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Psychiatry > Week 3- psychosis and schizophrenia > Flashcards

Week 3- psychosis and schizophrenia Flashcards

1
Q

What is psychosis?

A

A mental disorder sufficiently impairing

  • thoughts
  • affective response or ability to recognise reality
  • ability to communicate and relate to others
  • greatly affects the capacity to deal with reality
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2
Q

What are the classic characteristics of psychosis?

A

Hallucinations, delusions and disorder of form of thought.

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3
Q

NOTE on psychosis

A

A completely different experience. Patient truly believes that its reality. They lack insight.

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4
Q

What is a hallucination?

A

A perception that occurs in the absence of external stimulus.

(note- appears to be originating in real space- not just in the persons thoughts)

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5
Q

When are hallucinations clinically significant?

A

When they are in the context of other relevant symptoms.

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6
Q

Which area of the brain lights up when someone is experiencing an auditory hallucination?

A

Brocas area.

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7
Q

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

A

The same area of the brain is active as when someone is having internal speech. However also motor areas light up.

(self-generated speech is not recognised as being that, and therefore is attributed to external reality)

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8
Q

Describe the types of auditory hallucinations you can get?

A

Second person- addressing you e.g. telling you to do something
Third person- talking about you- he/she/him/they
Thought echo

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9
Q

What is thought echo?

A

When the patients thoughts are being repeated back to them in the auditory hallucination.

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10
Q

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

A

Visual- simple e.g. flashes or complex e.g. figure or face
Gustatory- the way things taste
Olfactory- the way things smell
Somatic- e.g. feeling ants crawling on your skin.

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11
Q

What is the passivity phenomena?

A

Behaviour is experienced as being controlled by an external entity rather than by an individual.

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12
Q

What can passivity phenomena affect?

A

Thoughts- e.g. thought insertion, thought withdrawal or thought broadcasting
Actions- “being made to do something”
Feelings- “being made to feel a certain way”

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13
Q

When is something a delusion?

A

A belief that is kept, even if contradicted by fact, that is abnormal for the society/culture.

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14
Q

When do patients often come up with delusions?

A

To explain something e.g. they have a hallucination and then a delusion becomes the explanation for it.
Example
“My thoughts do not seem to be my own, they feel like they are coming from outside of me” is not a dellusion however “my thoughts are being transmitted from the FBI” is a delusion to explain something occurring to this patient.

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15
Q

What is a self-referential experience?

A

The belief that external events are related to oneself.

Example- walking down the street and a group of girls start giggling. People may think this is about them. Everyone has it to an extent.
Can vary in severity from a brief thought to delusions.

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16
Q

What are the differential diagnosis of psychotic symptoms?

A 
Schizophrenia
Depression
Delirium
Bipolar
Dementia
Substance abuse
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17
Q

What is schizophrenia?

A

Defined by some core symptoms
- auditory hallucinations- specific kinds- third person auditory hallucinations, thought echoes
Passivity phenomena- made to do acts/feel a certain way
Delusional perception- a fully formed delusion that arises from a real/genuine perception

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18
Q

Positive symptoms of schizophrenia?

A

Hallucination
Delusions
Passivity phenomena
Disorder of the form of thought

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19
Q

Negative symptoms of schizophrenia?

A

Reduced amount of speech
Reduced motivation/drive (nothing as extreme as depression)
Reduced interest/pleasure
Reduced social interaction
Restricted range of affect (blunted affect)

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20
Q

Who gets schizophrenia?

A

Generally a young persons illness (late teens-20’s)

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21
Q

Can you diagnose someone with schizophrenia from early signs? If so what are they?

A

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

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22
Q

Prodromally (just before onset of symptoms), how may a schizophrenic present?

A

Odd ideas and experiences, eccentricity, altered affect, odd behaviours.

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23
Q

Describe the three courses of schizophrenia?

A

Minority of people (20%)- have one episode and then return to normal
About 40% of people have multiple episodes but return to normal health after each episode
About 40% of people have multiple episodes but don’t return back to full health, they gradually get worse.

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24
Q

Name some bad prognostic indicators in schizophrenia?

A

Insidious onset
Early onset in child/adolescence
Cognitive impairment
Enlarged ventricles

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25
Q

Name some good prognostic indicators in schizophrenia?

A

Older age of onset
Female
Marked mood disturbance (especially elation)
Family history of mood disorder.

