Psychotic disorders Flashcards
What is psychosis?
The experience of losing touch with reality through delusions, hallucinations and/or formal thought disorder.
- Hallucinations
- Delusions
- Thought disorientation
- Abnormal attention/salience
- Inappropriate/blunted affect
- Clear consciousness and intellectual capacity usually preserved
Can be thought as “reality failure”
List some types of psychotic illnesses.
- Schizophrenia
- Acute and transient psychotic disorder
- Schizoaffective disorder
- Delusional disorder
- Schizotypal disorder
- Puerperal psychosis
What are the subtypes of schizophrenia?
- Paranoid
- Catatonic
- Hebephrenic
- Simple
- Residual
What are the causes of psychosis?
What are the differences between typical and atypical antipsychotics?
What is psychosis?
Severe mental disorders in which thought and emotions are so impaired that contact is lost with external reality
Signs and symptoms:
- Perceptions - hallucinations
- Beliefs - delusions
- Functioning - loss of insight
What is a hallucination?
Perception in the absence of an external sensory stimulus
Mainly auditory - mostly 3rd person (discussing the patient in first person); running commentary, thought echo (repeats patient’s thoughts), command hallucinations.
Rarely - visual, somatic, olfactory
What is a delusion?
An impression maintained despite being contradicted by reality or rational argument tgat is fixed, unshakable and out of keeping with cultural context.
- Symbolic misinterpretation that is accompanied by a strong sense of conviction
- Lack of rational grounds and fixity
- Occur in around 50% of people with schizophrenia
- Paranoia - exaggerated, self-referential, sense of threat to self
What is delusional mood?
A strange uncanny mood in which the environment appears to be changed in a threatening way, that is not understood
Experiences may solidify into beliefs
What are the components of insight?
- Acknowledgement of mental illness
- Appropriate attribution of symptoms
- Acceptance of need for treatment
- Awareness of the consequences of the disorder
What are the key features of schizophrenia?
What are the ‘first-rank symptoms’ of schizophrenia?
Kurt Schneider (German psychiatrist) – not diagnostic or common but still important in diagnosis.
Auditory hallucinations - Third person, running commentary, thoughts spoken aloud (‘thought echo’)
Passivity experiences - delusions of control e.g. made feelings and impulses
Thought withdrawal - thoughts being taken out of head // Thought insertion - thoughts ascribed to other people who are intruding into the patient’s mind
Delusional perception - linking normal perception to a bizarre conclusion e.g. see red car = I knew I had 2 souls
What are the negative symptoms of schizophrenia?
- Social withdrawal
- Reduction in speech production
- Apathy
- Anhedonia (inability to experience pleasure)
- Defects in attention control
Need to distinguish from depressive symptoms
What are the cognitive symptoms of schizophrenia?
- memory (immediate and delayed recall, verbal and spatial memory)
- attention (slowed cognitive speed)
- executive function (for example – sequencing, organisation, switching set – and learning new rules in Wisconsin card sorting test)
What is the prevalence of auditory hallucinations in the normal population?
~6-15%
What is the epidemiology of schizophrenia?
Lifetime prevalence 1.5%
Peak onset in late adolescence and early adulthood (but can occur any time between childhood and late life)
Males > females and onset later for femles
Higher incidence in minority ethnic communities (x0.9 in Afrocaribbeans, x5.8 in black Africans, x1.4 in south asians)
What is the prognosis at 5yrs in schizophrenia?
25% completely recover
40% have periods or intervals of recovery lasting several yeats
10% sustained deterioration with reduced social fuctioning and negative sympptoms, remainder episodic
What factors predispose to worse prognosis?
Longer duration of untreated psychosis
Prognosis worse if early onset
What is the life expectancy in schizophrenia?
Reduced life expectancy:
- 5-10% die by suicide
- cardiovascular disease
What are the social consequences of schizophrenia for the patient?
9 of 10 unemployed in London after diagnosis
What is the aetiology of schizophrenia?
Genetic factors and environmental factors likely lead to abberant brain development which predisposes to psychosis
Other:
- Perinatal trauma
- Cannabis use - high use in those with schizophrenia and may be responsible for 30% of psychosis in UK; causes more positive symptoms, violence and aggression.
