Week 3 - A - Schizophrenia - Symptoms, Diagnosis, Treatment and side effects, Depression/Mania/delirium with psychosis

Question 1

What is psychosis? What does psychosis impair?

Answer 1

Psychosis is a mental disorder, which sufficiently impairs,

* The thoughts,

* Affective response or ability to recognize reality,

* And the ability to communicate and relate to others

This significant impaairment interferes grossly with the patients capacity to deal with reality

Question 2

What are the classic characteristics of psychosis?

Answer 2

Hallucinations, delusions and disorders of form of thought

Question 3

In a patient with psychosis, do they understand that these hallucinations and delusions are not real?

Answer 3

The individual has the inability to distinguish between the subjective experience and reality and there is therefore the characteristic lack of insight in patients with psychosis

Question 4

What are the 4 different psychotic experiences in a patient with psychosis?

Answer 4

Hallucinations

Passivity phenomenon

Delusions

Formal thought disorder

Question 5

What part of the mental state examination do hallucinations and delusions come under?

Answer 5

Mental state examination

* Appearance + behaviour * Speech * Mood and affect * Thoughts * Perception * Cognition * Insights

Delusions come under disturbances in thought

Hallucinations come under disturbances in perception

Question 6

What is a hallucinations?

Answer 6

This is a perception that occurs in the absence of external stimulus

Question 7

Is a hallucination thought by the patient to be originating within onself or not? What modalities can the hallucinations occur although which is most common?

Answer 7

Hallucinations are thought to be originating in real space and not just in the patients inner self

Hallucinations can occur in any sensory modality althought is is most common to be an auditory hallucination, or second most common, a visual hallucination

Question 8

Hallucinations are clinically relevant, only when they are in the context of other relevant symptoms Can be induced in most people e.g. by sensory deprivation

What is the difference between a hypnagogic and hpnopompic hallucinations?

Answer 8

A hypnagogic hallucination occurs during the transition from wakefulness to sleep (this occurs at night)

Hypnopompic hallucinations occurs during the transition from sleep to wakefulness (ie in the morning)

Question 9

What is the most common type of hallucination again?

Answer 9

This would be auditory hallucinations

Question 10

Pattern of brain activity during auditory hallucinations is very similar to that in normal volunteers generating inner speech

Which area of the brain lights up when somebody is experiencing an auditory hallucinations?

Answer 10

Brocas area in the frontal lobe will light up when a patient is experiencing an auditory hallucination

Question 11

Describe the pattern of brain activity when someone is experiencing an auditory hallucination?

Answer 11

The same area of the brain is active as when somebody is having internal speech, however also motor areas will light up

Remember Brocas area will light up when someone is experiencing auditory hallucinations -

Brocas are is for speech production as well

Question 12

Describe the types of auditory hallucinations you can get?

Answer 12

Second person auditory hallucinations - where the person is talking to you

• * You do something, You are terrible etc

Third person auditory hallucinations - where there are people talking about you

• * He/she/him/her/they
• * These voices usually discuss the patient or provide a running commentary on his actions

And thought echo

Question 13

What is thought echo?

Answer 13

Thought echo is where there is the hallucination of someone speaking out the patients thoughts aloud or repeating the thoughts

Question 14

What other forms of hallucinations can you get- other than auditory?

Answer 14

Visual hallucinations - eg flashes, or even complex visual such as a figure or a face

Olfactory - the way things smell

Gustatory - the way things taste

Rarely there are also somatic bodily hallucinations (tactile) eg feeling ants or insects on your skin or being touched

Question 15

What is the sensation of eg ants crawling on your skin? In somatic hallucinations this sensation is a lot worse and more persistent

Answer 15

This is known as formication

Question 16

What is passivity phenomena?

Answer 16

This is were behaviour is experienced as being controlled by an external agency rather than by the individual

Question 17

Passivity phenomena can affect your thoughts, actions and feelings. How does passivity affect the thoughts?

(3 ways)

Answer 17

Thoughts - can affect thought possession in three ways:

Thought insertion - when there thoughts are not their own and something is putting them there

Thought withdrawal - when trying to think of something and something steals the thought out of their head

Thought broadcasting - this is where the patient believes that everybody can already hear their thoughts

Question 18

Remember passivity phenomena affects thoughts by Thought insertion, withdrawal and broadcasting How does the phenomena affect the patients actions and feelings?