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26
Q

Name some risk factors for developing schizophrenia?

A 
Family history
Birth complications (prematurity, prolonged labour, deal distress, exposure to viral infections in the 2nd trimester)
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27
Q

Macroscopically, what occurs to the brain in schizophrenia?

A

Lateral ventricles are enlarged (doesn’t get worse over time)

28
Q

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

A

Reduced frontal lobe volume
Reduced frontal lobe grey matter
Enlarged lateral ventricles.

29
Q

What specific test can be used in schizophrenia and what does it indicate?

A

Stroop test- say the colour of the word.

Indicates reduced activation of prefrontal areas doing specific tasks

30
Q

Which neurotransmitter is indicated to be a cause of schizophrenia?

A

Typically it has been blamed on dopamine. Dopamine enhancing drugs e.g. amphetamine, produce psychotic states.
However now there is evidence for serotonin receptor and glutamate receptor involvement.

31
Q

What does dopamine inhibit?

A

Dopamine inhibits prolactin.

32
Q

How does amphetamine affect the synapse?

How do anti-psychotic drugs affect the synapse?

A

Means more dopamine is released from presynaptic vesicles into the synapse.
Anti-psychotic drugs block the dopamine post-synaptic receptors meaning that the excess dopamine can’t bind.

33
Q

Describe the dopamine hypothesis?

A

Subcortical dopamine activity leads to psychosis

Mesocortical dopamine hypoactivity leads to negative and cognitive symptoms

34
Q

Which drugs can induce a psychotic state?

A

Drugs which release dopamine in the brain and D2 receptor agonists

35
Q

Describe the gene alterations and the significance of these in schizophrenia?

A

Neuregulin- a signalling protein essential in development of multiple organ systems and cell-cell interactions.
Dysbindin-essential for adaptive neural plasticity
DISC-1- involved in neurone outgrowth and cortical development

36
Q

How do you treat drug induced psychosis?

How long do symptoms last?

A

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

37
Q

How do psychotic symptoms present in depression?

A

Tend to be mood congruent hallucinations e.g. the voices are telling them they are worthless.
Delusions of worthlessness

38
Q

How would someone in mania present with psychosis?

A

Mood congruent content of psychotic symptoms e.g. delusions of grandiosity/special ability/persecution/religiosity.
Flight of ideas.

39
Q

What occurs during delirium?

A

Clouding of consciousness- ranges from subtle drowsiness to unresponsiveness. Disorientation in time, place and person. Fluctuates in severity. Tends to be worse at night.
Impaired concentration/memory- especially new memories.

40
Q

How can psychosis present in delirium?

A

Visual hallucinations/illusions with/without auditory hallucinations
Persecutory delusions
Psychomotor disturbance- agitation or retardation
Irritability
Insomnia

41
Q

What do third person auditory hallucinations suggest?

A

Schizophrenia

42
Q

How can antipyschotics be split?

A

Into typical and atypical.

43
Q

What are typical antipsychotics?

A

Drugs originally developed.

44
Q

How do antipsychotics work?

A

They block the D2 receptor in the nigrostriatal pathway.

45
Q

Do antipsychotics work immediately? Explain your answer?

A

They immediately block the D2 receptor however there is a delay in onset of clinical effect therefore there must be some sort of neuronal adaptation going on aswell.

46
Q

What are atypical antipsychotics less likely to do?

A

Less likely to cause extra-pyramidal side effects.

47
Q

Name some extra-pyramidal side effects?

A 
Tardive dyskinesia- abnormal involuntary movement of the face
Parkinsonian symptoms
akinesia
Akithesia 
acute dystonia
48
Q

What do atypical antipsychotics have a greater efficacy for?

A

negative symptoms (control them better).

49
Q

Give examples of atypical antipsychotics?

A

Olanzapine, risperidone, quetiapine, clozapine, aripiprazole, amisulpride

50
Q

Give examples of typical antipsychotics?

A 
Chlorpromazine
Thioridazine
Fluphenazine
Haloperidol
Zuclopentixol
51
Q

What effect can antipsychotics have on other hormones?

A

Dopamine usually inhibits prolactin, therefore when you block the dopamine, prolactin can increase.

52
Q

What symptoms can high prolactin cause?

