
Q

What is Schizotypal disorder?

A

Eccentricity with abnormal thoughts - not full schizophrenia/milder symptoms

20
Q

What are the indications for admission for schizophrenia?

A
  • Suicide/homicide risk
  • Severe symptoms (psychotic, depressive or catatonic)
  • Lack capacity
  • Significant medication changes
  • Address comorbid conditions
21
Q

Why is early intervention for psychosis important?

A
  • Psychosis is neurotoxic
    • The longer a patient is psychotic, the more it will affect them
  • Early treatment leads to a better prognosis
    • Aim to keep Duration of Untreated Psychosis <3 months
22
Q

What is the biological treatment of schizophrenia?

A
  • 1st line (6 weeks): Atypical antipsychotic – “Start low, go slow”:
    • Less strong, less side effects = Aripiprazole , Quetiapine
    • Stronger, more side effects = Olanzapine, Risperidone
      • Start with low-dose aripiprazole/high-dose olanzapine + education and support
    • Augmentation
      • BDZ (i.e. diazepam) if non-acute anxiety
      • Mood stabiliser (lithium, anticonvulsant) if schizoaffective disorder suspected
    • Non-compliance = once-monthly IM depot injection (i.e. zuclopenthixol decanoate 200mg depot injection; ‘Clopixol’)
  • 2nd line (6 weeks): Typical antipsychotics
  • 3rd line/Treatment resistance: Clozapine
    • Tx-failure = failure to respond to ≥2 antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks
    • Clozapine is a dirty drug that is hard to manage so should be avoided if possible
23
Q

What psychological treatments can be used in schizophrenia?

A
  • CBT - offer to all patients, regardless of level of schizophrenia
    • At least 16 sessions
    • Emphasis on testing reality
      • i.e. If the Prime Minister is watching you, how do they find time to run the country?
  • Family therapy - if needed; especially if young
    • At least 10 sessions
    • To help control the highly expressed emotions of schizophrenia (helps family cope)
24
Q

What social treatments can be used in schizophrenia?

A
25
Q

What has to be risk assessed in a schizophrenic person?

A
  • To self = suicide, neglect, social decline
  • To others = violence hx, substance misuse, non-concordance, specific threats
  • From others = victim of crime, discrimination
26
Q

What baseline tests should be done before starting an anti-psychotic?

A
  • Basic obs: weight, waist circumference, pulse and BP
  • Bloods: FBC, U&E, LFTs, fasting BM, HbA1c, lipid profile, prolactin, (more frequent if on clozapine)
  • Assessment of any movement disorders
  • Assessment of nutritional status: diet and physical activity (incl. CVD assessment)
  • ECG (if cardiovascular risk factors present or recommended by the chosen medication)
27
Q

When should monitoring for patients on anti-psychotics start following on from initiation?

A
  • 1, 2, 3, 4, 5, 6 weeks = weight, waist
  • 12 weeks = weight, waist, HR, BP
  • Annually = weight, waist, HR, BP
    • ​Annual monitoring from now on
28
Q

What should be monitored for patients on anti-psychotic medication?

A
  • Response to treatment and side-effects
  • Emergence of movement disorders
  • Adherence
  • Overall physical health
  • Basic obs
    • Weight and waist circumference (weekly for 6 weeks, at 12 weeks, annual thereafter)
    • Pulse and BP (at 12 weeks, annual thereafter)
    • Patients on anti-psychotics have a high CVD risk
29
Q

What is the prognosis of schizophrenia?

A
  • Good prognostic indicators
    • ​Sudden, late onset
    • Onset following a stressful event
    • No FHx
    • Higher IQ
  • Bad prognostic indicators
    • Gradual, early onset
    • Lack of precipitant
    • FHx
    • Low IQ
30
Q

Define schizoaffective disorder.

A

A group of disorders in which BOTH affective and schizophrenic (psychotic) symptoms are prominent equally (50/50) but do not justify a full diagnosis of either schizophrenia or depressive/manic episodes

31
Q

What is manic schizoaffective disorder?

A
  • Both schizophrenic and manic symptoms prominent
    • Develop at the same time
  • Single episode, or recurrent disorder (majority manic episodes)
32
Q

What is depressive schizoaffective disorder?

A
  • Both schizophrenic and depressive symptoms prominent
    • Develop at the same time
  • Single episode, or recurrent disorder (majority depressive episodes)
33
Q

What are the defining features of schizoaffective disorder according to DSM-V?