Answer 18

Actions - something is making him do something

Feelings - person is being made to feel a certain way

Question 19

What is a delusion?

Answer 19

This is a strongly fixed belief that is unfix-able despite logical reason and argument and is abnormal for society/culture of the patient

Question 20

The different categories of delusions are usually depressive in nature, schizophrenic in nature and manic in nature How do these delsuions usually present?

Answer 20

Nihilistic/sinful and guilty delusions (ie - world is ending anyway, its all my fault that that boy died in new jersey when you live in Glasgow) - these are usually seen in severe depression

Delusions of love, religion, persecution - usually seen in shizophrenia

Delusions of grandeur (grandiose delusions, persecution) - seen in mania

Question 21

Can get primary delusions that come out of nothing and are very uncommon Secondary delusions are far more common When do secondary delusions often occur?

Answer 21

Secondary delusions usually occur when the patient tries to explain eg they have a hallucination, passivity phenomena, depression and use the delusion to explain

Question 22

”My thoughts do not see to be my own. They feel like they are coming from outside of me” “they are being transmitted by the Mafia” What is each part here referring to?

Answer 22

The top statement refers to the patients thoughts being inserted - thought insertion - passivity phenomena

The explanation for the thought insertion is the delusion

Question 23

What are self referential delusions? Give an example?

Answer 23

Self-referential delusions - this is the belief that external events are related to onself

Belief that the radio/TV is talking to me

Belief that others are talking about me / laughing at me

Belief that there are hidden messages in regi plates for me

Question 24

Example- walking down the street and a group of girls start giggling. People may think this is about them What is this?

Answer 24

This is indeed a self-referential experience although this is a brief thought

Self referential delusions are usually more severe/abstract Ie the group of girls were laughing cause they know i cant decipher the cracks in the wall

Question 25

What is formal thought disorder?

Answer 25

Thought disorder (TD) or formal thought disorder (FTD) refers to disorganized thinking as evidenced by disorganized speech.

Specific thought disorders include derailment, poverty of speech, tangentiality, illogicality, perseveration, and thought blocking.

Question 26

What are the differential diagnosis of psychotic symptoms?

Answer 26

Shizophrenia

Depression

Bipolar

Delirium

Substance misuse

Question 27

To confront or not to confront?- What do you say to psychotic patients about their psychosis? The discussion about a patient with psychotic symptoms is very sensitive and need to ask the patient the relevant questions without seeming like you dont believe them

How would you test the patients insights?

Answer 27

You need to examine a patient’s insight & this means being satisfied as to whether they consider psychotic symptoms as being “illness”

Question 28

It is important to recognise the importance of the experience & not give the impression that it is “all in your head”. Make the effort to understand as best you can what the patient is explaining in their own words: “I just want to check that I am understanding this correctly, I don’t want to misunderstand you, I think what you are saying is that … What are creative ways that you could challenge the patients thoughts?

Answer 28

“What would you say to me if somebody told you that these beliefs were not true”

“Could you explain to me how this is possible”

Question 29

There does come a time to say “I think that this is evidence that you are actually unwell and I think you need to be in hospital & receive treatment – although I recognise that you disagree with this” If the patient refuses to accept this and tries to leave, what must you try to do?

Answer 29

If the patient refuses to accept that they have a mental illness and refuses to stay, then they must be tried to be persuaded to stay but if adamant of leaving, you must detain, the person, under the mental health act scotland 2003

Question 30

Schizophrenia is a mental disorder characterized by abnormal social behavior and failure to understand reality. The symptoms of schizophrenia come under positive symptoms and negative symptoms

What are the positive symptoms of shizophrenia? Briefly describe these symptoms?

Answer 30

* Positive symptoms of shizophrenia - these are the stuff you have

* Hallucinations - usualy auditory, usully 3rd person, can also get visual and the other senses

Also thought echo

* Passivity phenomena - behavior experienced as being controlled by external entity - Thought insertion/withdrawal/broadacast, actions & feeling

* Delusions - secondary to the above & self-referential

* Disorders of form of thought

Question 31

What are the negative symptoms of shizophrenia that may feature?

