Psychotic disorders Flashcards
What is affective psychosis?
A typically episodic psychosis with a tendency to remit. Psychotic symptoms occur only during peak severity of the episode
What is schizophrenic psychosis?
Chronic psychosis typically associated with deficits in insight.
What is the prevalence of schizophrenia?
1 in 100 people
What is the male to female ratio of schizophrenia?
1.4:1
What is the typical age of diagnosis for schizophrenia?
Usually late teens to early 30’s. Men (18-25) Women (25-35 with a later post-menopause peak >40)
What is the current consensus on the genetic basis for Schizophrenia?
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.
What is the current consensus on pregnancy and birth factors contributing to the development of schizophrenia?
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
What is the current consensus on post-birth environmental factors contributing to the development of schizophrenia?
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.
What neurotransmitters have been implicated in the pathophysiology of schizophrenia?
Dopamine (most attention) Serotonin Glutamate GABA Cholinergic neurotransmitters
What are the neuropathological correlates of schizophrenia?
Reduced brain weight and volume, due to increased neuronal density (same number of neurons, smaller space) ++medial temporal lobe Enlarged lateral ventricles
What are the five symptom domains of schizophrenia?
Positive symptoms Negative symptoms Disorganisation Neurocognitive impairment Affective features
What are the positive symptoms associated with schizophrenia?
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
What are some common Schneiderian first rank symptoms?
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
What is a delusion?
False beliefs which cannot be shaken by logic or reason AND are not to be expected based on the persons background or culture.
What are the negative symptoms associated with schizophrenia?
Poverty of speech Affective blunting Reduced motivation, energy, and social engagement
What is disorganisation, in regards to it as a symptom domain of schizophrenia?
Formal though disorder Attentional impairment Inappropriate affect Disorganised behaviour
What is neurocognitive impairment in regards to it as a symptom of schizophrenia?
Poor executive function Reduced reaction time Short attention span Difficulty learning new tasks
What is executive function?
Planning and maintaining focus.
What are affective features in regards to them as a symptom domain of schizophrenia?
Manic symptoms (acute psychosis) Depression (acute or chronic phase) Anxiety and panic (General symptom) Instability of mood and perplexity (resembles delirium, indicates good prognosis)
What are the stages of schizophrenia?
Prodrome Acute episode Residual phase
What are the key aspects of the prodromal phase of schizophrenia?
Depression Pervasive sense of anxiety Suspiciousness Social withdrawal Insomnia
Why is early intervention important in schizophrenia?
Because prognosis is worse, the more acute episodes a patient experience. Best prognosis is effective treatment of first episode.
What are factors which lead to good prognosis?
Female sex Later onset Lower number of acute episodes Being married Good premorbid functioning Positive response to medication Onset subsequent to clearly defined stressor
What is a general description of Schizophreniform disorder?
Simmilar symptoms to schizophrenia, but duration of thee illness does not exceed 6 months.
What is a general description of Schizoaffective disorder?
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.
What is a general description of brief psychotic disorder?
Sudden onset psychotic symptoms lasting from days to weeks followed by full recovery.
What is a general description of delusional disorder?
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.
What is a general description of substance induced psychosis?
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
What is a general description of psychotic disorder due to another medical condition
Psychotic symptoms, but there is evidence that these symptoms are a direct pathophysiological consequence of another medical condition.
What medical conditions have been associated with psychotic disorder due to another medical condition?
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
What substances have been associated with substance induced psychosis?
Anticholinergics Dopamine agonists Digoxin Steroids Cimetidine Amphetamines Cannabinoids Narcotics
What are the key points of the DSM 5 criteria for the diagnosis of Schizophrenia?
- 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.
What needs to be specified in a schizophrenia diagnosis after the person has had it for one year?
Episode (first or multiple), Stage (acute, partial remission, or full remission) Specify whether catatonia is present Specify current severity (not 100% needed)
What is severity measurement of schizophrenic symptoms?
Scale for 0-4 for each symptom for current severity (over previous 7 days)
What is the management of prodromal schizophrenia?
Close monitoring CBT SSRI Omega-3 (EPA- eicosapentaenoic acid) Ultra low dose antipsychotics (poor evidence)
What is the management for the first psychotic episode in scizophrenia?
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.
What is the management for the recovery and relapse phase of schizophrenia?
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
What is the management of relapse in schizophrenia?
Consider Depot antipsychotics Add lithium if there are affective symptoms (++mania)
What is the management for treatment-resistant schizophrenia
Clozapine Started at a low dose, increased to 200-600mg per day. Need serum monitoring during clozapine treatment
What is the required monitoring for clozapine?
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
What drugs can you not take with clozapine?
Anything that causes blood dyscrasias Carbamazepine Chemo agents Any drugs that inhibit or induce CYP1A2 (smoking, can cause increase serum concentration on cessation)
What is the management of schizophrenia with prominent negative symptoms?
- 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)
What is the preferred antidepressant used in schizophrenia?
Fluoxetine
What is the management of acute dystonias from antipsychotic treatment
Benzatropine 1-2mg IV or IM as a single dose
What is the management of parkinsonian movement disorders from antipsychotic treatment?
- Benzatropine 0.5-2mg oral, daily 2. Benzhexol 2mg oral, daily (up to 10mg per day in 3-4 doses)
What is the management of akathisia from antipsychotic treatment?
- Propranolol 20-40mg oral 3-4 times per day 2. Diazepam 2-5mg orally 3 times per day
What needs to be done when switching antipsychotic medications? What do you need to be cautious of?
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)
