12b.) Psychosis

Question 1

What is psychosis?

Answer 1

• Presence of hallucination or delusions
• Describes symptoms, not a diagnosis itself

Question 2

What are hallucinations?

Answer 2

Perceptions without a stimulus. They can be in any sensory modality e.g. hearing voices, seeing things…

Question 3

Visual hallucinations are usually organic; true or false?

Answer 3

True (by organic we mean caused by sort of physcial definable problem such as one with eyes or brain)

Question 4

Hallucinations are normal when going to sleep and/or waking up; what do we call the hallucinations that occur when you:

• Go to sleep
• Wake up

Answer 4

Question 5

What are delusions?

Answer 5

Fixed false belief which is unshakeable and is outside of cultural norms.

*NOTE: normal for some cultures to believe in e.g. witchcraft so this wouldn’t be a delusion

Question 6

Patients with schizophrenia don’t have split mind or personality; true or false?

Answer 6

TRUE; common misconception that they have split mind/personality

*Other common misconceptions include: patients with shcizophrenia are more dangerous than other patients

Question 7

Kurt Schneider came up with the first rank symptoms for shizophrenia; state the 5 first rank symptoms

Answer 7

• Auditory hallucinations
• Passitivity experiences
• Thought withdrawal, broadcast or insertion
• Delusional perceptions
• Somatic hallucinations

Question 8

Describe the 3 types of auditory hallucinations

Answer 8

• Thought echo: hearing thoughts aloud
• Running commentary: e.g. he is brushing his teeth
• Third person: voices referring to the patient in 3rd person and conversing with each other about the patient

Question 9

What are passitivity experiences?

Answer 9

Patient believes an action or feeling is caused by an external force e.g. MI5 have been moving my leg

Question 10

Describe:

• Though withdrawal
• Thought broadcast
• Thought insertion

Answer 10

• Thought withdrawal: thoughts are being taken out of the mind
• Thought broadcast: everyone knows what the person is thinking
• Thought insertion: thoughts implanted by others

Question 11

What are delusional perceptions?

Answer 11

When someone attributes a new meaning, usually in the sense of self-reference, to a normally perceived object

Question 12

What are somatic hallucinations?

Answer 12

Mimics feelings from inside body e.g. feels like heart is twisting

Question 13

Schizophrenia has both positive & negative symptoms; state the symptoms in each category

Answer 13

Question 14

Which symptoms of schizophrenia are more difficult to treat; positive or negative?

Answer 14

Negative are more difficult to treat and patients often are treated for/no longer have positive symptoms but are left with the negative symptoms

Question 15

All patients with schizophrenia are different; true or false?

Answer 15

True

Question 16

There is clearer evidence for the pathophysiology of schizophrenia than there is for mood disorders; true or false?

Answer 16

True

Question 17

State the 3 main ideas in the pathophysiology of schizophrenia

Answer 17

• Abnormalities in dopamine pathways
• Brain changes
• Abnormalities/changes in limbic system

Question 18

Describe the dopamine theory of shcizophrenia, include:

• Whether dopamine is too low or too high
• Evidence for the above
• Two major dopamin pathways thought to be involved
• What is abnormal about these two pathways

Answer 18

• Dopamine is too high/in excess
• Evidence:
  
  • All medications that antagonise DA receptors help treat psychosis and those with strongest affinity for D2 receptors are most clinically effective
  • Drugs e.g. amphetamines which cause release of DA cause psychotic symptoms
• Mesolimbic pathway (overactive) and mesocortical pathway (underactive)

Question 19

State where the mesolimbic pathway (one of the dopamine pathways) goes from and to

Answer 19

Question 20

State where the mesocortical pathway (one of dopamine pathways) goes from and to

Answer 20

Question 21

State the 4 brain changes seen in schizophrenia

Answer 21

• Enlarged ventricles
• Reduced grey matter (with reduced brain weight)
• Decreased temporal lobe volume (thought to be responsible for auditory hallucinations)
• Reduced hippocampal formation, amygdala, parahippocmapla gyrus & cortex

Question 22

Describe the neuropathology of schizophrenia

Answer 22

Question 23

Why is it thought that limbic structures & basal ganglia are involved in schizophrenia?

