Psychotic Disorders Flashcards
Define and State the ICD11 criteria for Schizophrenia
Characterised by significant impairments in reality testing and alterations in behaviour that last <1 month with atleast 2 symptoms. 1 of which is from the first 4:
1) Persistent delusions
2) Persistent hallucinations
3) Formal thought disorder (disorganised thinking, circumstantiality, tangentiality)
4) Experiences of passivity or control
5) Negative symptoms (Flat affect, alogia, avolition, anhedonia etc)
6) Bizarre behaviour and plans with no logical goal
7) Psychomotor disturbances (Catatonic restlessness, agitation, posturing)
What is an insidious onset? is it usually better or worse for prognosis of psychotic disorders
Slow onset and it indicates worse prognosis
A Prodromal phase typically precedes some conditions such as schizophrenia and schizoaffective disorder. What are some signs of the prodromal phase?
Inversion of sleep cycle
Increased anxiety and agitation
Avolition
Self-neglect (personal hygiene)
Anhedonia
Schizophrenia is characterised by having both positive and negative symptoms
Name and define the negative symptoms (incl. 5As)
What do negative symptoms indicate about prognosis?
After prescribing medication what is expected to occur with the negative symptoms?
How is gender associated with these symptoms?
Negative symptoms: Flattened Affect, Alogia (impoverished speech), Abolition (Lack of drive/motivation), Apathy (Indifference/lack of suppression of emotions), Anhedonia (lol), Asociality (lol2), Attention disturbances (Neurocognitive deficit)
Indicates poorer prognosis
Medications and treatment often resolve many positive symptoms yet the negative ones remain for the long-term.
Women are more likely to have more positive symptoms and co-occurence of other mental/mood disorders => schizoaffective disorder. Men are more likely to have schizophrenia and more pronounced negative symptoms.
State the dopamine hypothesis for psychosis
Increased dopamine in mesolimbic system which controls behaviour and gives rise to positive symptoms such as hallucinations.
Decreased dopamine in mesocortiyal system => affecting cognitive function
What is the rating scale for schizophrenia?
PANSS. Positive and Negative syndrome scale
A patient was referred to your clinic after being referred by the GP for bizarre behaviour and suspicion of schizophrenia. On interview, you realise that there are only negative symptoms. What are your differentials?
Depressive disorder
Substance misuse
Physical illness cut as hypothyroidism, malignancy, Alzheimers.
Autism spectrum (significant difficulties with social interactions)
What is the heritability of schizophrenia and what are the chances of identical twins both developing schizophrenia?
80%
50%
What known genetic mutation results in 25% of people with the mutation developing schizophrenia?
Microdeletion of Chromosome 22q11
Children who later develop schizophrenia are distinguished from their peers by? (give 3)
Delayed developmental milestones
worse academic performance
Lower IQ
Believing other people can hear them, delusions of reference, believing people are spying on them
Give 3 brain abnormalities seen on CT/MRI for schizophrenic patients including what lobes and matter affected
What can be seen on FMRI?
CT/MRI: Increased ventricle/brain ratio
Cortical volume loss (smaller brain) especially in temporal lobe affecting grey matter more than white
Widened Sulci
FMRI: Disconnectivity between frontal and temporal lobes.
What are the top 3 causes of death in schizophrenic patients?
Natural death
CVD death
Malignancy
Define schizoaffective disorder
How would you manage a patient with schizoaffective disorder?
All diagnostic requirements of schizophrenia and a moderate/severe mood disorder episode met concurrently for at least 1 month!
If paired with depressive disorder, give antidepressant with antipsychotic. If paired with manic/BPAD, then give mood stabiliser (lithium) with antipsychotic.
Define Schizotypal disorder via full ICD-11 Criteria
The weird kid: An enduring pattern of unusual perceptions, beliefs, and behaviours that are not sufficient for schizophrenia nor delusional disorder with the following symptoms:
1. Blunted Affect (appears cold and Aloof (not friendly/forthcoming)
2. Behaviour and Appearance appears bizarre/unusual and inconsistent with cultural norms (Lucky trenchcoat they wearing lucky trench coat on a hot day).
