Psychotic Disorders Flashcards
Schizophrenia, Schizoaffective disorder, acute psychosis, delusional disorder
A 19-year-old woman is admitted as she has developed severe depression that has resulted in an overdose. She also complains of hearing voices speaking to her directly, saying that she is worthless and incapable. When speaking with her relatives, they noticed a gradual decline in her neurological and psychiatric health. It started with increased impulsivity in the form of shopping sprees uncharacteristic of her. She also would get some dystonic movements in her neck that was treated with physical therapy and muscle relaxants. Her family also noticed that she was more likely to bruise in the preceding 3 months. There is a family history on the mother’s side of psychiatric problems similar to this. They would occur at a similar age.
You take some bloods and notice that her liver enzymes are elevated.
What is the most likely diagnosis?
A. Schizophrenia
B. Wilson’s disease
C. Haemochromatosis
D. Bipolar disorder
E. Melancholic depression
Psychosis is a complication of Wilson’s disease
Neuropsychiatric symptoms is one of the most common manifestations of Wilson’s disease. They may experience depression, anxiety, and psychosis. These patients tend to present when they are teenagers or young adults and there is a family history of similar problems.
It can be easy to misdiagnose this as a psychiatric condition such as depression or schizophrenia. However, it is always important to rule out organic causes. A strong indication that her symptoms were organic in nature was the presence of her physical problems such as dystonia, which would not occur in other psychiatric conditions.
Wilson’s/haemochromatosis: autosomal recessive
Negative symptoms of schizophrenia: (mnemonic):
4As:
1. Alogia (poverty of speech)
2. Anhedonia (inability to derive pleasure)
3. Incongruity/blunting of affect
4. Avolition (poor motivation)
what is thought blocking?
Thought blocking is when a patient may stop speaking all of a sudden, and this can last for a few minutes. When the patient starts speaking again, they will talk about an entirely different topic. This can be similar to thought withdrawal, but the key to the diagnosis is the change of conversation topic.
A 19-year-old man is brought in by his family to the GP due to concerns about a change in behaviour over the past month. He has become quieter and spends less time with his family and friends. He stays in his room all day but does not do much. He does not care about his appearance and personal hygiene anymore. These symptoms started when he moved away from his family to study at a university in another city. He has lost motivation to study. He says his mood is ‘okay’ and does not feel low. He denies suicidal thoughts. He does not smoke cigarettes, drink alcohol or take drugs. His father has schizophrenia, and his sister has generalised anxiety disorder. He has a history of childhood abuse.
What would be the most appropriate next step in management given the likely diagnosis?
A. Prescribe haloperidol
B. Refer immediately to specialist mental health team
C. Prescribe sertraline
D. Refer to cognitive behavioural therapy
E. Review in one week time
B. Refer immediately to specialist mental health team
This man is showing signs and symptoms of prodromal schizophrenia – being socially withdrawn, loss of motivation in life, poor personal hygiene and lack of interest in day-to-day activities. These are also the negative symptoms of schizophrenia. This diagnosis is further supported by the predisposing factors: family history of schizophrenia and history of childhood abuse. It is likely precipitated by poor coping skills in transition to university studies. Prodromal schizophrenia can often be confused with depression or other mental health conditions. It is crucial, however, to recognise prodromal schizophrenia so that early interventions can be offered. NICE guidelines state that if a person is distressed, has a decline in social functioning and a first-degree relative with schizophrenia - refer them for assessment without delay to a specialist mental health service or an early intervention in psychosis service because they may be at increased risk of developing psychosis.
what are delusional perceptions? Eg:
Delusional perceptions are a 2 stage process where a normal object (in this case, the Queen on television) is perceived and secondly there is a delusional insight into its meaning (the mafia being sent to murder him). They are a key feature in schizophrenia
Which of the following features in the history is linked to a good prognosis for this patient?
A. Gradual onset
B. High IQ
C. History of social withdrawal prior to episode
D. Lack of obvious precipitant
E. Strong family history
B. High IQ
Factors associated with a better prognosis
There are a number of prognostic indicators in schizophrenia. The following are factors associated with a better prognosis:
- High IQ/education level
- Sudden onset
- Obvious precipitating factor such as a traumatic life event
- A strong support network
- Positive symptoms predominant
what indicators are associated with better prognosis for schizophrenia?
- High IQ/education level
- Sudden onset
- Obvious precipitating factor such as a traumatic life event
- A strong support network
- Positive symptoms predominant
what is the rule of quarters in schizophrenia?
