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Year 3 Psychiatry > Psychosis > Flashcards

Psychosis Flashcards

1
Q

What is an hallucination?

A

A perception in the absence of a stimulus

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2
Q

What is the difference between 2nd and 3rd person hallucinations?

A

2nd person = talking to you
3rd person = talking about you

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3
Q

What are the following:
- Thought broadcast
- Thought withdrawal
- Thought insertion

A

Broadcast = belief that you are transmitting your thoughts so people can hear them

Withdrawal = thoughts are being taken out of your mind

Insertion = you believe your own thoughts are someone else’s

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4
Q

What are the positive symptoms of schizophrenia?

A

Hallucinations
Delusions
Disordered thoughts

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5
Q

What are the negative symptoms of schizophrenia?

A

Flat affect
Poor motivation
Loss of social skills, social withdrawal
Poverty of thought
Reduced emotional reactivity
Increased self neglect

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6
Q

What are the cognitive symptoms of schizophrenia?

A

Poor attention
Poor memory
Poor planning ability

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7
Q

What is psychosis?

A

Illness characterised by loss of boundaries with reality and loss of insight.

Can have primary features of
- delusions
- hallucinations
- conceptual disorganisation
- negative symptoms
- cognitive disorder

Deemed to be of 1 week duration

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8
Q

What is a delusion?

A

A fixed, false belief not in keeping with social or cultural norms.

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9
Q

What is a delusion of reference?

A

When you think that everyone is looking at you and talking about you

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10
Q

What is conceptual disorganisation?

A

When the thought processes are confused, disconnected or disorganised.

Is observed by what the P says - is not something the P realises is happening.

AKA - Loosening of associations, Knight’s move thought, schizophrenic thought disorder, disorder of form of thought or formal thought disorder

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11
Q

Which sensory modality is most common for hallucinations in psychosis?

A

Auditory hallucinations are the most common

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12
Q

What is a possible explanation for auditory hallucinations in psychosis?

A

That the brain is failing to realise that the thoughts it is having are its own - instead are perceived as second person speech

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13
Q

Is there a genetic link for schizophrenia?

A

Yes - thought to be a 50% genetic risk and 50% environmental risk

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14
Q

What are the risk factors for psychosis?

A

Childhood trauma
Immigration status
Cannabis use
Obstetric complications

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15
Q

What is the most common age for prodromal Sx for schizophrenia?

A

12-18 years

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16
Q

What are subthreshold psychotic symptoms?

A

Ps who appear normal but quirky. Dont meet the criteria of definable psychotic episodes.

In some of these people - drugs can push them over into psychotic episodes = genetic predisposition

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17
Q

What is the definition of psychosis?

A

The P experiences a fundamental transformation in their experience of lived reality.

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18
Q

What is a disturbance of
- Thinking
- Beliefs
- Perceptions
known as?

A
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19
Q

How can you diagnose a thought disorder?

A

When the Sx are severe enough to impair communication

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20
Q

What is the difference between thought stream and thought form disorders?

A

Thought stream = amount and speed of thoughts are changed

Thought form = difficulty linking the thoughts together

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21
Q

What type of mood is associated with pressure of thought?

A

Elevated mood

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22
Q

What type of mood is associated with poverty of thought?

A

Depression

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23
Q

What is the difference between primary and secondary delusions?

A

Primary = appear fully formed with no preceding reason - out of the blue. Good indicator of schizophrenia

Secondary = arise from an attempt to understand an abnormal experience (e.g. delusions of guild in depression)

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24
Q

What types of auditory hallucinations are there?

A

Command
Second Person
Running Commentary
Third Person

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25
Q

What types of hallucinations are there?

A

Auditory
Visual
Gustatory
Olfactory
Tactile
Somatic

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26
Q

For a P with psychotic Sx - what are the possible differentials?

A
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27
Q

What are possible organic causes of psychotic Sx?

A
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28
Q

What is the difference between schizophrenia, schizoaffective disorder and schizotypal disorder?

