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M2 Psych > 10/19 Psychosis - Tobia > Flashcards

10/19 Psychosis - Tobia Flashcards

1
Q

psychosis

how to approach deciding if someone has psychosis

A

rule out life threatening causes:

  1. stat EKG
  2. vital signs
  3. consider withdrawal syndromes (esp from alcohol, sedative hypnotics)

then, make sure psychosis isnt caused by an underlying medical condition

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2
Q

which neurotransmitter is implicated in all psychoses

A

dopamine

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3
Q

Hibernotherapie

A

compound used by French anesthesiologist who noticed that using it allowed for significantly less anesthesia intraoperatively

  • as a result: pts experienced drop in all-cause mortality

psychiatrist friend decided to try on psych patients to reduce agitation

  • as a result: pt reported less agitation AND improvement of psychotic sx

FDA approved as clorpromazine

  • hits DA receptors in CNS
  • first antipsych!
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4
Q

role of dopamine in psychoses

A

final common pathway for all psychoses

  • substance-induced (ex. stimulants)
  • resulting from general medical condition
  • deliriums
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5
Q

DA neuroanatomy

long tracts

short tracts

A

long tracts:

  1. nigrostratal tract
  2. mesolimbic tract
  3. mesocortical tract

short tracts:

  1. tubero-infundibular tract
  2. retina and adrenal medulla
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6
Q

nigrostriatal tract

fxs

cell bodies/projections

what does DA excess in this tract look like?

A
  • synthesizes most of CNS dopamine
  • influences fx of extrapyramidal motor system
  • cell bodies found in substantia nigra pars compacta → project to D2 receptors in striatum (caudate and putamen)

dopaminergic excess in nigrostriatal tract

  • neurocognitive deficits: speech, memory, attn/conc
    • increase in DA in striatum thought to be related to neurocog deficits in schizophrenia
  • movement disorders (hyper/brady/akinesis)
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7
Q

common side effect of antipsychotics and why?

A

Parkinsonism (hypokinetic movement disorders)

  • psychosis is resulting from relative or absolute high level of DA in CNS
  • antipsychotics reduce DA → drop DA that would hit inhibitory D2 receptors in the indirect pathway (basal ganglia) → overall bradykinetic
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8
Q

mesolimbic tract

A

cell bodies in VTA of midbrain → project to D4 receptors in limbic system

hyperactivity?

  • positive sx of schizophrenia
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9
Q

mesocortical tract

A

cell bodies in VTA of midbrain → project to frontal cortex, cigulate and prefrontal gyri

hypoactivity via D2 receptor antagonism

  • negative sx
  • mood and cognition effects
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10
Q

schizophrenia and the DA shunt

A

conditions like schizophrenia have both positive and negative sx

  • potentially explained by thinking of a “dopamine shunt” moving DA from mesocortical tract → mesolimbic tract
    • hypoactivity in mesocortical tract → negative sx
    • hyperactivity in mesolimbic tract → positive sx
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11
Q

tuberoinfundibular tract

links ___ & ___

function

effect of antipsychotics

A

TI tract (short pathway)

links hypothalamus → pituitary

  • chronic DA secretion → decr prolactin secretion
  • therefore…one side effect of medications that lower CNS DA concentration is: HYPERPROLACTINEMIA
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12
Q

common side effects of medications to decrease CNS DA

A
  1. reduction of positive sx (mesolimbic)
  2. aggravation of negative sx (mesocortical)
  3. hyperprolactinemia (TI tract)
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13
Q

retina DA

A

believed that excess DA here → visual hallucinations associated with psychosis

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14
Q

psychotic disorders

2 groups, disorders within them

A

schizophrenia spectrum

  • brief psychotic disorder
  • schizophreniform disorder
  • schizophrenia (schizoaffective disorder)

other psychotic disorders

  • delusional disorder
  • catatonia
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15
Q

schizophrenia

A

two or more for a 1-month period

  • positive sx
    • delusions
    • hallucinations
    • disorganized speech
    • disorganized or catatonic behavior
  • negative sx
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16
Q

(formerly) Schneider’s First Rank sx

A

1. delusional perceptions (aka ideas of reference): thought or belief that is 1. not bound in reality and 2. fixed/rigid

  • two-stage phenomenon consisting of a normal perception followed by a delusional interpretation
  • special and highly personalized significance

2. somatic passivity → belief that:

  • pt is a passive recipient of bodily sensations that are imposed from the outside
  • affect, impulses, and/or motor activities are controlled by an outside force

3. thought insertion: belief that thoughts are put into mind by external force

4. thought withdrawal: belief that thoughts are being removed from mind by external force

5. thought broadcast: belief that thoughts are somehow transmitted to others

6. hallucinations: perceptual disturbances that have no environmental cue

7. illusions: misinterpretation in response to an environmental cue

17
Q

negative sx of schizophrenia

A

5 A’s

  1. aPathy/avolition
  2. aLogia (poverty of speech/thought)
  3. Affective flattening
  4. aNhedonia/asociality (withdrawal)
  5. aTtention deficit

due to mesocirtical tract (DA hypoactivity → neg sx)

18
Q

schizophrenia

A

social/occupational dysfx

6mo

exclusionary criteria:

