Psychotic Disorders Flashcards
What is psychosis?
Not a condition or a syndrome - an umbrella term for a form of disorder. It is a disorder of perception, where people experience the world to be different from how it is in actuality
There any different syndromes and diseases that have psychotic features
List some examples of disorders/diseases where psychotic symptoms can occur (12)
1) Delusional disorder
2) Schizophrenia
3) Schizoaffective disorder
4) Acute and transient psychosis
5) Substance misuse (cannabis, LSD, shrooms)
6) Substance withdrawal (alcohol and opiates)
7) Dementia (LBD)
8) Sleep deprivation
9) Post-partum
10) Sensory deprivation
11) Severe depression or mania
12) Bereavement
What are three broad features of psychosis?
1) Thought disorder
2) Delusions
3) Hallucinations
What is a thought disorder?
An abnormality in the mechanism of thinking such that to an outside observer the person speaking does not make any sense
What is a delusion?
A false, unshakeable belief despite compelling evidence to the contrary that is not held by others in the same culture and held with intense personal conviction or certainty
What is a hallucination?
A perception which occurs in the absence of a stimulus
The perceptual experience is false but to the person experiencing it, has the full force and impact of a real perception and is consequently indistinguishable from a real perception
Occurs in external space (not in mind’s eye)
Auditory, Visual, Olfactory, Gustatory, Tactile, Somatic
What is the most common type of hallucination in psychosis?
Auditory
When do visual hallucinations tend to occur?
Not a feature of psychosis but tend to be more common in organic disorders
What is a pseudo-hallucination?
A sensory experience vivd enough to be regarded as a hallucination but recognised by the subject not to be the result of external stimuli and therefore not real
What questions are important to ask to someone who is hearing voices?
Start with - do you ever hear voices when no one else is around / that no one else can hear?
1) How many are there?
2) What gender are the voices?
3) Are they talking about you or to you?
4) Do you recognise the voices?
5) Is there anything that triggers the voices?
6) What do they say?
7) How do they make you feel?
8) Are they constant / worse at a specific time of day?
9) Do they ever command you to do anything?
10) Do you think theres any chance the voices might not be real?
What is thought broadcast?
The subject experiences his thoughts as actually being shared with others, often with large numbers of people
The subject often claim this sharing is via telepathy, radio and TV
What is adhedonia?
A total inability to enjoy anything in life or even get the accustomed satisfaction from everyday events or objects
What is lability?
The subjects affect is rapidly changeable and there are marked fluctuations
The subject maybe cheerful and smiling and then shortly after crying (emotional incontinence may be used in this extreme)
What are ideas of reference?
A delusional belief that innocuous events or coincidences are directly linked and have personal significance to the subject
Eg the TV / radio is talking about / to them
What are neologisms?
New words that have no meaning
What is an illusion?
A false perception of a real stimulus. 3 types:
1) Affect
2) Completion
3) Pareidolia
What is loosening of associations?
Loss of normal structured thinking
The subjects discourse seems muddled and illogical and does not become clearer with further questioning
As the interviewer it may feel that the more questions you ask to gain clarity the more difficult it is to understand them
= Disorder of thought form
What is clouding of consciousness?
A step down from normal alertness
There is a deterioration in thinking, attention, perception and memory and usually drowsiness and reduced awareness of environment
What are 3rd person auditory hallucinations?
The subject hears voices talking about him / herm, referring to them in the third person
What is thought withdrawal?
The subject believes that their thoughts have been removed from their mind by an external agency and they do not have control over it
What is affect?
Short lived observable pattern of behaviour that expresses the subjective emotional state of an individual
Subject to variation over brief periods of time
Affect = Weather Mood = Climate
What are nihilistic delusions?
Delusions of extreme negativity - no longer existing, about to die or even being dead, about to experience terrible doom
What is concrete thinking?
The inability to understand abstract ideas or concepts
Subjects will be focused on the hear and now, physical objects and literal meanings / delusions
What are delusions of control / passivity?
The subject believes that their thoughts, feelings and/or actions are not their own but are being imposed/ controlled by an outside force
Eg they believe that someone else’s words are coming out using their voice or they are being made to think a certain way
What is a delusional perception?
