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Psychotic Disorders Flashcards

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1
Q

Define psychosis

A

Severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality

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2
Q

Sx of psychosis

A

perceptions - hallucinations
beliefs - delusions
functioning - loss of insight

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3
Q

define hallucinations

A

perception in the absence of external sensory stimulus

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4
Q

most common type f hallucination

A

auditory

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5
Q

types of auditory hallucinations

A

2nd person
3rd person
running commentary
Thought echo
command hallucinations

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6
Q

most common type of auditory hallucinations

A

3rd person

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7
Q

other types of hallucinations

A

visual
somatic
olfactory

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8
Q

what conditions get visual hallucinations

A

physical health conditions - epilepsy / tumour

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9
Q

define delusions

A

an impression maintained despite being contradicted by reality or rational argument that is fixed, unshakable and out of keeping with cultural context

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10
Q

what % of schizophrenic patients have delusions

A

50%

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11
Q

3 features of paranoid delusions

A

exaggerated, self referential, sense of threat to self

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12
Q

define a delusional mood

A

a strange, uncanny mood in which the environment appears to be changed in a threatening way, that is not understood

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13
Q

4 key features of a delusion

A

fixed
false
unshakeable
not in keeping with cultural background

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14
Q

components of insight

A

acknowledgement of mental illness
appropriate attribution of Sx
acceptance of need for Tx
awareness of consequences of disorder

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15
Q

what benefit does insight incur in schizophrenia

A

better prognosis

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16
Q

2 classification systems for schizophrenia

A

ICD 10 and DSM 5

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17
Q

ICD 10 definition of schizophrenia

A
  • fundamental distortion of thinking and perception
  • blunted / flat affect
  • clear consciousness is maintained
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18
Q

ICD Sx of schizophrenia

A

thought disorder, delusions of control, auditory hallucinations, negative Sx

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19
Q

ICD course of schizophrenia

A

continuous, episode or multiple episodes with complete / incomplete remission

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20
Q

ICD exclusion criteria of schizophrenia

A

depression/mania/brain disease/drug intoxication/withdrawal

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21
Q

3 types of schizophrenia

A

paranoid
catatonic
residual

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22
Q

what is paranoid schizophrenia

A

dominated by relatively stable paranoid delusions, usually accompanied by auditory hallucinations

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23
Q

what is catatonic schizophrenia

A

prominent psychomotor disturbance - hyperkinetic or stupor

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24
Q

what is residual schizophrenia

A

chronic negative symptoms

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25
Q

what is persistent delusional disorder

A

either a single set or set of related delusions in the absence of hallucinations/delusions of control/blunting of affect/brain disease

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26
Q

what are acute / transient psychotic disorders

A
  • acute onset of psychotic Sx
  • delusions/hallucinations disrupt ordinary behaviour
  • within 2 weeks or less
  • complete recovery within days
  • often associated with acute stress
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27
Q

DSM5 definition of schizophrenia

A

characterised by delusions, hallucinations, disorganised speech/behaviour
+ social / occupational dysfunction
must have been going on 6 months and 2 present Sx

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28
Q

key features of schizophrenia

A

positive sx - delusions, hallucinations
negative sx - affective flattening, alogia, avolition, anhedonia
disorganisation - formal thought disorder
dysphoria /depressive features - suicide, hopelessness
disturbed behaviour - social withdrawal, thought disturbance, antisocial behaviour
impaired social cognition
neucognitive function - attention, memory, executive function

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29
Q

what are the first rank symptoms of schizophrenia

A

Delusional perception - linking normal perception to a bizarre conclusion
Thought withdrawal / insertion
Passivity - delusions of control
Hallucinations - auditory

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30
Q

List types of negative symptoms

A

social withdrawal
reduction in speech production
apathy
anhedonia
defects in attention control

