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Y5 Psych > Psychotic Disorders > Flashcards

Psychotic Disorders Flashcards

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1
Q

What are 3 key psychotic symptoms?

A

Delusions
Hallucinations
Formal thought disorders

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2
Q

What is a hallucination

A

Perception without external stimulus

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3
Q

What is a delusion

A

Fixed, false belief held despite rational argument/evidence in contrary that is outside of cultural norms

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4
Q

What is a formal thought disorder?

A

Illogical /muddled thinking with loosening of association

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5
Q

When does the onset of psychotic disorders generally occur?

A

late teens/early 20s

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6
Q

What are risk factors for psychosis?

A
  • GENETICS
  • Obstetric complications (maternal malnutrition, viral infections, pre-exlampsiastress, hypoxia, foetal growth restrictions)
  • Childhood adversity/abuse
  • Social disadvantage
  • Urbanism
  • Migrants
  • Substance use (CANNABIS)
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7
Q

What. are the three theories for psychosis?

A

Neural development
Neurotransmitter
Psychological

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8
Q

Explain the neural development theory

A

Enlarged ventricles,
Reduced cortex/amygdala
Disorganised white matter

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9
Q

Explain neurotransmitter theory

A

+ve symptoms: excess dopamine

-ve symptoms: insufficient dopamine

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10
Q

What are the three stages of psychosis?

A
  1. ARMS (At Risk Mental State)
  2. Acute
  3. Chronic
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11
Q

What happens in ARMS?

A

mild/brief symptoms
social withdrawal
loss of interest in activities
No FRANK psychotic symptoms

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12
Q

What happens in acute phase?

A

delusion
hallucinations (auditory)
formal thought disorder

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13
Q

What happens in chronic phase?

A

NEGATIVE symptoms

Apathy 
Blunted emotions 
Anhedonia 
Societal withdrawal 
Poverty of thought/speecy
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14
Q

What are organic differentials for psychosis?

A
  • 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)
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15
Q

What are non-organic causes for psychosis?

A

Schizophrenia
Acute and transient psychotic disorder
Schizoaffective disorder
Delusional disorder

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16
Q

Schizophrenia requirements

A

sx >1 month
Affect multiple areas of mental state e.g. hallucinations, delusions, thought disorder, affective blunting, apathy, impaired attention/memory

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17
Q

What are antipsychotics you can give?

A

first generation - typical

second gen - atypical

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18
Q

How do antipsychotics work?

A

Dopamine antagonists (block postsynaptic D2 receptors)

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19
Q

What dose of antipsychotic should you aim for?

A

the lowest dose possible

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20
Q

What are examples of first gen antipsychotics?

A

Haloperidol
Chlorpromazine
Sulpiride
Zuclopentax

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21
Q

What are benefits of first gen antipsychotics?

A

Effective

Cheap

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22
Q

What are negatives of first gen antipsychotics?

A

EPSEs
Hyperprolactinaemia
Cardiac toxicity

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23
Q

What are examples of second gen antipsychotics?

A

Olanzapine, risperidone, aripiprazole, clozapine

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24
Q

What are side effects of second gen antipsychotics?

A

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

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25
Q

What is used for treatment resistant psychosis?

A

clozapine

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26
Q

What other therapies can be used for psychotic disorders?

A

CBT
Family intervention
Arts therapies

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27
Q

What is a dangerous side effect of clozapine?

A

Agranulocytosis

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28
Q

What intervention needs to be set into place if patient is prescribed clozapine?

A

Blood tests weekly for 18 weeks, then fortnightly (to pick up low WBC)

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29
Q

What is another option if patient has poor adherence to oral medication?

A

Give depot injection

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30
Q

What are the positive symptoms of schizophrenia?

A

Hallucinations

Delusions

31
Q

Why are people born in winter more likely to have schizophrenia?

A

Because the mothers are more likely to have had a viral infection

32
Q

What are the negative symptoms of schizophrenia?

A 
Blunted affect 
Apathy 
Anhedonia 
Social withdrawal 
Reduction in speech production 
Loss of concentration
33
Q

What type of family behaviour. can cause worsening of schizo symptoms?

A

Expressed emotion (over critical/over involved relatives)

34
Q

What are most common types of auditory hallucination in schizophrenia?

A

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

35
Q

What are the most common types of delusion in schizophrenia?

A

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

36
Q

What is thought interference’?

A

The belief that patient thoughts are under control of something else

37
Q

What are the types of thought interference?

A

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

38
Q

How does formal thought disorder present in schizo?

A 
Loosening of association 
Word salad (words so disconnected that sentences do not make any sense)
39
Q

What are they types of schizophrenia that can occur?

A 
Paranoid
Catatonic 
Hebephrenic 
Simple 
Residual
40
Q

How does catatonic schizo present?

A

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

41
Q

How does a hebephrenic schizo present?

A

Disargonised and chaotic mood

Affect is shallow, inappropriate

42
Q

What are Shneider’s first rank symptoms?

A

Delusional perception
Passivity
Delusions of thought interference (thought insertion withdrawal, broadcasting)
Auditory hallucinations (thought echo, third person, running commentary)

43
Q

How does hyperprolactinaemia present?

A

Short term: sexual dysfunction, galactorrhea, infertility, amenorrhoea, gynaecomastia

Long term: reduces protective effect of oestrogen, causing osteoporosis and breast cancer

44
Q

How do EPSEs present?

