Psychotic Disorders Flashcards
Define psychosis
Severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality
Sx of psychosis
perceptions - hallucinations
beliefs - delusions
functioning - loss of insight
define hallucinations
perception in the absence of external sensory stimulus
most common type f hallucination
auditory
types of auditory hallucinations
2nd person
3rd person
running commentary
Thought echo
command hallucinations
most common type of auditory hallucinations
3rd person
other types of hallucinations
visual
somatic
olfactory
what conditions get visual hallucinations
physical health conditions - epilepsy / tumour
define delusions
an impression maintained despite being contradicted by reality or rational argument that is fixed, unshakable and out of keeping with cultural context
what % of schizophrenic patients have delusions
50%
3 features of paranoid delusions
exaggerated, self referential, sense of threat to self
define a delusional mood
a strange, uncanny mood in which the environment appears to be changed in a threatening way, that is not understood
4 key features of a delusion
fixed
false
unshakeable
not in keeping with cultural background
components of insight
acknowledgement of mental illness
appropriate attribution of Sx
acceptance of need for Tx
awareness of consequences of disorder
what benefit does insight incur in schizophrenia
better prognosis
2 classification systems for schizophrenia
ICD 10 and DSM 5
ICD 10 definition of schizophrenia
- fundamental distortion of thinking and perception
- blunted / flat affect
- clear consciousness is maintained
ICD Sx of schizophrenia
thought disorder, delusions of control, auditory hallucinations, negative Sx
ICD course of schizophrenia
continuous, episode or multiple episodes with complete / incomplete remission
ICD exclusion criteria of schizophrenia
depression/mania/brain disease/drug intoxication/withdrawal
3 types of schizophrenia
paranoid
catatonic
residual
what is paranoid schizophrenia
dominated by relatively stable paranoid delusions, usually accompanied by auditory hallucinations
what is catatonic schizophrenia
prominent psychomotor disturbance - hyperkinetic or stupor
what is residual schizophrenia
chronic negative symptoms
what is persistent delusional disorder
either a single set or set of related delusions in the absence of hallucinations/delusions of control/blunting of affect/brain disease
what are acute / transient psychotic disorders
- acute onset of psychotic Sx
- delusions/hallucinations disrupt ordinary behaviour
- within 2 weeks or less
- complete recovery within days
- often associated with acute stress
DSM5 definition of schizophrenia
characterised by delusions, hallucinations, disorganised speech/behaviour
+ social / occupational dysfunction
must have been going on 6 months and 2 present Sx
key features of schizophrenia
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
what are the first rank symptoms of schizophrenia
Delusional perception - linking normal perception to a bizarre conclusion
Thought withdrawal / insertion
Passivity - delusions of control
Hallucinations - auditory
List types of negative symptoms
social withdrawal
reduction in speech production
apathy
anhedonia
defects in attention control
what do you need to do if negative symptoms are present in schizophrenia
rule out depression
prevalence of schizophrenia
0.7%
1.5% lifetime prevalence
Other causes of hallucinations
hypnagogic / hypnopompic hallucinations
drug use
sensory deprivation
acute confusion / migraine / PD
acute anxiety / personality disorder
peak onset of schizophrenia
late adolescence / early adulthood
who is more at risk of schizophrenia
men > women
ethnic monitories > non
prognosis of schizophrenia
25% completely recovered
40% have periods or intervals of recovery lasting several years
10% sustained deterioration with reduced social functioning / negative symptoms
remainder episodic
what factors change prognosis
prognosis worse if early onset
longer duration of untreated psychosis = worse response to medication
better in resource-poor countries
how does schizophrenia affect life expectancy
reduced life expectancy - CVD, suicide etc
social consequence of schizophrenia
93% unemployed
16% never employed
aetiology of schizophrenia
genetic factors
perinatal trauma
winter births
cannabis
paternal age
family effect of schizophrenia
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
genetics of schizophrenia
