Psychotic Disorders and the Mental Health Act (DONE)

Question 1

Psychotic disorders

Answer 1

Psychosis is a symptom of the mind under severe stress. It can be caused by lack of sleep, physical illness, induced by drugs, or psychiatric illness
During a period of psychosis, a person’s thoughts and perceptions are disturbed and the individual may have difficulty understanding what is real and what is not.
Schizophrenia is a syndrome of these symptoms

Question 2

Schizophrenia

Answer 2

A chronic, relapsing, severe mental illness affecting 1% of the population
Originally described as dementia of early life, progressive disintegration of personality and the relationship between self and world
Characterised by a prodrome (social isolation, loss of interest) followed by distortions of thinking and perception (positive symptoms), and inappropriate or blunted affect and cognitive symptoms (negative symptoms)

Question 3

Disease classification and diagnosis based on:

Answer 3

ICD 10 in UK

DSM-5 in USA

Question 4

Schizophrenia diagnosis

Answer 4

ICD 10 based on at least one of: thought interference, delusions of control, auditory hallucinations, persistent delusions being completely impossible
Or at least two of: hallucinations with delusions/overvalued ideas, disorganised speech, catatonic behaviour, negative symptoms, significant change in personal behaviour and personality
Duration of one month or greater

Question 5

Delusions

Answer 5

An unshakeable, false belief, based on a mistake interpretation of reality inconsistent with the person’s cultural background

Question 6

Hallucinations

Answer 6

A perception in the absence of an external stimulus

May be: auditory, visual, olfactory, tactile or gustatory

Question 7

Auditory hallucinations

Answer 7

May present as: running commentary- voice or voices giving a description of a person’s actions; command- voice or voices giving instructions or orders
Thought interference: broadcasting, withdrawal, interference

Question 8

Negative symptoms

Answer 8

Blunted affect
Social withdrawal
Avolition
Poverty of speech
Cognitive defects

Question 9

Aetiology of schizophrenia

Answer 9

Biological factors: genetics, obstetric complications, neurochemical and structural abnormalities
Environmental/psychological factors: urban areas/socioeconomic status, seasonality of births, migration, life events and background stressors, cannabis and other drug use

Question 10

Dopamine theory

Answer 10

Increased mesolimbic dopamine transmission mediates positive symptoms of schizophrenia
Based on the observations that: amphetamine increases dopamine transmission and is associated with positive symptoms; antipsychotics are dopamine antagonists
Negative symptoms may result from reduced dopaminergic activity in the prefrontal cortex

Question 11

Role of glutamate

Answer 11

Abnormalities in glutamate activity may underlie other neurochemical changes
Ketamine and phencyclidine can induce both positive and negative symptoms of schizophrenia
Recent imaging studies have revealed increased glutamatergic (but not dopaminergic) activity in patients unresponsive to antipsychotic treatment

Question 12

Prognosis of schizophrenia

Answer 12

Variable but generally life long, associated with physical illness, self harm, suicide and victimisation. Life expectancy reduced by about 10 years.
1/3 recover, 1/3 improve but with significant impairment, 1/3 patients require frequent hospitalisation
Prognosis better in traditional societies
Prognosis worsened in: early onset, male gender, poor premorbid/cognitive functioning, poor insight, social isolation/adversity

Question 13

Treatment of schizophrenia

Answer 13

Assessment- ruling out non-psychiatric causes of psychosis e.g. delirium, emcephalitis
Psychological interventions- psychoeducation, CBT for psychosis, voice hearing groups. family work
Social interventions: occupational therapy, housing, employment, supported accommodation
Biological: antipsychotic medication

Question 14

Antipsychotics

Answer 14

Typical: older, produce greater motor side effects, hyperprolactinaemia, prolonged QTc, D2 receptor antagonists
Atypical: newer, les motor side effects, greater metabolic side effects, D2/5HT receptor antagonists
Before initiation need baseline observations- weight, BP, HR, glucose, lipids, prolactin and ECG

Question 15

Typical antipsychotics

Answer 15

Potent D2R antagonists: benperidol, pipothiazine, haloperidol, pimozide, fluphenazine
Moderatley potent D2R antagonists: chlorpromazine, perphenazine, trifluoperazine ,zuclopentixol, pericyazine
All antagonise a variety of receptors
Adverse effects mediated through antagonism of H1, ACh M, noradrenergic alpha 1, 5HT, K+ ion channel

