Psychotic Disorders Flashcards
What is a hallucination?
The perception of an object in the absence of an external stimulus
Can be any of the 5 modalities
Auditory most common in psychosis - can be 2nd or 3rd person
‘Hearing voices’ is pseudohallucination
What is a delusion?
A fixed, firmly held belief that is usually false, cannot be reasoned away, held despite evidence to the contrary
Is out of keeping with the person’s sociocultural norms
What is psychosis?
A mental state in which reality is greatly disorted.
Presents with delusions, hallucinations, thought disorder.
What is the ICD-10 classification of psychotic disorders?
Schizophrenia Schizotypal disorder Persistent delusional disorder Acute and transient psychotic disorder Induced delusional disorder Schizoaffective disorder Other non organ psychotic disorders Unspecified non-organic psychosis
What is formal thought disorder?
A problem of speech
Each sentence or phrase does not follow on from the next
What are the non-organic causes of psychosis?
Schizophrenia and Schizoaffective Persist for >1 month, paraphrenia presents late
Schizotypal disorder Acute and transient psychotic disorders Schizoaffective disorder Persistent delusional disorder Folie a deux - induced delusional Mood disorders with psychosis Puerperal psychosis Late paraphrenia
What are the organic causes of psychosis?
Drug induced psychosis Istrogenic - medication Complex partial epilepsy Delirium and dementia Huntington's SLE Syphilis Endocrine e.g. Cushing's Metabolic disorders
What is schizophrenia?
Most common psychotic condition, characterised by hallucinations, delusions and thought disorders which lead to functional impairment
Characterised by psychotic episodes (positive symptoms - added to normal experience) and negative symptoms
In the absence of organic disease, alcohol or drug-related disorders, not secondary to elevation or depression of mood.
What are the types of functional psychosis?
Schizophrenic - bizarre, persecutory, 3rd person
Manic - grandiose, 2nd person
Depressive - guilt, nihilism, 2nd person
What is the course of a psychotic episode?
Differs for patients
Can get better, have recurrent episodes, or personality change and recurrent episodes
Schizophrenia most likely to involve a personality change
What negative symptoms are found in schizophrenia?
Alogia - poverty of speech where patient gives short answers and no input into conversation
Avolition - decrease in motivation
Asocial behaviour
Anhedonia - lack in pleasure in activities prev enjoyed
Affect blunted
Attention - cognition deficits
What predisposing factors can increase risk of schizophrenia?
Genetic
Neurochemical - increase in dopamine, decrease in GABA and serotonin
Neurodevelopmental - intrauterine infection, premature birth, obstetric complications, age 13-35, extreme of parental age
Family history, childhood abuse
Substance misuse
Lower socioeconomic status
What is Schneider’s first rank symptoms?
Hearing own thoughts spoken aloud Hallucinatory voices - third person Running commentary Physical hallucinations Thought broadcasting - open to the world Thought withdrawal, insertion Influence of others - someone else controlling me Delusional perception
What precipitating factors can cause schizophrenia?
Smoking cannabis or using psychostimulants
Adverse life events
Poor coping style
Adverse life events
What are the perpetuating factors that can increase risk of schizophrenia?
Substance misuse Poor compliance to medication Adverse life events Social support Expressed emotion
What is the mnemonic for the ICD-10 classification of schizophrenia?
Paranoid Psychotic Humans Can’t Supply Understandable Reasoning
Paranoid schizophrenia Postschizophrenic depression Hebephrenic schizophrenia Catatonic schizophrenia Simple schizophrenia Undifferentiated schizophrenia Residual schizophrenia
What is paranoid schizophrenia?
Most common
Dominated by positive symptoms - hallucinations and delusions
What is post schizophrenic depression?
Depression predominates with schizophrenic illness in the past 12 months, some schizophrenic symptoms still present
What is hebephrenic schizophrenia?
Thought disorganisation predominates, onset of illness in earlier - 15-25
Has poorer prognosis
What is simple schizophrenia?
Rare
Negative symptoms develop without psychotic symptoms
What questions can you ask about hallucinations?
Have you heard voices
How many voices
Do they speak to you or about you - 2nd or 3rd person
Do they make comments about what you are doing - running commentary
Are you afraid someone is trying to harm you - persecutory
Do you have any special powers - grandiose delusions
What is observed in a MSE with someone with schizophrenia?
Appearance - normal or inappropriate with poor self care
Behaviour - preoccupied, restless, noisy, suspicious if positive symptoms
Withdrawn, poor eye contact, apathy - negative symptoms
Speech - may reflect underlying thought disorder, interruption to flow, poverty of speech
Mood - depression, anxiety, irritability, flattened affect
Thought - delusions, formal thought disorder, word salad, concrete thinking - all positive symptoms
Perception - hallucinations, especially third person auditory
Cognition - normal orientation, attention and concentration impaired, evidence of premorbid cognitive impairment
Insight is generally poor
What are the investigations for schizophrenia and psychosis?
Bloods: FBC (anaemia) TFTs, glucose or HbA1C as atypical antipsychotics can cause metabolic syndrome, serum calcium (hypercalcaemia)
U&Es, LFTs assess renal and liver function before antipsychotics
Urine drug test - illicit drugs
ECG - antipsychotics can cause prolonged QT interval
CT scan to rule out organic causes such as a SOL.
