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Psychiatry > Psychotic disorders > Flashcards

Psychotic disorders Flashcards

1
Q

What is psychosis?

A

In psychosis, people lose touch with reality, experiencing hallucinations, delusions and formal thought disorder.

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2
Q

What is a hallucination?

A

A perception in the absence of a stimulus

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3
Q

What is a delusion?

A

A fixed, false belief, held despite rational argument or evidence to the contrary. It cannot be explained by the patient’s cultural, religious or educational background.

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4
Q

What is formal thought disorder?

A

Illogical or muddled thinking; people may experience this as struggling to think clearly

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5
Q

What is the lifetime risk of developing schizophrenia and of any psychotic disorder?

A
  • Around 0.7%
  • 3%
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6
Q

When is the onset of schizophrenia? In what gender is it more common?

A

Late adolescence to the early twenties although can happen ate any age

Male:Female ratio is 3:2 and men are usually affected earlier and more severely than women.

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7
Q

What is the aetiology go schizophrenia comprised of?

A
  • Genetics
  • Obstetric complications
  • Childhood adversity
  • Social Disadvantage
  • Urbanicity
  • Migration and Ethnicity
  • Other conditions
  • Substance us disorders
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8
Q

What is the genetic aspect of schizophrenia?

A
  • 10-fold risk in those with first-degree relatives with schizophrenia
  • 40-fold in one whose parents are both effected
  • Overall heritability: 85%
  • Multiple susceptibility genes of small effect
  • Genes of interest: Coding for proteins involved in:
    • neurodevelopment
    • receptor function
    • synaptic pruning (elimination of weaker brain synaptic links)
    • These genes increase the risk of disorders including BPAD, schizoaffective disorders and autism
  • Increased paternal age
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9
Q

What is the significance of obstetric complications in schizophrenia?

A
  • Maternal prenatal malnutrition
  • Viral infections
  • Stress
  • Analgesic use
  • Pre-eclampsia → hypoxia
  • Low birth weight
  • Emergency C-section → hypoxia
  • May reflect underlying genetic abnormalities or hypoxic brain damage
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10
Q

What is the significance of childhood adversity in schizophrenia?

A
  • Child abuse
  • neglect
  • bullying
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11
Q

What is the significance of social disadvantage in schizophrenia?

A

Higher prevalence in adults of lower socio-economic status is not linked to status at birth

Downward ‘drift’ due to illness and results from social isolation and unemployment

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12
Q

What is the significance of urbanicity in schizophrenia?

A

Twice as prevalent in urban as in rural - might be due to drift or stress specific to urban environment

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13
Q

What is the significance of migration and ethnicity in schizophrenia?

A

First- and second-generation immigrants have an average threefold increase in risk of schizophrenia compared with indigenous population

Vary with ethnicity

o Black Caribbean and black African at highest rates (4-6 fold increase to white ethnicity)

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14
Q

What is the significance of premorbid personality in schizophrenia?

A

Premorbid schizoid personality precedes schizophrenia

Schizotypal disorder is more commonly associated with schizophrenia - ? genetic basis

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15
Q

What is the significance of substance use in schizophrenia?

A
  • Some drugs produce psychotic symptoms which subside as the drug wears off (‘drug- induced psychosis’),
  • e.g. cannabis, amphetamines, cocaine, and novel psychoactive substances (NPS).
  • Drug use can also trigger a relapse in people with a history of psychosis.
  • Additionally, there’s a dose- dependent association between cannabis use (particularly as a teenager) and the risk of later developing schizophrenia.
  • The risk is heightened for skunk, a form of cannabis with higher concentrations of tetrahydrocannabinol (THC), the chemical particularly associated with psychosis.
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16
Q

What are the main theories behind schizophrenia?

A
  • Neurodevelopmental theories
  • Neurotransmitter theories
  • Psychological theories
17
Q

What are the neurodevelopment theories behind schizophrenia?

A

Brain changes in people with schizophrenia

o Notably enlarged ventricles

o Reduced cortical, amygdala and hippocampal volume

o Disorganization fo white matter tracts in frontal/temporal regions

Lower pre-morbid IQ and deficits in learning, memory and executive functions

Initial brain abnormalities from either genetic origin or early brain damage progress as the brain matures through myelination and synaptic pruning

Maturation + risk factors → functional and connectivity abnormalities to evolve until schizophrenic symptoms emerge

18
Q

What are the neurotransmitter theories behind schizophrenia?

