Psychotic disorders

Question 1

What is affective psychosis?

Answer 1

A typically episodic psychosis with a tendency to remit. Psychotic symptoms occur only during peak severity of the episode

Question 2

What is schizophrenic psychosis?

Answer 2

Chronic psychosis typically associated with deficits in insight.

Question 3

What is the prevalence of schizophrenia?

Answer 3

1 in 100 people

Question 4

What is the male to female ratio of schizophrenia?

Answer 4

1.4:1

Question 5

What is the typical age of diagnosis for schizophrenia?

Answer 5

Usually late teens to early 30’s. Men (18-25) Women (25-35 with a later post-menopause peak >40)

Question 6

What is the current consensus on the genetic basis for Schizophrenia?

Answer 6

Multigene inheritance with environmental factors: Exponential decrease in risk as biological relationships become more distant Severe illness in monozygotic twins associated with higher concordance rates.

Question 7

What is the current consensus on pregnancy and birth factors contributing to the development of schizophrenia?

Answer 7

Hypoxia at birth can double risk Maternal infection (viral) can increase risk (shown by seasonal variation in birthdays. Low levels of vitamin D in gestation increase risk

Question 8

What is the current consensus on post-birth environmental factors contributing to the development of schizophrenia?

Answer 8

Stressful life events accumulated in childhood (abuse, neglect) Cannabis (dose-response relationships) especially use before the age of 15. Factors work in concert with genetic loading.

Question 9

What neurotransmitters have been implicated in the pathophysiology of schizophrenia?

Answer 9

Dopamine (most attention) Serotonin Glutamate GABA Cholinergic neurotransmitters

Question 10

What are the neuropathological correlates of schizophrenia?

Answer 10

Reduced brain weight and volume, due to increased neuronal density (same number of neurons, smaller space) ++medial temporal lobe Enlarged lateral ventricles

Question 11

What are the five symptom domains of schizophrenia?

Answer 11

Positive symptoms Negative symptoms Disorganisation Neurocognitive impairment Affective features

Question 12

What are the positive symptoms associated with schizophrenia?

Answer 12

Delusions and hallucinations. Often associated with reduced insight. Schneiderian ‘first rank’ symptoms such as: Passivity phenomena (thoughts/actions controlled by external force), thought broadcast, thought withdrawal Hearing own thoughts repeated aloud Hearing voices discussing patient in the third persons Hearing a running commentary of what the patient is doing or thinking

Question 13

What are some common Schneiderian first rank symptoms?

Answer 13

Passivity phenomena: thoughts/actions controlled by external force, thought broadcast, thought withdrawal Hearing own thoughts repeated aloud Hearing voices discussing patient in the third persons Hearing a running commentary of what the patient is doing or thinking

Question 14

What is a delusion?

Answer 14

False beliefs which cannot be shaken by logic or reason AND are not to be expected based on the persons background or culture.

Question 15

What are the negative symptoms associated with schizophrenia?

Answer 15

Poverty of speech Affective blunting Reduced motivation, energy, and social engagement

Question 16

What is disorganisation, in regards to it as a symptom domain of schizophrenia?

Answer 16

Formal though disorder Attentional impairment Inappropriate affect Disorganised behaviour

Question 17

What is neurocognitive impairment in regards to it as a symptom of schizophrenia?

Answer 17

Poor executive function Reduced reaction time Short attention span Difficulty learning new tasks

Question 18

What is executive function?

Answer 18

Planning and maintaining focus.

Question 19

What are affective features in regards to them as a symptom domain of schizophrenia?

Answer 19

Manic symptoms (acute psychosis) Depression (acute or chronic phase) Anxiety and panic (General symptom) Instability of mood and perplexity (resembles delirium, indicates good prognosis)

Question 20

What are the stages of schizophrenia?

Answer 20

Prodrome Acute episode Residual phase

Question 21

What are the key aspects of the prodromal phase of schizophrenia?

Answer 21

Depression Pervasive sense of anxiety Suspiciousness Social withdrawal Insomnia

Question 22

Why is early intervention important in schizophrenia?

Answer 22

Because prognosis is worse, the more acute episodes a patient experience. Best prognosis is effective treatment of first episode.

Question 23

What are factors which lead to good prognosis?

Answer 23

Female sex Later onset Lower number of acute episodes Being married Good premorbid functioning Positive response to medication Onset subsequent to clearly defined stressor

Question 24

What is a general description of Schizophreniform disorder?

Answer 24

Simmilar symptoms to schizophrenia, but duration of thee illness does not exceed 6 months.

Question 25

What is a general description of Schizoaffective disorder?

Answer 25

Where a person has psychotic features AND disordered mood, but no clear relationship exists between them. Schizophrenia + mood disorder which are concurrent or sequential but share distinct courses.

Question 26

What is a general description of brief psychotic disorder?

Answer 26

Sudden onset psychotic symptoms lasting from days to weeks followed by full recovery.

Question 27

What is a general description of delusional disorder?

Answer 27

Usually has a later age of onset and is characterised by non-bizarre delusions (not a priori false). Common in social isolation and sensory impairment which encourages misinterpretation of the motives of others.

Question 28

What is a general description of substance induced psychosis?

Answer 28

Psychotic symptoms, but there is evidence that these symptoms: 1. developed soon after or during intoxication or withdrawal from a substance 2. the implicated substance is capable of producing those symptoms. AND the symptoms cannot be better explained by another type of primary psychotic disorder

Question 29

What is a general description of psychotic disorder due to another medical condition

Answer 29

Psychotic symptoms, but there is evidence that these symptoms are a direct pathophysiological consequence of another medical condition.

