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Specialties > Psych Written - Psychotic & Dissociative Disorders > Flashcards

Psych Written - Psychotic & Dissociative Disorders Flashcards

1
Q

Clozapine monitoring

A

Requires normal FBC before starting Tx

THEN weekly FBC (for 18 weeks)

THEN bi-weekly (for 1 year)

THEN monthly

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2
Q

Standard anti-psychotic monitoring

A

BMI + waist circumference

BP

Bloods - FBC, LFTs, U&Es, lipids, glucose (+OGTT and HbA1c if abnormal)

+/- prolactin (if Sx or specific med - risperidone)

+/- EEG (older people, high dose med, clozapine)

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3
Q

How long should anti-psychotics generally be continued?

A

at least 3 years after 1st episode psychosis

longer if recurrent psychotic episodes

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4
Q

Indication for clozapine?

A

Treatment resistant SCZ

defined as:

  • 2 unsuccessful trials of antipsychotic
  • at least 1 being atypical
  • for minimum 6 weeks
  • at therapeutic dose
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5
Q

What is DUP? Why does it matter?

A

Duration of untreated psychosis = time from first clear psychotic Sx until start of effective Tx

Longer DUP = greater damage to cognitive abilities, insight, social

Aim to keep DUP < 3months

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6
Q

Indications for atypical antipsychotic?

A

1st line in new psychosis

Unacceptable SE from typical agent

Relapse on typical agent

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7
Q

Psychological Tx in psychotic disorders?

A

CBT - emphasis on reality testing + helping client to spot illogical thinking

Cognitive remediation therapy (CRT) - useful for negative Sx, improved neurocognitive skills

Family intervention - reduces high expressed emotion (e.g. over involvement, criticism) which can be detrimental

Arts therapy - often as group, can be effective during acute episode or for negative Sx in chronic phase

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8
Q

Lifetime suicide risk in psychotic disorders?

A

10%

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9
Q

Highest RF for suicide in psychotic disorders?

A

Intelligent young male with high premorbid IQ

Early after diagnosis
After first admission
Co-existing depression

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10
Q

Pathophysiology of negative Sx in SCZ

A

Dopamine under activity in mesocortical tracts

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11
Q

Pathophysiology of positive Sx in SCZ

A

Excess dopamine in mesolimbic tracts

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12
Q

Strongest RF for SCZ?

A

Family Hx

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13
Q

Other SCZ risk factors

A 
Migration
Black Caribbean
Urban environment
Cannabis (esp skunk)
Increased paternal age
Winter born
Social disadvantage
Childhood adversity
Obstetric complications
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14
Q

Diagnostic criteria for SCZ

A

1 of the first rank Sx

OR 2 of:

  • persistent hallucination in any modality
  • thought disorder
  • catatonai
  • negative Sx

for at least 1 month

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15
Q

1st rank Psychotic Sx

A

Thought disorder / alienation

  • broudcasting
  • withdrawal
  • insertion

Passivity phenomena

Auditory hallucinations

  • numerous 3rd person discussions ‘he/she is …’
  • running comentary
  • thought echo (repeats thoughts aloud just after)

Delusional perceptions - ordinary stimulus triggers delusional belief e.g. it was cloudy so I was God

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16
Q

Features of Paranoid SCZ subtype?

A 
Prominent hallucinations
(Usually) persecutory delusions
17
Q

Features of Catatonic SCZ subtype

A

Psychomotor disturbance

  • stupor
  • excitement
  • posturing
  • rigidity
  • waxy flexibility
  • automatic obedience
  • perseveration
18
Q

Management approach to SCZ

A

Bio: Antipsychotics –> Clozapine if Tx resistant

Psycho: CBT, CRT, behavioural family therapy, arts therapy

Social:
• Social skills training – improve interpersonal skills
• Psychoeducation
• Carer support – carers’ groups, social services
• +/- Admission
• Rehabilitation

19
Q

Good prognostic factors in SCZ

A

Patient factors:

  • Older age of & acute onset
  • Female
  • No personality problems
  • High premorbid IQ
  • No substance misuse

Disease factors

  • Positive Sx
  • Prominent mood component
  • Obvious precipitant
  • Tx compliance

Environment

  • No family Hx SCZ
  • Married, good social support
  • Low expressed emotion
20
Q

Criteria for diagnosis of Schizoaffective disorder

A

Satisfy criteria for SCZ AND mood disorder - during same episode

NOT the same as primary mood disorders where psychotic Sx emerge secondary to mood issues (as the mood becomes most extreme)

  • psychotic depression
  • mania with psychotic sx
21
Q

Criteria for diagnosis of Acute & Transient Psychosis

A

<2 weeks between first appearance of Sx and fully developed disorder

No evidence of drug use or organic disease (including HX of another MH problem)

Abrupt onset of delusions, hallucinations & incoherent speech

Precipitated by acute stressful event

22
Q

Criteria for diagnosis of delusional disorder

A

Delusions lasting >3 months

without clear mood disturbance

lacking other SCZ Sx

23
Q

Tx of delusional disorders

A

1st line = Olanzapine

24
Q

Features of Hebephrenic SCZ

A

Disorgansied, chaotic mood, behaviour & speech
Shallow or inappropriate affect
Aimless bvehaviour
Delusions & hallucinations less prominent

Often described as ‘childlike’

25
Q

Features of simple SCZ

A

negative Sx only

never shown positive Sx

26
Q

Features of residual SCZ

A

prominent negative Sx

remain after delusions/hallucinations subside

27
Q

Dissociative identity disorder - key features

A

2+ distinct personality states

Differences in emotion, behaviours, consciousness, memory, perception, cognition, sensation + movement

‘Memory gaps’ when recalling every events, personal info & traumatic events

That is NOT part of accepted cultural/religious practice

28
Q

Dissociative amnesia - key features

A

inability to recall important autobiographical info

cannot be explained by normal forgetting

localised & selective e.g. sexual assault OR generalised e.g. entire teenage years

29
Q

Depersonalisation - key features

A

experiences of unreality, detachment, or movement

where individual feels as if they are observing their own thoughts/feelings/sensations/body/actions

30
Q

Derealisation disorder - key features

A

experiences of unreality or attachment in relation to surroundings

e.g. people/objects feel unreal, dreamlike, foggy or distorted

31
Q

Dissociative fugue - key features

A

amnesia + purposeful travel (beyond the usual everyday range)

behaviour may appear ‘normal’ to outside observers

32
Q

Tx for dissociative disordeers

A

Bio:

  • naltrexone (non selective opioid antagonist)
  • lamotrigine in depersonalisation/derealisation
  • antidepressants for associated depression, anxiety, panic attacks

Psycho:

  • CBT
  • EMDR
  • dialectical behaviour therapy
  • family therapy
  • ?hypnosis for DID

Social:

  • journaling to improve awareness & notice worsening sx
  • mindfulness

+/- inpatient admission if suicidality or self harm

33
Q

Thought disorders

A

Thought alienation (a first rank Sx) - broadcasting, withdrawal, insertion

Flight of ideas - rapid changes in topic BUT there are some connections, may be linked to cue in the surrounding environment, elicited by associations stemming from the topic or merely by words (clang associations)

Knight’s move thinking - illogical or no link between topics

Tangentiality - excessive or irrelevant detail, des NOT ever reach essential point of a conversation/desired answer to Q

Circumstantiality - digresses to give unnecessary and often irrelevant details before arriving at the main point.

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