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Psychotic Disorders Flashcards

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1
Q

What is the strongest risk factor for developing a psychotic disorder?

A

Family history

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2
Q

What is schizoaffective disorder?

A

A mental health condition that combines both symptoms of schizophrenia and a major mood disorder.

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3
Q

What are RFs of schizoaffective disorder?

A
  • Genetics
  • FHx increases risk

> First-degree relatives have an increased risk for both mood disorders and schizophrenia

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4
Q

What are the types of schizoaffective disorder?

A

Manic Type

  • Both schizophrenic and manic symptoms prominent
  • Develop at the same time
  • Single episode, or recurrent disorder (majority manic episodes)

Depressive Type

  • Both schizophrenic and depressive symptoms prominent
  • Develop at the same time
  • Single episode, or recurrent disorder (majority depressive episodes)
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5
Q

What is the DSM-V criteria for diagnosis of schizoaffective disorder?

A

Requires 2 episodes of psychosis:

  1. Symptoms of psychosis without major mood disorder to persist for ≥2 weeks
  2. Major mood episode with schizophrenia symptoms uninterrupted to persist for ≥2 weeks
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6
Q

What is the management of schizoaffective disorder?

A

1st line:

  • BIO: Atypical antipsychotic e.g. olanzapine or quetiapine
  • PSYCHO: CBT, psychoeducation
  • SOCIAL: Social skills training

Consider:

  • Lithium if inadequate response with antipsychotic or mania / mixed manic-depressive symptoms
  • Antidepressant e.g SSRI if depressive symptoms
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7
Q

What is psychosis?

A

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

Affects:

  • Perception (e.g hallucinations)
  • Beliefs (e.g. delusions)
  • Functioning (e.g. loss of insight)
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8
Q

What is delusional mood?

A

A change of mood preceeding a delusion. The mood is often one of perplexity in which the patient senses an unexplicable change in his/her environment.

  • Experiences may solidify into beliefs
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9
Q

What is acute psychosis?

A

Sudden onset psychosis, resolving in <3 months

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10
Q

What are delusions?

A

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

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11
Q

What are delusions of reference?

A

Person believes events are aimed at them

E.g. newspaper article directed at person

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12
Q

What are grandiose delusions?

A

Person believes they have unique significance or power

E.g. person thinks they are the queen.

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13
Q

What are paranoid delusions?

A

Person believes they are being harmed or watched

E.g. van outside the house is filled with people trying to spy on them.

> Can lead to patients not taking their meds

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14
Q

What are delusions of control?

A

Person thinks their thoughts or actions are being controlled

E.g. person thinks an alien is controlling their thoughts.

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15
Q

What are erotomanic delusions?

A

Person thinks someone is in love with them

E.g. thinks Justin Bieber is in love with them.

> Can lead to legal issues e.g. restraining orders

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16
Q

What are hallucinations?

A

Perception in the absence of an external sensory stimulus

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17
Q

What are auditory hallucinations?

A

> Most common

Second person = addressing patient directly
Third person = discussing patient in first person

E.g.

  • Commands in their head
  • Running commentary
  • Random noises
  • Thought echo: repeat patient’s thoughts
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18
Q

What are visual hallucinations?

A
  • Usually simple e.g. flashes of colour
  • Can be clear / identifiable objects
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19
Q

What age does acute psychosis usually occur?

A

The peak age of first-episode psychosis is around 15-30 years

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20
Q

What are the S/S of acute psychosis?

A

Main features:

  • Hallucinations
  • Delusions
  • Disorganised behaviour
  • Disorganised thinking

Associated features:

  • Agitation/aggression
  • Neurocognitive impairment (e.g. in memory, attention or executive function)
  • Depression
  • Thoughts of self-harm
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21
Q

Linking real words incoherently / nonsensical content ?

A

Word salad

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22
Q

Putting words together because of how they sound instead of what they mean?

A

Clanging

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23
Q

Answers diverge from topic and never return?

A

Tangentiality

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24
Q

Little information conveyed by speech / difficulty with speaking / tendency to speak little ?

A

Alogia / poverty of speech

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25
Q

What conditions can acute psychosis occur in?

A
  • Schizophrenia (most common psychotic disorder)
  • Affective disorders - severe depression, BPAD
  • Organic - dementia, delirium
  • Puerperal psychosis
  • Brief psychotic disorder (symptoms last <1 month)
  • Prescribed drugs e.g. corticosteroids
  • Certain illicit drugs e.g. cannabis, phencyclidine
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26
Q

What is the management of acute psychosis?

