Psychotic Disorders

Question 1

ACUTE AND TRANSIENT PSYCHOTIC DISORDERS

• no definitive guidance.
• order of priority:
• commonly superseded by later Dx. of schizophrenia

Answer 1

a) acute onset(within 2w), *abrupt onset(within 48h without prodromal phase, poorer prognosis)

b) Presence of typical syndrome
- polymorphic states(markedly variable hallucinations. delusions and emotional turmoil from day to day), schizophrenic Sx.

c) Presence of associated acute stress.
* exclude organic causation and intoxication. Does not fulfill criteria of manic episode, depressive episode and schizophrenia.

Question 2

DEFINITIONS

1. Psychosis
2. Hallucination
3. Illusion
4. Pseudohallucination

Answer 2

1. Mental state in which reality is grossly distorted leading to symptoms of delusions, hallucinations and thought disorders.
2. Perceptions occurring in the absence of external stimulus.
3. Misperception of real external stimulus.
4. Personal experience that arises in subjective inner space of mind, not through external sensory organs.
   * some would define it as hallucinations that patients recognize as false perceptions.

Question 3

HALLUCINATIONS

1. Auditory
2. Visual
3. Somatic
4. Olfactory and Gustatory

Answer 3

1. a) Elementary: simple noises
   b) Complex:
   - First person: thoughts being said out aloud(audible thoughts). *if thoughts echoed by voice right after=thought echo
   - Second person: persecutory/critical/command in low mood, complimentary in mania.
   - Third person: running commentary, patient being discussed by voices.
2. More common in organic causes and pshycoactive substance use.
   * autoscopic hallucination, Charles Bonnet syndrome, Lilliputian hallucinations.
3. a) Superficial:
   - tactile: experience of skin being touched/pricked
   - formication: insects crawling below skin, assoc with coccaine use and alcohol withdrawal.
   b) Visceral: organs being stretched/ distended
   c) Kinaesthetic: limbs vibrating/being twisted
4. Commonly occur together
   - rule out epilepsy and organic brain disorders.

Question 4

ABNORMAL BELIEFS:
DELUSIONS
- unshakeable false belief not accepted by other members of patient's culture; due to false reasoning; outwith patient's social and cultural background.
a) Primary delusions
b) Secondary delusions
c) Partial delusions
d) Different types

Answer 4

a) Delusion that developed in absence of any previous psychopathological state, may be preceded by delusional atmosphere(mood).
- commonly in schizophrenia and primary psychotic disorders
b) Delusions that develop as a consequence of pre-existing psychopathological state.
- usually mood-congruent
c) Beliefs previously held with delusional intensity but now less conviction.
d)
1. Persecutory delusions
2. Grandiose delusions
3. Delusions of reference
- certain objects/people/events have intense personal significance and refer specifically to oneself.
4. religious delusions
5. Erotomania
- delusions of love *de Clerambault syndrome
6. Delusions of infidelity/morbid jealousy
- Othello syndrome
7. Delusions of misidentification
- Capgrass syndrome: stranger replaced someone familiar
- Fregoli sydrome: stranger is familiar person already known
8. Nihilistic delusions
- End of world, non-existence
9. Somatic delusions
- Hypochondrial delusions. body not functioning appropriately.
10. Delusions of infestation(Ekbom’s syndrome)
- can be secondary to formification.
11. Delusions of control
- passivity
- thoughts/feelings/actions/impulses controlled/made by external agency
- first-rank Sx. of schizophrenia.
- thought insertion, withdrawal, broadcasting

Question 5

OVERVALUED IDEAS

Answer 5

Unreasonable preoccupation with plausible belief to the extent of causing distress to patient and those around.

• differs from delusion such that no abnormal reasoning.
• differs from obsession such that no recurrent intrusions.

Question 6

THOUGHT FORMS:

a) Normal
b) Circumstantiality
c) Tangentiality
d) Flight of ideas
e) Loosening of association
f) Thought blocking
g) Neologisms
h) Perseveration
i) Echolalia

Answer 6

a) Relevant associations, goal-directed
b) Less relevant associations, goal-directed
c) Less relevant associations, goal not reached.
d) Tangentiality at accelerated speed
e) Unrelated concepts, unrclear goal.
- when most severe, ‘word salad’ phenomenon
f) Stops mid sentence and talks about diff topic
g) making own words or idiosyncratic use of words
h) inappropriate repetition of initially correct resopnse, palilalia, logoclonia(repeating last syllable of last word)
i) repeating word/phrase spoken by others.

Question 7

NEGATIVE SX.

Answer 7

Blunted affect, social withdrawal, poverty of thought and speech, marked apathy, poor self-care, cognitive impairment

Question 8

PSYCHOMOTOR FN.

*extrapyrimidal SEs of neuroleptic medication.

Answer 8

1. Catatonic rigidity
2. Catatonic posturing
3. Catatonic negativism
   - motiveless resistance to instructions/attempts to be moved. may do opposite of what was told.
4. Catatonic waxy flexibility
5. Catatonic excitement
   - agitated, excited and apparently purposeful motor activity wout influence from external stimulus.
6. Catatonic stupor
   - akinesis, mutism, extreme unresponsiveness but otherwise alert/slight clouding of consciousness.
7. Echopraxia
8. Mannerisms
   - goal-directed movements at socially inappropriate times
9. Stereotypes
   - complex non-goal directed movements
10. Tics
    - sudden, rapid, recurrent, non-rhythmic motor movements/vocalizations.

Question 9

DDx:

Answer 9

1. Psychotic disorders:
   - Schizophrenia
   - Schizophrenia-like psychotic disorder
   - Schizoaffective disorder
   - Delusional disorder
2. Mood disorders
   - Manic/severe depression
3. Psychoactive substance use
   * Medications ie antiparkinsonian drugs, corticosteroids, anticholinergics
4. Dementia esp. Lewy body dementia
5. Delirium
6. Personality disorder
   - no clear psychotic Sx.
   - schizotypal personality disorder more prevalent among relatives of schizophrenics, can progress to schizophrenia
   - borderline, paranoid and schizoid personality disorder.
7. Neurodevelopmental disorder(autistic spectrum)
   * Patients with personality and neurodevelopmental disorder have never achieved normal baseline in contrast to schizophrenia
8. Secondary to general medical condition.

Question 10

INVESTIGATIONS:

1. Bloods
2. ECG
3. Scans
4. Urine

Answer 10

1. FBC, U+E’s, LFTs, TFT, glucose, calcium, ESR, syphilis serology(if suspected).
   - exclude organic causes, evaluate liver and kidney fn.
2. Antipsychotics can cause long QT => ventricular arrhythmias
3. *EEG/CT if atypical case/tx-resistant/cognitive or neurological abn.
4. Drug screen

Question 11

DIAGNOSTIC ALGORITHM

Answer 11

1. Psychotic Symptoms
2. Secondary to medical condtion/pshycoactive substance use?
   a) Y => Organic psychotic disorder/substance-induced psychotic disorder
3. N => duration <1/12
   a) Y => Schizophrenia-like psychotic disorder/acute and transient psychotic disorder
4. N => Delusions only and duration >3/12
   a) Y => Delusional disorder
5. N => Typical schizophrenic Sx. in absence of prominent mood Sx.
   a) Y => Schizophrenia
6. N => Typical schizophrenic Sx. in presence of mood Sx.
   a) Y => Schizoaffective Disorder
7. N => Psychotic Sx.(usually mood-congruent) in presence of prominent mood Sx.
   a) Y => Depression/Mania w Psychotic Features