Psychotic Disorders Flashcards
What are 3 key psychotic symptoms?
Delusions
Hallucinations
Formal thought disorders
What is a hallucination
Perception without external stimulus
What is a delusion
Fixed, false belief held despite rational argument/evidence in contrary that is outside of cultural norms
What is a formal thought disorder?
Illogical /muddled thinking with loosening of association
When does the onset of psychotic disorders generally occur?
late teens/early 20s
What are risk factors for psychosis?
- GENETICS
- Obstetric complications (maternal malnutrition, viral infections, pre-exlampsiastress, hypoxia, foetal growth restrictions)
- Childhood adversity/abuse
- Social disadvantage
- Urbanism
- Migrants
- Substance use (CANNABIS)
What. are the three theories for psychosis?
Neural development
Neurotransmitter
Psychological
Explain the neural development theory
Enlarged ventricles,
Reduced cortex/amygdala
Disorganised white matter
Explain neurotransmitter theory
+ve symptoms: excess dopamine
-ve symptoms: insufficient dopamine
What are the three stages of psychosis?
- ARMS (At Risk Mental State)
- Acute
- Chronic
What happens in ARMS?
mild/brief symptoms
social withdrawal
loss of interest in activities
No FRANK psychotic symptoms
What happens in acute phase?
delusion
hallucinations (auditory)
formal thought disorder
What happens in chronic phase?
NEGATIVE symptoms
Apathy Blunted emotions Anhedonia Societal withdrawal Poverty of thought/speecy
What are organic differentials for psychosis?
- Dementia
- Delirium
- Medication side effects
- Cerebral pathology (e.g. stroke, SOL)
- Systemic illness e.g. Wilson’s, porphyria, Cushings
- Drug use
Alcohol (delirium tremens, alcoholic hallucinosis)
What are non-organic causes for psychosis?
Schizophrenia
Acute and transient psychotic disorder
Schizoaffective disorder
Delusional disorder
Schizophrenia requirements
sx >1 month
Affect multiple areas of mental state e.g. hallucinations, delusions, thought disorder, affective blunting, apathy, impaired attention/memory
What are antipsychotics you can give?
first generation - typical
second gen - atypical
How do antipsychotics work?
Dopamine antagonists (block postsynaptic D2 receptors)
What dose of antipsychotic should you aim for?
the lowest dose possible
What are examples of first gen antipsychotics?
Haloperidol
Chlorpromazine
Sulpiride
Zuclopentax
What are benefits of first gen antipsychotics?
Effective
Cheap
What are negatives of first gen antipsychotics?
EPSEs
Hyperprolactinaemia
Cardiac toxicity
What are examples of second gen antipsychotics?
Olanzapine, risperidone, aripiprazole, clozapine
What are side effects of second gen antipsychotics?
Metabolic side effects
- HTN
- Obesity
- Raised glucose, cholesterol
- CVD , T2DM
Peripheral oedema
Constipation
Same SE as typical antipsychotics, but less likely to occur due to weaker D2 binding
What is used for treatment resistant psychosis?
clozapine
What other therapies can be used for psychotic disorders?
CBT
Family intervention
Arts therapies
What is a dangerous side effect of clozapine?
Agranulocytosis
What intervention needs to be set into place if patient is prescribed clozapine?
Blood tests weekly for 18 weeks, then fortnightly (to pick up low WBC)
What is another option if patient has poor adherence to oral medication?
Give depot injection
What are the positive symptoms of schizophrenia?
Hallucinations
Delusions
Why are people born in winter more likely to have schizophrenia?
Because the mothers are more likely to have had a viral infection
What are the negative symptoms of schizophrenia?
Blunted affect Apathy Anhedonia Social withdrawal Reduction in speech production Loss of concentration
What type of family behaviour. can cause worsening of schizo symptoms?
Expressed emotion (over critical/over involved relatives)
What are most common types of auditory hallucination in schizophrenia?
Third person - voices discussing/arguing about the patient
Running commentary - voice says patients thoughts out loud
Thought echo - voice says person’s thoughts out loud
What are the most common types of delusion in schizophrenia?
DELUSIONAL PERCEPTION - a real perception is interrupted in a delusional way e.g. the traffic light changed to green and I knew I was king of Thailand
DELUSIONAL PASSIVITY - believing movement, emotion, sensation are controlled by outside form
What is thought interference’?
The belief that patient thoughts are under control of something else
What are the types of thought interference?
Thought withdrawal - thoughts are removed from patient’s mind
Thought insertion - thoughts are placed into patients mind
Thought broadcasting - thoughts are broadcasted to others, so people can know what they are thinking
How does formal thought disorder present in schizo?
Loosening of association Word salad (words so disconnected that sentences do not make any sense)
What are they types of schizophrenia that can occur?
Paranoid Catatonic Hebephrenic Simple Residual
How does catatonic schizo present?
Stupor - immobile, mute, unresponsive, despite appearing to be conscious (eyes open and follow people around the room)
Excitement - periods of extreme hyperactivity
Posturing - inappropriate/bizarre postures
Rigidity - holding a rigid posture against effort to be placed
Perseveration in speech
How does a hebephrenic schizo present?
Disargonised and chaotic mood
Affect is shallow, inappropriate
What are Shneider’s first rank symptoms?