A
  • Psychotic states to persist for ≥2 weeks without concurrent affective symptoms
  • Requires 2 episodes of psychosis
    • 1 episode lasting >2w without mood disorder symptoms
    • 1 episode requires obvious overlap of mood and psychotic symptoms
34
Q

How is schizoaffective disorder managed?

A
  • Treat as schizophrenia
  • Add a mood stabiliser if affective component isn’t well controlled
35
Q

Define acute psychosis.

A

Sudden onset psychosis that resolves in <3 months.

  • Tend to lack insight
36
Q

What are the symptoms of acute psychosis?

A
  • Psychosis/Same as +ve schizophrenia
    • Delusions
    • Hallucinations
    • Thought interference (insertion, withdrawal, broadcast to public)
    • Sense of being controlled (passivity)
37
Q

What are differentials should be considered for suspected acute psychosis?

A
  • Organic – dementia or delirium
  • Substance misuse (steroids)
  • Schizophrenia
  • BPAD
  • Depression
  • Personality disorder
38
Q

What are the biological and psychosocial treatments of acute psychosis?

A
  • Biological:
    • Short term antipsychotics/BDZ (acute behavioural disturbance)
      • 1st line = low dose aripiprazole
    • Antidepressants/mood stabilisers useful to prevent relapse
    • Stop offending medication that is causing psychosis
  • Psychosocial:
    • Specific social issues
    • Reality-oriented/adaptive/supportive psychotherapy
39
Q

What is the prognosis of acute psychosis?

A
  • Better prognosis
    • Short interval between onset and full-blown symptoms
    • Perplexity or confusion
    • Good premorbid social and occupational functioning
    • Blunted affect
  • Relapse common
  • Increased risk of suicide
40
Q

What is delusional disorder?

A
  • Persistent/life-long (≥3 months) delusions with few/no hallucinations
    • Cannot include:
      • Clear auditory hallucinations
      • Schizophrenic symptoms (delusions of control, blunting of affect)
      • Evidence of organic/brain disease
41
Q

What are the risk factors for delusional disorder?

A
  • Old age
  • Social isolation
  • Group delusions
  • Low socioeconomic status
  • Premorbid personality disorder
  • Sensory impairment
  • Immigration
  • FHx
  • Head injury
  • Substance abuse
42
Q

What onset of delusional disorder has a better prognosis?

A

Acute or insidious

43
Q

What are the biological causes of delusional disorder?

A
  • Excess DA and ACh activity
    • Neurological lesions to temporal lobe, limbic system, GB
    • Cortical damage - persecutory delusions
44
Q

What are the psychosocial causes of delusional disorder?

A
  • Freud - delusions serve defensive functions
  • Distrustful/Suspicious/Jealous
  • Low self-esteem
  • Social isolation
  • Seeing own defects in others
  • Rumination over meaning and motivation
45
Q

What are the signs and symptoms of delusional disorder?

A
  • Appearance and behaviour = Nil
  • Speech = Nil
  • Emotion = Nil
  • Perception (Hallucinations & Delusions)
    • Non-bizarre delusions
    • Rarely hallucinations
  • Thought
    • Process unimpaired, content preoccupied, single theme of thoughts
    • Erotomaniac (excessive sexual desire, often believe a VIP in love with them)
      • “De Clerembault’s syndrome”
    • Othello syndrome (believe partner unfaithful)
    • Fregoli syndrome (≥2 people are same person changing disguises to deceive)
    • Folie → deux (shared delusions/hallucinations between people)
    • Factitious disorder (consciously pretending you have a medical illness)
  • Insight = Impaired (delusions affect thought and behaviour)
  • Cognition = Nil
46
Q

What are the differentials for suspected delusional disorder?

A
  • Substance-induced
  • Mood disorder with delusions
  • Schizophrenia
  • Dementia + Delirium
  • Body dysmorphia
  • OCD
  • Hypochondriasis
  • Paranoid (personality disorder)
47
Q

What are the biological and psychosocial treatments of delusional disorder?

A
  • Consider admission - if high risk to self, to others or from others
  • Biological (limited evidence)
    • Antipsychotics (poor evidence)
    • SSRI (cover other potential missed differentials)
    • BDZ (for anxiety)
  • Psychological
    • Individual CBT
    • Psychoeducation
  • Social
    • Social skills training
    • Family Therapy
    • Psychoeducation

Y5 Psychiatry (11 decks)

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