Psychotic Disorders

Question 1

Define and State the ICD11 criteria for Schizophrenia

Answer 1

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)

Question 2

What is an insidious onset? is it usually better or worse for prognosis of psychotic disorders

Answer 2

Slow onset and it indicates worse prognosis

Question 3

A Prodromal phase typically precedes some conditions such as schizophrenia and schizoaffective disorder. What are some signs of the prodromal phase?

Answer 3

Inversion of sleep cycle
Increased anxiety and agitation
Avolition
Self-neglect (personal hygiene)
Anhedonia

Question 4

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?

Answer 4

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.

Question 5

State the dopamine hypothesis for psychosis

Answer 5

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

Question 6

What is the rating scale for schizophrenia?

Answer 6

PANSS. Positive and Negative syndrome scale

Question 7

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?

Answer 7

Depressive disorder
Substance misuse
Physical illness cut as hypothyroidism, malignancy, Alzheimers.
Autism spectrum (significant difficulties with social interactions)

Question 8

What is the heritability of schizophrenia and what are the chances of identical twins both developing schizophrenia?

Answer 8

80%
50%

Question 9

What known genetic mutation results in 25% of people with the mutation developing schizophrenia?

Answer 9

Microdeletion of Chromosome 22q11

Question 10

Children who later develop schizophrenia are distinguished from their peers by? (give 3)

Answer 10

Delayed developmental milestones
worse academic performance
Lower IQ
Believing other people can hear them, delusions of reference, believing people are spying on them

Question 11

Give 3 brain abnormalities seen on CT/MRI for schizophrenic patients including what lobes and matter affected
What can be seen on FMRI?

Answer 11

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.

Question 12

What are the top 3 causes of death in schizophrenic patients?

Answer 12

Natural death
CVD death
Malignancy

Question 13

Define schizoaffective disorder

How would you manage a patient with schizoaffective disorder?

Answer 13

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.

Question 14

Define Schizotypal disorder via full ICD-11 Criteria

Answer 14

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)

Question 15

What is acute and transient psychotic disorder?

Answer 15

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!!

Question 16

Every disorder has a common ICD criteria that should be mentioned. This criteria also gives you 2 differentials that can apply to any case.

Answer 16

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

Question 17

What are the most common of delusions in delusional disorder and define it.

Answer 17

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.

Question 18

What must the duration of psychotic symptoms be to qualify as diagnosable?

Answer 18

1 week/7 consecutive days

Question 19

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?

Answer 19

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.

Question 20

When prescribing any antipsychotic, how would you manage the dosage?

Answer 20

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

Question 21

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?

Answer 21

Continue at the dose and consider switching to depot for discharge

Question 22

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

Answer 22

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

Question 23

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?

Answer 23

Increase dosage

Question 24

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?

Answer 24

Change the drug and repeat the titration to minimum effective dose and work up as if it was a new drug

Question 25

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?

Answer 25

Find out reason behind the patient’s non-adherence and change from oral to depot such as haloperidol, paliperidone or aripiprazole

Question 26

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?

Answer 26

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

Question 27

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?

Answer 27

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

Question 28

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)

Answer 28

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)

Question 29

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?

Answer 29

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

Question 30

To start Clozapine, you need a normal leukocyte count. What is the normal WBC count and Neurophil count?
How often is it monitored?

Answer 30

WBC > 3,500/mm3
Neutrophils > 2000mm3
Weekly for first 18 weeks, then fortnightly until 1 year and then mostly thereafter

Question 31

What are the indications for clozapine

Answer 31

treatment resistant schizo or mania
Psychosis in parkinsons, Huntingtons and tar dive dyskinesia

Question 32

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?

Answer 32

Clozapine/Norclozapine (active substance) ratio
Normal = 1.33
Poor compliance <0.5
Not at trough stage/not settled yet) >3

Question 33

What are the main side effects of clozapine other than agranulocytosis (give 6).

Answer 33

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

Question 34

Where are depot injections given?
What are the side effects of depot injections vs oral?
What are the indications?

Answer 34

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

Question 35

State the frequency of receiving depot injections for the following drugs
Haloperidol, olanzapine, Risperidone, paliperidone, aripriprazole

Answer 35

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

Question 36

What psychological interventions should be given to all patients with psychosis?

Answer 36

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

Question 37

Differentiate between primary and secondary delusions

Answer 37

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”

Question 38

Define delusion

Answer 38

Fixed false belief not inkeeping with the individual’s cultural or societal norms. Cannot be argued against.

Question 39

What are abnormalities of thought form expected to see in psychosis?

Answer 39

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)

Question 40

How would schizophrenia differ in childhood onset?

Answer 40

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