Answer 23

Question 24

What’s the most broadly accepted theory behind schizophrenia?

Answer 24

Dopamine theory: excess dopamine

• Mesolimbic: overactive
• Mesocortical: underactive

Question 25

What drug class do we use to treat schizophrenia?

Answer 25

Antipsychotics

Question 26

Discuss the difference between typical and atypical antipsychotics

Answer 26

Antipsychotics are dopamine antagonists _Typical Antipsychotics_ * Block D2 receptors in ALL CNS dopaminergic pathways * Main action as antipsychotic is on mesolimbic & mesocortical pathways * But get lots of side effects e.g. parkinsonism due to antagonising D2 receptors in other pathways _Atypcial Antipsychotics_ * Lower affinity for D2 receptors * Milder side effects as dissociate rapidly from D2 receptor * Also block 5HT2 receptors * Less parkinsonism symptoms but get other symptoms such as: weight gai, diabetes, hypercholesterolaemia, prolonged QT interval

Question 27

Where are D2 receptors found in CNS?

Answer 27

Question 28

Question 29

State where the nigrostriatal pathway is from and to

Answer 29

Question 30

Explain why antipsychotics, particularly typical antipsychotics, can cause parkinsonism

Answer 30

* Antipsychotics= dopamine antagonists * Inhibit actions of dopamine * Act on all dopamine receptors in CNS (but note that atypical antipsychotics have less affinity for D2 receptors and much less likely to cause parkinsonism symptoms) * Dopamine in nigrostriatal pathway involved in movement (partiucularly in initiation & ceasing of movement) * Less dopamine acting on putamen due to antipsychotics = less movement

Question 31

Why do we monitor Parkinson's patients for psychotic symptoms

Answer 31

* We treat them with levodopa (dopamine precursor) * Excess dopamine can lead to psychotic symptoms

Question 32

Untreated schizophrenic patients can develop catatonia; what is catatonia?

Answer 32

Catatonia is a neuropsychiatric condition that affects both behavior and motor function, and results in unresponsiveness in someone who otherwise appears to be awake.

Question 33

At least 3 out of 12 symptoms of catatonia must be present to diagnose someone with catatonia; state some of the 12 symptoms

Answer 33

* Stupor (oblivous inability to move or respond to stimuli) * Mutism (little to no verbal communication) * Negatvisim (lack of verbal response) * Waxy flexibility (body remains in whatever position it was place din) * Posturing (holding a position or posture that goes against gravity) * Excitement * Command automatism

Question 34

If dopamine promotes movement, then why do untreated schizophrenic patients (who have excess dopamine) develop catatonia?

Answer 34

Probably due to less GABA binding loss of inhibitory effect

Question 35

Explain why antipsychotics can cause hyperprolactinaemia

Answer 35

* Remember that dopamine is also called PIH (prolactin release inhbiiting hormone) * Antipsychotics are dopamine antagonists * Less effective dopamine * More prolactin released from pituitary

Question 36

State some effects of hyperprolactinaemia in both mean & women *\*Remember, prolactin inhibits GnRH release*

Answer 36

_Women_ * Amenorrhoea * Galactorrhoea _Men_ * Impotence _Both_ * Decreased libido * Decreased fertility * Long term lead to osteopenia/osteoporosis

Question 37

Why is it often difficult to treat people with schiophrenia?

Answer 37

Lack of insight (i.e. they don't believe they are unwell) hence medications often not taken. We can give in different ways e.g. short acting IM, or depot injections (long lasting)

Question 38

Discuss some factors that will aid a good prognosis for someone with schizophrenia

Answer 38

* Early treatment * Absence of family history * Good premorbid function * Acute onset * Mood disturbance * Maintenace of initiative & motivation

Question 39

Dicuss the prognosis of a diagnosis of schizophrenia

Answer 39

* Mortality twice as high as general population * Shorter life expectancy * Higher incidence of CVS disease, respiratory disease, cancer * Suicide risk 9x higher * Death from violent incidents 2x high * About 50% have substance misuse problem * Higher rate of cigarette smoking