Pyschosis Flashcards
What is psychosis?
difficulty perceiving and interpreting reality
What can cause psychosis?
Schizoaffective disorder Bipolar Schizophrenia Delusional disorder Substance related Depression with psychotic features Due to other medical condition
What are the three symptom domains in psychosis?
Postitive symptoms
Negative symptoms
Disorganisation
What are positive symptoms?
Hallucinations
Delusions
What are the main features of hallucinations?
Percepts in absence of a stimulus
Auditory Voices commenting on you Voices talking to each other Visual Somatic/tactile Olfactory (rare)
What are the main features of delusions?
Fixed, false beliefs, out of keeping with social/cultural background
Persecutory Control Reference Mind reading Grandiosity Religious Guilt/sin Somatic Thought broadcasting Thought insertion Thought withdrawal
What are negative symptoms?
Alogia
Anhedonia/Asociality
Avolition/Apathy
Affective flattening
What is alogia?
Poverty of speech
Paucity of speech, little content
Slow to respond
What is anhedonia?
Few close friends
Few hobbies/interests
Impaired social functioning
What is avolition?
Poor self-care
Lack of persistence at work/education
Lack of motivation
What is affective flattening?
Unchanging facial expressions Few expressive gestures Poor eye contact Lack of vocal intonations Inappropriate affect
What are disorganisation symptoms?
Bizarre behaviour
Thought disorder
What characterises bizarre behaviour?
Bizarre social behaviour
Bizarre clothing/appearance
Aggression/agitation
Repetitive/sterotyped behaviours
What characterises thought disorder?
Derailment Circumstantial speech Pressured speech Distractibility Incoherent/illogical speech
Describe the onset of psychosis
Can occur at any age
Peak incidence in adolescence/early 20s
Peak later in women
Describe the course of psychosis
Often chronic & episodic
Very variable
Describe morbidity with psychosis
Substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
Significant impact on education, employment and functioning
Describe mortality with psychosis
Substantial
All-cause mortality 2.5x higher, ~15 years life expectancy lost
High risk of suicide in schizophrenia – 28% of excess mortality
What comprises a psychiatric history?
History of Presenting Concern Past Psychiatric History Background History (Family, Personal, Social) Past Medical History and Medicines Corroborative History
How do you explore the history of the presenting complaint?
The patient’s description of the presenting problem – nature, severity, onset, course, worsening factors, treatment received
Circumstances leading to arrival to hospital
WHY NOW?
How do you explore past psychiatric history?
Any known diagnosis?
Any treatment?
Known to a community team?
Any previous admissions to hospital?
What do you explore when taking a family history?
Age of parents, siblings, relationship with them
Atmosphere at home
Mental disorder in the family, abuse, alcohol/drugs misuse, suicide
What do you explore when taking a personal history?
Mother’s pregnancy and birth
Early development, separation, childhood illness
Educational and occupational history
Intimate relationships
What do you explore when taking a social history?
Living arrangements
Financial issues
Alcohol and illicit drug use
Forensic History
What do you explore when taking a past medical history?
Medical problems = a cause or consequence of
mental disorder or psychiatric treatment
What do you explore when asking about medication?
Regular medications?
Compliance?
Over the counter medications?
Interactions?
What do you need to consider when taking a corroborative history?
Need for consent!
Informants: relatives, friends, authority
Confidentiality
What do you look at in a mental state examination?
Appearance and Behaviour Speech Mood Thoughts Perceptions Cognition Insight
What do explore when looking at appearance and behaviour?
General appearance Facial expression Posture Movements Social behaviour
What issues may there be with someone’s general appearance?
neglect: alcoholism, drug addiction, dementia, depression, schizophrenia
weight loss: anorexia nervosa, depression, cancer, hyperthyroidism, financial issues/homelessness
What issues may there be with someone’s facial expression?
depressive, anxious,
“wooden” parkinsonian
What issues may there be with someone’s posture?
hunched shoulders, downcast head and eyes – depressive
sitting upright, head erect, hands gripping the chair – anxious
What issues may there be with someone’s movements?
overactive, restless – manic inactive, slow - depressive immobile, mute – stupor tremors, tics, choreiform movements, dystonia, tardive dyskinesia mannerisms, stereotypies
What issues may there be with someone’s social behaviour?
disinhibited, overfamiliar
withdrawn, preoccupied
signs of impending violence: raised voice, clenching fists, pointed fingers, intrusion into personal space
What do you look at when exploring someone’s speech?
Quantity
Rate
Spontaneity
Volume
What issues could there be with quantity of speech?
less, more, mutism
What issues could there be with rate of speech?
slow, fast, pressure of speech (cannot stop them they go at 100 miles an hour)
What issues could there be with spontaneity of speech?
Latency
What do you look at when you consider mood?
Subjective Objective Predominant mood Constancy Congruity
What is subjective mood?
What the patient feels
What is objective mood?
How you think the patient feels
What do you look for specifically with constancy of mood?
emotional lability/incontinence
reduced reactivity/blunting/flattening
irritability
What is congruity?
cheerful while describing sad events
What do you explore when looking at thoughts?
Stream
Form
Content Preoccupations Morbid thoughts, suicidality Delusions, overvalued ideas Obsessional symptoms
What issues can there be with stream of thought?
pressure, poverty, blocking
What issues can there be with form of thought?
flight of ideas, loosening of associations, preservation
What are primary and secondary delusions?
primary – occurs suddenly
secondary – arises from previous abnormal idea/experience (hallucination/mood/delusion)
What is folie à deux?
Shared delusion
Give examples of delusional ideas?
paranoid of reference grandiose/ expansive of guilt/ worthlessness hypochondriacal of jealousy sexual/ amorous religious of control concerning the possession of thought (insertion, withdrawal, broadcast)
What are obsessional symptoms?
obsessional thoughts: dirt and contamination, aggressive actions, orderliness, disease, sex, religion
compulsions: checking, cleaning, counting, dressing rituals
What are perceptions people may have?
Illusions
Hallucinations
Distortions
What are illusions?
misperception of a real external stimulus
What are hallucinations?
perception in the absence of external stimulus
What are the different types of hallucinations?
true perception
coming from outside the head
(pseudohallucination)
What senses can hallucinations affect?
auditory – second person, third person visual – Charles Bonnet syndrome olfactory gustatory tactile, of deep sensation
What do you look at exploring cognition?
Consciousness Orientation Attention and concentration Memory Language functioning Visuospatial functioning
What are the main features of insight?
Awareness of oneself as presenting phenomena that other people consider abnormal
Recognition that these phenomena are abnormal
Acceptance that these abnormal phenomena are caused by mental illness
Awareness that treatment is required
Acceptance of the specific treatment recommendations
How can you make it seem to the patient that you are on the same page?
Mirror their language
Where else can you get information?
Family
Friends
Work/Education
Healthcare records
GP
Mental Health
How can psychosis be managed pharmacologically?
Antipsychotic medications
Often mainstay of treatment
How can psychosis be managed psychologically?
CBT for psychosis
Newer therapies like avatar therapy
What social support can you give to those with psychosis?
Supportive environments, structures and routines
Housing, benefits
Support with budgeting /employment
What are the side effects of anti-psychotics?
Sedation Constipation Increased prolactin (release is suppressed by dopamine) Increased appetite Weight gain Diabetes Dysrhythmia Long QTc
What is word salad?
Stream of words
No grammatical sense
