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MD3 Mental Health > Psychotic Disorders > Flashcards

Psychotic Disorders Flashcards

1
Q

DSM-V Criteria for Schizophrenia

A

A. Characteristic symptoms: ≥2 of the following, each present for a significant period during 1 month:

  • Delusions
  • Hallucinations
  • Disorganised speech
  • Grossly disorganised or catatonic behaviours
  • Negative symptoms

B. Social or occupational dysfunction: for a significant portion of time since onset of the disturbance & affecting ≥1 major areas, e.g. work, social, self-care

C. Duration: persisting ≥6 months (and has to include A)

D. Schizoaffective and mood disorders exclusion: if mood episodes have occurred during active phase, their total duration has been brief relative to duration of active residual periods

E. Substance / general medical condition exclusion

F. Relationship to Autism Spectrum Disorder or Communication Disorder of Childhood: if there are history of either one, additional dx of Schizophrenia can be made if there is prominent DELUSIONS and HALLUCINATIONS present for ≥1 month

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2
Q

What are 5 examples of negative symptoms that can be seen in Schizophrenia?

A
  1. Anhedonia
  2. Affective flattening
  3. Avolition (severe lack of initiative and motivation)
  4. Alogia (lack of additional, unprompted content seen in normal speech - poverty of speech)
  5. Social withdrawal
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3
Q

What are some examples of structural brain abnormalities seen in Schizophrenia?

A
  • Decreased brain volume
  • Increased ventricular-to-brain ratio, especially in the LEFT lateral ventricle
  • Decreased medial temporal structure, e.g. hippocampus
  • Brain abnormalities usually precede onset of illness
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4
Q

What are the 4 pathways affected in the DOPAMINE HYPOTHESIS of Schizophrenia and what are the clinical relevance of each neural pathway?

A
  1. Mesolimbic pathway (motivation and reward): positive symptoms
  2. Mesocortical pathway: hypoactivity, negative symptoms, and cortical impairments
  3. Nigostriatal pathway (extra-pyramidal system): movement disorder (EPSE of anti-psychotics)
  4. Tuberoinfundibular pathway: hyperprolactinaemia (secondary to dopamine deficiency w/ anti-psychotics)
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5
Q

What are the predictors of GOOD outcome in Schizophrenia?

A

Sociodemographic:

  • Married
  • Female sex

Pre-morbid conditions:

  • No previous psychiatric history
  • No pre-morbid personality issues
  • Good social support
  • Good work and educational history

Clinical presentation:

  • Acute onset
  • Onset precipitated by stressful events
  • Older age of onset
  • Short episode
  • Florid psychosis
  • Good initial response to medications
  • Continued treatments or medication use
  • Absence of ventricular enlargement or sulcal widening
  • Good neuropsychological functioning
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6
Q

What are the predictors of POOR outcome in Schizophrenia?

A
  • Males
  • Early age of onset
  • Insidious onset
  • Poor pre-morbid functions
  • Neurological soft signs
  • Significant neurocognitive deficits
  • Structural brain abnormalities
  • Severe negative symptoms
  • No affective symptoms
  • Lack of precipitating factors
  • Long duration of untreated psychosis
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7
Q

What are the perpetuating factors for Schizophrenia?

A
  • Suboptimal treatments
  • Poor adherence to medications
  • Side effects of medications
  • Substance abuse
  • Family and social situation
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8
Q

What are 7 examples of the individual issues to be addressed in Schizophrenia patients?

A
  1. Persistent positive and negative symptoms
  2. Co-morbid anxiety and mood disorders
  3. Substance abuse, incl. alcohol, smoking, drugs
  4. Sedentary lifestyle and general health
  5. Social inclusion
  6. Vocational
  7. Medication, adherence, side effects
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9
Q

What are the 4 neurotransmitters targeted by TYPICAL antipsychotics?

A
  • Dopamine, especially D2 (indirect pathway)
  • Alpha-1
  • Muscarinic M1
  • Histamine H1
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10
Q

What is the Weinberger hypothesis relating to Schizophrenia?

A
  • Positive Schizophrenia symptoms are related to increased dopamine activity in the MESOLIMBIC pathway
  • Negative symptoms and cognitive impairments are due to reduced dopamine in MESOCORTICAL pathway
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11
Q

What are the side effects of TYPICAL anti-psychotics (based on neurotransmitter actions)?

