PSYCHOTIC DISORDERS Flashcards
What are the main types of psychotic disorders?
Schizophrenia Schizoaffective disorder Delusional disorder Acute psychosis Transient psychosis
What does the term schizophrenia actually mean?
Splitting of the mind
What is the incidence of schizophrenia in the UK?
15/100 000 per year
What is the prevalence of schizophrenia in the UK?
1%
What is the typical age of onset for schizophrenia?
Late teens to mid-30s
Which gender group tends to see a later average age of onset of schizophrenia?
Female (25-35)
Male (18-25)
Members of which gender group are more likely to develop schizophrenia?
Males (1.4:1), however, the prevalence is actually the same (1%) most likely due to higher mortality in males
Is schizophrenia a disease of the rich or of the poor?
There is increased prevalence in lower socioeconomic classes. However, this is probably more likely the result of social drift (impairment as a result of disease leading to drift down social scale) than social causation.
Which groups in the UK are most classically associated with schizophrenia?
Migrants (relative risk of 4.6)
What are some of the positive symptoms of schizophrenia?
Hallucinations
Delusions
Ideas of reference
What are the negative symptoms of schizophrenia?
Under-activity Few leisure interests Lack of convention Social withdrawal ↓ speech ↓ motivation ↓ emotional responsiveness (flat affect)
What does the terms “ideas of reference” mean with regard to schizophrenia?
It is “the notion that everything one perceives in the world relates to one’s own destiny.”
What are the most commonly seen symptoms in acute schizophrenia?
Lack of insight (94%)
Auditory hallucinations (74%)
Ideas of reference (70%)
What are the most commonly seen symptoms in chronic schizophrenia?
Social withdrawal (74%) Under activity (56%) Lack of convention (54%)
What are the types of auditory hallucinations seen with schizophrenia?
Complex hallucinations such as:
Hearing thoughts aloud (1st person)
Hearing thoughts discussing patient (3rd person)
Hearing running commentary
These occur more commonly than more elementary hallucinations such as a single repeated sound or indeed than 2nd person auditory hallucinations which tend to be more associated with mood disorders with a psychotic element.
What are the 5 characteristic symptoms of schizophrenia as set out in criterion A of the DSM-V?
- Delusions
- Hallucinations
- Disorganized speech
- Grossly disorganized or catatonic behavior
- Negative symptoms (i.e., diminished emotional expression or avolition)
What criteria does the ICD-10 set out for the diagnosis of schizophrenia?
At least one of:
• Thought echo, insertion, withdrawal, and broadcast
• Delusions of control, influence, or passivity
• Voices giving a running commentary or discussing
• Persistent delusions of other kinds
…or at least two of: • Other hallucinations • Thought disorder • Catatonic behaviour, • "negative" symptoms • Significant and consistent change in behaviour
For at least a month, in absence of intoxication, brain disease or extensive manic / depressive symptoms.
What are the predominant features of paranoid schizophrenia versus other forms of schizophrenia?
Prominent delusions, usually + hallucinations
What are the predominant features of hebephrenic schizophrenia versus other forms of schizophrenia?
Prominent disorganized mood, behaviour, speech.
What are the predominant features of residual schizophrenia versus other forms of schizophrenia?
After a period of positive symptoms subside, negative symptoms remain
What are the predominant features of simple schizophrenia versus other forms of schizophrenia?
Negative symptoms, without positive symptoms
What is the difference between a hallucination and an illusion?
Hallucinations are perceptions occurring in the absence of any external stimulus. (eg hearing a voice)
Illusions are misperceptions of real external stimuli. (eg perceiving a hanging coat as a person)
What is the difference between a hallucination and a pseudohallucination? Are both associated with schizophrenia?
Pseudohallucinations are perceived within the mind and the patient recognises that they are not real external stimuli. (eg a voice inside my head). They tend not to be associated with true psychotic experiences, despite sometimes being very traumatic.
Hallucinations are perceived as real external stimuli and therefore insight tends to be reduced. (eg an invisible person talking to me). They are one of the classic symptoms of psychosis.
Are visual hallucinations typically associated with schizophrenia?
No, they tend to be more associated with organic disturbances of the brain. This includes delirium, occipital lobe tumours, epilepsy and dementia. Certain substances can also induce visual hallucinations - LSD, petrol/glue sniffing, alcoholic hallucinosis.
Apart from visual and auditory hallucinations, what other types of hallucinations do patients sometimes report?
Somatic hallucinations - tactile, kinaesthetic, visceral
Olfactory hallucinations
Gustatory hallucinations
Is a delusion always false?
No. A delusion might end up being true but what makes it a delusion is the logic used to come to the conclusion.