A
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29
Q

How can you differentiate between delusional disorder and schizophrenia?

A

Delusional disorder presents with delusions but lacks other criteria for schizophrenia. May retain functional ability.

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30
Q

Psychosis can be preceded by a prodromal period - how long can this last for?

A

From days to 18 months

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31
Q

What are possible Sx of a psychosis prodrome?

A

Social withdrawal and isolation
Transient low intensity psychotic Sx
Irritability and anger
Sleep disturbance
Functional impairment
Blunted affect

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32
Q

What is usually first line choice AP for psychosis?

A

Atypicals / 2nd generation

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33
Q

How do first generation / typical APs work?

A

They are mainly D2 antagonists

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34
Q

Which drugs are first generation APs?

A

Haloperidol
Clopixol
Chlorpromazine
Depixol
Trifluoperazine
Sulpiride

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35
Q

Which drugs are second generation APs?

A

Risperidone
Olanzapine
Quetiapine
Clozapine
Aripiprazole

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36
Q

How do first generation APs differ from second generation APs?

A

Have less cardiometabolic SEs but more extra pyramidal SEs

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37
Q

How do second generation APs work?

A

Act on 5HT2, DA2 and DA4 receptors

38
Q

What are possible side effects of APs?

A
39
Q

What scale can be used to measure AP side effects?

A

Glasgow Antipsychotic Side Effect Scale (GASS)

40
Q

Which physical parameters need to be monitored the taking APs?

A

Initially get a baseline

Then check
- prolactin
- lipids
- HbA1c
- Renal function & LFTs

ECG - check for QTc interval delay

BMI, BP, HR

Sexual dysfunction

41
Q

What are the important factors according to Zubin & Spring about whether someone will develop schizophrenia?

A

Stress (work, sleep deprivation, substance misuse)

Vulnerability - family Hx

42
Q

How is different dopaminergic transmission in the brain linked to schizophrenia?

A

Thought that there is increased dopaminergic transmission in the mesolimbic and basal ganglia in acute schizophrenia

Also decreased dopaminergic transmission in the prefrontal context in chronic schizophrenia

43
Q

Which factors are thought to be predisposing and precipitating to an illness of schizophrenia?

A

Predisposing = genetics, ACEs, social deprivation, head injury, structural brain changes

Precipitating = life events (stressful), substance misuse, sleep deprivation, trauma, social adversity, migration

44
Q

What age does psychosis in schizophrenia normally first appear at?

A

80% aged 16-30
5% less than 15

45
Q

What is the ICD11 diagnostic criteria for schizophrenia?

A

At least 2 Sx present for at least 1m.
Affective Sx not prominent and no organic cause.

Positive Sx = delusions, hallucinations, thought disorder, passivity experiences, thought interference

Negative Sx = flattened affect, paucity of speech, anhedonia, loss of motivation, social withdrawal

Psychomotor disturbance = catatonia, posturing (uncomfortable position), restlessness, mutism

46
Q

What is it called when a P is unable to be still?

A

Akathisia

47
Q

What is neuroleptic malignant syndrome?

A

Life-threatening neurologic emergency associated with the use of antipsychotic (neuroleptic) agents and characterized by a distinctive clinical syndrome of mental status change, rigidity, fever, and dysautonomia.

48
Q

What extrapyramidal side effects can be caused by APs?

A

Dystonia
Parkinsonism
Akathisia
Tardive Dyskinesia

49
Q

What do early intervention services for psychosis do?

A
50
Q

How does depot medication differ from oral medication?

A

Lasts longer
Same side effects as oral meds

51
Q

What can you do for Ps with treatment resistant schizophrenia?

A

Use Clozapine

52
Q

When is schizophrenia diagnosed as treatment resistant?

A

If 2 different AP drugs have been used - at least 1 of which is a non-clozapine 2nd generation AP

53
Q

What diseases is clozapin licensed for?

A

Schizophrenia
Psychosis in Parkinsons disease

54
Q

What are the risks of taking clozapine?