A

Parkinsonism
Dystonia (uncontrollable muscle contraction)
Akathisia (restlessness)
Tardive dyskinesa (chewing, smacking lips _ continue even after you stop medication)

45
Q

What is akathisia

A

Subjective feeling of restlessness, causing constant fidgeting eg. crossing, uncrossing leg

46
Q

What is tardive dyskinesia

A

choreoathetoid movements (twitching, tongue protrusion, chewing)

47
Q

What would you administer for Parkinsonian tremor EPSE?

A

procyclidine PO/IM

48
Q

What are the four key signs of Neuroleptic Malignant Syndrome?

A

Heath Ledger Is A Clown

Hyperthermia
leadpipe rigidity
Instability autonomic (tachicardia, labile BP)
consciousness altered

49
Q

What is the cause of NMS?

A

A new antipsychotic/dose increase

causes lack of dopamine > severe, life threatening symptoms

50
Q

What is defined as treatment resistant schizophrenia?

A

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

51
Q

What are other side effects of clozapine (other than AGRANULOCYTOSIS)

A

CONSTIPATION

Excessive sedation, seizures
hypersalivation 
Postural hypertension
Weight gain/metabolic syndrome 
Anticholinergic effects 
Cardiomyopathy
Fatal myocarditis
52
Q

What should you do if the patient is only recently become unwell?

A

Refer to EARLY INTERVENTION SERVICE

Aims to engage patients with very early symptoms (antipsychotics and psychosocial interventions)

53
Q

give examples of thought disorder

A 
loosening of association / knights move thinking 
poverty of speech 
pressure of speech
distractible speec h 
tangentiality, circumstantialoity 
word salad
clanging 
neologism 
perseceration 
echolalia
54
Q

How can you assess symptoms in schizophrenia (i.e. with what tool)

A

Positive and negative symptom scale

55
Q

What organic causes must you exclude for schizophrenia

A

substance misuse

neuro:
- epilepsy
- brain tumour
- stroke
* * charles bonnet syndrome (if hallucinating)

memory clinic:
dementia
delirium

Infectious:

  • HIV
  • syphilis

metabolic disorders:

  • WIlson’s
  • porphyria
56
Q

what differentials exist for schizophrenia

A 
organic causes (see above) 
Acute and Transient psychotic episode 
Mood disorder (severe depression/mania) 
Schizoaffective 
Persistent delusional disorder
Schizotypal disorder 
PD
57
Q

when can you diagnose schizophrenia in the presence of mood disturbance

A

NEVER, unless the schizo symptoms came first

58
Q

what investigations must you get for schizo

A

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

59
Q

what other type of history must you NOT FORGET for schizo

A

collateral

60
Q

explain the effect of schizophrenia on the circuits on the brain, and how that causes symtoms

A

excess dopamine in mesolimbic pathway > positive symptoms

insuff dopamine in mesocortical pathway > negative symptoms

61
Q

explain how antipsychotics interfere on circuits of the brian

A

deplete dopamine from the nigrostriatal pathway > EPSE

deplete dopamine from the tuberoinfindubilar pathway > underactivity > hyperprolactinaemia

62
Q

How does dystonia present? describe in general + 2 specific presentations

A

Sustained muscle contractions

  • torticollis (uncontrolled neck movements)
  • oculogyric crisis (uncontrolled eye movements, rotation)
63
Q

Explain the third side effect of antipsychotics, other than EPSE and hyperprolactinaemia

A

Prolonged QT > torsade de pointes

64
Q

what do you go to avoid TdP in antipsychotics

A

Do ECG before starting antipsychotic prescriuption

65
Q

what medication you give as rapid tranq for acute psychotic episode

A

IM Lorazepam
Second line: antipsychotic (need ECG)
Third line: promethazine (sedating anti histamine)

66
Q

what are benefits of lorazepam

A

fast acting
short term
safe (hard to OD)
no risk of NMS)

67
Q

what are risks of lorazepam

A

dependence
resp depression
syncope
sedation

68
Q

who is lorazepam (and benzos in general) contraindicated for?

A
  • elderly (risk of syncope > falls)
  • COPD (blue boaters, risk of resp depression)
  • OSA
69
Q

What is the procedure for an agitated schizo patient

A
  1. risk assess
  2. attempt to de-escalate
    3- Intervene. physical intervention/restraint or rapid tranq
70
Q

How do you go about offering Rapid tranq

A
  1. offer PO in calm, respectful manner
  2. If patient refuses, give IM
    ALWAYS MONITOR VITALS/OBS as risk of arrest / emergewncy
71
Q

what is charles bonnet syndrome

A

persistent/recurrent complex hallucinations

  • Occur under clear consciuosness
  • in patient with VISUAL IMPAIRMENT
  • with no other psychological disturbance
72
Q

what blood tests should you get for suspected NMS and what will they show

A

CK +++ (rhabdomyolysis)
WCC elevated
U&E (renal function - rhabdomyolysis could cause AKI)
ABG (acidosis if AKI)

73
Q

what long term monitoring is necessary for patients on antipsychotics

A

REGULAR
BMI, waist circumference
BP
FBC, LFT, U&E, GTT , lipids

Consider prolactin and ECG

Y5 Psych (17 decks)

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