Eg. A man’s delusional belief that his wife is having an affair may actually be true, but it remains a delusion because the logic behind his belief is that she is part of some top secret sexual conspiracy to prove that he is homosexual.
What are the different ways that we classify a delusion?
- Primary or secondary
- Mood congruent or mood incongruent
- Bizarre or non-bizarre (impossibility)
- By content
What is the difference between a primary and a secondary delusion?
Primary delusions appear suddenly without any mental event leading to them.
Secondary delusions occur secondary to a morbid experience,
such as a change in mood, an hallucination, or another delusion.
What is an overvalued idea with reference to psychosis?
A plausible belief that a patient becomes preoccupied with to an unreasonable extent.
What are the thought disorders that are common symptoms in the psychotic patient?
Circumstantial speech Tangential speech Flights of ideas Idea crowding Derailment (Knight's move thinking) Thought blocking Neologism Perseveration Echolalia Irrelevant answers
What is circumstantial speech/thinking (one of the thought disorders of psychosis and mania)?
Speech or thought that is delayed in reaching its final goal because of the over inclusion of detail and diversions.
What is tangential speech/thinking (one of the thought disorders of psychosis and mania)?
Speech or thought that never reaches its destination as the speaker diverts from the original train of thought and never ends up returning to the original point. This is more psychopathological than circumstantial speech which is often found in normal individuals.
What is flight of ideas (one of the thought disorders of psychosis and mania)?
This is markedly accelerated thinking resulting in a stream of connected concepts. In schizophrenia the link between the different ideas become incoherent.
What is loosening of association (derailment/knight’s move thinking)?
This is when a patient’s train of thought shifts suddenly from one very loosely or unrelated idea to the next.
What is thought blocking (one of the thought disorders of psychosis)?
The patient experiences a sudden cessation to their flow of thought, often in mid sentence (observed as sudden breaks in speech)
What is neologisms and idiosyncratic word use (thought disorders of psychosis)?
Neologisms are new words created by the patient that have no meaning to anyone else.
Idiosyncratic word use is using words in the wrong context.
What is perseveration (one of the thought disorders of psychosis)?
The patient repeats the initially correct response to a question, either as an answer to the next question or without prompting.
What is echolalia (one of the thought disorders of psychosis)?
This is when the patient senselessly repeat words or phrases spoken around them by others. This can land the patient in trouble if they echo someone who is unaware of their condition.
What are the psychomotor abnormalities that a schizophrenic patient might present with?
Catatonia
Echopraxia
Mannerisms
Tics
Remember that most of the motor symptoms seen in schizophrenic patients will be due to antipsychotic medications which have strong extra-pyramidal side effects.
What are Schneider’s first rank symptoms of schizophrenia?
Delusional perception
Delusions of thought control: insertion, withdrawal, broadcast
Delusions of control: passivity experiences of affect (feeling, impulse, volition, and somatic passivity (influence controlling the body)
Hallucinations: audible thoughts (first person or thought echo), voices arguing or discussing the patient, voices giving a running commentary
What is Capgras syndrome?
This is an example of a delusion of mis-indentification. The patient believes that a familiar person has been replaced by an exact double (an impostor)
What is Fregoli syndrome?
This an example of a delusion of mis-identification. the patient believes that a complete stranger is someone very familiar to them.
What is the relative prognosis of paranoid schizophrenia compared to other subtypes?
Usually better. Onset of illness is also later than other subtypes.
Which age group is most likely to develop hebenephric (disorganised) schizophrenia?
Younger people 15-25 years of age
What is schizoaffective disorder?
Presentation of both schizophrenia and mood (depressed or manic) symptoms. The symptoms should meet the criteria for either a depressive or manic episode, as well as at least 2 schizophrenic symptoms.
Remember that if the mood symptoms are the more prominent aspect of a patient with some psychotic symptoms then the typical diagnosis is “depression or mania with psychotic features”.
What is the difference between schizotypal (personality) disorder and schizophrenia?
Schizophrenia is usually a clear change in behaviour and personality, sometimes with a prodrome. Whereas patients with schizotypal disorder have typically never reached a normal baseline.
Fill in the blanks
(This slide needs algorithm)
A - ORGANIC PSYCHOTIC DISORDER or SUBSTANCE-INDUCED PSYCHOTIC DISORDER
B - SCHIZOPHRENIA-LIKE PSYCHOTIC DISORDER (ACUTE AND TRANSIENT PSYCHOTIC DISORDER
C - DELUSIONAL DISORDER
D - SCHIZOPHRENIA
E - SCHIZOAFFECTIVE DISORDER
F - DEPRESSION OR MANIA WITH PSYCHOTIC FEATURES
What are the commonly used first generation (typical) antipsychotic agents?
