Psychosis Flashcards
(63 cards)
1
Q
Definition of Schizophrenia
A
- Need 2 or more of for 6 months:
- Delusions, hallucinations, disorganized speech, disorganized/catatonic behaviour, negative symptoms (flat affect, alogia, avolition, anhedonia)
- Also affects attention, conecntration, memory
- Onset in late teens/ 20s, earlier onset in men
2
Q
Etiology of schizophrenia
A
- environmental (maternal infection, nutrient deficiency, adversity, immigrant, cannabis, decreased motor/ cognitive/ social function)
- genetics (higher risk in twins/ children/ siblings)
- Over 150 associated SNPs i.e 22q11.2 deletion
3
Q
Pathophysiology of schizophrenia
A
- drugs that increase DA
- increases in mesolimbic pathway leads to positive symptoms
- decreases in mesocortical pathway leads to negative symptoms and cognitive impairment
- decreased cortical thickness
4
Q
What are the 4 dopamine pathways?
A
- Nigrostriatal
- Mesolimbic
- Mesocortical
- Tuberoinfundibular
5
Q
What makes up the striatum? What 3 pathways run towards it?
A
- Caudate nucleus and Putamen
1. Limbic - emotion and motivation
2. Associative (DA release is increased here in schizo) - higher level cognition
3. Sensorimotor - body and eye movements
*info from the cortex flows through these 3 pathways to the striatum, which integrates output to the thalamus for feedback to the cortex
6
Q
DDx for delusions/ hallucinations
A
- epilepsy, frontal lobe tumors, SLE, hypoxia, B12/thiamine deficiency, levodopa, prednisone, cannabis, cocaine, benzo withdrawal, bipolar
7
Q
How to distinguish primary vs secondary psychosis
A
- Primary (i.e. schizophrenia) has normal consciousness i.e. will be able to tell you the date
- Prominent visual hallucinations are more common in secondary psychosis
8
Q
Distinguishing schizophrenia vs drug induced vs medically induced
A
Schizo –> gradual, normal consciousness, multiple auditory hallucinations, remitting and relapsing
Substance –> sub/acute, consciousness and orientation may be altered, SUD, resolves
Medical –> variable onset, acute, Px findings, consciousness may be altered, orientation impaired, resolves
9
Q
Common symptoms characteristic of schizophrenia?
A
audible thoughts, arguing voices, voices commenting on actions, somatic passivity (being controlled), thought withdrawal and broadcasting
10
Q
Psychotic disorders and their criteria
A
Schizophrenia - over 6 months
Schizophreniform - 1 to 6 months
Brief psychotic disorder - 1 day to 1 month
Schizoaffective - psychosis and a mood disorder (depression or mania)
Delusional disorder - only delusions
Substance/ Medication induced psychosis
11
Q
Prognosis after first schizophrenic episode
A
- decline is more pronounced in early stages
- relapse rate is 2 years post 1st episode
- life span is decreased 10 years (not only suicide!)
Worse prognosis if chronically progressive
Better prognosis if remitting/ relapsing
12
Q
What are risk factors of schizophrenia? What factors lead to a poor prognosis?
A
- male, decreased cognition, older paternal age, obstetric complications
- low SES, SUD, early onset, longer time untreated, increased lateral ventricle
13
Q
Describe the mesocortical pathway
A
- VTA to the PFC
- cognition, emotion, affect
- issues here lead to the (-) sx of schizophrenia
14
Q
Describe the mesolimbic pathway
A
- VTA to the nucleus accumbens
- memory, emotional behaviours, reward
- activity here leads to the (+) sx of schizophrenia
15
Q
Describe the nigrostriatal pathway
A
- SN to the basal ganglia
- controls motor movement
16
Q
Describe the tuberoinfundibular pathway
A
- hypothalamus to the infundibular area
- controls prolactin secretion
17
Q
1st Generation Antipsychotics
- MOA
- drawbacks
- side effects
- examples, and which ones are high/low potency for D2
A
- antagonize D2, H1, A1, M1 receptors
- antagonism of mesolimbic D2 treats (+) sx
- BUT antagonism of mesocortical D2 may lead to (-) sx (neuroleptic induced deficit syndrome), as well as extrapyramidal sx in nigrostriatal, and increased prolactin via inhibition of the TI pathway
- anti-H (sedation and weight gain), anti A (dizziness and lower BP), anti M (dry mouth, constipation, blurry vision, and urinary retention)
- Chlorpromazine low potency for D2
- Haloperidol high potency for D2
18
Q
2nd Generation Antipsychotics
- MOA
- examples
A
- antagonize D2, H1, A1, M1, 5HT2A and some are partial agonists of 5HT1A
- 5HT2A receptor normally inhibits the release of DA, so antagonizing this receptor increases release of DA which can improve (-) sx as well as extrapyramidal sx and help inhibit prolactin release
- Clozapine, Quetiapine, Risperidone
19
Q
3rd Generation Antipsychotics
- MOA
- Examples
A
- antagonize H1, A1, M1, 5HT2A and partial agonists of D2, D3 and 5HT1A
- partial agonism helps with extrapyramidal sx and inhibiting prolactin secretion, also lessens orthostatic hypoTN/ sedation/ dizziness/ dry mouth/ constipation
- Apriprazole (which has the most partial agonist activity)
20
Q
What are the treatment guidelines for schizophrenia?