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31
Q

what do you need to do if negative symptoms are present in schizophrenia

A

rule out depression

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32
Q

prevalence of schizophrenia

A

0.7%
1.5% lifetime prevalence

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33
Q

Other causes of hallucinations

A

hypnagogic / hypnopompic hallucinations
drug use
sensory deprivation
acute confusion / migraine / PD
acute anxiety / personality disorder

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34
Q

peak onset of schizophrenia

A

late adolescence / early adulthood

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35
Q

who is more at risk of schizophrenia

A

men > women
ethnic monitories > non

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36
Q

prognosis of schizophrenia

A

25% completely recovered
40% have periods or intervals of recovery lasting several years
10% sustained deterioration with reduced social functioning / negative symptoms
remainder episodic

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37
Q

what factors change prognosis

A

prognosis worse if early onset
longer duration of untreated psychosis = worse response to medication
better in resource-poor countries

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38
Q

how does schizophrenia affect life expectancy

A

reduced life expectancy - CVD, suicide etc

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39
Q

social consequence of schizophrenia

A

93% unemployed
16% never employed

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40
Q

aetiology of schizophrenia

A

genetic factors
perinatal trauma
winter births
cannabis
paternal age

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41
Q

family effect of schizophrenia

A

the closer you are in relation to someone with schizophrenia, the greater the chance of you having it
48% in identical twins
6% if parents

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42
Q

genetics of schizophrenia

A

genes involved in neurodevelopment / environmental brain insults –> aberrant brain development –> predisposition to psychosis

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43
Q

impact of cannabis of schizophrenia

A

increased positive symptoms, violence and aggression
responsible for 12% of UK schizophrenics

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44
Q

Ddx of schizophrenia

A

affective psychosis
drug induced psychosis
delirium
personality disorder
physical health conditions

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45
Q

how does schizophrenia differ from affective psychosis

A

affective psychosis - congruous affect, less likely to have 1t rank Sx, flight of ideas

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46
Q

how does schizophrenia differ from drug induced psychosis

A

drug induced psychosis - paranoia inducing drugs

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47
Q

how does schizophrenia differ from personality disorder

A

personality disorder - fleeting psychotic like symptoms, insight preserved

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48
Q

types of physical health conditions that could cause schizophrenia Sx

A

metabolic disturbance
systemic infection
epilepsy
thyroid issues
stroke
neurodegenerative diseases - Huntingtons, FTD
drug Tx - steroids, anti PD meds

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49
Q

Ix for schizophrenia

A

Hx and MSE
Physical exam - head to toe
UDS
Bloods - FBC, UEs, lipids, endocrine
EEG / MRI

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50
Q

how does schizophrenia differ from delirium

A

delirium - visual hallucinations, clouding of consciousness

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51
Q

list 6 core interventions of Schizophrenia

A

CBT for psychosis
family interventions
treatment with clozapine
physical health assessments / interventions
education / employment support
carer focused education / support

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52
Q

for how long do medications need to be continued / monitored on anti psychotics

A

1-2 years from point of remission for 1st episode
2 years monitoring after following slow discontinuation

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53
Q

list 1 st generation (typical) antipsychotics

A

chlorpromazine
haloperidol

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54
Q

what are 1st gen meds

A

dopmine antagonists

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55
Q

side effects of 1st gen

A

sedation, extrapyramidal, tardive dyskinesia

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56
Q

list 2nd gen (atypical) antipsychotics

A

olanzapine
risperidone
aripiprazole

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57
Q

how do 2nd gen work

A

dopamin, serotonin, adrenergic and histamine effects

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58
Q

side effects of 2nd gen

A

weight gain, dyslipidaemia, glucose metabolism

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59
Q

how do you decide on which gen to give

A

depends on which side effects are most beneficial eg if they can’t sleep , then give 1st gen that will make them sleepy

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60
Q

when is clozapine used

A

treatment resistant schizophrenia (unresponsive to 2 other drugs)