A

DOPAMINE HYPOTHESIS

Schizophrenia = dopamine over activity in certain areas of the brain

Positive symptoms (hallucinations and delusions) = excess dopamine in mesolimbic tracts

Negative symptoms (apathy, social withdrawal) = dopamine under activity in mesocortical tracts

Evidence includes

o All known antipsychotics are dopamine receptor antagonists
o Antipsychotics work better against positive sx
o Dopaminergic agents (amphetamine, cocaine, L-dopa, bromocriptine) can all induce psychosis = symptomatically indistinguishable from schizophrenia

Dysfunction of glutamate (the main excitatory neurotransmitter in the brain) may be fundamental:

  • Glutamate transmission affects dopamine transmission.
  • The street drugs phencyclidine (PCP) and ketamine cause a schizophrenia- like psychosis by blocking glutamate transmission at NMDA receptors.

Serotonin overactivity may also be important,

e.g. atypical antipsychotics are effective serotonin

antagonists

19
Q

What are the psychological theories behind schizophrenia?

A

Subtle defects of thinking→tendency to jump to conclusions without adequately examining contradictory evidence

Fear of madness→ defences of denial and rationalisation→delusional system to explain persecutory voices

20
Q

What are the three stages of schizophrenia?

A

At risk mental state - ARMS

Acute phase: positive symptoms (hallucinations and delusions)

Chronic phase: negative symptoms (reflect things that are lost in schizophrenia e.g. motivation)

21
Q

What is ARMS?

A

Those who develop ARM are at 20-30% risk of developing psychosis, half of whom meet criteria for schizophrenia

Low-grade symptoms

o Very mild, brief psychotic symptoms

o Social withdrawal
o Loss in interest in work, study and relationships

o Mood symptoms

• Typically someone in late-teens or early-20s who has dropped out of college/work after a period of increased absence

They may deny emerging psychotic symptoms for fear of their significance.

Psychosocial treatment with CBT and family intervention is recommended

22
Q

What is the acute phase of schizophrenia?

A

Striking and florid psychotic features: positive symptoms - delusions (usually persecutory) and hallucinations (commonly auditory)

Thinking is disturbed

o Formal thought disorder: Muddled speech

Thought blocking (a sudden stop in the flow of thoughts, leading to silence) may also occur.
• Behaviour may be withdrawn, overactive or bizarre
23
Q

What are Schneider’s First Rank Symptoms?

A
24
Q

What is the chronic phase of schizophrenia?

A
  • Chronic negative symptoms which may last indefinitely and may be disabling
    • Apathy
    • Blunted affect (decreased reactivity of mood)
    • Anhedonia
    • Social withdrawal
    • Poverty of thought and speech
  • May manifest as
    • Lack of attention to personal hygiene and care
    • Limited repertoire of daily activities
    • Social isolation
  • May also be residual positive symptoms
25
Q

What is the differential diagnosis of schizophrenia?

A

Organic

  • Dementia or Delirium
  • Epilepsy (temporal lobe epilepsy)
  • Medication side effect e.g. steroids, dopamine agonists
  • Cerebral pathology: brain tumour, stroke, HIV, syphilis
  • Systemic Illness e.g. Wilson’s, porphyria
  • Drug use: amphetamine, cocaine/ crack cocaine, LSD, ecstasy, ketamine, GHB (gamma-hydroxybutrate)/ GBL (gamma- butyrolactone), phencyclidine (PCP) and many NPS.
  • Alcohol. Heavy use can cause:
    • Alcohol hallucinosis
    • Delirum tremens

Non-organic

  • Schizophrenia - symptoms should be present for at least 1 month and affect multiple areas of the mental state
  • Acute and Transient Psychotic Episode - symptoms peak within 2 weeks and resolve within a month
    • Can resolve completely within a few months
    • Linked to stress
  • Schizoaffective disorders
    • Picture of schizophrenia and a mood disorder simultaneously
  • Delusional disorder
    • Delusions lasting more than 3 months without clear mood disturbance or other schizophrenia symptoms
  • Schizotypal disorder
    • enduring state lasting several years or more.
    • Eccentricity: people may dress, behave, think,and speak oddly.
    • They may be suspicious, aloof, and struggle to make close relationships.
  • Puerperal (post-partum) psychosis
    • occurs within a few weeks of delivery

Other

  • Personality disorder
    • Paranoid PD
    • Schizoid PD
    • Borderline personality pattern
26
Q

What are the subtypes of schizophrenia?