The subject receives a normal perception which is then interpreted ith delusional meaning and has immense personal meaning
Eg on seeing a traffic light change from green to red, a man declared that he was the King of Mars
What is psychomotor retardation?
The subject sits abnormally still / walks abnormally slowly / takes a long time to initiate movement
What is euthymia?
Happy, contented mood (happy medium)
What is depersonalisation?
TA peculiar change in the awareness of self, in which the individual feels as if they are not real and detached
They may feel that they have changed and that the world around them is vague, dreamlike or lacking in significance
The subject retains a measure of understanding and knows that the condition is abnormal
What is pressure of speech?
The subject talks too much and fast with a sense of urgency
Speech is often difficult to interrupt
What is derealisation?
An alteration in the perception or experience of the external world so that it seems unreal
The subject may experience anything as colourless and artificial
Eg an office / bus / street seems like a stage with actors rather that real people going about their business
The subject retains a measure of understanding and knows that the condition is abnormal
What is thought echo?
The subject experiences his own thoughts as if they were being spoken out loud
The repetition may not be a simple echo but subtly or grossly changed in quality
What are grandiose delusions?
Delusions of being of special status or significance, or having special powers or attributes, or a special mission or purpose
What are negative symptoms?
A cluster of symptoms that often occur together in chronic schizophrenia
1) Poverty of speech
2) Flat affect
3) Poor motivation
4) Poor attention
Can result in low activity levels and poor self care
What is dysthymia?
A chronic state of low mood, usually with an insidious onset and lasting at least 2yrs
What is flight of ideas?
Rapid flow of thought, manifested by accelerated speech with abrupt changes from topic to tpoic although there is often some form of link between topics
There is a loss of the normal structure of thought, appearing illogical or muddled
Often seen in mania
What is aphasia?
Np speech, inability to produce words orally
What is perseveration?
The repetition of a particular response (eg phrase, word, utterance or gesture) despite the absence or cessation of the stimulus
Often seen in organic brain disorders
What are 2nd person auditory hallucinations?
The subject hears voices which appear to talk to them directly
What is thought insertion?
The subject experiences thoughts which are not their own intruding into their mind
Eg alien thoughts are said to have been inserted into the mind from outside, by means of radar telepathy etc
What is alexithymia?
An inability to verbally express one’s emotions
What is mood?
A word used to describe a sustained and pervasive emotion
Mood = Climate Affect = Weather
What is the most common psychotic disorder?
Schizophrenia
How common is schizophrenia?
Approx 1% of population
What is the typical age of onset of schizophrenia?
20-28yrs males
26-32yrs female
In which populations is schizophrenia more common?
M>F (only slightly)
Lower SES
Urban areas
What are some risk factors for schizophrenia? (5)
FH +++++ Long term cannabis use Living in urban environment Black or Caribbean ethnicity Being a migrant
What are some causes of schizophrenia?
No specific causation but list of associations and risk factors
Genetic associations:
- Higher concordance in Mz twins vs Dz twins
- Babies adopted away from their schizophrenic parents still retain their risk
Winter babies at higher risk:
- ?second trimester influenza infection
Brain abnormalities
Neurotransmitter abnormalities
Life events (stress)
What neurotransmitter abnormalities are noted in schizophrenia?
SPECT scans show greater occupancy of DA receptors:
Overactivity of dopamine
- Particularly in the mesolimbic pathway
This is the focus of pharmacological treatments that try and block D2 receptors (5 types but mainly D2)
- Side effects are due to non-specificity of blockade
Serotonin might also be implicated because drugs blocking 5-HT pathway also seem to be effective treatments
What brain abnormalities are noted on CT scans in those with schizophrenia? What is the problem with this?
- Ventricular enlargement = associated with negative symptoms
- Reduced brain size = frontal and temporal lobes, hippocampus, amygdala, para-hippocampal gyrus
Unknown if this is due to disorder or treatment
What are the four dopamine pathways in the brain?
1) Mesolimbic
2) Mesocortical
3) Tuberoinfundibular
4) Nigrostriatal
What is the mesolimbic pathway involved in?