A

Myocarditis
Agranulocytosis / Neutropenia
Intestinal obstruction
Reduces seizure threshold
Weight gain
T2DM

55
Q

How does smoking affect clozapine?

A

It reduces the amount of clozapine levels in the blood. Therefore important to note if Ps have reduced / stopped smoking as the clozapine levels will need to be adjusted

56
Q

Which Ps require lower doses of clozapine?

A

Elderly
Women
Non-smokers
Enzyme inhibitors

57
Q

How is schizoaffective disorder diagnosed?

A

Need Sx for at least 1m

Postive, negative or psychomotor Sx of schizophrenia + affective episode - both occurring simultaneously or within a few days of each other

58
Q

How is schizoaffective disorder treated?

A

Antipsychotics, antidepressants if depressed
Mood stabilisers

59
Q

What is the criteria for delusional disorder?

A

Lasts at least 3m

No affective symptoms
Delusions but no other Sx of schizophrenia

Often occurs later than other psychotic disorders.
Often P still able to function.

60
Q

How are delusional disorders treated?

A

Antipsychotics + social interventions

61
Q

What is the prognosis for delusional disorders?

A

More stable than other disorders - less likely to need hospitalisation

Difficult to fully treat

62
Q

What is schizotypal disorder?

A

Over 2 years of Sx

Eccentricities of behaviour, appearance and speech, unusual beliefs, reduced capacity for relationships

Type of personality disorder

63
Q

How is schizotypal disorder managed?

A

Psychological interventions + poss antipsychotics

64
Q

What is acute and transient psychotic disorder?

A

Acute onset over 2w - often less than 4w

Rapidly fluctuating Sx - hallucinations, delusions, psychomotor disturbance, mood disturbance, confusion

Deterioration in function

Cannot have negative Sx or organic cause.

Often brought on by an episode of acute stress. Should regain premorbid level of function on remission.

If Sx continue - alternate diagnosis should be considered.

Treat as for other psychotic disorders

65
Q

The mesolimbic system is involved in reward processing and evaluation of salience. What is its role in the cause of psychosis?

A

Salience = threat evaluation.
In psychosis - the salience pathway can become dysfunctional - tagging inappropriate things as salient - thus causing some of the psychotic Sx.

Chronic drug use can also cause dysregulation of this salience pathway = causes drug-induced psychosis.

66
Q

The mesocortical system is involved in cognition, motivation and social engagement. What happens to this system in psychosis?

A

Dysfunction of this system in psychosis makes it hypoactive => negative Sx such as cognitive impairment and social withdrawal.

67
Q

How do antipsychotics affect the nigrostriatial system?

A

Nigrostriatal system = basal ganglia involved in movements - APs can interfere with this causing impaired movements.

68
Q

How do APs cause hormonal problems?

A

They interfere with the HPAA - thus causing hormonal problems in the body.

69
Q

What is the difference between an agonist and antagonist?

A

Agonist - binds to a receptor and causes a biological response.

Antagonist = binds to a receptor and blocks a biological response.

70
Q

How do antipsychotics work?

A

Are all postsynaptic dopamine antagonists. Prevent dopamine from binding to its receptors = inhibitory effects.

71
Q

How do antipsychotics affect the mesolimbic system?

A

Suppress both pleasure and threat evaluation = loss of pleasure (dysphoria).

Major factor why Ps stop taking their medications.

72
Q

How to antipsychotics affect the mesocortical system?

A

Suppress it further - worsening negative symptoms

Therefore good for positive (mesolimbic Sx) but bad for negative (mesocortical Sx).

73
Q

How do typical and atypical APs differ in terms of effect on the mesocortical system?

A

Atypicals suppress the mesolimbic whilst stimulating the mesocortical.

Typical - suppress both

74
Q

How do second generation APs differ from first generation in terms of SEs?

A

First generation = big dopamine blockers - lots of SEs. Had to titrate dose and take further drugs to minimise the SEs.