Chlorpromazine Haloperidol Sulpiride Flupenthixol (Depixol) Zuclopenthixol (Clopixol)
What are the commonly used second generation (atypical) antipsychotic agents?
Clozapine Olanzapine Quetiapine Risperidone Amisulpride
How long do antipsychotics usually take before full effects are felt?
Weeks to months
For the management of an acute episode of psychosis or schizophrenia, which drugs would you use?
Monotherapy of one of the atypical antipsychotic agents within BNF limits (eg. Olanzepine) NOT Clozapine
Which groups of psychotic patients is clozapine reserved for?
Resistant schizophrenia
What is the primary mechanism of action for all antipsychotics, except for clozapine?
Antagonist of dopamine (D2) receptors in the mesolimbic dopamine pathway.
What is the primary mechanism of action of clozapine when used as an antipsychotic?
Serotonin (5HT-2) antagonist and D4 receptor antagonist
It is also a weak agonist of D2 receptors.
As well as blocking dopamine (D2) receptors, what other receptors do antipsychotics block resulting in various unpleasant side effect?
Muscarinic
Histaminergic
α-adrenergic
How long would you try someone suffering their first episode of schizophrenia on an antipsychotic before deciding to switch them to another due to lack of response or side effects?
Try and keep them on for 4-6 weeks, then re-assess.
If someone is successfully treated for schizophrenia with an antipsychotic, ideally how long should the maintenance last for before being withdrawn?
1-2 years
If a GP decides to withdraw someone from antipsychotics, how should they go about doing this?
This should be done very gradually and the patient should be monitored for at least 2 years post stopping medication.
If after 4-6 weeks of trying a patient with an antipsychotic the desired response has not been reached, what should you do?
Start them on another antipsychotic (NOT clozapine)
If having tried a second antipsychotic, the desired response has not been reached, what should you do for the patient?
Start them on clozapine. Clozapine is the drug of choice for resistant schizophrenia.
What is the management of a patient who suffers an acute exacerbation of their schizophrenia?
Continue or restart them on their usual antipsychotic treatment - avoid increasing the dose
Consider using a short term sedative such as a benzodiazepine
Consider switching antipsychotic if exacerbation happens despite compliance with original medication
If ineffective, consider clozapine
What are the main side effects of the antipsychotic medications as a result of D2 receptor blocking?
Worsening of negative and cognitive symptoms
Extrapyramidal side effects
Hyperprolactinaemia
What are the main side effects of the antipsychotic medications as a result of muscarinic receptor blockade?
Dry mouth
Constipation
Urinary retention
Blurred vision
What are the main side effects of the antipsychotic medications as a result of α-adrenergic receptor blockade?
Postural hypotension
What are the main side effects of the antipsychotic medications as a result of histaminergic receptor blockade?
Sedation
Weight gain
What are the cardiac side effects of the antipsychotic medications?
Prolongation of QT interval
This can lead to arrythmias and sudden death
Myocarditis
What are the metabolic side effects of the antipsychotic medications?
Increased risk of metabolic syndrome (abdominal obesity, elevated blood pressure, elevated fasting plasma glucose, high serum triglycerides, and low high-density lipoprotein (HDL) levels.)
What are the extrapyramidal side effects associated with antipsychotic medications?
Parkinsonian syndrome Acute dystonia Akathisia Tardive dyskinesia Neuroleptic malignant syndrome
Are first generation (typical) or second generation (atypical) antipsychotics more associated with extrapyramidal side effects?
First generation. This does not mean that second generation drugs do not also cause some of these effects.
What are the features of Parkinsonian syndrome, an extrapyramidal side effect of antipsychotic agents?
Muscular rigidity
Bradykinesia
Resting tremor
These features will usually occur within a month of starting the antipsychotic medication.
What are the features of acute dystonia, an extrapyramidal side effect of antipsychotic agents?
Involuntary sustained muscular contractions or spasms, often of the neck (spasmodic torticollis)
Clenched jaw (trismus)
Protruding tongue
Eyes roll upwards (oculogyric crisis)
These features happen more in young men and will usually occur within 72 hours of the beginning of treatment
What are the features of akathisia, an extrapyramidal side effect of antipsychotic agents?
Subjective feeling of inner restlessness and muscular discomfort
These features can appear anywhere from 6 to 60 days after starting medication.
What are the features of tardive dyskinesia, an extrapyramidal side effect of antipsychotic agents?
Rhythmic involuntary movements of the head, limbs and trunk - examples include chewing, grimacing, protruding of the tongue
These features develop in roughly 20% of patients on antipsychotic medications and can be irreversible, so swapping antipsychotic is necessary (possibly to clozapine)
How can you alleviate features of Parkisonian syndrome in patients on antipsychotics?