Arousal
Memory
Behaviour
INcreased activity = positive symptoms
What is the mesocortical pathway involved in?
Cognition
Socialisation
DECreased activity = negative symptoms
What is the tuberoinfundibular pathway involved in?
Regulation of prolactin
Increased activity = elevated prolactin levels
What is the nigrostriatal pathway involved in?
Modulation of extrapyramidal symptoms
Increased activity = EPSE’s
How may schizophrenia present?
Positive symtoms
Negative symptoms
Schneider’s first rank symptoms
What are positive symptoms? Do these carry a good or bad prognosis in schizophrenia?
Hallucinations (mostly auditory)
Delusions
Thought disorder
Rare, good prognosis
Tends to present earlier
What are negative symptoms? Do these carry a good or bad prognosis in schizophrenia?
Lack of motivation Poverty of speech Blunt affect Anhedonia No relationship desires
Variants of normal traits, less treatment response
Worse prognosis
What are Schneider’s first rank symptoms?
1) Auditory hallucinations
- 3rd person
- Discussing / commentating
2) Delusions of control
- Thought insertion
- Withdrawal
- Broadcast
- Echo = auditory hallucination
3) Delusions of passivity
- Affect, sensations and impulses are under external agent’s control
FRS help to distinguish schizophrenia from other psychotic disorders
- Absent in 20% of those with schizophrenia but do not occur in other mental illness
What are the four types of schizophrenia?
1) Paranoid
2) Hebephrenic
3) Catatonic
4) Undifferentiated
Briefly describe paranoid schizophrenia
Stable, paranoid delusions and hallucinations
Briefly describe hebephrenic schizophrenia
Prominent affective changes:
- Blunted and inappropriate
- Incoherent speech
- Disorganised thoughts
- Irresponsible and unpredictable behaviour
Briefly describe catatonic schizophrenia
Psychomotor disturbance Posturing Mutism Staring Rigidity
10-15%
Briefly describe undifferentiated schizophrenia
Meets the general criteria but no symptom subtype predominates
What may be found upon MSE of a pt with schizophrenia?
A&B - may be normal, social awkwardness, inappropriate smiling, withdrawal
- Arousal eg aggression less common
Speech - may be difficult to follow is acutely ill, poverty of speech, neologism
Mood - changes are uncommon, blunting / indifference, depression and euphoria, incongruous (not in keeping with trigger)
Thought form - difficult to follow, concrete ideas, loosening of associations, thought block (stop mid sentence)
Thought content - delusions common, often persecutory and sometimes grandiose, delusions of reference, control, passivity
Perception - mostly auditory hallucinations
Cognition - reduced, may not be orientated
Insight - variable
How is schizophrenia diagnosed?
> 1 month of symptoms:
“Fundamental and characteristic distortions of thinking and perception with inappropriate or blunted affect”
Diagnosis should not be made in the presence of extensive depressive or manic symptoms unless schizophrenic symptoms clearly predate the affective disturbance
NOT in the presence of overt brain injury (including epilepsy), during state of drug intoxication, use of psychoactive substances or withdrawal
What investigations should be done for schizophrenia?
FBC ESR U&Es TFTs LFTs Glucose Calcium Syphilis HIV Urine drug screen ECG (anti-psychotics prolong QT)
List some organic ddx for schizophrenia (8)
1) Delirium
2) Dementia
3) Stroke
4) CNS infection
5) Brain tumour
6) Huntington’s
7) Wilson’s
8) Brain lesion - temporal lobe, limbic system, basal ganglia
List some psychological ddx for schizophrenia (10)
1) Drug induced psychosis
2) Schizoaffective disorder
3) Psychotic depression
4) Manic psychosis
5) Puerperal psychosis
6) Personality disorder
7) Schizotypal disorder
8) OCD
9) Body dysmorphia
10) Hyperchondriasis
Who is involved in care in a first episode of psychosis?
First episode of psychosis often requires urgent hospital admission
Early assessment:
- Early intervention team
- Crisis team
- Inpatient care
MDT - psychiatric, medical wellbeing, psychological, occupational, social
Risk assessment
What is the short term management of schizophrenia?
Medication
- Antipsychotics
Psycho-social
- Psycho education
- CBT / family interventions
What is the long term management of schizophrenia?