Answer 31

There is reduced amounts of speech

Reduced motivation / drive

Reduced interests / pleasure

Reduced social interaction

Restricted range of emotion - this is a blunted affect

Question 32

In early 1970s, large differences between diagnosis of schizophrenia in USA & UK Now have ICD-10 diagnostic guidelines based on Schneider’s symptoms of First Rank What are schnieder’ symptoms of first rank in relation to?

Answer 32

Shneider’s symptoms of first rank are suggestive of schizophrenia in the abence of drug use or organic impiarment but these symptoms are not pathognomic of shizophrenia remember

Question 33

The core symptoms of schneiders symptoms of first rank are audiotry hallucinations, passivity phenomena and delusional perceptions What is a delsuional perception?

Answer 33

This is a delusion (a fixed belief that is unmovable) in response to a genuine perception ie - the light just turned green so i created the world

Question 34

What is the lifetime incidence of shizophrenia? What is the onset in adults?

Answer 34

Lifetime incidence of schizophrenia is 1%

Onset in males is usually around the ages of 15-25

Onset in females is usually around the ages of 25-35

Higher incidence in lower socioeconomic class

Question 35

Can you diagnose someone with schizophrenia from early signs? If so what are they? Prodromally (just before onset of symptoms), how may a schizophrenic present?

Answer 35

You wouldn’t be able to diagnose someone with schizophrenia from early signs however retrospectively there are some indications e.g. child never quite fit in, was a bit clumsy etc.

Prodromally - schizophrenia may present as the gradual onset of non-specific symptoms such as odd ideas and experiences and odd behaviours

Question 36

Describe the three courses of schizophrenia? (ie the three different outcomes after treatment)

Answer 36

20% of patients have one episode, it is treated and they have no/minimal impairment

40% of patients have multiple episode with significant chronic progressive impairment

Question 37

Name some bad prognostic indicators in schizophrenia?

Answer 37

Insidious onset

Early onset in child/adolescence

Cognitive impairment

Enlarged ventricles

Question 38

Name some good prognostic indicators in schizophrenia?

Answer 38

Older age of onset and in a female patient

Marked mood disturbance - especially elation

Family history of a mood disorder

Question 39

Name some risk factors for developing schizophrenia?

Answer 39

Family history

Birth complications (prematurity, prolonged labour, deal distress, exposure to viral infections in the 2nd trimester)

Question 40

Macroscopically describing the brain, what may indicate poor prognosis in schizophrenia?

Answer 40

There is reduced grey matter in the frontal lobe

There is reduced frontal lobe volume

The lateral ventricles are enlarged

There is little progression in the size of the grey matter over time

Question 41

Usually is frontotemporal that is affected in schizophrenia What specific test can be carried out in shizophrenia? The test helps to indicate reduced activatin of prefrontal areas doing specific tests

Answer 41

This is stroops test

Ask the patient to say the colour of the word and not the actual word

This shows impairment of tasks that involve frontal areas (e.g. executive function)

Question 42

Which neurotransmitter is indicated to be a cause of schizophrenia?

Answer 42

Typically the causes of shizophrenia have been blamed on the actions of dopamine - when in excess is believed to cause schizophrenia

There is now arising evidence that serotonin and glutamate receptors are involved in schizophrenia as well

Question 43

What is the dopamine hypothesis of schizophrenia? What does dopamine inhibit?

Answer 43

It is thought that drugs which release dopamine in the brain (amphetamine) or D2 receptor agonists produce a psychotic state

Dopamine receptor antagonists are therefore used to treat the symptoms of schizophrenia due to the assumption that it occurs due to over-activity of the dopamine pathways in the brain

Dopamine inhibits prolactin

Question 44

How does amphetamine affect the synapse? How do anti-psychotic drugs affect the synapse?

Answer 44

Amphetamine causes more dopamine to be released into the synaptic cleft from the presynaptic vesicles

Anti-psychotic drugs block the dopamine post-synaptic receptors meaning that the excess dopamine cannot bind

Question 45

Which drugs are usually used to treat psychosis and why?

Answer 45

Drugs which einhibit the dopamine release in the brain are used - typically they are D2 antagonists

Question 46

How do you treat drug induced psychosis? How long do symptoms last?

Answer 46

Take away the causative drug.

Psychosis tends to go quicker with these patients than with a schizophrenic who has also taken psychotic-inducing drugs.