  • schizoaffective and mood disorder
  • autism spectrum disorder
  • substance/GMC
19
Q

defense mech that best characterizes sx of schizophrenia

how do we distinguish between plain old personality disorder and psychosis (ex. schizophrenia)

A

projection

distinguish between personality disorder (ex. paranoid PD) and psychosis (ex. schizophrenia) by looking at frontal lobe fx

  • loss of the protective override between 18-35 → psychosis
20
Q

psychological determinants of schizophrenia

A

unconscious process through which individual attributes his/her unacceptable feelings, impulses or thoughts to another

  • ego process
  • characterized by impaired frontal lobe fx
21
Q

social determinants of schizophrenia

myths and accepted social theories

A

myths

  • schizophrenogenic mom
  • double bind (family dynamic theory that said individ gets two opposing messages from same communication)

accepted social theories

  • downward drift: schizophrenia causes poverty
  • stress-diathesis model: genetic/biological factors can predispose but psych/social factors are precipitants
    • ​i.e. anyone can be made psychotic with enough psych/social stressors…the level req is determined by genetic predisp
22
Q

schizophreniform disorder

A

schizophrenia that lasts between 1-6 months

past 6mo → schizophrenia

23
Q

brief psychotic disorder

A

ONE or more schizophrenia sx for 1-mo

  • NOT INCLUDING NEGATIVE SX

duration: 1day-1mo

recovery: full return to premorbid fx

usually precipitated by a stressor:

  • witness to catastrophic event
  • childbirth → postpartum onset
24
Q

how do you determine if BPD or early schizophrenia?

A

presence of negative sx will point towards schizophrenia!

25
Q

schizophrenia spectrum disorders

differentiation based on timecourse and sx

A

1day-1mo : brief psychotic disorder

  • negative sx NOT part of dx criteria

1mo-6mo : schizophreniform disorder

6mo + : schizophrenia

26
Q

schizophrenia

need to rule out:

  • schizoaffective and mood disorder
  • autism spectrum disorder
  • substance/GMC
A

if you see co-occuring psychotic AND mood sx, consider something other than schizophrenia

  • MDD w/ psychotic features
    • sx of mood sx concurrent with sx of schizophrenia BUT NOT DURING WHOLE DURATION OF ILLNESS
  • schizoaffective disorder
    • sx of mood episode concurrent with sx of schizophrenia through whole duration of illness
    • delusions or hallucinations for 2 or more weeks in absence of mood sx
27
Q

schizophrenia

need to rule out:

  • schizoaffective and mood disorder
  • autism spectrum disorder
  • substance/GMC
A

first dx’d in infancy, childhood, or adolescence

  • severe impariment in several areas of devpt
  • social interaction, communication deficits also seen in schizophrenia SO might be tempted to re-classify them →→→ NO.

how can you dx someone with schizophrenia in addition to ASD?

  • disorganized social interaction + disorganized communication PLUS delusions or hallucinations
28
Q

delusional disorder

A

individ suffers from a fixed belief → significant impairment

  • 1 or more delusions for 1+ month in individual with no prior hx of schizophrenia
  • fx is NOT markedly impaired (minus impact of delusion)
    • if there was signif impairment…schizophrenia!
  • mood episodes are brief

need to rule out other substance/gen med condition

29
Q

topography of delusions and hallucinations

A
30
Q

5 general themes of thought content in delusional disorder

A
  1. jealousy
  2. persecutory
  3. erotomanic (de Clerambault’s)
    • fixed belief that an individual adores/is in love w you
  4. grandiose
  5. somatic

mixed, unspecified

31
Q

Capgras syndrome

A

unspecified form of delusional disorder

  • individ believes that someone close to them has been replaced by an imposter
    • imposter isk ey figure for pt at time of sx onset
    • ex. if married, almost always spouse
  • may accompany fxal psychoses other than schizophrenia (affective, organic disorder)
32
Q

Fregoli’s syndrome

A

variant of Capgras syndrome

  • delusion that persecutors or familiar persons can assume guise of strangers
    • familiar persons can change themselves into other persons at will (intermetamorphosis)
    • ex. The Matrix
33
Q

Cotard syndrome

A
  • complaint of having lost possessions and status
    • ex. loss of heart, blood, intestines (Wizard of Oz)
34
Q

catatonia

A

marked behavioral (psychomotor) disturbance

abnormal motor activity

  • decreased
  • excessive (or peculiar)

decreased engagement

35
Q

substance-induced psychotic disorder

A

intoxication from ALL SUBSTANCES EXCEPT

  • caffeine
  • nicotine
  • opioids

withdrawal FROM

  • alcohol
  • sedatives
  • hypnotics

exam tip: if substance prescription or use within past 30 days, it is highly likely that psychosis is linked to substance use!

36
Q

evaluation of psychosis:

general medical conditions

A

complete H&P

  • neuro exam
  • MSE
  • focal deficits? → head CT or MRI
  • screening lab exams
    • IheartLADYMACBETH
37
Q

ABC STAMP LICKER

positive sx of psychosis/schizophrenia

negative sx of psychosis/schizophrenia

A

+++++

Behavior

Speech

Thought

Perceptions

  • disorganized behavior
  • disorganized speech
  • delusions
  • hallucinations

Speech (possibly alogia)

Affect (flattened affect)

Cognitive fx (attn deficit)

M2 Psych (24 decks)

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