Schizophrenia and psychosis Flashcards
Define psychosis
Out of touch with reality, experiencing a different reality to the rest and no insight of this
Define paranoia
mental illness where a delusional belief of any variety is the most prominent feature
Define delusion
a fixed false unshakable belief that the patient holds despite evidence to the contrary and is out of keeping with persons sociocultural norms
Name and describe 3 examples of specific delusions types
- Persecution: being followed/ spied on
- infestation: skin infected with parasites causing itching
- religious
- grandiose: beleive fantastic
- reference: everythings about you
- misidentification: they think those close to them have been replaced by an exact copy or that a single person is impersonating multiple familliar ppl
- jealousy: belief a sexual partner is cheating
- erotomanic: usually a celebrity/ high profile person is in love with them and secretly sends them messages or signs
- communicated: an already psychotic person transmits their belief to another
What is meant by ‘ideas of reference’
coincidental or innocuous events are interpreted as having great personal significance, associated with social phobias, psychosis or stress
What is an illusion
misinterpretation of a sensory stimulus that can occur in any sensory modality
What is a hallucination?
The perception of an object in absence of an external stimulus (may be auditory, visual (more likely delerium, olefactory (frontal lobe pathology), sensory)
What are the different types of auditory hallucinations? (4)
- 2nd person: talk directly to the pt
- 3rd person: talk about the pt
- running commentary: provide constant commentary on the pts actions
- may be elementary (hissing/ whistling)
- must be felt to originate from outside the body and be out of conscious control
- hearing voices in their head is not a hallucination- pseudohallucination
When are visual hallucinations common?
- eye pathology
- delerium
- epielpsy
- not so much in psychosis
- often bought on by tiredness or emotion
What is organic disorder?
- tactile or visual hallucinations without any auditory input
- seen in alcohol withdrawal
What is an obsessional thought?
- unwanted intrusive thought that the pt attempts to resist and causes them distress
- a person recognises a voice as their own
What is thought alienation
Experience of ones thoughts being under the control of an outside agency. May get thought insertion, thought withdrawl or thought broadcasting. Is a first rank symptom of schizophrenia
List 5 causes of psychosis other than schizoprenia
- amphetamines, stimulants and hallucinogens
- other psychiatric disorders: bipolar, depression, perpural psychosis, schizoaffective disorder, persitent delusional disorder, acute transient psychotic episode
- delerium
- dementia
- infections eg GPI
- temporal lobe epilepsy
- brain tumours
- cannabis
- cushings and steroids
- thryotoxicosis
- many meds
- drug and alcohol abuse and withdrawl
- encephalitis
- lupus
- hypercalcaemia
What are the hallmark features of acute psychosis?
- delusions
- hallucinations (every day for weeks)
- formal thought disorder (problem of speech and flow of thought- each sentence doesnt flow onto the next and they dont really make sense. this is rarer)
- disorders of self
- lack of insight
What are the first rank symptoms of schizophrenia (these are rare in organic causes of psychosis) (A-D)
- lack of insight
- Auditory hallucinations
- thought insertion, removal, interruption or Broadcasting
- External Control/ passivity (feelings, thoughts and actions are under external control)
- Delusional perceptions
What are the negative symptoms of schizophrenia
- underactivity
- low mood
- ambivalence
- social withdrawl
- emotional flattening
- self neglect
What is needed for schizophrenia diagnosis
- at least 1 of: thought disorder, somatic passivity,auditory hallucination or persistent delusions
- or 2 of’: hallucinations, breaks in train of thought, catatonic behaviour, negative symptoms
- symptoms must be present much of the time for at least 1 month (if <1mo= acute transient psychotic episode)
- marked impairment in functioning
- other causes ruled out
What are the 4 classifications of psychosis
- affective psychosis: experiences are conguent with mood, generally in those with mood or emotional disorders (schizoaffective disorder, mania or psychotic depression)
- transient psychotic disorders: substance misuse
- psychosis due to medical disorder: eg brain tumours
- schizophrenia like non affective disorder
What are the different subtypes of schizophrenia?
- paranoid: delusions or hallucinations prominent
- simple: mostly negative symptoms, few positive
- hebephrenic: loss of inhibition and perceptions of appropriateness, age 15-25 onset, fleeting fragmented delusions and hallucinations
- catatonic: mutism, posturing, waxy flexibility, command automatism. May arise from depression or untreated schizophrenia
- undifferentiated schizophrenia: insufficient symptoms to meet other subtypes or fit into more than one
How should schizophrenia be investigated?
- blood to rule out organic cause of psychosis
- BMI, ECG, FBC, prolactin, U&E, glucose and lipids before starting antipsychotics
- Urine drug screens
- MRI to rule out organic causes. may show larger lateral ventricles, reduced frontal lobe and parahippocampal gyrus
- reduced temporal lobe, hippocampus and amygdala
- reduction in grey matter
What is schizotypal disorder?
a personality disorder which may represent partial expression of schizophrenia
What is schizophreniform disorder?
those that fail to meet threshold for schizophrenia but have some symptoms of schizophrenia and declining functioning. treat with antipsychotics
How should schizophrenia be managed?
- bio: investigations (bloods etc), antipsychotics
- psycho: MSE, collateral then supportive counselling, family therapy (esp if from high expressed emotion families)
- social: talk to carers, housing officer then debts, housing benefits, supported accom, occupational therapy
- assess risk and insight level to decide where they can be most safely managed
- social: individualised care plans with psychosocial inteventions and support for families
- manage concurrent substance misuse
What is burnout?