A

Dopamine D2 blocker:

  • MLC: reduced positive symptoms
  • MCC: exacerbate negative symptoms
  • TIF: hyperprolactinaemia (hypogonadism causing bone loss/osteoporosis; sexual dysfunction incl. menstrual disturbance, loss of libido, galactorrhoea, erectile dysfunction, infertility)
  • Nigostriatal: EPSE (Parkinsonism, akathisia, dystonia, TD)

ɑ1 blocker:

  • Reduce blood pressure
  • Dizziness
  • Drowsiness

M1 blocker:

  • Constipation
  • Blurred vision
  • Dry mouth
  • Drowsiness

H1 blocker:

  • Weight gain
  • Drowsiness
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12
Q

How can the side effects of typical antipsychotics be classified based on acute/subacute/late presentations?

A

ACUTE:

  1. Acute dystonia due to co-contractions of agonist and antagonist, e.g. in neck, arm, oculogylar crisis
  2. Akithisia: most common EPSE, presenting initially with restlessness and can lead to suicidal ideation
  3. Neuroleptic malignant syndrome

SUBACUTE:
1. Parkinsonism, either neuroleptic or drug induced

LATE:
1. Tardive dyskinesia or dystonia due to D2 receptors trying to cope causing hyperkinetic movements, mainly in oromandibular and limb area

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13
Q

Easiest way to differentiate between drug induced vs. neuroleptic Parkinsonism

A

Drug induced parkinsonism is usually bilaterally symmetrical

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14
Q

How to manage drug-induced parkinsonism?

A
  • Cease psychotropic drugs

- Use anticholinergics

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15
Q

Acute dystonia can be considered as emergency situation, what are the prevention and treatment strategies for this condition?

A

Emergency: IM/IV Benztropine (anticholinergic)
Prophylaxis: Anticholinergic 48h - 2 weeks

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16
Q

What are the treatment strategies for akathisia?

A
  • If the only presentation without other EPSE and not asthmatic: β-blocker
  • If asthmatic: benzodiazepine, e.g. clonazepam
  • If other EPSE present: benztropine
17
Q

What are the clinical features of Neuroleptic Malignant Syndrome?

A
  • Temperature (fever)
  • Rigidity and CK >300
  • Autonomic instability
  • Delirium and confusion
  • Left shift neutrophilia
18
Q

How to manage NMS and what is the patient has concurrent psychosis with NMS?

A
  1. Cease psychotherapy
  2. Symptomatic therapy, e.g. paracetamol, BZP, muscle relaxant (e.g. dentroline)
  3. If NMS + psychosis, treat with ECT!!
19
Q

What is a complication of NMS to watch?

A

Microglobulinaemia -> can cause renal failure

20
Q

What are the symptoms of hyperprolactinaemia?

A 
Hypogonadism: bone loss / osteoporosis
Sexual dysfunction:
- Galactorrhoea
- Erectile dysfunction
- Loss of libido
- Menstrual disturbance
- Infertility
21
Q

What is the classification and examples of antipsychotics?

A

TYPICAL ANTIPSYCHOTICS:

  • Phenothiazine: e.g. chlorpromazine, trifluoperazine, thioridazine, fluphenazine
  • Butyphenone: e.g. haloperidol, droperidol
  • Piperidazine: e.g. flupenthixol, zuclopenthixol depot (also known as acuphase)

SEROTONIN + DOPAMINE ANTAGONIST (SDA):

  • Clozapine
  • Olanzapine
  • Quetiapine
  • Risperidone or Paliperidone
  • Ziprasidone
  • Sertindole
  • Asenapine
  • Lurasidone

THIRD GENERATION:

  • Aripriprazole (partial D2 agonist, partial 5HT2 agonist)
  • Amisulpride (D2 antagonist, pre-synaptic D2 blocker, and 5HTT receptor blocker)
22
Q

What is the mechanism of action of SDA?

A
  • Short-term block of post-synaptic D2 (hit & run)
  • Post-synaptic block of 5HT2A, 5HT2C
  • Pre-synaptic block of 5HT1

Post-synaptic block of 5HT2A and 5HT2C increases dopamine in nigostriatal, mesocortical, and tubuloinfundibular pathways which minimises the side effects

23
Q

What is the side effect of Risperidone that is similar to typical antipsychotics?

A

Increase in prolactin to 3000-4000 (normal <400 mU/L)

24
Q

What are the side effects of SDA?

