Psychotic disorders

Question 1

How does psychosis typically present?

Answer 1

Delusions - fixed, false belief, firmly held despite evidence on the contrary going against normal social and cultural belief system

Hallucinations - perception in the absence of an external stimulus

Thought disorder

Question 2

Name some non-organic causes of psychosis?

Answer 2

Schizophrenia

Schizotypal disorder

Schizoaffective disorder

Acute psychotic episode

Mood disorder with psychosis

Drug-induced psychosis

Delusional disorder

Puerperal psychosis

Question 3

What are some organic cause of psychosis?

Answer 3

Drug induced psychosis

Iatrogenic (medication)

Epilepsy

Delerium

Dementia

SLE

Endocrine disturbances e.g. Cushing’s syndrome

Vit B12 deficiency

Question 4

What is schizotypal disorder?

Answer 4

Aka latent schizophrenia characterised by eccentric behaviour, suspiciousness, unusual speech, deviations of thinking but there are no hallucinations or delusions

Question 5

What is an acute and transient psychotic disorder?

Answer 5

Psychotic episode appearing as schizophrenia but lasting < 1 month so not meeting the criteria

Question 6

What is schizoaffective disorder?

Answer 6

Both symptoms of schizophrenia and mood disorder (depression or mania) in the same episode

Question 7

What is delusional disorder?

Answer 7

Single or set of delusions of at least 3 months, content of the delusion is often persecutory, grandiose or hypochondrial in nature

Question 8

What is induced delusional disorder (folie a deux)?

Answer 8

‘Shared paranoid delusion’ = similar delusion in 2 or more individuals

Question 9

What is schizophrenia?

Answer 9

Psychotic condition characterized by hallucinations, delusions and thought disorderswhich lead tofunctional impairment

Question 10

What are some risk factors for schizophrenia?

Answer 10

• Positive family history
• Obstetric complications, fetal injury and low birth weight
• Adverse life events and psychological stress
• 15-35 years old
• Extremes of parental age
• Childhood abuse
• Substance misuse
• Low socio-economic status

Question 11

What is the strongest risk factor for psychotic disorder?

Answer 11

Family history

Question 12

What is the dopamine hypothesis of schizophrenia?

Answer 12

Schizophrenia is secondary to over-activity of mesolimbic dopamine pathways in the brain (supported by the fact that conventional antipsychotics work by blocking dopamine receptors )

Question 13

What are the positive symptoms of schizophrenia?

Answer 13

• Delusions (usually persecutory, grandiose, nihilistic or religious)
• Hallucinations
• Formal thought disorder (thoughts are linked in abnormal ways)
• Thought interference (insertion, withdrawal, broadcast)
• Passivity phenomenon (actions, feelings or emotions are being controlled by an external force)

Question 14

What are Schneider’s first rank symptoms?

Answer 14

Symptoms, which, if one or more are present, are strongly suggestive of schizophrenia (alternative tool to ICD-10 in diagnosing schizophrenia)

Question 15

What are Schneider’s first-rank symptoms?

Answer 15

• Delusional perception (delusion which forms in response to a real perception e.g. traffic light turned red so I am the chosen one)
• Third person auditory hallucinations
• Thought interference (withdrawal, insertion and broadcast)
• Passivity phenomenon (bodily sensations being controlled by external force)

Question 16

What are the negative symptoms of schizophrenia?

Answer 16

Avolition (reduced motivation)

Asocial behavious

Anhedonia

Alogia (poverty of speech)

Affect blunted

Attention deficits

Question 17

What do the following forms of thought disorder mean:

Circumstantiality

Tangentiality

Neoligism

Clang association

Word salad

Knight’s move thinking

Flight of ideas

Perseveration

Answer 17

Circumstantiality = inability to answer a question without giving excessive, unnecessary details

Tangentiality = wandering from a topic without returning

Neoligism = new word formulation

Clang association = ideas are related to each other only by the fact they sound similar

Word salad = real words together in nonsense sentence

Knight’s move thinking = loosening of associations, unexpected, illogical leaps in schizophrenia

Flight of ideas = leaps from one topic to another with links

Perseveration = repetition of ideas or words despite an attempt to change topic

Echolalia = repetition of someone else’s speech

Question 18

What is paranoid schiophrenia?

Answer 18

Most common - dominated by positive symptoms (hallucinations and delusions)

Question 19

What is hebephrenic schizophrenia?

Answer 19

Thought disorganization predominated (onset of illness is usually earlier) with poorer prognosis

Question 20

What is simple schizophrenia?