Falling performance and personal accomplishments, emotional exhaustion, negative affect, poor leadership and depersonalization brought on by months or years of overexposure to emotionally demanding situations at work, the battlefield or at home
How is burnout managed?
- diagnose and treat depression
- allow time for person to recognise they have a problem
- more hobbies and holidays
- learn new professional skills
- set acheiveable goals in work and leisure
- return meaning and purpose to life via dialogue and sense of connection to others
Describe the symptoms of the prodrome that commonly occurs from around 18 months before months before schizophrenia presents
- transient and or attenuated psychotic symptoms
- odd thought, beliefs and behaviours
- concentration problems
- altered affect
- social withdrawl
- reduced interest in daily activity
Give 2 examples of typical and atypical antipsychotics
- typical: haloperidol and chlorpromazine
- atypical: olanzapine, risperidone, clozapine, aripiprazole
How do typical and atypical antipsychotics work
typical: block D2 receptors- treats positive symptoms only- target mesolimbic and mesocortical pathways . Nigrostriatal (parkinsonism) and tuberoinfundibular (HPA axis) are also affected to cause side effects.
atypical: weak D2 receptor blockers, 5HT2 and D4 blockers - treats positive and negative symptoms
Give 3 side effects of typical anti psychotics
- extrapyramidal side effects: parkinsonism (bradykinesia, muscle stiffness, tremor), tardive dyskinesia, akathesia, acute dystonia - more for typical
- hyperprolactinaemia (dopamine inhibits prolactin remember)
- dizziness
- sexual dysfunction
- metabolic syndrome
Give 3 side effects of atypical antipsychotics?
- agranulocytosis
- gastrointestinal hypomobility causing constipation and bowel obstruction
- hypersalivation
- urinary incontinence
- sedation
- metabolic syndrome (weight gain)
- impotence
What monitoring is needed for atypical antipsychotics
- FBC, Lipids, LFTs, HbA1c, ECG, blood pressure and pulse at baseline, 3 months and yearly
- body weight weekly
How should agranulocytosis be managed/ avoided?
- consider prophylactic abx
- consider lithium and G- CSF to stimulate WCC
- if occurs, stop drug, avoid infection and contact haematology
What is neuroleptic malignant syndrome?
a rare life threatening reaction to antipsychotics characterised by fever, confusion, muscle rigidity, sweating and autonomic instability. Causes death due to rhabdomialysis, renal failure and seizures. biggest risk if high dose typical antipsychotics and young male.
Bloods show raised CK and WCC, AKI, metabolic acidosis, leukocytosis, derranged LFTs and raised LDH
How should neuroleptic malignant syndrome be managed?
- emergency refferal to A&E
- stop antipsychotics
- give benzos for acute behaviour disturbances
- fluid resus
- oxygen
- cool temp
- fluids and sodium bicarbonate for rhabdomialysis
- lorazepam for muscle relaxant
What is used to treat extrapyramidal side effects?
Anticholinergics- eg procylidine
What is acute dystonia and how is this side effect managed?
- sustained, often painful, muscle spasms, producing twisted abnormal postures
- stop antipsychotics, administer IM/ IV anticholinergics- 1st line procyclidine and continue 1-2 days after dystonia resolves
Name and describe the 4 extrapyramidal side effect symptoms
- pseudoparkinsonism: stooped posture, shuffling gait, tremor, ridgity, bradykinesia
- acute dystonia: facial grimacing, involuntary upward eye movements, muscle spasms of neck, tongue, face and back, laryngospasm
- tardive dyskinesia: protrusion and rolling of otngue, sucking and smacking of lips, chewing motion, facial dyskinesia, involuntary movement of body and limbs
- akathesia: restless, trouble standing still, paces the floor, feet in constant motion rolling back and forth
What are the 3 classes of hypnotics (sleeping drugs)? Give an example of each
- benzodiazepines (diazepam, lorazepam, rohypnol)
- non benzos/ z drugs (zopiclone, zolpidem)- work in similar way to benzos but structurally different
- antihistamines (promethazine)- less potency for dependance
Give 3 side effects of benzos
- drowsy
- lethargic
- problems concentrating
- headaches
- vertigo
- loss of libido
- addiction/ tolerance
- dont take with alcohol or if hepatic or renal impairment
How long should benzos be prescribed for at most?
4 weeks, then slowly taper dose
What is disorders of the self?
the individual cannot distinguish between himself and the world, includes thought broadcasting, passivity phenomena (someone else making them move), thought insertion- one of the 4 hallmarks of acute psychosis but is more rare
When should clozapine be used? what are the major side effects?
- in shciophrenia after 2 antipychotics have not worked, clozapine is like the best antipsychotic
- significant potential for agranulocytosis- need close monitoring of FBC weekly for first 18 weeks then fortnightly then monthly
- significant potential for GI hypomobility, constipation and bowel obstruction
- hypersalivation, sedation, BP changes, tachycardia (usually benign but canbe liked to myocarditis), weight gain, fever, seizures, GORD, nausea, nocturnal enuresis also possible
what is used to treat extrapyramidal side effects from antipsychotics?
procyclidine- anticholinergic, will not reduce tardive dyskinesia but will reduce others
Which antipsychotic is good if theyre refusing oral treatment?
paliperidone, is an IM depot of risperidone which is needed on day 1,8 and then monthly
what antipsychotic doesnt cause weight gain?
aripiprazole, this is also safest in cardiac disease as is the only one which doesnt prolong qtc
What symptoms of schizophrenia suggest they are increased risk to others?
- specific persecutory delusions or hallucinations
- command auditory hallucinations