A

Immediate:
If patient severely agitated

  • 1st line = de-escalation techniques
  • 2nd line = oral BZN e.g. lorazepam
  • 3rd line = rapid tranquillisation e.g. lorazepam

Antipsychotics:

  • Refer to specialist
  • Atypical antipsychotic e.g. olanzapine
  • Procyclidine as required for SE of antipsychotics

Long-term:

  • CBTp to all patients
  • +/- Family interventions
  • Social care and support
  • Support for carers
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27
Q

What is delusional disorder?

A

Persistent / life-long delusions without other psychotic symptoms (no / few hallucinations).

Otherwise function normally e.g. socially / at work.

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28
Q

How is delusional disorder classified based on timescale?

A

<3 months = temporary

≥3 months = persistent

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29
Q

What is the DSM-V diagnostic criteria for delusional disorder?

A
  • Delusions present for at least 1 month
  • No other psychotic symptoms (e.g. cannot include: clear auditory hallucinations, Schizophrenic symptoms)
  • Functioning not affected
  • Other causes ruled out e.g. no evidence of organic/brain disease

NOTE: the presence of an occasional or transitory auditory hallucination does NOT rule out the diagnosis

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30
Q

What is the aetiology/RFs of delusional disorder?

A
  • Old age
  • Social isolation
  • Group delusions
  • Low socioeconomic status
  • Premorbid personality disorder
  • Sensory impairment
  • Immigration
  • FHx
  • Head injury
  • Substance abuse
  • Neurological lesions to temporal lobe, limbic system, BG
  • Cortical damage (persecutory delusions)
  • Distrust, suspicion, jealousy, low self-esteem
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31
Q

What are the S/S of delusional disorder?

A
  • Non-bizarre delusions, rarely hallucinations
  • Process unimpaired, content preoccupied, single theme of thoughts
  • Insight impaired (delusions affect thought and behaviour)
  • Cognition intact
32
Q

Delusion where they believe partner is unfaithful?

A

Othello syndrome / delusional jealously

33
Q

Delusional belief that one or more familiar persons repeatedly change their appearance?

A

Fregoli syndrome

34
Q

Shared delusions/hallucinations between people?

A

Folie á deux

35
Q

Consciously pretending you have a medical illness?

A

Factitious disorder

Patient wants to be sick
Will falsify symptoms

36
Q

What are the investigations for delusional disorder?

A
  • Full history and collateral history + MSE
  • Exclude organic causes
37
Q

What is thought withdrawal / thought broadcasting?

A

Withdrawal = stolen thoughts
Broadcasting = everyone can hear thoughts

38
Q

What are the differentials for delusional disorder?

A
  • Substance-induced
  • Mood disorder with delusions
  • Schizophrenia
  • Dementia + delirium
  • Body dysmorphia
  • OCD
  • Hypochondriasis
  • Paranoid (personality disorder)
39
Q

What is the management of delusional disorder?

A

Biological (limited evidence)

  • Antipsychotics (poor evidence)
  • SSRI (cover other potential missed differentials)
  • BDZ (for anxiety)

Psychological:

  • Individual CBT
  • Psychoeducation

Social:

  • Social skills training
  • Family therapy
40
Q

What is the Early Intervention in Psychosis (EIP) Service?

A

Psychosis is toxic:
The longer a patient is psychotic, the more it will affect their cognitive abilities, insight and social situation. Sooner effective treatment started = better prognosis.

  • Service aims to engage patients with very early symptoms, from adulthood till ~35 years
  • Patients are offered antipsychotics and psychosocial interventions with the aim of keeping the duration of untreated psychosis (DUP) under 3 months
  • 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

41
Q

What is the management for schizophrenia?

A

BIO:

  • 1st line = atypical antipsychotic (e.g. olanzapine)
  • Procyclidine as required for SE of antipsychotics
  • ECT may be required in patients resistant to pharmacological management / need rapid reduction of symptoms
  • Offer combined healthy eating and physical activity programme
  • Offer interventions for metabolic complications of antipsychotics (e.g. weight gain, high cholesterol)
  • Help with smoking cessation

PSYCHO:

  • CBTp offered to all patients (can aid compliance)
  • Family therapy

SOCIAL:

  • Social skills training (targeting accommodation, finances, and daily activities)
  • Support for carers (including education/support programmes, inform them of their right to a formal carer’s assessment)
  • Specialist teams e.g. EIP, assertive outreach, rehab, CC

N.B. 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)

42
Q

Describe typical and atypical antipsychotics

A

Typical Antipsychotics (FGAs)

  • Older drugs
  • Examples = Chlorpromazine, Haloperidol, Flupentixol decanoate
  • Cause EPSEs at normal doses
  • Effective, cheap and provide depot options
  • SEs include sedation

Atypical Antipsychotics (SGAs)

  • Examples = Olanzapine, Risperidone (available as depot), Quetiapine, Aripiprazole, Clozapine, Amisulpride
  • SEs include weight gain, dyslipidaemia, glucose metabolism

Start atypical antipsychotic when:

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

NOTE: Avoid using more than 1 antipsychotic

43
Q

How do atypical antipsychotics work?