genes involved in neurodevelopment / environmental brain insults –> aberrant brain development –> predisposition to psychosis
impact of cannabis of schizophrenia
increased positive symptoms, violence and aggression
responsible for 12% of UK schizophrenics
Ddx of schizophrenia
affective psychosis
drug induced psychosis
delirium
personality disorder
physical health conditions
how does schizophrenia differ from affective psychosis
affective psychosis - congruous affect, less likely to have 1t rank Sx, flight of ideas
how does schizophrenia differ from drug induced psychosis
drug induced psychosis - paranoia inducing drugs
how does schizophrenia differ from personality disorder
personality disorder - fleeting psychotic like symptoms, insight preserved
types of physical health conditions that could cause schizophrenia Sx
metabolic disturbance
systemic infection
epilepsy
thyroid issues
stroke
neurodegenerative diseases - Huntingtons, FTD
drug Tx - steroids, anti PD meds
Ix for schizophrenia
Hx and MSE
Physical exam - head to toe
UDS
Bloods - FBC, UEs, lipids, endocrine
EEG / MRI
how does schizophrenia differ from delirium
delirium - visual hallucinations, clouding of consciousness
list 6 core interventions of Schizophrenia
CBT for psychosis
family interventions
treatment with clozapine
physical health assessments / interventions
education / employment support
carer focused education / support
for how long do medications need to be continued / monitored on anti psychotics
1-2 years from point of remission for 1st episode
2 years monitoring after following slow discontinuation
list 1 st generation (typical) antipsychotics
chlorpromazine
haloperidol
what are 1st gen meds
dopmine antagonists
side effects of 1st gen
sedation, extrapyramidal, tardive dyskinesia
list 2nd gen (atypical) antipsychotics
olanzapine
risperidone
aripiprazole
how do 2nd gen work
dopamin, serotonin, adrenergic and histamine effects
side effects of 2nd gen
weight gain, dyslipidaemia, glucose metabolism
how do you decide on which gen to give
depends on which side effects are most beneficial eg if they can’t sleep , then give 1st gen that will make them sleepy
when is clozapine used
treatment resistant schizophrenia (unresponsive to 2 other drugs)
side effects of clozapine
weight gain, sedation, hyper salivation, agranulocysteiss, constipation –> toxic megacolon
what must be done if pt is on clozapine
regular WBC monitoring (weekly for first 18 weeks)
benefits of clozapine
suicidality reduced
increased adherence
increased effectiveness
what Ix are done before starting on an antipsychotic or when the dose is changed
baseline bloods - look at cholesterol, HbA1c
ECG - look at QT interval (<440 in men, 460 in women)
what is the % of death from agranulocytosis in clozapine
0.03%
what is agranulocytosis
not producing any granulocytes eg neutrophils etc so can’t fight infections
what is the adherence to tx in psychosis
50% in 1st year
25% partially / non adherent in first 10 days of discharge
which type of medication has the best adherence in psychosis
depots 75%
how do depots affect relapse
30% lower relapse rate
why aren’t people adherent to their anti psychotics
lack of insight that they’re unwell
side effects
illicit drug use - forget / trading their meds for drugs
family pressures
what is CBTp
CBT for psychosis
what happens in CBTp
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
what % actually undertake CBTp
46%
when should CBTp be offered
all first episode psychosis patients
what are psychosis family interventions
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
benefits of family intervention
improved functioning
reduced relapse and readmission
reduced expressed emotion
carer burden improved by end of Tx
what is expressed emotion in schizophrenia
schizphrenogenic mother - very anxious/overcaring/overinvolved/intrusive can perpetuate schizophrenia and have a negative impact on prognosis - increased relapse, admissions and increased negative symptoms
list physical health interventions in psychosis
smoking
life-style - eating habits, drug habits
weight
exercise
why do we try and stop schizophrenics smoking
smoking impacts level of clozapine in the blood - if they suddenly stop / start smoking then the level of clozapine will go up / down
other social interventions in psychosis
employment and education
- reintegration into society
- crime prevention
- future goals
when are social interventions done
when they are in remission
other psycho-social interventions
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