Second generation - used other receptors inc serotonergic pathways - had dopamine blockage plus some serotonergic activity. Caused less movement and hormonal problems - but did have more cardio metabolic Sx.

75
Q

How do second generation APs actually work differently from first generation APs?

A

Both block 60-70% of dopaminergic receptors

2nd generation = have more dynamic off time - helps reduce the SEs.

2nd generation also bind to 5HT receptors and release some of this whilst blocking dopamine receptors.

76
Q

Which AP has the best efficacy despite significant cardio-metabolic SEs?

A

Clozapine

77
Q

When is clozapine prescribed?

A

In treatment-resistant illness
Try two other APs first (including a 2nd generation before you can be prescribed.

78
Q

What do we know about the long-term effects of being on antipsychotics?

A

Is a difficult question to determine whether there are long term side effects.

We do however know that Ps on long term APs were better than those switched to a placebo.

79
Q

What does dopamine blocking in the nigrostriatal pathway cause in terms of side effects?

A

Extra-pyramidal SEs = including dystonia, akathisia, Parkinsonism, tardive dyskinesia

80
Q

Why do second generation APs induce cardiometabolic Sx?

A

Impact on hypothalamus - satiety no longer exists
Incs blood lipids and cholesterols
Affects insulin production and glucose tolerance =» T2DM

81
Q

What effect can APs have on the heart?

A

Can affect the QTc interval = prolongation
Significant problem - needs regular ECGs

82
Q

A 22 year old engineer is admitted to an acute mental health ward with a relapse of schizophrenia. His psychosis has not improved despite taking aripiprazole at maximum dose for a month and then olanzapine at maximum dose for a month. He is still experiencing severe symptoms of psychosis.

Which medication should be considered next?

a) Clozapine
b) Combine Aripiprazole and Olanzapine
c) Haloperidol
d) Olanzapine over maximum BNF limit
e) Risperidone

A

Correct answer: a) Clozapine

Clozapine is licensed only for use in treatment resistant schizophrenia, which is defined by NICE as ‘Schizophrenia which has not improved despite the sequential use of adequate doses of at least 2 different antipsychotics, at least 1 of the drugs should be a non clozapine second generation antipsychotic’. NICE guidelines recommend consideration of clozapine in this situation. It won’t be right for everyone, because of the need for regular monitoring and the possible adverse effects, but should be considered.

83
Q

A 34 year old woman has been admitted to a mental health unit. On her notes the junior doctor has written that she is presenting with ‘a fixed belief held despite evidence to the contrary and that is not shared with others of the same culture and background”.

What is the term used to refer to this phenomenon?

a) Delusion
b) Hallucination
c) Obsession
d) Over-valued idea
e) Thought disorder

A

Correct answer: a) Delusion

The definition given is that of a delusion. Obsessions are recurrent intrusive thoughts/images/urges, which cause distress and are recognised as internal in origin. An overvalued idea is similar to a delusion (i.e. strongly held belief) but not held with the same intensity (can acknowledge alternative explanation) and typically causes marked distress and impaired function. Hallucination refers to perception without a stimulus e.g. hearing voices or seeing things that aren’t there.

Formal thought disorder (disorder of thought form) refers to problems with organizing words, concepts and ideas into a logical form so that they can be effectively communicated to others. Formal thought disorder includes circumstantiality, tangentiality, derailment/loosening of associations, clanging, neologisms, incoherence.

84
Q
  1. A 38 year old man with a history of schizoaffective disorder is prescribed the maximum dose of risperidone during a hospital admission. After discharge he sees his GP with concerns his libido is very low and he has noticed a small amount of white discharge from his nipples.