Medication
- Antipsychotics (oral / depot)
- Antidepressants
- Lithium
Psycho-social
- CBT
- Supported employment
- Family interventions
- Reduced expressed emotion
- Relapse signature
- Art therapy
What antipsychotics are used in the management of schizophrenia?
Depends on age, co-morbidities, previously tried and tolerated, SE impact
First generation (typical)
- Chlorpromazine
- Flupenhazine
- Flupenthizol
- Zuclopenthixol
- Haloperidol
Second generation (atypical) - Olanzapine - Risperidone - Amisulpride - Quetapine (Any 2nd gen that is not clozapine)
3rd generation = Aripiprazole
- Dopamine Serotonin system stabiliser
What is the goal of antipsychotics?
Stabilise high levels of dopamine that are seen in the brain in psychosis
Antagonise hyperactivity of dopamine in the mesolimbic pathway
Done by antagonising D2 receptors
However, SE occur as antipsychotics do not just block receptors in mesolimbic pathway
What is the side effect profile of first generation (typical) antipsychotics?
Movement disorders due to extrapyramidal side effects (D2 antagonists)
1) Acute dystonia = painful spastic contractions to maximal limit of certain muscle groups, usually neck, eyes, trunk
- Eg torticollis - abnormal position of neck or an oculogyric crisis
- Treat with anticholinergics (procyclidine 5-10mg PO/IM/IV)
2) Parkinsonism = triad of tremor, rigidity and bradykinesia
- Occurs >1wk after administration
- More common in F and those with pre-existing neurological damage
- Treat with anticholinergics
3) Akathisia = restlessness, usually in lower limbs and drive to move
- Occurs >1month after initiation
- Difficult to treat, use BDZs and propranolol
4) Tardive dyskinesia = continuous slow writhing movements and sudden involuntary, repetitive movements usually in oral-lingual area
- Eg grimacing or smacking of the lips
- Presents late after treatment
5) Neuroleptic malignant syndrome
6) Hyperprolactinaemia
What medication can be given to treat tardive dyskinesia resulting from first generation antipsychotics?
Tetrabenazine or procyclidine
What is the side effect profile of second generation antipsychotics?
Side effects due to the tubero-fundibular action = effects on metabolism (D2 / 5HT2A antagnoists)
1) Hyperlipidaemia
2) Sexual dysfunction
- Decreased libido
- Erectile / ejaculatory dysfunction
3) Weight gain
(Hyperprolactinaemia = tends to only occur at higher doses, more a problem in typical)
- Galactorrhoea
- Gynaecomastia
What is clozapine? When is it used? What are the SE?
Clozapine = 2nd gen (atypical) antipsychotic
Used for Treatment Resistant Schizophrenia (TRS)
- If pt fails to respond to 2 other 2nd generation antipsychotics that have been trailed at adequate an dose and for an adequate time
- Not advised if immunosuppressed eg HIV / chemo
Risk of AGRANULOCYTOSIS
- Regular FBC to check WCC
- Titrate dose up slowly, if dose missed have to restart slow titre
- If neutropenia spotted at any time then immediately stopped
Can also lower seizure threshold
NB smoking cessation can cause a rise in clozapine
Other than dopamine related SE, what are some SE of antipsychotics?
Anti-cholinergic:
- Dry mouth, blurred vision, constipation, urinary retention
Anti-adrenergic (alpha 1)
- Postural HTN, sexual dysfunction
Anti-histamine (H1)
- Sedation, anti-emetic
Hepatotoxicity
- Chlorprimazine
Diabetes / dyslipidaemia
- Olanzapine, clozapine
Blood dyscrasias
- ALL esp clozapine
Which generation of antipsychotics can lead to weight gain?
2nd generation
Which generation of antipsychotics can lead to dyslipidaemia?
2nd gen
Which generation of antipsychotics can lead to tardive dyskinesia?
1st gen
Which generation of antipsychotics can lead to QTc prolongation?
Both
Which generation of antipsychotics can lead to changes to plasma glucose and DM?
2nd gen
Which generation of antipsychotics can lead to changes to seizure threshold?