what anti psychotic is non teratogenic
olanzopine
which drugs have the most impact on pregnancy
mood stabilisers esp lithium - teratogenic
2 services of perinatal mental health
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
what is the toxic trio for ADEs in children
parental mental health issues
drug use
domestic violence
what is the difference between attachment and bonding
attachment is infant to caregiver (develops over 1st year)
bonding is caregiver to infant (develops rapidly)
what effect can a secure attachment between parent and child have on the child
happier, more independent, resilient adults
list features of parenting that lead to secure attachment
consistency, responsiveness, sensitivity
give % of types of attachments in population
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
how can pregnancy affect mental health
unmask subclinical psychiatric symptoms
relapse of pre-existing mental illness
infant can present with disturbances indicative of mothers mental health
is perinatal mental health treatable
yes very treatable
when does post natal psychosis occur most often
within first 2 weeks
what is the largest cause of death occurring within a year after the end of pregnancy
maternal suicide
criteria for referral for perinatal psychiatry
anxiety and trauma related - affects daily functioning, with disproportionate concerns about baby
EDs
affective illness
emergency: psychotic Sx
gender differences of psychosis
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
prevalence of post natal psychosis
2 in 1000
50% first mental health issue
how should post natal psychosis be handled
psychiatric emergency
risks of post natal psychosis
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
PCs of post natal psychosis
can present with anxiety first
mania
paranoid psychosis
rapidly changing mood
perplexity
rapid progression and changing kaleidoscopic picture
perinatal red flags
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
concerning signs in infant
self harming - head banging, not eating, breath holding
distressed - no interest/pleasure, self soothing
developmental delays
Mx of post natal psychosis
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
highest risk of post natal psychosis
bipolar type 1 and previous history and family history
is it murder if woman kills child within first year
no - its manslaughter (Infanticide act 1922) in theory, but hard to persuade juries of this
risks of post natal depression
history of childhood abuse / poor attachment
domestic violence is MAIN ONE
younger, lower socioeconomic class
social perfectionism
fertility Tx / prev preganncy loss
what is the baby blues
up to 48 hours
weepy, emotional lability, irritability
within 1st 2 weeks
differentiate between baby blues and PND
PND has suicude, deep guilt and self harm risks
PND is much longer lived
maternal OCD
obsessions - recurrent unwelcome thoughts
thoughts of them / others harming their baby
constantly waking up baby to check its okay
fear of touching baby
what meds are licensed in pregnancy in psych
NON - they are all used off licence and using minimum effective dose
1st line antidepressant for PND
sertraline
what antipsychotic can’t be used in pregnant women and why
risperidone - 26% cardiac malformations in 1st trimester
which antipsychotic drugs have a stable plasma level in pregnancy
olazapine only
what drug can not be prescribed in pregnancy and why
VALPROATE - highly teratogenic
what is the risk of lithium in pregnant women
Ebsteins abnomally - low risk though (overestimated historically)
what is considered in prescribing in breast feeding
relative infant dose - up to 10% is considered acceptable
what drugs should not be prescribed in breast feeding mothers and why
lithium - variable dose passed into baby
benzodiazepines - build up dose in babies
what drugs can reduce breast milk supply
aripiprazole and promethazine
what are antipsychotics used for
psychosis
depression
Torettes
other conditions
describe the dopamine theory of psychosis
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
list 1st gen antispychotics
chlorpromazine
haloperidol
clopixol
depixol
list 2nd gen antipsychotics
clozapine
olanzapine
quetiapine
risperidone
paliperidone
aripiprazole
how do antipsychotics work
block D2 Rs within mesolithic dopamine pathway
–> modern atypicals work as partial agonists
contrast typical vs atypicals
atypicals have lower risk of EPS due to being serotonin 2A R antagonists, which increases DA in nigrostriatal DA pathway.