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61
Q

side effects of clozapine

A

weight gain, sedation, hyper salivation, agranulocysteiss, constipation –> toxic megacolon

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62
Q

what must be done if pt is on clozapine

A

regular WBC monitoring (weekly for first 18 weeks)

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63
Q

benefits of clozapine

A

suicidality reduced
increased adherence
increased effectiveness

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64
Q

what Ix are done before starting on an antipsychotic or when the dose is changed

A

baseline bloods - look at cholesterol, HbA1c
ECG - look at QT interval (<440 in men, 460 in women)

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65
Q

what is the % of death from agranulocytosis in clozapine

A

0.03%

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66
Q

what is agranulocytosis

A

not producing any granulocytes eg neutrophils etc so can’t fight infections

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67
Q

what is the adherence to tx in psychosis

A

50% in 1st year
25% partially / non adherent in first 10 days of discharge

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68
Q

which type of medication has the best adherence in psychosis

A

depots 75%

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69
Q

how do depots affect relapse

A

30% lower relapse rate

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70
Q

why aren’t people adherent to their anti psychotics

A

lack of insight that they’re unwell
side effects
illicit drug use - forget / trading their meds for drugs
family pressures

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71
Q

what is CBTp

A

CBT for psychosis

72
Q

what happens in CBTp

A

normalisation of psychotic experience
coping skills for managing voices
exploring the evidence for unusual / distressing beliefs
exploring the role that the interpretation / behaviour may have in maintaining negative emotions

73
Q

what % actually undertake CBTp

A

46%

74
Q

when should CBTp be offered

A

all first episode psychosis patients

75
Q

what are psychosis family interventions

A

10 group sessions over 6 to 12 months
pt talks to family about what is helpful/unhelpful to improve relationships in family
encouraging family to recognise Sx of relapse and ask for help
create boundaries for family

76
Q

benefits of family intervention

A

improved functioning
reduced relapse and readmission
reduced expressed emotion
carer burden improved by end of Tx

77
Q

what is expressed emotion in schizophrenia

A

schizphrenogenic mother - very anxious/overcaring/overinvolved/intrusive can perpetuate schizophrenia and have a negative impact on prognosis - increased relapse, admissions and increased negative symptoms

78
Q

list physical health interventions in psychosis

A

smoking
life-style - eating habits, drug habits
weight
exercise

79
Q

why do we try and stop schizophrenics smoking

A

smoking impacts level of clozapine in the blood - if they suddenly stop / start smoking then the level of clozapine will go up / down

80
Q

other social interventions in psychosis

A

employment and education
- reintegration into society
- crime prevention
- future goals

81
Q

when are social interventions done

A

when they are in remission

82
Q

other psycho-social interventions

A

appoint care coordinator
assertive outreach - maintain contact with patient who may not want contact with services
early intervention in psychosis - reducing duration of untreated psychosis
recovery - finding a way to live with psychosis

83
Q

what anti psychotic is non teratogenic

A

olanzopine

84
Q

which drugs have the most impact on pregnancy

A

mood stabilisers esp lithium - teratogenic

85
Q

2 services of perinatal mental health

A

pre conception advice - mental health problem & are planning a pregnancy
early detection and treatment team - treating women who are pregnant and have mental health issues

86
Q

what is the toxic trio for ADEs in children

A

parental mental health issues
drug use
domestic violence

87
Q

what is the difference between attachment and bonding

A

attachment is infant to caregiver (develops over 1st year)
bonding is caregiver to infant (develops rapidly)

88
Q

what effect can a secure attachment between parent and child have on the child

A

happier, more independent, resilient adults

89
Q

list features of parenting that lead to secure attachment

A

consistency, responsiveness, sensitivity

90
Q

give % of types of attachments in population

A

65% secure
8-10% insecure anxious / resistant - parents respond intrusively, erratically
10-15% insecure avoidant - parent responds punitively
disorganised (80% in abused) - parent is chaotic/frightening