A
  • Paranoid
    • Most common
    • Acute phase description
    • Main symptoms = delusions and hallucinations
  • Catatonic
    • Psychomotor disturbance
    • Stupor: state of being immobile, mute and unresponsive despite appearing to be conscious (eyes open and follow you around the room)
    • Excitement: periods of extreme and purposeless motor hyperactivity
    • Posturing: assuming and maintaining bizarre or inappropriate positions
    • Rigidity
    • Waxy flexibility: patient’s limbs offer minimal resistance to being placed in odd positions which are maintained for unusually lengthy periods (cataplexy)
    • Automatic obedience
    • Perseveration: inappropriate repetition of words or movements
  • Hebephrenic
    • Onset aged 15-25 years
    • Disorganised and chaotic mood, behaviour and speech
    • Affect is shallow and inappropriate
    • Delusions/hallucinations not prominent
  • Simple
    • Negative features only
    • No psychotic symptoms
  • Residual
    • Prominent negative symptoms are all that remain after delusions and hallucinations subside
27
Q

What are the investigations for schizophrenia?

A

• Bloods: FBC, TFTs, U&Es, LFTs, CRP, fasting G
o HIV & syphilis serology may be considered
o Check lipids before starting long-term antipsychotics

MSU
Urine drug screen
CT head if organic pathology suspected
EEG is epilepsy or organic cause suspected
Symptom rating scales to assess severity and monitor response to tx OT assessment of ADLs
Social work assessment of housing, finances and carers’ needs Collateral hx

28
Q

How should you treat schizophrenia?

A

Use a Biopsychosocial model

  • Biological therapies - mainly antipsychotics
  • Psychological therapies
  • Social Interventions
  • Early Intervention in Psychosis (EIP) service
  • Other …
  • Consider Tx resistance
29
Q

What are the Early Intervention Services?

A

Early Intervention in Psychosis (EIP) Service

o Psychosis is toxic: the longer a patient is psychotic, the more it will affect their cognitive abilities, insight and social situation
o The sooner effective treatment can be started the better the prognosis
o The service aims to engage patients with very early symptoms, from adulthood till ~35 years
o Patients are offered antipsychotics and psychosocial interventions with the aim of keeping the duration of untreated psychosis (DUP) under 3 months

o The service can be used in children >14 years old

  • CAMHS can manage psychosis in children up to 17 years old

• Note: if urgent intervention is necessary, use the crisis resolution team and home treatment team

30
Q

What are the biological interventions for schizophrenia?

A

• Antipsychotics

Dopamine antagonists (block post-synaptic D2 receptors)

Where possible, medications should be chosen with the person, using the lowest dose that controls symptoms without causing unpleasant side effects.

Lower doses may be possible during remission, but the general advice is to continue medication for up to 3 years after a first episode of psychosis; longer periods are often needed with recurrent psychosis.

First Generation Antipsychotics (FGA)/Typical Antipsychotics

o Older drugs

o Examples:

  • Chlorpromazine
  • Haloperidol
  • Sulpiride
  • Trifluoperazine,
  • Zuclopenthixo
  • Flupentixol decanoate

o Cause EPSEs and/or hyperprolactinaemia at normal doses

o Effective, cheap and provide depot options

Some are available as long- acting injections (‘depots’) → useful when people have difficulties taking daily tablets consistently, e.g. flupentixol decanoate, fluphenazine decanoate, haloperidol decanoate, zuclopenthixol acetate.

Second Generation Antipsychotics (SGA)/Atypical Antipsychotics

o In addition to dopamine receptors, these also block serotonin 5-HT2 receptors (different side effect profile to FGAs)

  • They cause fewer EPSEs and generally don’t increase prolactin levels, but are more likely to cause metabolic side effects:
    • hypertension
    • central obesity
    • raised fasting plasma glucose
    • hypertriglyceridaemia
    • low high density lipoprotein cholesterol.

o Examples:

Olanzapine (available as depot)
Risperidone (available as depot)

Quetiapine
Aripiprazole (available as depot)
Clozapine
Amisulpride

Lurasidone

o Consider starting an atypical antipsychotic when:

  • Choosing 1st line treatment in newly diagnosed schizophrenia
  • There are unacceptable side-effects from typical antipsychotics
  • Relapse occurs on a typical antipsychotic

o Avoid using more than 1 antipsychotic

31
Q

What are the side effects of antipsychotics?

A

Side-Effects of Antipsychotics

o Extrapyramidal Side-Effects

Dystonia

Akathisia Parkinsonism

Tardive dyskinesia

Hyperprolactinaemia
o Galactorrhoea, amenorrhoea, gynaecomastia and hypogonadism

o Sexual dysfunction
o Increased risk of osteoporosis

Weight gain (especially olanzapine and clozapine)

Sedation

Increased risk of diabetes (olanzapine)

Dyslipidaemia

Anticholinergic side-effects (dry mouth, blurred vision, constipation, urinary retention, tachycardia)

Arrhythmias

Seizures (reduces seizure threshold)

Neuroleptic malignant syndrome

32
Q

When would you use clozapine?