Anticholinergics, most commonly procyclidine. If the patient is unable to swallow, procycline can be given IM or IV
How can you alleviate features of acute dystonia in patients on antipsychotics?
Anticholinergics, most commonly procyclidine. If the patient is unable to swallow, procycline can be given IM or IV
How can you alleviate features of akathisia in patients on antipsychotics?
Propanolol is often used, as are short-term benzodiazepines (eg lorazepam).
It is also advisable to switch antipsychotic medication or reduce the dose.
How can you alleviate features of tardive dyskinesia in patients on antipsychotics?
There is no effective treatment. The antipsychotic medication must be swapped. Benzodiazepines can help short term.
It is important to remember that antimuscarinic agents such as procyclidine must not be used in patients with tardive dyskinesia and they can make the symptoms worse.
Which antipsychotics can be used as an intramuscular depot preparation which is administered every 1-4 weeks?
Typicals:
Haloperidol
Flupenthixol
Zuclopenthixol
Atypicals:
Risperidone
Aripiprazole
What are the features of neuroleptic malignant syndrome, an extrapyramidal side effect of antipsychotic agents?
Reduced activity
Severe rigidity (‘lead pipe’) - stiff pharyngeal and thoracic muscles can lead to dysphagia and dyspnoea
Bradyreflexia
High fever
Confusion
Unstable blood pressure
Tachycardia
The onset of these features is usually insidious and they tend to occur anywhere between 4-11 days after starting medication.
What investigations would you do for someone with suspected neuroleptic malignant syndrome? What results would you suspect to find?
U+Es show elevated creatinine kinase
FBC shows elevated white cell count
LFTs show elevated AST and ALT
ABG shows metabolic acidosis
How do you treat neuroleptic malignant syndrome, a extrapyramidal side effect of some antipsychotics?
Neuroleptic malignant syndrome is a life threatening scenario
Treatment:
- Discontinue medication
- Cool the patient
- Monitor and manage TPR (total peripheral resistance) ie fluids
- Consider ITU - Artificial ventilation
- Use benzodiazepines for sedation (eg. Lorazopam)
- Use Dantrolene as muscle relaxant
- Use Bromocriptine to reverse dopamine effects
- ECT should be considered to manage psychosis
After an antipsychotic induced epidose of neuroleptic malignant syndrome, how long should the patient remain off antipsychotics and what should they be started on when they do restart?
Minimum 5 days
They should start on a different unrelated antipsychotic to the one they were on. Preferably not a long acting one and one with low dopamine affinity.
A good example is Quetiapine
What are the major side effects associated with clozapine?
Constipation
Weight gain and metabolic syndrome
Hypersalivation
Urinary incontinence
Agranulocytosis (leukopenia mainly neutropenia) and bone marrow suppression
CNS depression
Lowers seizure threshold
Myocarditis
Cardiomyopathy
Tachycardia and Arrhythmias
Hypotension
PE
What monitoring do patients on clozapine require due to the vast number of dangerous side effects?
ECG
FBC - these need to be weekly for at least the first 18 weeks - there is a green, amber and red system for monitoring patients on clozapine
BP
HR
What medications does clozapine interact with and are hence contraindicated or tightly controlled?
Carbamazepine, cytotoxics and other medicines which cause neutropenia are contraindicated
Fluvoxamine (SSRI) inhibits the metabolism of clozapine which in turn means higher levels are found in the blood.
Why is it particularly important to warn smokers about clozapine?
Smoking induces P450 enzymes which means that doses for smokers will often be higher than for non-smokers. This is relevant if the smoker decides to stop smoking without warning their doctor.
What can you do for someone who has been prescribed clozapine but this does not seem to be working in treating their psychosis?
Check clozapine levels to check compliance
Introduce a second anti-psychotic eg Amiosulpiride - risk of high dose problems with this though
Switch to high dose olanzepine or quetiapine (little evidence for either of these)
Lamotrigine is an option as it reduces the release of glutamate. Note that this is not recommended by NICE.
Which antipsychotic medication is best at treating the negative symptoms of schizophrenia?
Clozapine
A 35-year-old man with a history of schizophrenia is brought to the Emergency Department by worried friends due to drowsiness. On examination he is generally rigid. A diagnosis of neuroleptic malignant syndrome is suspected. Each one of the following is a feature of neuroleptic malignant syndrome, except:
Renal failure
Pyrexia
Elevated creatine kinase
Usually occurs after prolonged treatment
Tachycardia
Usually occurs after prolonged treatment.
Neuroleptic malignant syndrome is typically seen in patients who have just commenced treatment. Renal failure may occur secondary to rhabdomyolysis