Which finding on a blood test is the most likely to explain these symptoms?

a) Low cortisol
b) Low testosterone
c) Raised HBA1C
d) Raised oestrogen
e) Raised prolactin level

A

Correct answer: e) Raised prolactin level

Raised prolactin (hyperprolactinemia) is a relatively common side effect from antipsychotic medication, more likely with first generation medications (e.g. haloperidol) and with risperidone. It occurs due to reduced dopamine inhibition on pituitary gland. Common symptoms of hyperprolactinemia are amenorrhoea, low libido, erectile dysfunction, subfertility, breast enlargement/tenderness and nipple discharge (galactorrhoea).

85
Q
  1. A 25 year old woman with bipolar affective disorder is found collapsed at home by the crisis team. She has been under their care for two weeks due to a severe depressive episode. She is found to have several empty packets of Quetiapine next to her and a note saying she has taken an overdose of this.

Which ECG change might have been associated with her collapse?

a) Sinus bradycardia
b) PR interval prolongation
c) QTc prolongation
d) Right bundle branch block
e) ST elevation

A

Correct answer: c) QTc prolongation

QTc prolongation should always be monitored when patients are prescribed antipsychotics, although less likely with Aripiprazole. Quetiapine is more likely than other antipsychotics to cause prolonged a prolonged QT interval, this risk will be elevated in the context of overdose and can lead to ventricular tachycardia or torsade de points, which are risk factors for sudden cardiac death. In general antipsychotics are more likely to cause a tachycardia and hypotension rather then bradycardia. Other options are unlikely.

86
Q
  1. A 59 year old man has been taking medication for schizoaffective disorder for thirty years. He has been taking haloperidol for the last ten years. Over the past year his wife has noticed he has developed some repetitive movements around his mouth, including sticking his tongue out or grimacing. He does not seem to notice them.

What is the most likely cause of these movement symptoms?

a) Akathisia
b) Dystonia
c) Tardive dyskinesia
d) Parkinson’s disease
e) Tic disorder

A

Correct answer: c) Tardive dyskinesia

Tardive dyskinesia is an involuntary neurological movement disorder caused by medications that cause dopamine blockade and is usually associated with long-term antipsychotic use (especially first generation/typicals). It usually take months to years to appear. The patient sometimes does not notice the movements. Common features are abnormal orofacial repetitive movements, it can also cause dyskinesia in the legs and arms. The symptoms continue after stopping or changing the medication.

Akathisia refers to an inner restlessness and tends to occur soon after initiation of antipsychotic treatment. Dystonia may occur with antipsychotic and is an emergency – most commonly it is in the form of an oculogyric crisis (painful dystonia of extraocular muscles) or painful spasms affecting the neck, jaw, back or tongue. Parkinson’s disease is a neurodegenerative disorder characterized by tremor, rigidity and bradykinesia. Tic disorders are characterized by motor and/or vocal tics (fast, repetitive body jolts or noises/utterances).

87
Q
  1. A patient with Schizoaffective disorder has had 3 hospital admissions in a year. Each one was precipitated by them stopping their prescribed Risperidone. They have not been on any previous medication. On admission they presented with severe psychotic symptoms and a significant risk to others. They quickly improved on the ward after restarting Risperidone and are now informal. Now that they are well, they feel motivated to continue treatment, as they have after previous relapses. There is no substance misuse.

What would be the most appropriate management plan to reduce their risk of relapse?

a) Consider change to oral clozapine
b) Consider change to oral olanzapine
c) Consider change to risperidone depot
d) Consider use of the Mental Health Act to mandate risperidone compliance (Community Treatment Order)
e) Consider use of the Mental Capacity Act

A

Correct answer: c) Consider change to risperidone depot

Depot medication should be considered in this scenario to try and optimise compliance. Clozapine is not indicated as they have only had one antipsychotic and do not meet criteria for treatment resistant schizophrenia. Oral olanzapine would not improve compliance, and there is no clear indication to change the medication type because risperidone has been showed to be effective. So it would be preferable to stick to the same medication but to give it in a form that enables it to be administered reliably. With respect to the legal options, the least restrictive options should be tried in first instance; a CTO cannot be applied unless someone is already detained under MHA.