A

1st line: Clozapine

Treatment Resistance: failure to respond to two or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks

NB: there is a small but significant risk of agranulocytosis (0.7%)

Requires weekly blood tests to detect early signs of neutropaenia

The sooner an effective treatment is started, the better the person’s prognosis. Hence, if other treatments fail, a trial of clozapine should follow promptly.

If there is a lack of response to clozapine, consider augmentation with another antipsychotic

33
Q

What are the psychological interventions for schizophrenia?

A

• CBT

o CBT has not been shown alone to improve outcomes, but combined with other therapies can be helpful in treating schizophrenia

In CBT, the therapist aims to gently challenge the person’s beliefs, helping them to spot illogical thinking, e.g. ‘I’m a bit confused by that. If the Prime Minister’s stalking you all day, how do they find the time to run the country and appear on TV?’ The person is encouraged to think about the evidence for and against a belief and to consider alternative explanations

o CBT has been shown to help positive symptoms

o Social skill training better in helping negative symptoms

Cognitive remediation therapy (CRT) is particularly helpful in negative symptoms: it aims to improve neurocognitive skills such as concentration, memory, and problem- solving— often using computer- based programmes

• Family Therapy

Can reduce relapse rates
o Effects of high expressed emotion can be ameliorated through communication skills, education about schizophrenia, problem-solving and helping patients expand their social network
o Can offer respite for the families

Family intervention is a type of therapy that works with the patient and their family or cohabitees. It can reduce the effects of high EE through communication skills training, education about psychosis, and problem- solving techniques.

• Duration
o CBT: at least 16 sessions

o Family therapy: at least 10 sessions

• Arts therapies

-Allows pts to discover new forms of expression

34
Q

What are the social approaches to treating schizophrenia?

A

Multidisciplinary approach:

  • Social workers,
  • benefits advisors
  • occupational therapist

Practical needs should be addressed, e.g. benefits, housing, training, and education

Befriending and peer support may help develop social confidence. Mental health organizations such as Rethink and Mind provide a wealth of patient resources, as well as carrying out important work in promoting social inclusion and helping tackle stigma at a personal and societal level

Psychoeducation is vital to reduce relapse. This a collaborative approach where people are encouraged to ask and find out more about their illnes

Needs to address

o Education, training and employment
o Skills (e.g. budgeting, cooking)
o Housing (e.g. supported accommodation, independent flats)

o Accessing social activities
o Developing personal skills (e.g. creative writing)

May include admission to hospital for observation, treatment or refuge

• Support for Carers

oOffer support for carers (including education and support programmes)
o Inform them of their right to a formal carer’s assessment (available for free through social services)
o Consider peer support (support from someone who has recovered from psychosis)

Rehabilitation

35
Q

What should we do when giving patients antipsychotics?

A

Physical Health

oOffer combined healthy eating and physical activity programme
o Offer interventions for metabolic complications of antipsychotics(e.g.weight gain, high cholesterol)
o Help with smoking cessation (consider nicotine replacement therapy or bupropion or varenicline)

  • Bupropion and varenicline have an increased risk of adverse neuropsychiatric symptoms so should be monitored closely for the first 2-3 weeks

o Regularly monitor weight and other cardiovascular/metabolic parameters

• Monitoring
o Baseline Measurements before starting an antipsychotic:

  • Weight
  • Waist circumference
  • Pulse and BP
  • Fasting BM, HbA1c, lipid profile, prolactin
  • Assessment of any movement disorders
  • Assessment of nutritional status, diet and physical activity
  • ECG (if cardiovascular risk factors present or recommended by the chosen medication)
  • Children should also have height measured every 6 months

o Monitoring

  • Response to treatment and side-effects
  • Emergence of movement disorders Waist circumference
    Adherence
  • Overall physical health
  • Weight
    • Weekly for 6 weeks
    • At 12 weeks
    • At 1 years
    • Annually thereafter
  • Pulse and blood pressure
    • At 12 weeks
    • 1 year
    • Annually
36
Q

Summarise the management of schizophrenia?

A

1st line: atypical antipsychotic (e.g. quetiapine)

CBT should be offered to all patients

Close attention should be paid to cardiovascular risk factor modification due to the high rates

of cardiovascular disease in schizophrenic patients (due to medication and high smoking rates)

37
Q

What is the prognosis of psychosis?

A
  • ¼ recover and experience no further diffculties after a single psychotic episode
  • ⅔ develop schizophrenia, which can relapse whenmedication is stopped.
  • 1/10 will be seriously and continuously disabled
  • ⅓ tx resistant illness
38
Q

What are the prognostic indicators of schizophrenia?

A

Psychiatry (13 decks)

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