A

They block dopamine receptors and serotonin 5-HT2 receptors

44
Q

What is the management of acute dystonia?

A

Procyclidine

45
Q

What are the SEs of antipsychotics?

A

Extrapyramidal Side-Effects (EPSEs):

  • Acute dystonia
  • Akathisia
  • Parkinsonism
  • Tardive dyskinesia

Hyperprolactinaemia:

  • Galactorrhoea, amenorrhoea, gynaecomastia and hypogonadism
  • Sexual dysfunction
  • Increased risk of osteoporosis

Also:

  • Sedation
  • Hypotension
  • Weight gain (especially olanzapine and clozapine)
  • Anticholinergic (dry mouth, blurred vision, constipation, urinary retention, tachycardia)
  • Impaired glucose tolerance - increased risk of diabetes
46
Q

What is acute dystonia?

A

Sustained muscle contraction e.g.

  • Torticollis - twisting of the neck that causes the head to rotate and tilt at an odd angle
  • Oculogyric crisis - involuntary upward deviation of both eyes
47
Q

What is tardive dyskinesia?

A

Sudden, irregular movements which you cannot control:

  • Lip-smacking, chewing, pouting of jaw, excessive blinking, tongue-poking
48
Q

What needs to be monitored during schizophrenia management?

A

Baseline Measurements before starting an antipsychotic:

  • Weight, waist circumference
  • HR and BP
  • Fasting BM, HbA1c, lipid profile, prolactin
  • Assessment of any movement disorders
  • Assessment of nutritional status, diet and physical activity
  • ECG (if cardiovascular RFs present or recommended by chosen medication)

Monitoring:

  • Response to treatment and SEs
  • Emergence of movement disorders
  • Waist circumference
  • Adherence
  • Overall physical health
  • Weight: Weekly for 6w > At 12w > At 1y > Annually
  • HR and BP: At 12w > 1y > Annually
49
Q

Describe treatment resistance in schizophrenia

A

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

  • 1st line = Clozapine
  • Requires weekly blood tests to detect early signs of neutropaenia
  • If there is a lack of response to clozapine, consider augmentation with another antipsychotic
50
Q

What is Schizophrenia?

A

Schizophrenia is a serious mental condition that affects a persons ability to think, feel and behave clearly.

  • Loss of insight
51
Q

What are the S/S of Schizophrenia?

A

Positive symptoms

  • Delusions
  • Hallucinations
  • Disorganised speech e.g. word salad
  • Disorganised behaviour e.g. wearing loads of layers on a hot day
  • Catatonic behaviour (strange movements / responses)

Negative symptoms
Reduction/removal of normal processes e.g. decrease in emotions they can express or loss of interests

  • Flat effect (inappropriate response)
  • Alogia (lack of info in speech)
  • Avolition (decreased motivation)

Cognitive symptoms
Affects memory / learning / understanding

  • Subtle / difficult to notice
  • E.g. unable to keep track of several things at once

+Insomnia

52
Q

Describe the phases of Schizophrenia

A

Prodromal

  • Withdrawn
  • Seems similar to depression / anxiety

Active

  • Severe psychotic symptoms

Residual phase

  • Cognitive symptoms / become withdrawn again
53
Q

What is the DSM-V diagnostic criteria for Schizophrenia?

A

1. Two of the following symptoms:

  • Delusions
  • Hallucinations
  • Disorganised speech
  • Disorganised / catatonic behaviour
  • Negative behaviour

2. At least 1 of them has to be delusions, hallucinations or disorganised speech

3. Must be ongoing for at least 6m, with at least 1m of the active phase symptoms

4. Symptoms can’t be attributable to another condition e.g. substance abuse

54
Q

What is the aetiology of Schizophrenia?

A

Unknown

  • Likely genetic basis
  • Early/prenatal infection and autoimmune disorders have been linked
  • RF = cannabis use
55
Q

Describe the epidemiology of Schizophrenia

A
  • More common in males, less severe sx in females
  • M onset = mid-twenties
  • F onset = late-twenties

> May relate to oestrogen regulation of dopamine

56
Q

What is the prognosis of Schizophrenia?