3. Social withdrawal and poor rapport
4. Perceptual distortions (derealisation/depersonalisation, intense illusions/hallucinations)
5. Paranoid delusions: constantly suspicious
6. Obsessive ruminations without a sense that it is foreign, unwanted, or unusual (putting scarecrows on room for a month)
What is acute and transient psychotic disorder?
it is the
1. acute onset of psychotic symptoms (onset <2 weeks) and
2. duration <3 months (normally week-1month) with
3. dramatic day-day changes with the absence of
4. absence of negative symptoms during episode!!
Every disorder has a common ICD criteria that should be mentioned. This criteria also gives you 2 differentials that can apply to any case.
Symptoms are not a manifestation of another medical condition such as hyperthyroidism and are not due to the effects of a substance or medication on the central nervous system including withdrawal effects. It is also important that the symptoms result in significant distress and impact on daily life
Gives organic cause and substance-induced disorder
What are the most common of delusions in delusional disorder and define it.
Delusional disorder is characterised by the presence of delusions (most commonly nihilistic delusions, persecutory delusions, grandiosity, jealousy, and infidelity) with the absence of any formal thought disorder or perceptual abnormalities.
What must the duration of psychotic symptoms be to qualify as diagnosable?
1 week/7 consecutive days
2/3 of new onset psychosis occurs below the age of 35 and 15% before 18. The duration of untreated psychosis (DUP) is clinically significant as it is associated with worse outcomes for the patient. It is comprised of 2 components what are they?
What psychological intervention can be used to reduce this?
First Delay = Help seeking delay: delay between the onset of symptoms and the time the individual or family seeks help.
Second Delay = Treatment seeking delay: Delay between seeking help and receiving appropriate treatment.
EIP - Early intervention in psychosis.
When prescribing any antipsychotic, how would you manage the dosage?
once you’ve chosen an antipsychotic, titrate to minimum effective dose and then adjust for therapeutic response. This is then assessed over 2-3 weeks
You’ve prescribed an antipsychotic 2-3 weeks ago and the patient has come back to you for the scheduled review. Based on your investigations and interview, the antipsychotic has been effective. What is your next course of action?
Continue at the dose and consider switching to depot for discharge
You’ve prescribed an antipsychotic 2-3 weeks ago and the patient has come back to you for the scheduled review. Based on your investigations and interview, the antipsychotic has not been effective at all. What is your next course of action?
also consider the scenario where the plan you suggested also did not work
Change drug and repeat the titration to minimum effective dose and work up as if it was a new drug.
If that still doesn’t work, switch to clozapine
If that still doesn’t work the augment clozapine with haloperidol, risperidone or aripriprazole
You’ve prescribed an antipsychotic 2-3 weeks ago and the patient has come back to you for the scheduled review. Based on your investigations and interview, the antipsychotic has been somewhat effective. What is your next course of action?
Increase dosage
You’ve prescribed an antipsychotic 2-3 weeks ago and the patient has come back to you for the scheduled review. Based on your investigations and interview, the antipsychotic is not being tolerated. What is your next course of action?
Change the drug and repeat the titration to minimum effective dose and work up as if it was a new drug
You’ve prescribed an antipsychotic 2-3 weeks ago and the patient has come back to you for the scheduled review. Based on your investigations and interview, the antipsychotic has not been effective due to poor compliance. What is your next course of action?
Find out reason behind the patient’s non-adherence and change from oral to depot such as haloperidol, paliperidone or aripiprazole
What investigations would you carry out for any antipsychotic? What are the typical intervals for monitoring after starting medication?
Based on these investigations and your own knowledge give 6 side effects of 2nd generation antipsychotics (no EPSE shit here)
There is one rare but severe side effect of antipsychotics what is it called?
weight, bloods (blood lipid profile, fasting glucose, HbA1c, Prolactin/calcium), pulse and BP, ECG: when starting > at 12 weeks > at 1 year > annually
waist circumference: yearly
Impaired glucose tolerance, dyslipidemia (increased cholesterol), weight gain, hypertension, postural hypotension, increased prolactin, sedation, sexual dysfunction, QT prolongation.
NMS - Neuroleptic malignant syndrome
What receptors do first generation antipsychotics target?
What does targeting these receptors do?
What drug is the most potent and hence the most likely to have these symptoms?
What pathway is involved here?
What type of symptoms in schizophrenia are these drugs most effective at treating?