Answer 20

Rare form where negative symptoms develop without psychotic symptoms

Question 21

What is undifferentiated schizophrenia?

Answer 21

Meets diagnostic criteria for schizophrenia but doesn’t conform to any of the subtypes

Question 22

What are the investigations for patients presenting with symptoms of schizophrenia?

Answer 22

Bloods: FBC (anaemia), TFTs (psychosis), glucose (atypical antipsychotics = metabolic syndrome), serum calcium, U&Es and LFTs (before antipsychotics), cholesterol (metabolic syndrome), vit B12 and folate (deficiencies can cause psychosis)

Urine drug test: illicit drugs can cause and exacerbate psychosis

ECG (antipsychotics and prolonged QTc)

CT scan

EEG (temporal lobe epilepsy)

Question 23

Why is a CT performed in elderly patients with first episode of psychosis?

Answer 23

Rule out brain tumour, stroke or CNS infection

Question 24

What are the management steps for schizophrenia? (Biopsychosocial)

Answer 24

• Risk assessment / MHA
• For first presentation then early intervention in psychosis team should be involved (to reduce the duration of untreated psychosis)

Biological = Antipsychotics (atypical e.g. risperidone / olanzapine), depot formulation considered, clozapine for treatment resistant schizophrenia, benzos for short term relief, antidepressants / lithium can also be use, ECT for catatonic schizophrenia

Psychological = CBT (reduces residual symptoms), family intervention (helps reduce high levels of expressed emotion), art therapy (alleviation of negative symptoms), social skills training

Social = support groups, peer support worker delivered by someone who has recovered

Question 25

What are poor prognostic factors for schizophrenia?

Answer 25

Pre-morbid social withdrawal

Low IQ

FH of schizophrenia

Gradual onset

Lack of obvious precipitant

Question 26

What is the main effect of GABA?

Answer 26

Enhances the effect of GABA - main inhibitory neurotransmitter

Question 27

How do benzos work? What are their uses?

Answer 27

Increase the frequency of chloride channels

• Sedation
• Hypnotic
• Anxiolytic
• Anticonvulsant
• Muscle relaxant

Question 28

Why are benzos not used long term?

Answer 28

Patients usually develop a tolerance and dependence so only for 2-3 weeks

Question 29

How should benzos be withdrawn?

Answer 29

About an 1/8 of the dose every fortnight

Question 30

What are the features of benzo withdrawal?

Answer 30

Insomnia

Irritability

Anxiety

Tremor

Loss of appetite

Tinnitus

Perspiration

Perceptual disturbances

Seizures

Question 31

What is Cotard syndrome?

Answer 31

Delusion where the affected patient believes that they (or in some cases a part of their body) is dead or non-existent - diffucult to treat as the patient may stop eating as they don’t deem it necessary

Associated with severe depression and psychotic disorders

Question 32

How do typical antispsychotics work?

What are their side effects?

Give an example?

Answer 32

Dopamine D2 receptor antagonists

Extrapyramidal and hyperprolactinaemia

Haloperidol and chlopromazine

Question 33

What are the extrapyramidal side effects?

Answer 33

Parkinsonism

Acute dystonia (sustained muscle contraction e.g. torticollis, oculogyric crisis - may be managed with procyclidine)

Akathisia (severe restlessness)

Tardive dyskinesia (most common = chewing and pouting of jaw)

Question 34

What is the mechanism of action, adverse effects and examples of atypical antipsychotics?

Answer 34

Mechanism of action = act on variety of receptors (D2, D3, D4 and 5-HT)

Adverse effects = EPSE, hyperprolactinaemia, metabolic effects

Examples = clozapine, risperidone or olanzapine

Question 35

What is the risk in elderly patients on antipsychotics?

Answer 35

Increased risk of stroke and VTE

Question 36

What are the other side effects of aytpical antipsychotics?

Answer 36

Antimuscarinic: dry mouth, blurred vision, urinary retention, constipation

Sedation, weight gain

Raised prolactin (galactorrhoea)

Impaired glucose tolerance

Neuroleptic malignant syndrome: pyrexia, muscle stiffness

Reduced seizure threshold

Prolonged QT (especially haloperidol)

Question 37

What is the risk with clozapine?

Answer 37

Agranulocytosis and FBC monitoring is essential

Seizures (3% of patients)

Constipation

Neutopenia

Myocarditis

Arrhythmias

Excessive salivation

Weight gain

Smoking cessation can cause a rise in clozapien blood levels

Question 38

What is a very common side effect of atypical antipsychotics?

Answer 38

Weight gain