A
  • Relapses are common (esp if not on antipsychotics)
  • Baseline gets worse after relapse
57
Q

Which factors are associated with poor prognosis in schizophrenia?

A
  • Strong family history
  • Gradual onset
  • Low IQ
  • Prodromal phase of social withdrawal
  • Lack of obvious precipitant
  • Male
  • Earlier onset
58
Q

What are the SEs of clozapine?

A
  • Agranulocytosis (1%), neutropaenia (3%)
  • Reduced seizure threshold - can induce seizures in up to 3% of patients
  • Constipation/intestinal obstruction
  • Myocarditis (CP): a baseline ECG should be taken before starting treatment
  • Hypersalivation
59
Q

If someone on antipsychotics has intolerable SEs, which drug should they be switched too?

A

Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation

60
Q

The repetition of someone else’s speech including the questions being asked?

A

Echolalia

61
Q

What are the risks of using antipsychotics in elderly patients?

A
  • Stroke
  • VTE
62
Q

What is the management of tardive dyskinesia?

A

Tetrabenazine
(if moderate/severe TD)

or switch to an atypical

63
Q

What are the first rank symptoms of schizophrenia?

A

If any symptom is present most of the time for at least 1 month = diagnosis

1. Auditory hallucinations

  • Third person
  • Running commentary
  • Thought echo

2. Passivity of thought

  • Thought withdrawal
  • Thought insertion
  • Thought broadcasting

3. Delusions of control

  • Actions/feelings/impulses under external control
  • Bodily sensations due to external influence

4. Delusional perception

  • Normal perception of common place object/sight leads to sudden, intense, self-referential delusion e.g. see red car = I knew I had 2 souls
64
Q

What are in investigations for schizophrenia?

A

Clinical diagnosis based on criteria

  • History, MSE, & collateral history
  • Urine drug screen
  • Bloods (FBC, U&Es, HbA1c, lipids, endocrine tests)
  • +/- CT/MRI (rule out masses/changes associated with dementia)
65
Q

What are Long Acting Injectable Antipsychotics (LAIs)?

A

Also known as “depots”

  • Antipsychotics that are given via a long acting IM injection rather than as an oral tablet
  • Beneficial for patients with poor oral compliance
  • Loss of insight is a core feature of psychosis, patients can therefore be unwilling to engage in treatment planning as they do not believe they are unwell
  • Not all oral tablets are available as depots
66
Q

What dose of antipsychotic should be used?

A
  • Start at low doses to minimise side effects, especially in those who are antipsychotic naïve as they are at higher risk of experiencing EPSEs
  • Doses are significantly lower in elderly populations
67
Q

What is rapid tranquillisation?

A

IM administration of antipsychotics use to help manage acutely agitated patients (often undertaken with the use of restraint)

  • Olanzapine and haloperidol are most commonly used

Typically antipsychotics are 3rd line choices after benzodiazepines and promethazine have been tried

68
Q

What is the main cardiac SE of antipsychotics?

A

QTc Prolongation

  • Typically should be <440ms in male, <470ms in females
  • QTc prolongation is a RF for developing cardiac arrhythmia’s - specifically Torsade de Pointes

Relative risk:

  • High = haloperidol
  • Moderate = chlorpromazine
  • Low = olanzapine, risperidone
  • Nil = aripiprazole
69
Q

What is the management of drug-induced Parkinsonism?

A
  • Switch medication
  • Procyclidine
70
Q

What can cause a rise in clozapine blood levels?

A

Stopping smoking
Alcohol binging

71
Q

What can reduce clozapine blood levels?

A
  • Starting smoking / smoking more
  • Stopping drinking
  • Omitting doses
72
Q

What is the best course of action to address missed doses of Clozapine?

A

If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly

73
Q

What is used to treat hyper-salivation?

A

hyoscine

74
Q

When a patient thinks a closely related person, usually their loved one, has been replaced by an exact double?

A

Capgras syndrome

75
Q

What is a PET scan likely to show in someone with schizophrenia / any major psych disorder?

A
  • Hypoactivity of prefrontal lobes
  • Enlarged cerebral ventricles
76
Q

Belief that his/her body, mainly their skin, is infested by small organisms or bugs?

A

Ekbom syndrome (delusional parasitosis)

77
Q

What is Munchausen’s syndrome?

A

Purposefully causing symptoms e.g. hypoglycaemia

Aka factitious disorder

Psych (18 decks)

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