what meds can be used as depots (LAIs)
not all of them can be used as depots
clopixol
depixol
haloperidol
olanzapine
aripirazole
benefits of depot
IM injection so good for poor oral compliance
what % of DRs have to be blocked to get clinical benefit
60-80%
how do you prescribe anti-psychotics
start on low dose and titrate up - esp if antipsychotic naive / elderly
how long does it take for anti-psychotics to have an effect
sedative effect within mins-hours
have anti-psychotic benefit after 1-2 weeks
when can you give clozapine
if 2 antipsychotics have been tried to no effect
what is rapid tranquillisation
anti-psychotics used IM for sedative effects
which drugs are used in rapid tranquillisation
- usually olanzapine / haloperidol
what needs to be done pre haloperidol
ECG - look for QT prolongation
when is rapid tranq used
after benzodiazepines and promethazine has been tried
what is accuphase
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
what needs to be monitored post rapid tranq
respiratory rate - can cause respiratory depression
what is HDAT
high dose antipsychotic Tx
above BNF max dose
when is HDAT used
treatment resistant populations
lots in forensics
what is done prior to depot starting
test dose is given to look for side effects
list EPSE of antipsychotics
dystonia
akathisia
Parkinsonism
tardive dyskinesia
time onset / description / Tx of dystonia
occurs in hours - days
sustained muscle contraction - eg can’t open eyes / close mouth
Tx if benzotropine / antihistamine
time onset / description / Tx of akathisia
days to weeks
restlessness - keep moving/fidget
Tx = BBB –> beta blockers, benzodiazepines, benzotropines. Change medications
time onset / description / Tx of parkinsonism
weeks to months of Tx
tremors, rigidity, bradykinesia, postural instability
Tx = switch medication, add in antimuscarinic (procyclidine)
time onset / description / Tx of tardive dyskinesia
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
when does drug induced parkinsonism occur
when 80% of DA neurones are blocked within substantial nigra
how does drug induced parkinsonism differ from PD
bilateral but PD is unilateral
who gets tardive dyskinesia
long term typical antipsychotics, high doses or elderly people
what causes tardive dyskinesia
chronic blockade of D2 Rs in basal ganglia causes them to become hypersensitive
what is tortocolis
head and neck twisted to one side
risk factors of dystonia
antipsychotic nave, young male, high dose typical use
risk of akathisia
increased risk of suicide
risk factors for akathisia
typical antipsychotics but also aripirazole / lurasidone
list side effects of antipsychotics
EPS - parkinsonism, akathisia, tardive dyskinesia, dystonia
hyperprolactinaemia
QT prolongation
metabolic syndrome
Sx of hyperporloactinaemia
F = reduced libido, amenorrhoea, galactorrhea, osteoporosis, increased risk of breast ca
M = reduced libidio, erectile dysfunction, gynaecomastia, galactorrhea
Mx of hyperprolactinaemia
switch to prolactin sparing agent
add in aripiprazole
DA agonists avoided
RULE OUT PROLACTINOMA - do MRI head
what is normal QT interval
<440 males and <470 females
corrected for heart rate
risk of QTc prolongation
VT - Torsade de Pointes
which antipsychotics have the highest effect on QTc
High dose of any antipsychotic
haloperidol
pimozide
which antipsychotics have the lowest effect on QTc
aripirazole - no effect on QTc
clozapine
olanzapine
risperidone
other drugs affecting QTc
citalopram
venflafaxine
clarithromycin
what is meant by metabolic syndrome side effects of antipsychotics
weight gain, dyslipidaemia, insulin insensitivity
Ix for metabolic syndrome effects
monitor weight, BP, lipid profile, HbA1c
Mx of metabolic syndrome effects
treat complications - anti HTN, DM Tx, statins
Lifestyle and healthy eating advice
Sx of neuroleptic malignant syndrome
sweating excessively
agitated
muscle stiffness
high temperature
hyporeflexia
autonomic dysregulation - tachycardia, hypotensive
confusion
what is neuroleptic malignant syndrome
clinical emergency
acute life threatening complication
Rfs for neuroleptic malignant syndrome
high dose typical, rapid dose change, male gender, younger age
prevalence of neuroleptic malignant syndrome
<1% of patients
Ix for neuroleptic malignant syndrome
Bloods - CK (raised), leucocytosis, deranged LFTs and renal functions (secondary to rhabdomyolysis from raised CK)
Mx of neuroleptic malignant syndrome
stop causative antipsychotic
transfer to medics / ITU
supportive care - fluids
benzodiazepines - relax muscles
bromocriptine (DA agonist) and dantrolene (muscle relax)
when is clozapine used
treatment resistant illness
after 2 antipsychotics tried (at least 1 atypical)
how any respond to clozapine
1/3
side effects of clozapine
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
what is clozapine similar to
olanzapine, mirtazapine, quetiapine
clozapine is the only medication with evidence to treat what
treats negative symptoms
downside to clozapine
lots of side effects
high risk of rebound psychosis within 2 weeks of stopping abruptly
how is clozapine prescribed
start at low dose and titrated slowly
restart titration if stopped for 48 hours+
Ix for clozapine
FBC monitoring - neutropenia/leucopenia/agranulocytosis
weekly then fortnightly then monthly after 1 year of Tx