Both
When should aripiprazole used?
Has a very minimal side effect
2nd gen, use if prolactin SE troubling
What antipsychotics are most commonly used in pregnancy?
Haloperiodol
Olanzapine
What may clozapine interact with?
Both clozapine and carbamazepine can cause agranularcytosis
Should never be used together
What may quetiapine interact with?
Erythromycin
Both prolong QT interval
Why may antipsychotics interact with metaclopraminde?
Both have anti-cholinergic effects
What investigations should be done before starting antipsychotics?
FBS, U&Es, LFTs Lipids and weight Fasting blood glucose Prolactin BP ECG
What investigations should be done during treatment with antipsychotics?
FBC, U&Es, LFTs
- At least annually
- For clozapine = weekly FBC for first 18 weeks, then fortnightly, then after 1 year done monthly
Lipids and weight
- After 3 months of treatment and then annually
Fasting blood glucose ad prolactin
- After 6 months of therapy and then yearly
BP
What is the course of anti-psychotic medication?
Select appropriate medication and begin, assess over 2/3 weeks:
- Some effect = continue for 4 weeks then reassess
- No effect = increase dose and if still no effect consider change
If two unsuccessful consider clozapine
Continue for 1-2yrs
Discontinuation should be gradual
- High risk of relapse of psychotic symptoms when antipsychotics are discontinued suddenly
What are the timeframes of the following effects of antipsychotics:
1) Tranquillising
2) Side effects
3) Antipsychotic effects
1) Tranquillising - hrs
2) Side effects - hrs to days
3) Antipsychotic effects - days to weeks
What is a depot?
IM slow release antipsychotic preparation
When are depots used?
Good if chaotic and poor compliance
Various FGA available - Risperidone, paliperidone, olanzapine
Give initial test dose then use 2-4 weekly dose
Usually PO required until steady state reached
Long half life - wait weeks/months to see effects
Other than antipsychotics, what medications can be given in schizophrenia?
Augmentation with lithium if unresponsive to clozapine
BDZs to treat anxiety and agitation
- Rapid transuilisation = lorzepam 1mg PRN up to 4mg per 24hrs
Antidepressants and ECT to treat negative symptoms
What factors suggest a poor prognosis in schizophrenia?
Gradual onset Positive FH Low educational attainment Pre-morbid evidence of social isolation Male Single Insidious onset Substance abuse Negative symptoms Early onset Delayed response to treatment
What factors suggest a good prognosis in schizophrenia?
Good educational attainment Sudden onset Recognisable precipitating event Female Married Acute onset Affective symptoms Older onset Rapid response to treatment
What is the prognosis of schizoprenida
1/3rd live independently (more than a third)
1/3rd live independently with treatment and various levels of support
1/3rd need long term dependence care
5% suicide rate
What is schizoaffective disorder?
Disorder combining features of both schizophrenia and bipolar affective disorder
Where classification into either of the categories would not correctly classify the disease
How may schizoaffective disorder present?
Schizophrenia and mood order in the same episode
At least one (preferably 2) of Schneider’s first rank symptoms several
Plus affective symptoms - depression, anxiety and mania
Symptoms occurring simultaneously or within a few days of each other
What are the two types of schizoaffective disorder?
Schizomanic = manic symptoms
Schizodepressive = depressed symptoms
Which type of schizoaffective disorder carries a better prognosis?
Schizomanic
How are delusional disorders distinct from schizophrenia?
Development of a single set of delusions for the period of >3 months is the prominent or only feature
List some types of delusion (8)
1) Grandiose
2) Persecutory
3) Bizarre
4) Jealousy
5) Nihilistic
6) Guilt
7) Hypochondrial
8) Delusions of control / passivity - don’t have control of your actions or thoughts
- Somatic passivity = something else controlling symptoms or physical sensations such as sexual feelings
What features are incompatible with a diagnosis of delusional disorder?
Clear and persistent auditory hallucinations
Delusions of control
Marked blunting of affect
Definite evidence of brain disease
NB presence of occasional auditory hallucinations esp in elderly does not exclude the diagnosis provided they are not typically schizophrenic and form only a small part of the overall picture
What is the delusional belief that a partner is having an affair? What is it associated with / what are the risks?