91
Q

how can pregnancy affect mental health

A

unmask subclinical psychiatric symptoms
relapse of pre-existing mental illness
infant can present with disturbances indicative of mothers mental health

92
Q

is perinatal mental health treatable

A

yes very treatable

93
Q

when does post natal psychosis occur most often

A

within first 2 weeks

94
Q

what is the largest cause of death occurring within a year after the end of pregnancy

A

maternal suicide

95
Q

criteria for referral for perinatal psychiatry

A

anxiety and trauma related - affects daily functioning, with disproportionate concerns about baby
EDs
affective illness
emergency: psychotic Sx

96
Q

gender differences of psychosis

A

women develop it later
better social integration and educational achievements
engage in sex more than psychotic men
post menopausal onset / worsening of Sx
better response to 1st gen antipsychotics
more affective symptoms

97
Q

prevalence of post natal psychosis

A

2 in 1000
50% first mental health issue

98
Q

how should post natal psychosis be handled

A

psychiatric emergency

99
Q

risks of post natal psychosis

A

bipolar type 1
live birth (not still birth)
medication, history of relationship with menstrual cycle, stability of mood, timing of episodes
multiparity
prev history of post natal psychosis
family history - mother/sister

100
Q

PCs of post natal psychosis

A

can present with anxiety first
mania
paranoid psychosis
rapidly changing mood
perplexity
rapid progression and changing kaleidoscopic picture

101
Q

perinatal red flags

A

new feelings or thoughts that make you feel adsorbed / anxious
suicide / DSH
incompetent / can’t cope / estranged from baby - persistent
do you feel you are getting worse

102
Q

concerning signs in infant

A

self harming - head banging, not eating, breath holding
distressed - no interest/pleasure, self soothing
developmental delays

103
Q

Mx of post natal psychosis

A

urgent Tx with antipsychotics - olanzopine / haloperidol
rapid tranquillisation
enhanced nursing (1:1 or 2:1)
collateral Hx
admission to MBU or PICU if high risk to others

104
Q

highest risk of post natal psychosis

A

bipolar type 1 and previous history and family history

105
Q

is it murder if woman kills child within first year

A

no - its manslaughter (Infanticide act 1922) in theory, but hard to persuade juries of this

106
Q

risks of post natal depression

A

history of childhood abuse / poor attachment
domestic violence is MAIN ONE
younger, lower socioeconomic class
social perfectionism
fertility Tx / prev preganncy loss

107
Q

what is the baby blues

A

up to 48 hours
weepy, emotional lability, irritability
within 1st 2 weeks

108
Q

differentiate between baby blues and PND

A

PND has suicude, deep guilt and self harm risks
PND is much longer lived

109
Q

maternal OCD

A

obsessions - recurrent unwelcome thoughts
thoughts of them / others harming their baby
constantly waking up baby to check its okay
fear of touching baby

110
Q

what meds are licensed in pregnancy in psych

A

NON - they are all used off licence and using minimum effective dose

111
Q

1st line antidepressant for PND

A

sertraline

112
Q

what antipsychotic can’t be used in pregnant women and why

A

risperidone - 26% cardiac malformations in 1st trimester

113
Q

which antipsychotic drugs have a stable plasma level in pregnancy

A

olazapine only

114
Q

what drug can not be prescribed in pregnancy and why

A

VALPROATE - highly teratogenic

115
Q

what is the risk of lithium in pregnant women

A

Ebsteins abnomally - low risk though (overestimated historically)

116
Q

what is considered in prescribing in breast feeding

A

relative infant dose - up to 10% is considered acceptable

117
Q

what drugs should not be prescribed in breast feeding mothers and why

A

lithium - variable dose passed into baby
benzodiazepines - build up dose in babies