- Parental age
Schizophrenia is 9th leading cause of disability worldwide
What are the psychiatric differential diagnoses for schziophrenia?
Affective psychosis - congryent affect, less likely to have 1st rank symptoms, increased volume of speech, flight of ideas, punning
Drug-induced psychosis - e.g. cannabis, khat and ketamine can cause paranoia and thought disorder, rarely produce negative sympoms and usually resolve with drug cessation
Delirium - visual hallucinations, disorientated, foggy ‘clouding of consciousness’
Personality disorder - ‘fleeting’ psychotic-like symptoms, insight preserved
What physical health conditions can be differential diagnoses for schizophrenia?
- metabolic disturbance - porphyria
- systemic infection - syphilis, HIV-associated, epilepsy, brain lesions
- stroke
- endocrine - hyperthyroidism, hypothyroidism
- neurodegenerative diseases - Huntington’s disease, frontotemporal dementia, and the Lewy body dementias
- drug treatments - steroids, anti-Parkinson’s medications, withdrawal from BNZPs
What investigations should you do for schizophrenia?
- History and mental state examination
- Physical examination (neurological system, cardiovascular system incl. weight, blood pressure)
- Urine drug screen
- Blood tests (FBC, electrolytes, HbA1c, lipids, endocrine tests)
EEG when investigating TLE or post-ictal symptoms
NICE 2008: Use MRI/ CT to exclude organic causes if indications from history/physical examination (MRI may influence clinical management in approximately 5% of people with psychosis CT scanning in 0.5%)
What is the management of schizophrenia?
- Medication
- CBT for psychosis
- Family interventions
- Psychosocial rehabilitation
What medication can be used in schizophrenia?
1 st generation (chlorpromazine, haloperidol) dopamine antagonists –
- reward and salience,
- sedation,
- extrapyramidal side effects – tardive dyskinesia
2 nd generation (olanzapine, risperidone, aripiprazole) variable effects on dopamine, serotonin, adrenergic and histamine. (D, HT, H, A)
- weight gain,
- dyslipidemia,
- glucose metabolism
Clozapine: licensed for treatment-resistant schizophrenia (unresponsive to two other drugs) weight gain, hypersalivation, agranulocytosis (fatal in 0.03%) regular WBC monitoring (additional costs ?and benefits)
What is the relapse rate on medication vs with withdrawal in schizophrenia?
Evidence from RCTs, including discontinuation studies: withdrawal relapse rate - 53%, maintenance -16% (Gilbert et al 1995)
What is the adherence rate in schizophrenia?
- Around 50% in the first year
- 25% partially or non-adherent 10 days after discharge
- 75% adherence with depot injections
NB: 30% lower rate of relapse in adherent individuals
How is CBT used in schizophrenia?
16+ one-to-one sessions over 6 months
Focus on “here and now”
Focus on normalization of the psychotic experience (stigma), coping skills for managing voices, exploring the evidence for unusual and distressing beliefs, exploring the role that the interpretation and behaviour may have in maintaining negative emotions
NICE - all adults with psychosis or schizophrenia should be offered CBTp (CBT for psychosis)
What family interventions can be used in psychosis?
10 group sessions over 6-12 months
Pt can talk to their family about what helps and is unhelpful. Aims to improve relationships by encouraging people to listen to each other and negotiate potential solutions.
Recommended by NICE to family members living with someone with psychosis
What psychosocial interventions are important in psychosis?
Care-coordination - mental and physical health problems, drug use, social problems e.g. accommodation
Assertive outreach - maintain contact with pt who may not want contact with services
Early intervention in psychosis - reduces duration of untreated psychosis which overcomes division between CAMHS and services for adults
Recovery - process of getting well and finding a way to live with psychosis that allows a person to have a fulfilling and meaingful life
What are the barriers to employment in schizophrenia?
Barriers include symptoms, stigma, expectations of famly members and clinicians, ‘benefits trap’
- Vocational rehabilitation
- Individual placement and support
What is an important antipsychotic SE to ask about in those who are young and in relationships?
Libido - sexual function and desire can occur in both males and females
