Psychotic Disorders Flashcards
Hallmark symptoms of psychotic illness
- Delusions
- Hallucinations
- Thought disorder
- Lack of insight
What investigations need to be done to rule out an organic cause?
- LFTs and macrocytosis on FBC are suggestive of alcohol abuse
- Syphilis and HIV serology
- Urine screen for drugs of abuse, particularly cannabis
Where there are focal signs, CT scanning may be indicated
Schneider’s First Rank Symptoms
- Thought echo, thought insertion, thought withdrawal, and/or thought broadcast
- Delusions of somatic passivity i.e. being controlled by an external force
- Auditory hallucinations giving running commentary, echoing of thoughts, or discussing the patient in the third person
- Delusional perceptions i.e. a normal event is regarded with abnormal significance
- External control of emotions
Less Specific Symptoms of Schizophrenia
- Persistent hallucinations accompanied by delusions
- Breaks or interpolations in the train of thought
- Negative symptoms
- Catatonic behaviour
- Lack of motivation
- Apathy
- Poverty of thought and speech
- Significant and consistent change in personal behaviour
How is a diagnosis of schizophrenia made
Diagnosis can be made by the presence of one specific symptom, or two less-specific symptoms present for at least one month
Reasons behind positive and negative symptoms
- Positive symptoms are thought to occur due to an excess of dopamine in the mesolimbic areas of the brain
- Negative symptoms are thought to be due to a lack of dopamine in the mesocortical pathways
MSE Findings
- Appearance and behaviour: withdrawal, suspicion
- Speech: interruptions to the normal flow (thought blocking), loosening of associations of thought
- Mood: flattened, odd
- Abnormal thoughts and perceptions, especially auditory hallucination
Treatments in Schizophrenia
Biopsychosocial Model
Antipsychotics
Psychological Treatments: Supportive therapy, family therapy, CBT
Social: avoidance of drugs and alcohol, support in financial, housing and employment issues
ECT-Resistance to pharmacological therapy
Antipsychotic
Typical-First generation e.g. haloperidol, chlorpromazine, flupentixol
Atypical-Second generation e.g. Olanzapine, amisulpride, risperidone quetiapine, aripiprazole
Side Effects of Typicals
Dopamine related SE: Galactorrhoea, sexual dysfunction Acute dystonia-oculogyric crisis-reversible with procyclidine Parkinsonism Akathisia-restless legs-reversible with anticholinergics, BZDs, B blockers Tardive dyskinesia-uncontrollable facial and truncal movements, irreversible Anticholinergic SE: Constipation urine retention Dry mouth Blurred vision Confusion Histamine related SE: Sedation A Receptors SE: Postural hypotension Impotence Weight gain, arrhythmia (long QT), decreased seizure threshold and NMS
Neuroleptic Malignant Syndrome
Rigidity
Hyperthermia
Autonomic dysfunction
Pyrexia and rhabdomyolysis-high mortality
Treat with supportive therapy and discontinue all neuroleptic meds
Side Effects of Atypicals
EPSE at high doses Lower risk of tardive dyskinesia Sedation Weight gain Decreased seizure threshold Metabolic syndrome-baseline and 3 monthly BP, BMI, lipids and glucose measurement
Clozapine
Atypical antipsychotic that also has an effect on negative symptoms
Indicated in treatment resistant cases, initiated in hospital
SE: sedation, weight gain, anticholinergic effects, decreased seizure threshold, hypersalivation, agranulocytosis
FBC-Baseline, check weekly for 18 weeks, fortnightly for first year then monthly thereafter
Rated red, yellow, green
Yellow-Increase monitoring 2x per week
Red-Stop med, monitor daily until normal
Management of Schizophrenia
1st Line: Newer Atypical either risperidone or olanzapine
Inpatient treatment-noncompliance, treatment failure or risk of harm to self or others
Acute Exacerbation-Amisulpride, olanzapine, risperidone
Rapid Tranquilisation
Rapid tranquilisation is the use of medication to calm/lightly sedate the patient so that psychiatric evaluation can take place
- Assessment should always precede RT. This should include history, collateral history, legal status (mental capacity act, mental health act), full medication history and recent drug screen
- Antipsychotic hypersensitivity occurs in Lewy body dementia and Parkinson’s disease
Side effects can include loss of consciousness, airway obstruction, respiratory and cardiovascular collapse, seizure, and extra-pyramidal side effects
- Always ensure facilities for CPR and flumazenil are available
Oral medication is always preferred to parenteral where possible. Risperidone can also be used. Where there is no psychotic context to agitation, lorazepam should be used
- Do not give lorazepam within 1 hour of olanzapine
- For elderly patients, give half-doses
- IV medications can only be given in exceptional circumstances, and the decision to give them should not be made by junior staff alone
Schizotypal Disorder
Schizotypal disorder is a personality disorder characterised by eccentric behaviour and anomalies of thinking. Features of the condition include
- Inappropriate or constricted affect
- Poor rapport and social withdrawal
- Suspicious/paranoid ideas
- Obsessive ruminations lacking resistance
- Unusual perceptual experiences
- Vague, circumstantial, over-elaborate thinking with odd speech
Schizotypal disorder tends to have a chronic and fluctuating course, and may evolve into schizophrenia. Treatment with risperidone cam be effective
Schizoaffective Disorder
Schizoaffective disorder has equally prominent features of both affective disorder and schizophrenia
- Treatment is as for schizophrenia and bipolar disorder
Delusional Disorder
Delusional disorder is a single delusion or set of related delusions. The delusions have variable content, and may be related to the current life situation of the patient (non-bizarre delusions)
- There are no hallucinations, thought disorder, mood disorder, or flattening of affect
Diagnosis of the condition is made where there are conspicuous delusions present for at least 3 months with no evident underlying cause
Management is with SSRIs and antipsychotics (due to overlap with psychosis and OCD) as well as psychotherapies e.g. individual therapy, supportive therapy, and cognitive techniques
- Treatment is difficult as the patient usually lacks insight and denies the illness
Puerperal Psychosis
Post-natal psychosis is a severe mental illness with sudden onset in the first few weeks following childbirth, manifesting as a rapidly evolving psychosis
- Risk is highest in women with previous history of mental illness and family/personal history of post-partum psychosis
The condition typically presents early following childbirth, in the first two weeks. Symptoms include
- Severe confusion, agitation and irritability
- Feelings of paranoia or suspicion
- Rapid mood fluctuation
- Racing thoughts
- Delusional ideas (generally odd fixed beliefs relating to self and/or baby) and hallucinations
This condition is a psychiatric emergency. Women should be managed in specialist perinatal psychiatry services, and admission is usually required at a mother and baby unit.