Delusional perception
Passivity
Delusions of thought interference (thought insertion withdrawal, broadcasting)
Auditory hallucinations (thought echo, third person, running commentary)
How does hyperprolactinaemia present?
Short term: sexual dysfunction, galactorrhea, infertility, amenorrhoea, gynaecomastia
Long term: reduces protective effect of oestrogen, causing osteoporosis and breast cancer
How do EPSEs present?
Parkinsonism
Dystonia (uncontrollable muscle contraction)
Akathisia (restlessness)
Tardive dyskinesa (chewing, smacking lips _ continue even after you stop medication)
What is akathisia
Subjective feeling of restlessness, causing constant fidgeting eg. crossing, uncrossing leg
What is tardive dyskinesia
choreoathetoid movements (twitching, tongue protrusion, chewing)
What would you administer for Parkinsonian tremor EPSE?
procyclidine PO/IM
What are the four key signs of Neuroleptic Malignant Syndrome?
Heath Ledger Is A Clown
Hyperthermia
leadpipe rigidity
Instability autonomic (tachicardia, labile BP)
consciousness altered
What is the cause of NMS?
A new antipsychotic/dose increase
causes lack of dopamine > severe, life threatening symptoms
What is defined as treatment resistant schizophrenia?
failure to respond to two or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for min 6 weeks
What are other side effects of clozapine (other than AGRANULOCYTOSIS)
CONSTIPATION
Excessive sedation, seizures hypersalivation Postural hypertension Weight gain/metabolic syndrome Anticholinergic effects Cardiomyopathy Fatal myocarditis
What should you do if the patient is only recently become unwell?
Refer to EARLY INTERVENTION SERVICE
Aims to engage patients with very early symptoms (antipsychotics and psychosocial interventions)
give examples of thought disorder
loosening of association / knights move thinking poverty of speech pressure of speech distractible speec h tangentiality, circumstantialoity word salad clanging neologism perseceration echolalia
How can you assess symptoms in schizophrenia (i.e. with what tool)
Positive and negative symptom scale
What organic causes must you exclude for schizophrenia
substance misuse
neuro:
- epilepsy
- brain tumour
- stroke
* * charles bonnet syndrome (if hallucinating)
memory clinic:
dementia
delirium
Infectious:
- HIV
- syphilis
metabolic disorders:
- WIlson’s
- porphyria
what differentials exist for schizophrenia
organic causes (see above) Acute and Transient psychotic episode Mood disorder (severe depression/mania) Schizoaffective Persistent delusional disorder Schizotypal disorder PD
when can you diagnose schizophrenia in the presence of mood disturbance
NEVER, unless the schizo symptoms came first
what investigations must you get for schizo
Hx, MSE
Full physical exam, and ix to exclude organic cause and establish baseline physical health
Blood tests (FBC, TFT, U&E, CRP, fasting glucose)
Consider HIV and VDRL test
CHECK LIPIDS
MSU
urine drug screen
consider CT head or EEG to exclude brain pathology
what other type of history must you NOT FORGET for schizo
collateral
explain the effect of schizophrenia on the circuits on the brain, and how that causes symtoms
excess dopamine in mesolimbic pathway > positive symptoms
insuff dopamine in mesocortical pathway > negative symptoms
explain how antipsychotics interfere on circuits of the brian
deplete dopamine from the nigrostriatal pathway > EPSE
deplete dopamine from the tuberoinfindubilar pathway > underactivity > hyperprolactinaemia
How does dystonia present? describe in general + 2 specific presentations
Sustained muscle contractions
- torticollis (uncontrolled neck movements)
- oculogyric crisis (uncontrolled eye movements, rotation)
Explain the third side effect of antipsychotics, other than EPSE and hyperprolactinaemia
Prolonged QT > torsade de pointes
what do you go to avoid TdP in antipsychotics
Do ECG before starting antipsychotic prescriuption
what medication you give as rapid tranq for acute psychotic episode
IM Lorazepam
Second line: antipsychotic (need ECG)
Third line: promethazine (sedating anti histamine)
what are benefits of lorazepam
fast acting
short term
safe (hard to OD)
no risk of NMS)
what are risks of lorazepam
dependence
resp depression
syncope
sedation
who is lorazepam (and benzos in general) contraindicated for?
- elderly (risk of syncope > falls)
- COPD (blue boaters, risk of resp depression)
- OSA
What is the procedure for an agitated schizo patient
- risk assess
- attempt to de-escalate
3- Intervene. physical intervention/restraint or rapid tranq
How do you go about offering Rapid tranq
- offer PO in calm, respectful manner
- If patient refuses, give IM
ALWAYS MONITOR VITALS/OBS as risk of arrest / emergewncy
what is charles bonnet syndrome
persistent/recurrent complex hallucinations
- Occur under clear consciuosness
- in patient with VISUAL IMPAIRMENT
- with no other psychological disturbance
what blood tests should you get for suspected NMS and what will they show
CK +++ (rhabdomyolysis)
WCC elevated
U&E (renal function - rhabdomyolysis could cause AKI)
ABG (acidosis if AKI)
what long term monitoring is necessary for patients on antipsychotics
REGULAR
BMI, waist circumference
BP
FBC, LFT, U&E, GTT , lipids
Consider prolactin and ECG