88
Q
  1. A 31 year old bus driver has a history of recurrent depressive disorder. After a big argument with his boss and difficulties at work in general, his sleep deteriorates and he ruminates over the possibility that he will be fired. A few weeks later, his wife calls the Urgent Mental Health Helpline because he has spent their savings on a boat and believes that he can hear the voice of God telling him to heal the world. He hasn’t slept for three days and spends hours walking around their town looking for people he can ‘heal’.

The patient has a mental illness. Based on the limited information available, which mental illness seems most likely at the moment?

a) Bipolar affective disorder
b) Schizophrenia
c) Delusional Disorder
d) Hypomania
e) Schizoaffective disorder

A

History of depressive disorder and new onset mania with psychotic symptoms so bipolar disorder most likely. Does not meet diagnostic criteria for Schizophrenia (duration under one month and prominent affective symptoms present). Delusional disorder would not present with affective symptoms and perceptual abnormalities. Hypomania does not present with psychotic symptoms and does not impact so severely on day to today life. Schizoaffective disorder is possible, but given history of previous affective episode (depression) without psychotic symptoms, schizoaffective disorders is likely.

89
Q
  1. A 34 year old physiotherapist has a diagnosis of treatment resistant schizophrenia. She has been prescribed a new medication after her symptoms have not responded to two antipsychotics at maximum dose for several months. She is having regular blood tests. Three weeks after starting this medication she develops a fever and becomes septic; the origin of the sepsis is not yet clear.

What is the most likely mechanism behind this?

a) Agranulocytosis
b) Aplastic anaemia
c) Diabetic ketoacidosis
d) Eosinophilia
e) Intestinal obstruction

A

Correct answer: a) Agranulocytosis

From the vignette, the most likely medication she is taking is clozapine, because no other antipsychotic would require regular bloods tests and it is being used specifically for treatment resistant schizophrenia. The most likely mechanism is agranulocytosis which is a recognised side effect of clozapine; it occurs in around 1% patients prescribed clozapine and can lead to sepsis. Intestinal obstruction could possibly be answer as this is another serious side effect and could potentially lead to perforation and sepsis, but the history not suggestive of this.

90
Q
  1. A 55 year old man has a history of COPD. He saw his GP a week ago as he was experiencing worsening shortness of breath and a cough and was prescribed a course of medication that he has not had before. He has now presented to the emergency department with persecutory delusions and second personal auditory hallucinations. He is in clear consciousness and lacks insight into his symptoms; he scores 10/10 on the Abbreviated Mental Test. There are no focal neurological signs.

What is the most likely cause of this presentation?

a) Alcohol withdrawal
b) Delirium
c) Schizophrenia
d) Intracranial pathology
e) Steroid induced psychosis

A

Correct answer: e) Steroid induced psychosis

History suggestive of short course of steroids for infective exacerbation of COPD. Given age and underlying organic cause not likely to be schizophrenia. Delirium would present with confusion and clouding of consciousness. No symptoms suggestive of alcohol withdrawal and intracranial pathology less likely from history and lack of focal neurological signs.

91
Q
  1. A 35 year old woman with a history of bipolar disorder asks for an appointment in clinic to speak to her psychiatrist about her medication. She was prescribed the medication during a recent episode of mania and has put on a stone in weight over the past eight weeks and feels very tired. The psychiatrist agrees that it is likely that one of the psychiatric medications that she has been prescribed is responsible for this.

What is the most likely medication she has been prescribed to cause this?

a) Lamotrigine
b) Aripiprazole
c) Mirtazapine
d) Olanzapine
e) Clozapine

A

Correct answer: d) Olanzapine

First line treatment options for mania are antipsychotics and of the above list olanzapine known to commonly cause weight gain and sedation. Clozapine not licensed for use in mania (although does often cause weight gain). Aripiprazole unlikely to cause weight gain. Mirtazapine is contra-indicated in mania because it is an antidepressant. Lamotrigine also not first line treatment for mania.

92
Q
A

Year 3 Psychiatry (11 decks)

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