EEG: rule out temporal lobe epilepsy
What are poor prognostic factors for schizophrenia?
Strong family history Gradual onset Decreased IQ Premorbid history of social withdrawal No obvious precipitant
What is the general management of schizophrenia and psychosis?
Risk assessment Use of Mental Health Act may be required if refuse admission Care Programme Approach Early intervention Assess social circumstances Bio-psychosocial model
What is the bio-psychosocial approach to the management of schizophrenia?
BIOLOGICAL
Antipsychotics:
atypical are first line e.g. risperidone or olanzapine, clozapine is most effective used for treatment-resistant schizophrenia
Adjuvants: benzos can provide short term relief for behaviour, antidepressants and lithium to augment antipsychotics
ECT: if resistance to pharmacological agents, or have catatonic schizophrenia
PSYCHOLOGICAL CBT: reduces residual symptoms Family intervention: psychoeduction Art therapy: alleviates negative symptoms Social skills training
SOCIAL
Support groups e.g. Rethink and SANE
Peer support
Supported employment programmes
What is recommended in the management of first-episode schizophrenia?
Either agree choice of antipsychotic with patient and/or worker, or start second generation antipsychotic
Titrate to minimum effective dose, adjust according to response and tolerability
Assess over 2-3 weeks
If effective - continue
Not effective - change and restart
If not tolerated - discuss poor compliance, consider early use of depot injection
Still not effective - clozapine
What are the types of delusions a patient may have in psychosis?
Grandiose - special powers, wealth, talents etc.
Persecutory - other people conspiring against them
Reference - Random events or others behaviour have special significance
Guilt - belief they have done something shameful
Hypochondrial - belief they have illness
Morbid jealousy - belief spouse is being unfaithful
What are the types of thought disorder?
Broadcasting - internal thoughts can be heard out loud by others
Insertion - thoughts being put into your mind
Withdrawal - thoughts are being removed
What is a thought disorganisation?
Impairment in ability to form thoughts from logically connected ideas
What are some types of thought disorganisation?
Loosening of associations - loss of normal structure of thought
Tangential disorder - person divert from original thought but never return
Circumstantiality - Thinking proceed slowly with many unnecessary details before getting to the point
Neologisms - Words and phrases devised by patient
Alogia - little information conveyed by speech
Word salad - real words but linked incoherently i.e. talking nonsense
What is schizoaffective disorder?
Symptoms of schizophrenia and a mood disorder in the same episode
How does schizotypal disorder appear?
No hallucinations or delusions
Eccentric behaviour, suspiciousness and unusual speech
What prodrome may indicate schizophrenia?
Patients show:
- Loss of interest
- Social withdrawal
- Self-neglect
- Depression and anxiety
- Brief psychotic episodes
What is Charles Bonnet syndrome?
Visual release hallucinations
Type of psychophysical visual disturbance - person with partial or severe blindness experiences visual hallucinations
May see simple repeated patterns or complex images of people, objects or landscapes
More likely to occur if vision loss affects both eyes, common in macular degeneration
What is Cotard syndrome?
Walking corpse syndrome
Person holds delusional belief that they are dead, do not exist, putrefying (decomposing) lost their blood or internal organs.
What is De Clerambault syndrome?
Erotomania
Paranoid condition characterised by an individual’s delusions of another person being infatuated with them
What is pseudohallucination?
An involuntary sensory experience vivid enough to be regarded as a hallucination, but recognised by the person experiencing it as being subjective and unreal.
What are the differentials of psychosis?
Schizophrenia
Bipolar disorder - may have some of the first rank symptoms, but elation, erratic behaviour and grandiose delusions rather than persecutory
Alcoholic hallucinations in withdrawal
Drugs e.g. cannabis, steroids, cocaine, ecstasy, LSD
Organic disorders - temporal lobe seizures in epilepsy, dementia, trauma, hypos
Other mental health disorders e.g. brief psychotic, delusional, morbid jealousy, erotomania
What is thought to be the pathology of schizophrenia?
Excess dopaminergic activity
Thought the excitatory neurotransmitter glutamate is involved
Neuroimaging may show increased size of lateral ventricles, reduced brain size usually in temporal lobes
Reduced connections between different brain areas can often be deduced from EEGs
What are the types of schizoaffective disorder?
Bipolar type - manic or mixed episode occurs
Depressive type - illness mainly depressive episodes
What must be present in a major depressive episode in schizoaffective disorder?
Depressed Decreased pleasure Weight loss Insomnia or hypersomnia Fatigue Feelings of guilt or worthlessness Recurrent thoughts of death or suicidal notions
What must be present in a manic episode in schizoaffective disorder?
Inflated self esteem Grandiosity Reduced need for sleep Pressure of speech Flight of ideas Easily distracted Psychomotor agitation Increase in goal-directed activity Excessive involvement in high risk activities
What schizophrenic symptoms need to be present in schizoaffective disorder?
Two or more during one month of the illness
Delusions
Hallucinations
Speech abnormalities e.g. incoherent or derailment
Behavioural abnormalities
Negative symptoms e.g. apathy, lack of emotions
What are the differentials for schizoaffective disorder?
Substance misuse Organic e.g. hypothyroid, delirium, HIV Medication side-effects Depressive episode Dementia, delusional disorder