-25% never have another episode
-25% improve substantially on treatment
-25% have some improvement
-25% are resistant to treatment.
what conditions can mimic schizophrenia?
- Substance induced psychotic disorder (commonly drugs of abuse, but can be iatrogenic e.g. steroids)
- Organic psychosis caused by infection, brain injury and CNS diseases such as Wilson’s disease
- Metabolic disorder such as hyperthyroidism and hyperparathyroidism
- Dementia and depression can also co-occur with psychosis
A 24 year old man, who has not had any previous contact with mental health services, presents to his GP saying he has been hearing voices for the last two months. The voices comment on his behaviour as he goes about his daily routine and can be derogatory in nature. He is certain that other people are putting thoughts into his mind and he cannot be persuaded otherwise. What is the most appropriate first-line treatment?
A. Clozapine
B. Risperidone
C. Haloperidol
D. Sertraline
E. Lorazepam
B. Risperidone
This is the correct answer. This man is experiencing auditory hallucinations which provide running commentary, as well as thought insertion, for more than one month, fitting diagnostic criteria for paranoid schizophrenia. This is treated first-line with atypical antipsychotics such as Risperidone
Not C: Haloperidol
While Haloperidol is an antipsychotic, it is a typical (or ‘first generation’) antipsychotic, which carries an increased risk of extra-pyramidal side effects than atypical antipsychotics such as Risperidone, and so they are no longer used first-line in the treatment of psychotic disorders like paranoid schizophrenia
1st line medication for schizophrenia
Atypical antipsychotic eg risperidone (not typical eg haloperidol)
A young male with schizophrenia says the MI5 have been sending him secret messages through newspapers and radio broadcasts. He has a large folder full of newspaper clippings with no connection between them all and random words highlighted to form sentences.
What type of thought disorder is exhibited?
A. Delusional perception
B. Thought withdrawal
C. Thought blocking
D. Thought insertion
E. Thought broadcasting
A. Delusional perception
Delusional perception is when a patient attributes a false meaning to a true perception. An example of might be a TV presenter wearing a blue tie means that it is dangerous to go outside today.
Not D: Thought insertion
Thought insertion is the delusion that some of their thoughts are not their own but have been implanted by an outside agency. So, this would be true if the patient said the MI5 was sending messages telepathically to him.
what is alogia?
poverty of speech
what are some atypical antipsychotics
quetiapine, olanzapine, risperidone, paliperidone (metabolite of risperidone), aripriprazole, clozapine
A 25-year-old man has been diagnosed with schizophrenia after being found behaving strangely in public.
Which of the following features in his history is most associated with an increased risk of developing schizophrenia?
A. Smoking marijuana twice as a teenager
B. Maternal grandfather diagnosed with schizophrenia
C. Living in a rural area
D. Living in a less economically developed country
E. Being born in the summer months
B. Maternal grandfather diagnosed with schizophrenia
The risk of developing schizophrenia is increased with a positive family history. The risk of developing schizophrenia with an affected grandparent is around 3-5% (compared to a background risk of 1%)
Urban living has been linked to an increased risk of developing schizophrenia, rather than a rural environment
Urban> rural
-more developed country vs less developed
-winter months (slightly increased risk, ? influenza exposure to mother)
risk of schizophrenia:
A) 1st cousin
B) affected grandparent
C) either a parent or sibling
D) both parents/identical twin
A) 2% risk with an affected first cousin
B) 5% risk with an affected grandparent, aunt/uncle, niece/nephew
C) 10% risk if either a parent or sibling is affected
D) 50% if both parents are affected or an identical twin is affected
Background risk of schizophrenia
1% background risk
lifetime risk of mental health disorder needing treatment:
1 in 6 will need treatment for mental ill health during their lifetime.