Question 47

How do psychotic symptoms present in depression?

Answer 47

The psychotic symptoms in depression tend to be mood congruent with hallucinations which are 2nd order telling them they are worthless

Question 48

How would someone in mania present with psychosis?

Answer 48

Typified by mood congruent content of psychotic symptoms

Delusions of grandeur / special ability / persecution / religiosity Hallucinations: auditory (e.g. God’s voice)

Flight of ideas

Question 49

Shneider’s symptoms of first rank are suggestive of schizophrenia in the abence of drug use or organic impiarment but these symptoms are not pathognomic of shizophrenia remember What percentage of patients who meet the criteria for shcneiders symptoms of first rank instead have bipolar disorder?

Answer 49

1/5th of patients

Question 50

What is delirium defined as?

Answer 50

Acute onset + inattention with fluctuation course, plus one of - disorganised thining or altered levels of consciousness

Question 51

Delirium * Clouding of consciousness ranges from subtle drowsiness to unresponsive * disorientation in time, place & person * fluctuating severity over time (lucid intervals) * worse at night ,Impaired concentration / memory * especially for new information Acute onset, inattention with fluctuating course + one of disorganised thinking or altered levels of consciousness How does pshycosis present in delirium?

Answer 51

Delirium usually presents with

* Visual hallucinations/illusions with / without auditory hallucinations

* Persecutory delusions

* Psychomotor disturbance- agitation or retardation

* Irritability

* Insomnia

Question 52

What is an illusion?

Answer 52

An illusion is a misinterpretation or misunderstanding of a perception

Question 53

What do third person auditory hallucinations suggest?

Answer 53

They suggest schizophrenia

Question 54

How can antipyschotics be split? Which type of anti-psychotics were the first developed? How do antipsychotics work?

Answer 54

Antipsychotics can be split in typicals and atypicals

Typical antipshycotics are first generation as they were developed first

Antipsychotics work by blocking the D2 receptor in the nigrostriatal pathway

Question 55

Do antipsychotics work immediately? Explain your answer?

Answer 55

They immediately block the D2 receptor however there is a delay in onset of clinical effect and therefore there must be some sort of neuronal adaption going on as well

Question 56

Which symtpoms are thought to be better treated by typical vs atypical anti-psychotics?

Answer 56

Typical anti-psychotics are thought to be very effective in treating psychotic symptoms where as atypical anti-psychotics are thought to be better at treating the negative symptoms

Question 57

What is the difference between typical and atypical anti-psychotics mechanism of action? Why are atypicals better at treating the negative symptom of shizophrenia?

Answer 57

Typical anti-psychotics - act mainly through the D2 receptor inhibition

Atypical anti-psychotics - these have a high 5-HT2a recpetor antagonistic action as well as D2 receptor antagonism - as it inhibits the serotonin (5HT2a - type of serotoin), it is better at treating the negative symptoms

Question 58

What side effects are atypical antispychotics more likely to cause? What side effects are typical anti-psychotics more likely to cause?

Answer 58

Atypical antipsychotics- due to the 5HT receptor antagonism are more likely to induce metabolic symptoms such as weight gain - but these are less likely to cause extrapyramidal side effects - these are shown to have good efficacy when typical dont work or are not tolerated

Typical anti-psychotics are more likely to cause extra pyramidal side effects

Question 59

Give examples of typical and atypical anti-psychotics?

Answer 59

Typical anti-psychotics - these are the older generation drugs- mainly D2 receptor inhibiton

* Chlorpromazine Haloperidol

* Thioridazine Zuclopentixol Fluphenazine

Atypical antipsychotcs - these are the newer generation drugs - mainly 5HT2a antagonism but also D2 antagonism

* Olanzapine Risperidone

* Quetiapine Clozapine

* Aripiprzole Amisulpride

Question 60

What hormonal effects to both anti-psychotics cause?

Answer 60

Due to dopamine inhibition, there is an increase in prolactin so galactorrhea (breast milk production)and gynaecomastia (male breast tissue enlargement)

Question 61

Name some extra-pyramidal side effects of of the anti-psychotics (more common in typicals?

Answer 61

Acute dystonia

Parkonsonism

Akinesia

Akithesia

Tardive dyskinesia

Question 62

What is acute dystonia? How does it present? How is it treated?