Othello syndrome
No evidence / misinterprets minor evidence
Associated with alcohol dependence and sexual dysfunction
Risk of stalking and / or violence to partner
What is De Clerambault’s syndrome?
Erotomania
Delusional belief that another (often famous) person is in love with them
Can’t declare love so via secret signs / communication
What is delusional misidentification?
Capgras syndrome
Relative / spouse / close friend replaced by identical looking double or impost
Is Capgras syndrome more common in M or F?
M:F 2:3
In what syndrome is there the belief that different people are a single person who changes appearance or is in disguise?
Fregoli’s syndrome
Often believe they are being persecuted by that person
What is Cotards syndrome? What does it often coexist with?
Delusion of being dead, dying, non-existent, ortting, lost part s of body / organs
Often co-exists with depression
What is delisional parasitosis?
Ekboms syndrome
Delusion of being infested with parasites
No evidence - only little marks / freckles / spots
Associated with formincation
Risk of self harm to get rid of parasties
Where does Ekboms syndrome often present?
Deramtologists
What is delusional cleptoparasitosis?
Delusion that house / home infested
What is folie à deux?
Induced delusional disorder
Psychosis shared by two people - often one primary person with a delusional disorder who will induce delusions in the other
When separated, non-psychotic pt tends to recover
What other features may be present in delusional disorders?
Hallucinations - can be a feature but are usually fleeting and not schizophrenic in nature
Depressive episodes can occur but they are often brief
Affect, speech and behaviour are often all normal and pt have good social skills / appear wel
What is the management of delusional disorders?
Antipsychotics
Antidepressats if indicated
Psychotherapy
Supportive therapy
Are delusional disorders more common in F or M?
F
What is Charles-Bonnet syndrome
Visual hallucination
Associated with eye disease, particularly peripheral field visual loss
Common things to hallucinate include faces, animals and children
Occurs in clear consciousness
Other risk factors include social isolation and increased age
What % of pt do not respond to D2 antagonists?
20-50%
List some indications for antipsychotics
1) Psychosis
2) Bipolar disorder
3) Sedation
4) Severe anxiety
5) Agitation
6) Behavioural symptoms in dementia
7) Depression
8) Nausea
9) Anaesthetsia premedication
10) Intractable hiccups
11) Terminal illness
What is neuroleptic malignant syndrome (NMS)?
Sympathetic hyperactivity as a result of dopaminergic antagonism in the context of psychological stressors and genetic predisposition
Rare (0.5-1%)
How does NMS present?
Muscular rigidity Decreased conscious level Hyperthermia Labile BP, tachycardia Increased CK Diaphoreses Abnormal LFTs
What are some risk factors for NMS?
High potency typical antipsychotics Rapid dose increases / reductions Agitation Dehydration Alcoholism Antipsychotic polypharmacy
Over what time period does NMS take place?
Evolves rapidly over 24-72hrs
What is the prognosis of NMS?
5-20% of pt on PO medication and 30% on depot will die if untreated
Usual cause of death is renal failure secondary to rhabdomyolysis
Outline ATHLETICS for atypical antipsychotics
A - Schizoprenia is caused by an over-activity of chemicals in transmission of messages in the brain.
Olanzapine works by blocking the receptors in the brain that are involved in transmitting these messages between the nerve cells
T - tablet daily or depot injection every 2-4 weeks
H - tablet or depot. Start at a small dose and build up over 1 / 2 weeks. Dose adjusted depending on persons response
L - long term (keeps symptoms from returning). Tell doctor if wanting to get pregnant
E - several days / weeks
T - occasional LFTs (may impair liver function)
I - anti-dopaminergic (tardive dyskinesia, tremor, movement disorders), anti-cholinergic (constipation, dry mouth), anti-histaminergic (weight-gain, dizziness, drowsiness), anti-adrenergic (hypotension)
C - complications: NSM (high fever and muscle rigidity), agranulocytosis (swelling of mouth or throat or rash), withrawal
CI: liver failure, phaeochromocytoma
Caution: epilepsy, DM, glaucoma, Parkinsons, heart, prostate or kidney problems, pregnancy
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