A

Galactorrhoea- breast milk production

Gynacomastea- male breast tissue enlargement

53
Q

What is acute dystonia?
When does it occur?
How can you stop it?

A

When all the muscles contract (sustained contraction).
Occurs hours to days after anti-psychotics
Give them IV anticholinergic (there is an imbalance between dopamine and acetylcholine, so it re-rights this imbalance).

54
Q

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

A

It takes days to months

Change the drug or reduce the dose.

55
Q

What is akathisia?

A

Internal restlessness- patients may complain of constantly needing to move.

56
Q

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

A

Repetitive involuntary purposeless movements- grimacing, sticking tongue out, lip smacking, lip pursing etc.
Occurs generally years after taking the medication
Generally persists even with medication withdrawal.

57
Q

What is a psychotomimetic drug?
What do they cause?
Which receptor do they act on?

A

A drug which is capable of producing psychosis. E.g. amphetamine.
Hallucinations and thought disturbance
5HT2 receptor.

58
Q

Drugs that block the 5HT2 receptor can cause what side effects?

A

Metabolic syndrome- weight gain, sedation, insulin resistance,

59
Q

What other drug types (other than anti-psychotics) may be useful in psychosis?

A

Anti-histamines- can cause sedation, increased apetite
Alpha-adrenergic blockade- may cause postural hypotension, dizziness, lightheadedness.
Muscarinic blockade-target parasympathetic- dry mouth, constipation, urinary retention, sedation and confusion.

60
Q

When is clozapine used?

A

Generally as a last line anti-psychotic if someone is resistant to atleast two of the other treatments.

61
Q

What side effects can clozapine cause?

A

Weight gain, hypersalvation, AGRANULOCYTOSIS, myocarditis

62
Q

How does clozapine get monitored?

A

Weekly blood tests for the first 6 months
Then 2 weekly for the next six months
Then monthly thereafter.

63
Q

Case 1- give a diagnosis
79 year old man retired bank manager admitted for elective fem-pop bypass graft (22/09/17)
PMH: aortic stenosis, LVH. No PPH
? post-op MI (24/09/17)
referred to psychiatrist on-call 2:00am 28/09/17
increasingly difficult to manage,
? hallucinated, disorientated in time & place,
trying to leave the ward

Further info
From nursing staff:
trouble was “mostly at night”
verbally aggressive 
from patient history:
feels “choky” + “scared”
very vague re: events since admission
paranoid delusions re: wife/daughter
“there’ll be murder tonight”
Patient mental state:
agitated, distractible, restless, irritable
visual hallucinations, auditory illusions
Ward 7, Ninewells
Tuesday 18/6/2001
MOYB:	D,O,N
	D,S
	D,N,S,J,J,A
no insight
A

Delirium after MI.

64
Q

Case 2- give a diagnosis
55 year old farmer brought by his wife to GP
He believes he has brought financial ruin to his whole family and deserves to die
He admits to very poor sleep, has no energy or appetite and has lost 1st weight in the past 2 months
His thoughts are generally pessimistic and negative towards himself & the future
From his wife:
she says that the farm has been struggling over the past year but that they are managing & that it’s the same for all the farmers at the moment
From mental state:
his eyes are downcast, he makes no eye contact and very few spontaneous movements
his speech is slowed down and he says very little
he appears sad & tearful

A

Depression with psychotic features i.e. delusions of guilt/poverty

65
Q

Case 3- give a diagnosis
23 year old unemployed graduate presents to his GP
he has been involved in a number of new business ventures over recent weeks involving a proposed sum of £150 000. He has also tried to buy a Porsche on credit.
He has been involved with a number of new girlfriends and was caught speeding on the A90 at 110mph
He admits to poor sleep over the last 3 weeks but does not feel tired.
He feels full of energy and new ideas and can’t see that he has done anything wrong.
He says he just found out that he is Madonna’s secret son and stands to inherit £5 000 000 next month.
He knows this because she has broadcast messages to him over the radio & TV
He believes that some other people know this and are trying to steal it from him and so are following him and communicating to each other with car lights
Mental state:
he acts quite superior, is quite irritable and dressed extravagantly
speaks very loudly & rapidly with several puns & jokes
he says he feels ‘great’ & appears elated
there is evidence of delusions of grandeur, self-referential delusions & 2nd person auditory hallucinations

A

Mania

Psychiatry (17 decks)

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