D2 receptors which are D2,3,4. They cause EPSEs beginning with acute dystonia > akathisia > Parkinsonism > tar dive dyskinesia (tx by clozapine)
Haloperidol
Nigrostriatal pathway
Positive symptoms
What receptors do second generation antipsychotics target?
What does targeting these receptors do?
What pathways are involved here and what type of symptoms in schizophrenia are these drugs most effective at treating for each pathway (including the pathway causing a side effect)
5HT (serotonin) and D2 (D234)
metabolic effects (increased weight and glucose tolerance) + a little bit of anticholinergic effects
Pathways: Mesolimbic (-ve symptoms), Mesocortical (cognitive sx), Tuberofundibular (causes increased prolactin)
What drug is the most susceptible to Neuroleptic malignant syndrome?
What are the main symptoms of NMS?
Give 2 essential investigations to conduct in this case
Give your management plan.
In severe cases, a major complication may occur (must have stated in symptoms or you’re an idiot). How would you treat that specifically?
Haloperidol as risk increases with potency
Lead pipe muscle rigidity, Autonomic dysfunction (tachycardia, tachypnea, hypotension, diaphoresis), leukocytosis, Rhabdomyolysis
Investigations: Mainly LFT (due to increased transaminases) and Serum CPK (increased CPK/urinary myoglobin)
Management:
1. Stop antipsychotics for at least 5 days and start back slowly and monitor CPK levels especially when restarting
2. Supportive measures such as IV fluids and O2
3. Benzo (Lorazepam) for rigidity
4. Dopamine agonist (Bromocriptine) to reverse dopamine blockage
In cases where rhabdomyolysis occurs, give IV sodium bicarbonate for alkalisation of urine + prevent renal failure
To start Clozapine, you need a normal leukocyte count. What is the normal WBC count and Neurophil count?
How often is it monitored?
WBC > 3,500/mm3
Neutrophils > 2000mm3
Weekly for first 18 weeks, then fortnightly until 1 year and then mostly thereafter
What are the indications for clozapine
treatment resistant schizo or mania
Psychosis in parkinsons, Huntingtons and tar dive dyskinesia
When monitoring for plasma levels of clozapine, what are you looking for? at what value is it therapeutic and at what value would it indicate poor compliance? What would a value of over 3 indicate?
Clozapine/Norclozapine (active substance) ratio
Normal = 1.33
Poor compliance <0.5
Not at trough stage/not settled yet) >3
What are the main side effects of clozapine other than agranulocytosis (give 6).
Among antipsychotics, clozapine has the most weight gain, highest risk of hypertension and reduces seizure threshold the most
SE: Weight gain, Hypertension, Hypotension, Seizures, Hypersalivation, tachycardia, QTc prolongation, sedation
Where are depot injections given?
What are the side effects of depot injections vs oral?
What are the indications?
Deltoid or glues maximus
Same as oral but also pain at injection site
Indications: Poor compliance (incl. due to memory) and if failure to respond to oral
State the frequency of receiving depot injections for the following drugs
Haloperidol, olanzapine, Risperidone, paliperidone, aripriprazole
Risperidone: 2 weeks
Haloeridol and olanzapine: 2-4 weeks
Aripriprazole: Monthly
Paliperidone: up to every 3 months but given like this
Loading dose, 1 week later, monthly for 4 months, then every 3 months
What psychological interventions should be given to all patients with psychosis?
CBT 1 on 1 for at least 16 weeks
Family intervention (including patient if possible)
Art therapies
note: do not give adherence training to social skills training
Differentiate between primary and secondary delusions
Primary delusions have no rationale and come out of the blue. “I am being tracked by the government:
Secondary delusions have some rationale behind them. “The reason I hear cameras and monitoring equipment in my home is because I am being tracked by the government”
Define delusion
Fixed false belief not inkeeping with the individual’s cultural or societal norms. Cannot be argued against.
What are abnormalities of thought form expected to see in psychosis?
Circumstantial thinking: Unnecessary trivial details but eventually, the goal (e.g. answering the question) is reached
Tangential thinking: Goal not reached
Flight of Ideas: Logical connection between sequential ideas is maintained but the flow is accelerated (esp. if hx of bipolar/schizoaffective)
How would schizophrenia differ in childhood onset?
Hallucinations tend to be less complex/elaborate. Hallucinations are also more common than delusions and tend to be the presenting complaint
Marked changes in affect