A
  1. Metabolic due to actions on 5HT2A and 5HT2C:
    - Appetite increase
    - Weight gain 2-5kg in 10 weeks
    - Insulin resistance, increase BSL, diabetes
    - Increase triglycerides
    - Hypertension
    - Ischaemic Heart Disease
  2. Sedation
  3. Increase salivation (if there is M4 receptor agonism)
  4. Rarer side effects, more specific to Clozapine:
    - Agranulocytosis
    - Myocarditis causing cardiomyopathy
    - Paralytic ileus
    - Embolism or thromboembolic episode
    - Myoclonic jerks / seizure (more dose-dependent)
25
Q

What is the mechanism of action of Aripriprazole and its effects on weight on its own and in combination with SSRI?

A

Mechanism of action:

  • Partial Dopamine agonist
  • Partial 5HT2 agonist

Weight: causing weight loss, can be significant

  • reduces gluconeogenesis (similar to metformin)
  • acts centrally to suppress appetite

When used in combination with SSRI, it acts as an antagonist and witll cause weight gain

26
Q

What is the mechanism of action of Amisulpride and its effects on symptoms and common antipsychotic side effects?

A
  1. D2 antagonist: minimise positive symptoms
  2. Pre-synaptic D2 blocker:
    - Improve negative and cognitive symptoms
    - Minimise side effects, especially EPSE
    - May still cause hyperprolactinaemia
  3. 5HTT blocker
27
Q

DSM-V Criteria for Schizoaffective Disorder

A

A. Concurrent PSYCHOSIS + MOOD episode:
Psychosis follows Category A of Schizophrenia with ≥2 of the following, each present for a significant period during 1 month and at least one must be (i), (ii) or (iii):
- Delusions
- Hallucinations
- Disorganised speech
- Grossly disorganised or catatonic behaviour
- Negative symptoms

B. Delusions or hallucinations for ≥2 weeks in the absence of major mood episode during lifetime duration of the illness

C. Major mood episode symptoms are present for the majority of the total duration of active and residual periods of the illness

D. Substance / general medical condition exclusion

28
Q

What are the two specifiers of Schizoaffective disorder and in which age group is it more common?

A
  1. Bipolar type: more common in younger age group

2. Depressive type: more common in older adult

29
Q

What are 8 examples of disorganised behaviour?

A
  1. Catatonic stupor: fully conscious, but immobile, mute, and non-responsive
  2. Catatonic excitement: uncontrolled and aimless motor activity & maintaining bizarre position
  3. Stereotypy: repeated but non-goal directed movement
  4. Mannerism: goal-directed actions are odd and out of context
  5. Echopraxia: imitates movements and gestures of others
  6. Automatic obedience: carry out simple commands in a robot-like fashion
  7. Negativism: refuses to cooperate with simple requests for no apparent reason
  8. Inappropriate neglect, self care, affect, and other odd behaviours
30
Q

DSM-V Criteria for Brief Psychotic Disorder

A

Presence of at least 1 psychotic disorder with sudden onset and full remission within 1 month

31
Q

What are some other names for Brief Psychotic Disorder?

A
  • Bouffèe delirantés

- Cycloid psychosis

32
Q

What are some examples of delusions?

A
  • Persecutory delusions
  • Grandiouse delusions
  • Erotomanic delusions
  • Reference delusions
  • Somatic delusions
  • Control delusions
33
Q

What are 3 features suggestive of Brief Psychotic Disorder?

A
  • Symptoms preceded by marked stressor
  • Lack of negative symptoms
  • Confusion during early course of illness
34
Q

How do you treat Brief Psychotic Disorder pharmacologically?

A

Risperidone 1-2mg daily

  • Increase to 2-3mg daily over a week (for maximum dose of 8mg)
  • For EPSE, use benztropine
  • If agitated, use clonazepam 0.25mg BD (max 2mg BD)
  • Continue for 1-3 months following remission
  • When ceasing taper dose for 1-2 weeks while monitoring for early signs of relapse
35
Q

What are some examples of disorganised thought that can be observed through disorganised speech?

A
  • Alogia
  • Thought blocking
  • Loosen association
  • Tangentiality
  • Clanging
  • Word Salad
  • Perseveration
36
Q

DSM-V Criteria for Delusional Disorder

A

A. Presence of one or more delusions for at least one month

B. Criterion A for Schizophrenia has never been met

C. Function is not markedly impaired and behaviour is not obviously bizarre or odd

D. If manic or major depressive episodes have occurred, these have been brief relative to the
duration of the delusional periods

E. Substance / general medical condition exclusion

MD3 Mental Health (2 decks)

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