118
Q

what drugs can reduce breast milk supply

A

aripiprazole and promethazine

119
Q

what are antipsychotics used for

A

psychosis
depression
Torettes
other conditions

120
Q

describe the dopamine theory of psychosis

A

DA in mesolimbic pathway regulates motivation / reward
xs DA = + Sx of psychosis
prefrontal cortex is key for -/cognitive Sx (decrease in DA)
–> esp mesocortical pathway for - Sx
nigrostriatal = extrapyramidal Sx
tuberoinfundibulnar = hyperprolactinaemia

121
Q

list 1st gen antispychotics

A

chlorpromazine
haloperidol
clopixol
depixol

122
Q

list 2nd gen antipsychotics

A

clozapine
olanzapine
quetiapine
risperidone
paliperidone
aripiprazole

123
Q

how do antipsychotics work

A

block D2 Rs within mesolithic dopamine pathway
–> modern atypicals work as partial agonists

124
Q

contrast typical vs atypicals

A

atypicals have lower risk of EPS due to being serotonin 2A R antagonists, which increases DA in nigrostriatal DA pathway.

125
Q

what meds can be used as depots (LAIs)

A

not all of them can be used as depots
clopixol
depixol
haloperidol
olanzapine
aripirazole

126
Q

benefits of depot

A

IM injection so good for poor oral compliance

127
Q

what % of DRs have to be blocked to get clinical benefit

A

60-80%

128
Q

how do you prescribe anti-psychotics

A

start on low dose and titrate up - esp if antipsychotic naive / elderly

129
Q

how long does it take for anti-psychotics to have an effect

A

sedative effect within mins-hours
have anti-psychotic benefit after 1-2 weeks

130
Q

when can you give clozapine

A

if 2 antipsychotics have been tried to no effect

131
Q

what is rapid tranquillisation

A

anti-psychotics used IM for sedative effects

132
Q

which drugs are used in rapid tranquillisation

A
  • usually olanzapine / haloperidol
133
Q

what needs to be done pre haloperidol

A

ECG - look for QT prolongation

134
Q

when is rapid tranq used

A

after benzodiazepines and promethazine has been tried

135
Q

what is accuphase

A

24-36hrs until effective (so not rapid tranq but faster acting)
IM used for agitation
zuclopenthixol acetate
used as a last resort after IM rapid tranq

136
Q

what needs to be monitored post rapid tranq

A

respiratory rate - can cause respiratory depression

137
Q

what is HDAT

A

high dose antipsychotic Tx
above BNF max dose

138
Q

when is HDAT used

A

treatment resistant populations
lots in forensics

139
Q

what is done prior to depot starting

A

test dose is given to look for side effects

140
Q

list EPSE of antipsychotics

A

dystonia
akathisia
Parkinsonism
tardive dyskinesia

141
Q

time onset / description / Tx of dystonia

A

occurs in hours - days
sustained muscle contraction - eg can’t open eyes / close mouth
Tx if benzotropine / antihistamine

142
Q

time onset / description / Tx of akathisia

A

days to weeks
restlessness - keep moving/fidget
Tx = BBB –> beta blockers, benzodiazepines, benzotropines. Change medications

143
Q

time onset / description / Tx of parkinsonism

A

weeks to months of Tx
tremors, rigidity, bradykinesia, postural instability
Tx = switch medication, add in antimuscarinic (procyclidine)

144
Q

time onset / description / Tx of tardive dyskinesia

A

greater than 6 months of Tx (longterm Tx)
repetitive contraction of orofacial muscles eg lip smacking
Tx = stop the medication. valbenzine, tetrabezine or clozapine
can persist even when medication is stopped