Schizophrenia charities
SANE: schizophrenia helpline
Rethink.org (schizphrenia support groups)
mentalhealth uk.org
Investigations for schizophrenia:
- CT/MRI head
- HIV and syphilis screen
- Drug testing (urine drug screen)
- Routine bloods including FBC and TFTs
-endocrine disorders eg Wilson’s disease (copper levels), Thyroid (TFTs) - physical exam (neuro)
symptoms of catatonia (mnemonic):
WRENCHES
* Waxy flexibility (Patient’s limb can be placed in awkward posture and remain fixed in position for long time despite asking to relax)
- Rigidity
- Echopraxia (Imitation by the patient of interviewer’s movements)
- Negativism (Gegenhalten is opposition of passive movements by patient with a force equal to that being applied; Negativism is an extreme form of gegenhalten – motiveless resistance to suggestion/attempts of movements)
- Catalepsy (Motor symptom of schizophrenia same as waxy flexibility)
- High level of motor activity
- Echolalia (Repetition by the patient of the interviewer’s words/phrases)
- Stupor, Stereotypy (Regular, repetitive non-goal directed movements)
Types of schizophrenia (mnemonic):
PHC (primary healthcare) U R SO far
- Paranoid: The commonest type and good prognosis. The onset is later in life 3-4th decade. Major symptoms are delusion of persecution and grandeur.
- Hebephrenic (disorganised): 2nd most common and the worst prognosis. Disorganisation of thought/chaotic mood, speech, affect and personality is more prominent than other types. Also there is marked emotional impairment.
-child-like
-shallow & inappropriate affect - Catatonic: The best prognosis (especially reactive catatonia). Characterised by marked disturbance in motor activity. Further divided into 3 forms i.e. Excited, Stuporous, and one alternating between the two.
- Undifferentiated: Where symptoms do not fit in any subtypes.
- Residual: Chronic type where the positive symptoms vanish and patient is left with ‘residual’ negative symptoms
- Simple: only negative symptoms from onset (no positive symptoms at all)
- Others (f):
Schizophrenia + mental retardation = Pfropf syndrome
Schizophrenia + self-mutilation = Van-Gogh syndrome
drugs that can cause psychosis
TB drugs eg isoniazid, ethambutol
C: cannabis, cocaine
differentials of psychosis:
psychosis vs schizophrenia
positive & negative symptoms of psychosis:
“Positive’ symptoms are changes in thoughts and feelings that are “added on” to a person’s experiences (e.g., paranoia or hearing voices).
“Negative” symptoms reflect a decrease in, or loss of, normal functions. These symptoms are often less evident than positive symptoms and require careful assessment.
Some examples of negative symptoms include:
- inexpressive faces; little display of emotions
monotone and one-syllablexs (eg flat affect)
Negative symptoms reflect a decrease in, or loss of, normal functions. These symptoms are often less evident than positive symptoms and require careful assessment.
Some examples of negative symptoms include:
4As:
- Inexpressive faces: little display of emotions
monotone and one-syllable (eg flat affect) - general reduction in speech (poverty of speech/alogia)
- few gestures
- difficulties in thinking or coming up with ideas
- decreased ability to start initiate tasks
- lowered levels of motivation or drive (avolition)
- lack of interest in other people (asociality)
- inability to feel pleasure (anhedonia)
- lack of spontaneity
NMS vs SS
serotonin syndrome, which is often seen when serotonergic drugs are used in combination. These drugs include antidepressant medications and recreational drugs such as ecstasy and cocaine
NMS: tetrad of hypertonia, hyperthermia, autonomic instability and mental state change in the context of an anti-psychotic medication. This suggests the likely diagnosis of neuroleptic malignant syndrome (NMS). Creatinine kinase is often very high, especially in the context of severe rigidity.
In NMS patients can present with fever, muscular rigidity often with super-imposed tremor, profuse diaphoresis, labile or high blood pressure, tachycardia, tachypnoea, confusion and delirium, sometimes with mutism or catatonia. It is an idiosyncratic reaction to anti-psychotics, most commonly occurring within weeks of starting or increasing the dose. It is more common with first generation typical anti-psychotics.
Diagnostic criteria for schizophrenia (in absence of intoxication, epilepsy, mania or cerebral damage) ie schneiders 1st rank symptoms, mnemonic:
DEAD
PHDT:
Passivity phenomenon
Hallucinations (auditory)
(1. Thought echo
2. 3rd person voice
3. Running commentary)
Delusional perception
Thought disorder (broadcasting, withdrawal, insertion)
Positive symptoms of schizophrenia (type 1 schizophrenic symptoms)
THREAD
Acute dystonia vs tardive dyskinesia:
acute dystonia: torticolis, oliguric crisis
-involuntary muscular contractions that can affect the head, face, and neck
Tardive dyskinesia causes involuntary movements most commonly in areas of the face, eyes, and mouth.
Typical antipsychotics summary EPSEs
Types of EPSEs summary
antipsychotic management