Question 16

Extra-pyramidal side effects

Answer 16

Movement disorders
Cause by disruption in dopaminergic transmission in nigrostriatal pathway
Pseudo-Parkinsonsim: tremor, rigidity, dribbling, treat with anticholinergic e.g. procyclidine
Akathisia: restlessness, linked to suicide, treat with beta blockers, 5HT2C antagonists or BZDs
Dystonia: involuntary muscle contraction, oculogyric crisis, torticollis, treat with anticholinergic
Tardive dyskinesia: involuntary muscle movements, tongue rolling, lip smacking, treat with gradual dose reduction/tetrabenazine

Question 17

Other side effects of antipsychotics

Answer 17

Sedation
Sexual dysfunction, hypotension
Dry mouth, constipation
Raised prolactin levels
QT prolongation
Weight gain
Reduced seizure threshold
Neuroleptic malignant syndrome

Question 18

Examples of atypical antipsychotics

Answer 18

Amisulpride
Aripiprazole
Clozapine
Quetiapine
Olanzapine
Risperidone/paliperidone
Lurasidone

Question 19

What is atypicality?

Answer 19

Reduced incidence of EPSE- broader therapeutic index
Possibly due to 5HT2a receptor antagonism- 5HT modulates dopamine release, fast dissociation at D2 receptor
But: risperidone and olanzapine cause EPSE at higher doses despite 100% 5HT receptor occupancy
Possibly the pharmacology of some atypicals confers benefit vs cognitive symtpoms

Question 20

Dopamine D2/5HT2a receptor antagonists

Answer 20

Risperidone- most affinity for D2 receptors
Olanzapine- metabolic side effects
Quetiapine- least affinity, less EPSE

Question 21

Long acting injections

Answer 21

Non-compliance with anti-psychotics is a significant problem in practice- due to lack of insight, adverse effects, symptomatology, major factor in relapse
LAIs reduce covert non-compliance
Older drugs formulated as oily injections- release the drug over weeks/months, initial test dose followed by 2-4 weekly maintenance dosing, after stopping release of drug occurs for up to 3 months
Newer antipsychotics now available and use different methods of controlled release

Question 22

Aripiprazole

Answer 22

Licensed for schizophrenia, mania, bipolar disorder
Partial agonist at dopamine D2 receptor
Side effects: nausea, agitation, akathisia, some EPSE but may reverse prolactin elevation and weight gain associated with other drugs
May be useful for alerting properties
Oro-dispersible, liquid, IM formulations

Question 23

Limitations of antipsychotics

Answer 23

All act primarily on dopamine receptors
Approximately 30% of patients will not respond
However, treatments with alternative pharmacologies have been disappointing

Question 24

Clozapine

Answer 24

Different binding profile from any other antipsychotic, has relatively low affinity fro D2 receptors in the striatum and high affinity for D4 receptors in frontal cortex and 5HT receptors
Used for resistant schizophrenia- two failed treatments with other antipsychotics, one of which should be atypical
Approximately 1/3 of patients will respond at 6 weeks
Approximately 2/3 of patients will respond at one year

Question 25

Clozapine- FBC monitoring

Answer 25

Mandatory, risk of agranulocytosis
Drug company records WBC, NC, platelets, eosinophils- initially weekly for 18 weeks, then fortnightly, then monthly after first year of treatment; monitor for one month post discontinuation
Traffic light system: green is fine, amber requires additional monitoring (two per week), red- stop immediately

Question 26

Clozapine- common side effects

Answer 26

Hypersalivation
Constipation
Sedation
Weight gain
Hypotension/hypertension
Tachycardia
Fever
Seizures

Question 27

Neuroleptic malignant sydrome

Answer 27

Rare but potentially fatal side effect of all antipsychotics-
Hyperthermia, fluctuating level of consciousness, muscle rigidity, autonomic dysfunction
Associated with change in dose or formulation or initiating new medication using combinations of antipsychotic medications

Question 28

Mental health act

Answer 28

Section 2- can be kept in hospital for up to 28 days
Can be detained if: have a mental disorder (not drug or alcohol addiction), need to be in for an assessment, to protect self or others
Section 3- can be detained in hospital for treatment for up to 6 months
Section 5(4) nurse holding powers up to 6 hours
Section 5(2) doctors holding powers up to 72 hours