145
Q

when does drug induced parkinsonism occur

A

when 80% of DA neurones are blocked within substantial nigra

146
Q

how does drug induced parkinsonism differ from PD

A

bilateral but PD is unilateral

147
Q

who gets tardive dyskinesia

A

long term typical antipsychotics, high doses or elderly people

148
Q

what causes tardive dyskinesia

A

chronic blockade of D2 Rs in basal ganglia causes them to become hypersensitive

149
Q

what is tortocolis

A

head and neck twisted to one side

150
Q

risk factors of dystonia

A

antipsychotic nave, young male, high dose typical use

151
Q

risk of akathisia

A

increased risk of suicide

152
Q

risk factors for akathisia

A

typical antipsychotics but also aripirazole / lurasidone

153
Q

list side effects of antipsychotics

A

EPS - parkinsonism, akathisia, tardive dyskinesia, dystonia
hyperprolactinaemia
QT prolongation
metabolic syndrome

154
Q

Sx of hyperporloactinaemia

A

F = reduced libido, amenorrhoea, galactorrhea, osteoporosis, increased risk of breast ca
M = reduced libidio, erectile dysfunction, gynaecomastia, galactorrhea

155
Q

Mx of hyperprolactinaemia

A

switch to prolactin sparing agent
add in aripiprazole
DA agonists avoided
RULE OUT PROLACTINOMA - do MRI head

156
Q

what is normal QT interval

A

<440 males and <470 females
corrected for heart rate

157
Q

risk of QTc prolongation

A

VT - Torsade de Pointes

158
Q

which antipsychotics have the highest effect on QTc

A

High dose of any antipsychotic
haloperidol
pimozide

159
Q

which antipsychotics have the lowest effect on QTc

A

aripirazole - no effect on QTc
clozapine
olanzapine
risperidone

160
Q

other drugs affecting QTc

A

citalopram
venflafaxine
clarithromycin

161
Q

what is meant by metabolic syndrome side effects of antipsychotics

A

weight gain, dyslipidaemia, insulin insensitivity

162
Q

Ix for metabolic syndrome effects

A

monitor weight, BP, lipid profile, HbA1c

163
Q

Mx of metabolic syndrome effects

A

treat complications - anti HTN, DM Tx, statins
Lifestyle and healthy eating advice

164
Q

Sx of neuroleptic malignant syndrome

A

sweating excessively
agitated
muscle stiffness
high temperature
hyporeflexia
autonomic dysregulation - tachycardia, hypotensive
confusion

165
Q

what is neuroleptic malignant syndrome

A

clinical emergency
acute life threatening complication

166
Q

Rfs for neuroleptic malignant syndrome

A

high dose typical, rapid dose change, male gender, younger age

167
Q

prevalence of neuroleptic malignant syndrome

A

<1% of patients

168
Q

Ix for neuroleptic malignant syndrome

A

Bloods - CK (raised), leucocytosis, deranged LFTs and renal functions (secondary to rhabdomyolysis from raised CK)

169
Q

Mx of neuroleptic malignant syndrome

A

stop causative antipsychotic
transfer to medics / ITU
supportive care - fluids
benzodiazepines - relax muscles
bromocriptine (DA agonist) and dantrolene (muscle relax)

170
Q

when is clozapine used

A

treatment resistant illness
after 2 antipsychotics tried (at least 1 atypical)

171
Q

how any respond to clozapine

A

1/3

172
Q

side effects of clozapine

A

hyper salivation
cardiomyopathy / myocarditis
tachycardia / hypotension
lowering of seizure threshold
increased risk of DVT/PE due to prothombotic effect
neutropenia / agranulocytosis
severe constipation leading to toxic megacolon/bowel perforation

173
Q

what is clozapine similar to

A

olanzapine, mirtazapine, quetiapine

174
Q

clozapine is the only medication with evidence to treat what

A

treats negative symptoms

175
Q

downside to clozapine

A

lots of side effects
high risk of rebound psychosis within 2 weeks of stopping abruptly

176
Q

how is clozapine prescribed

A

start at low dose and titrated slowly
restart titration if stopped for 48 hours+

177
Q

Ix for clozapine

A

FBC monitoring - neutropenia/leucopenia/agranulocytosis
weekly then fortnightly then monthly after 1 year of Tx

Y5 Psych (10 decks)

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