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psychiatry > psychosis + confusion > Flashcards

psychosis + confusion Flashcards

1
Q

classic characteristics of psychosis

A

hallucinations
delusions
disorder of form of thought

lack of insight

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2
Q

primary vs secondary delusions

A

Primary = arrive fully formed in the consciousness without need for explanation

Secondary = are often attempts to explain anomalous experiences – hallucinations, passivity experiences, depression

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3
Q

thought interferences

A

 Clanging + punning – ding dong bell, go to hell
 Loosening of associations
 Knight’s move thinking – came here in dads car, he’s got a blue car, the sea is blue
 Neologisms
 Tangentiality
 Word salad/verbigeration

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4
Q

thought insertion

A

there are thoughts being put into my head that don’t belong to me – I haven’t thought them

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5
Q

thought withdrawal

A

= they can extract the information from me using the internet, they take my thoughts out of my head

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6
Q

thought broadcasting

A

it’s like everyone can know what I am thinking – my sky dish is beaming

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7
Q

thought blocking

A

it’s like I get halfway through thinking something + the thoughts jut dry up and I cant think of anything for a while

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8
Q

what do 3rd person auditory hallucinations suggest?

A

schizophrenia

(depression sometimes 2nd person hallucinations but never 3rd)

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9
Q

management of psychosis

A

1 - 4-6weeks trial of atypical
2 - 4-6weeks trial of second atypical or typical

3 - 6month trial of clozapine titrated up to 900mh/day (best efficacy but super bad side effects)

4 - adjuvant medication/ECT (in addition to clozapine)

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10
Q

drug induced psychosis

A

May be acute symptoms or more insidious + chronic
o Tend to be short is access to psychoactive substance is removed

Not the same as intoxication + withdrawal effects
Beware of comorbidity with schizophrenia + bipolar disorder

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11
Q

depressive psychosis

A

Characterised by mood congruent content of psychotic symptoms
Delusions - worthlessness/guilt/hypochondriasis/poverty

Hallucination - accusing/insulting/threatening voices
o Typically 2nd person

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12
Q

mania with psychosis

A

Delusions – grandeur, special ability, persecution, religiosity
Hallucinations – tend to be 2nd person + auditory
-  hearing God’s voice telling you you’re great

Flight of ideas

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13
Q

delirium

A

Acute transient confusion state – last from hrs to weeks
Assoc with physical insult or injury or environmental factors
Rapid in onset, 1-2days from precipitating insult

Duration varies but often continues beyond resolution of original insult – often by weeks or months

Medical emergency
o 35-40% patients die within one year
o Barriers to treatment – too agitated for IV lines etc

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14
Q

types of delirium

A

hypoactive - quiet, confused drowsy, fearful patient

hyperactive - driven, wandering, agitated, shouting out, aggressive

mixed - some periods of both of above

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15
Q

risk factors for delirium

A

older age
previous history of delirium
underlying cognitive deficits

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16
Q

delirium presentation

A

Clouding of consciousness
o Subtle drowsiness to unresponsiveness
o Disorientation in time, place + person
o Fluctuating severity over time – lucid intervals
o Worse at night
Impaired concentration/memory, especially for new information
Visual hallucinations/illusions +/- auditory – often threatening
Persecutory delusions
Agitation OR retardation
Insomnia

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17
Q

causes of delirium

A

I WATCH DEATH
- Infections
- Withdrawal
- Acute – electrolyte probs, acidosis
- Toxins – drugs, opiates
- CNS - Encephalitis, Stroke
- Hypoxia
- Deficiencies – thiamine, B12
- Endocrine – thyroid, adrenal, glycaemia
- acute vascular shock
- trauma - head injury, hypothermia
- heavy metals - lead, mercury

18
Q

delirium investigations

A

4AT

1 - alertness - normal/mild sleepiness
2 - AMT-4 = age, DOB, place, current tear
3` - attention = name months backwards
4 - acute or fluctuating course

19
Q

delirium treatment

A

treat underlying cause
reassurance + reorientation
low stimulus environment
use of appropriate legal measure to allow for treatment

pharma - assist with distress, agitation (supportive)
- consider low dose antipsychotic - haloperidol, quetiapine
–> NOT in PARKINSONS