Question 30

What medical conditions have been associated with psychotic disorder due to another medical condition?

Answer 30

Encephalopathies Temporal lobe epilepsy Cushings disease Thyroid disease Vitamin B12 deficiency Ovarian cancer Small cell lung cancer Hypoglycaemia Hyponatraemia Hypercalcaemia Hypocalcaemia Hypomagnesaemia SLE Wilson’s disease Prophyria

Question 31

What substances have been associated with substance induced psychosis?

Answer 31

Anticholinergics Dopamine agonists Digoxin Steroids Cimetidine Amphetamines Cannabinoids Narcotics

Question 32

What are the key points of the DSM 5 criteria for the diagnosis of Schizophrenia?

Answer 32

1. Two or more of the following with each present for a significant portion of time during a 1-month period (at least one *symptom*): *delusions*, *hallucinations*, *disorganised speech*, grossly disorganised or catatonic behaviour, negative symptoms. 2. Level of function must be impaired (work, relations, self care) 3. Continuous signs of disturbance persisting for 6-months 4. Schizoaffective disorder and depressive or bipolar disorder have been ruled out. 5. Disturbance not attributable to physiological effects of substances or organic pathology. 6. If pre-existing ASD / communication disorder diagnosis. Schizophrenia is only diagnosed where prominent delusions / hallucinations persist for at least 1 month.

Question 33

What needs to be specified in a schizophrenia diagnosis after the person has had it for one year?

Answer 33

Episode (first or multiple), Stage (acute, partial remission, or full remission) Specify whether catatonia is present Specify current severity (not 100% needed)

Question 34

What is severity measurement of schizophrenic symptoms?

Answer 34

Scale for 0-4 for each symptom for current severity (over previous 7 days)

Question 35

What is the management of prodromal schizophrenia?

Answer 35

Close monitoring CBT SSRI Omega-3 (EPA- eicosapentaenoic acid) Ultra low dose antipsychotics (poor evidence)

Question 36

What is the management for the first psychotic episode in scizophrenia?

Answer 36

Atypical antipsychotic drugs except Clozapine or sertindol. Diazepam 5-10mg as required (up to 40mg) for treatment of anxiety, agitation, insomnia and activation syndrome. If there is unacceptable partial response after 6-12 weeks switch to another antipsychotic: 1. Alternative atypical (first line); or 2. Chlorpromazine (200mg up to 800mg) 2. Haloperidol (1.5mg up to 10mg) 2. Pericyazine (10mg up to 75mg) Parenteral treatment is a last resort.

Question 37

What is the management for the recovery and relapse phase of schizophrenia?

Answer 37

Continue pharmacological treatment: 2-years following first episode 5-years if relapse occurs Consider depot formulations Monitor side effects Use a broadly based treatment program: Psychoeducation program Shared care program with GP CBT Cognitive remediation Employment & social supports Education and training assistance Monitor physical health: SNAPW Important because of metabolic side effects of antipsychotics Involve families and care givers: Family therapy Carer assistance programs Include family in psychoeducation

Question 38

What is the management of relapse in schizophrenia?

Answer 38

Consider Depot antipsychotics Add lithium if there are affective symptoms (++mania)

Question 39

What is the management for treatment-resistant schizophrenia

Answer 39

Clozapine Started at a low dose, increased to 200-600mg per day. Need serum monitoring during clozapine treatment

Question 40

What is the required monitoring for clozapine?

Answer 40

Initial ECG Regular vitals screening and regular cardiac screening (trops, CRP) for first 4 weeks WBC + neutrophils for first 18weeks Weight, BMI, Waist circumference, glucose, lipids - ongoing

Question 41

What drugs can you not take with clozapine?

Answer 41

Anything that causes blood dyscrasias Carbamazepine Chemo agents Any drugs that inhibit or induce CYP1A2 (smoking, can cause increase serum concentration on cessation)

Question 42

What is the management of schizophrenia with prominent negative symptoms?

Answer 42

1. Amisulpride (100-300mg daily) 1. Clozapine 1. Other atypical + antidepressant (fluoxetine preferred) 2. Clozapine + antidepressant (fluoxetine preferred) 2. Clozapine + Iamotrigine (25mg for two weeks. increase 15mg every 2 weeks up to 300mg twice daily)

Question 43

What is the preferred antidepressant used in schizophrenia?

Answer 43

Fluoxetine

Question 44

What is the management of acute dystonias from antipsychotic treatment

Answer 44

Benzatropine 1-2mg IV or IM as a single dose

Question 45

What is the management of parkinsonian movement disorders from antipsychotic treatment?

Answer 45

1. Benzatropine 0.5-2mg oral, daily 2. Benzhexol 2mg oral, daily (up to 10mg per day in 3-4 doses)

Question 46

What is the management of akathisia from antipsychotic treatment?

Answer 46

1. Propranolol 20-40mg oral 3-4 times per day 2. Diazepam 2-5mg orally 3 times per day

Question 47

What needs to be done when switching antipsychotic medications? What do you need to be cautious of?

Answer 47

Dose of first is tapered off and the second is tapered up over a period of two weeks. Need to monitor for breakthrough psychosis. Need to monitor for supersensitivity psychosis upon abrupt cessation (+++ Clozapine)