Answer 62

Acute dystonia

This presents usually hours days after anti-psychotics have been started

It happens due to all the muscles contracting - causing repetitive movemens or sustained contraction and is treated with IV anti-cholinergics (procyclidine)

Question 63

As a side effect of anti-psychotics, when does parkinsonianism present? How would you stop this side effect?

Answer 63

It usually takes days to months to present

Presents as shuffling gait, postural instability, tremor, bradykinesia

Change the drug - eg to an atypical or reduce the dose

Question 64

What is akathisia? (also known as tardive akathasia) What is akinesia?

Answer 64

Akathasia is internal restlessness or unease and patient may complain of constantly needing to move

akinesia loss or impairment of the power of voluntary movement.

Question 65

What is tardive dyskinesia? When does it occur? How can you treat it?

Answer 65

This is where there is repetitive involuntary movements eg grimacing, lip smacking, sticking tongue out

It occurs over a very long time ie years of taking the medication and generally persists even with medication withdrawal

Question 66

A lot of the atypical antipsychotics cause 5HT2 antagonism. HOWEVER pure 5-HT2A antagonists are not antipsychotic. What are the problems with giving 5-HT2a antagonsiits? Which type of anti-psychotics are these that exhibit 5HT2a atagonism > D2 receptor antagonism

Answer 66

These are the atypicals - quetiapine, cloazapine, olanzapine, risperidone, amisulpride, aripiprazole

Problems with giving 5HT2 receptor antagonists is they can cause metabolic syndrome - get weight gain and insulin resistance

Question 67

What was the first anti-psychotic to be recognised as atypical?

Answer 67

This was clozapine

Question 68

When is clozapine used?

Answer 68

• Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least 2 different antipsychotic drugs At least one of the drugs should be a non-clozapine second generation anti-psychotic

Question 69

Why is clozapine associated with hypersalviation?

Answer 69

Cloazpine may be an antagonisit of muscarinic receptors M1,2,3 and 5 but is a full agonist of the M4 receptor

Because M4 is highly expressed in the salivary gland, its M4 agonist activity is thought to be responsible for the hypersalivation

Question 70

What side effects can clozapine cause?

Answer 70

• Weight gain
• Hypersalivation
• Myocarditis
• Intestinal obstruction - the antipsychotic drug clozapine has been associated with varying degrees of impairment of intestinal peristalsis; this effect can range from constipation, which is very common, to very rare intestinal obstruction, faecal impaction, and paralytic ileus.
• Agranulocytosis

Question 71

What is agranulocytosis? Which drug treating hyperthyroidism can cause this?

Answer 71

Agranulocytosis is an acute condition involving a severe and dangerous leukopenia (lowered white blood cell count), most commonly of neutrophils causing a neutropenia in the circulating blood

Carbimzaole used in the treatment of hyperthyrodisim can also cause this (propothiouracil is much less common to cause this)

Question 72

What is presenting symptoms of agranulocytosis? How does clozapine get monitored? When do you measure after the cessation of clozapine?

Answer 72

Agranulocytosis may be asymptomatic, or may clinically present with sudden fever, rigors and sore throat.

Infection of any organ may be rapidly progressive (e.g., pneumonia, urinary tract infection). Monitoring

* For the first six months, measure FBC weekly

* For next six months, measure FBC fortnightly

* After this, monthly measurmeents

* For one month after cessation of clozapine

Question 73

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Answer 73

Patient is likely to have delirium after his MI secondary to MI, electrolyte disturbance, hypoxiapost-major surgeryetc, etc

Question 74

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Answer 74

Patient is likely to have depression with psychosis

Psychosis features - he is having self guilt delusions and poverty delusions

Question 75

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Answer 75

MANIA with psychosis

Delusions of grandeur and self-referential delusions as well as 2nd order auditory hallucinations

Question 76

WHat is neuroleptic malignant syndrome?

Answer 76

is a life-threatening idiosyncratic reaction to antipsychotic drugs characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction.

Question 77

When does neuroleptic malignant syndrome occur? What is the treatment?

Answer 77

The key to diagnosis is that NMS occurs only after exposure to an neuroleptic drug.

On average, onset is 4-14 days after the start of therapy; he most important intervention is to discontinue all neuroleptic agents.

Can then give a dopamine agonist eg bromicriptine