20
Q

post-ictal confusion

A

abnormal condition following a seizure

  • begins when seizure ends + ends when patient has returned to baseline
  • usually resolves within 30 mins
21
Q

post-ictal confusion presentation + management

A

drowsiness, nausea, confusion, exhaustion

Mx = supportive, seizure prevention

22
Q

chronic illnesses which cause confusion

A
  • Encephalitis
  • Hypoglycaemia
  • Hypothyroidism/hyperthyroidism
  • Vit B12 deficiency
  • Anaemia
  • Electrolyte disturbances
23
Q

schizophrenia

A

self-disorder due to perceptual incoherence

genetically determined neurodevelopmental vulnerability later triggered by environmental stressors

78% heritability, polygenic inheritance

24
Q

onset of schizophrenia

A

young adults

men - 12-25yrs

women - 25-35yrs

25
Q

schizophrenia risk factors

A

stress
drugs - heavy regular cannabis, cocaine
social adversity
neuro - enlarged ventricles, thinner cortices
neurochemical - altered dopamine signalling
genetics
birthcomplications

26
Q

which gene alterations are risk factors for schizophrenia?

A

neuregulin
dysbindin
DISC-1

27
Q

genetic risk in schizophrenia

A

o MZ twins 40-60%
o Both parents 50%
o One parent 15%
o Some mutations – 22q11
o Higher in African-Caribbean

28
Q

birth complications that increase risk of schizophrenia

A

Prenatal exposure to viral infections – 2nd trimester
o Maternal stress, malnutrition
o Higher rates of perinatal complications than controls – prematurity, prolonged labour., fetal hypoxia, pre-eclampsia
o Winter/spring births – due to viral illness

o Risk increases by 50% by childhood viral CNS infection

29
Q

pathophysio of schizophrenia

A

drugs which release dopamine in brain (amphetamine) or D2 receptor agonists (apomorphine) produce a psychotic state

-> it is assumed schizophrenia is related to overactivity of dopamine pathways in the brain
(dop receptor antagonist used to treat symptoms of schiz)

amphetamine can make symptoms of schizophrenia worse

30
Q

physical pathology of schizophrenia

A

enlarged lateral ventricles - non-progressive
reduced frontal-temporal lobe volume
reduced frontal lobe grey matter

reduced activation of prefontal areas on specific tasks - impairment of executive function (Stroop test - can only read words)

31
Q

first rank/Schneider’s symptoms of schizophrenia

A

delusions
auditory hallucinations - thoughts, voices
thought interference - passivity of thought, withdrawal, insertion, broadcasting

passivity phenomena - affect, impulse, volition, somatic

32
Q

schizophrenia presentation

A

positive -
hallucinations
delusions
passivity phenomena
disorder of form of thought

negative -
reduced speech
reduced motivation/drive (avolition)
reduced interest/pleasure (anhedonia)
apathy
blunting of affect

33
Q

sub-types of schizophrenia

A

paranoid
hebephrenic
catatonic
persistent delusional disorder

34
Q

most common type of schizophrenia

A

paranoid
- 80% of diagnoses
- first rank symptoms dominate

35
Q

hebephrenic schizophrenia

A

shallow + inappropriate emotional responses
bizarre behaviour

36
Q

catatonic schizophrenia

A

movement disorder predominates

37
Q

management of schizophrenia

A

1st = Risperidone, olanzapine -> 2nd gen oral (atypical) antipsychotics – 6-8weeks

2nd = haloperidol -> 1st or 2nd gen – 6-8weeks

3rd line – check diagnosis, optimise social supports, check compliance
o Compliance -> depot (long term) – IM weekly to 3 monthly -> haloperidol
o Consider clozapine – weekly blood tests tho
o Consider combining 2 antipsychotics

CBT to all

38
Q

treatment of schizophrenia side effect considerations

A
  • Medication induced weight gain -> cardiac problems
  • Falls due to EPSE
  • Cognitive effects of anticholinergic
  • Osteoporosis due to raised prolactin
  • Sedation leading to immobility

cardio risk modification - linked to antiosychotics + high smoking rates

39
Q

indicators of poor prognosis in schizophrenia

A

poor premorbid adjustment - prodromal phase of social withdrawal
insidious (slow, not obvious) onset
early onset - child/teen
long duration of untreated psychosis
cognitive impairment

enlarged ventricles
strong fam Hx, low IQ

40
Q

indicators of good prognosis in schizophrenia

A

females
marked mood disturbance especially elation
fam Hx of mood disorders
older age onset
shorter time of untreated psychosis

41
Q

schizophrenia prognosis

A

Suicide
o 10-15% suicide rate
o May occur following recovery of insight
o High risk time = first week of discharge from hospital
o Need to ensure adequate medical follow up as well as psychological + social support

Homicide by people with schizophrenia is rare
o Note in command hallucinations + delusions of jealousy

psychiatry (13 decks)

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