A
- Initially start with an SGA or TGA and evaluate over 2 weeks
- If no response, switch to a different drug (Clozapine) or increase the dose, consider a long acting injectable
- If the patient doesn’t show 20% sx decrease in the first 2 weeks it is unlikely it will work, but can wait up to 6-8 weeks to fully evaluate
- Threshold should be low for choosing to switch bc of side effects, but keep in mind that some side effects will decrease with time so consider waiting a bit if there is a therapeutic benefit
21
Q
Unique side effects of clozapine?
What factors increase or decrease its plasma concentration?
What should you consider if refractory (+)/(-)/ aggression?
A
- agranulocytosis, myocarditis
- increase –> female, pregnant, old, CYP1A2 inhibitors (valproic acid), infection, asian, obese, rapid titration
- decrease –> smoking, inducers (carbamazepine, valproic acid)
- apiprazole/ ECT for (+) sx
- anti-depressant/ ECT for (-) sx
- mood stabilizer or anti-psychotic for aggression
22
Q
What are general side effects of anti-psychotics? Treatment options
A
- pseudo-parkinsonism (anticholinergics)
- akathisia (benzos, propranolol, mirtazapine)
- tardive dyskinesia (TGA, cloz/quet)
- hyperprolactinemia (can lead to ED, gynecomastia, hirsutism, acne, etc.)
- weight gain, HTN, insulin insensitivity
23
Q
Personality
A
- internal characteristics, consistent over time, based in patterns of behaviour
- can be affected by situation
24
Q
5 Factor Model of Personality
A
Openness to experience (intellect, insight, creativity)
Conscientiousness (organized, dependable)
Extraversion (sociable, expressive, energetic)
Agreeableness (cooperative, empathic, respectful)
Neuroticism (insecure, touchy, excitable, anxious)
25
Personality Disorder DSM-5
Which personality disorders are most common?
- enduring pattern of behaviour that deviates from expectation of one's culture, distress and impairment
- must affect at least 2 areas: cognition, affect, impulse, interpersonal
- must be pervasive across time and situation
- late adolescence/ early adulthood onset
- OC, antisocial, schizotypical and paranoid are most common
26
Cluster A Personality Disorders
- Odd-Eccentric, shared schizophrenia vulnerability
1. Paranoid - distrust, self-righteous
2. Schizoid - detached, does not connect
3. Schizotypical - relationship discomfort, blurring of reality and fantasy, perceptual distortions, eccentric
27
Cluster B Personality Disorders
- Dramatic-Emotional
1. Borderline - impulsive, unstable in relationships and mood, suicidal, self harm
2. Histrionic - excessive emotions, attention seeking
3. Antisocial - disregard for others, superficially charming
4. Narcissistic - need admiration, lack empathy
28
Cluster C Personality Disorders
- Anxious-Fearful
1. Avoidant - sensitive, hesitant, feel inadequate
2. Dependent - submissive, clingy, need reassurance
3. Obsessive-Compulsive - perfectionist, controlling
29
Motor Circuit
- regulation of gaze and eye orientation
- putamen receives input from sensory/motor areas, then sends input to the thalamus via VA/VL which sends info back to the motor cortex
30
Associative Circuit
- planning complex motor activity
- when an action is well-learned, activity in this circuit decreases and will increase in the motor circuit
- input from SN, nucleus accumbens and caudate nucleus project to the thalamus
31
Limbic Circuit
- postures/ gestures/ expressions related to emotion, anticipatory reward, incentive based learning, rich in DA neurons,
- amygdala and hippocampus --> nucleus accumbens --> thalamus --> frontal association areas, orbitofrontal lobe, and anterior cingulate
32
How do D1 and D2 differ?
- D1 is excitatory, G-protein mechanism increases CAMP which increases intracellular Ca
- D2 is inhibitory, G-protein mechanism blocks CAMP
33
What leads to catalepsy symptoms due to anti-DA meds in schizophrenia?
- D2 receptor blockade on cholinergic neurons present in the indirect pathway
34
How is reward wired? How does schizophrenia affect this?
- VTA (midbrain), nucleus accumbens, SN
- motivation and reward are combined to create goal oriented behaviour
- VTA --> motivation, executive functioning, drug seeking, emotion, reward
- in schizophrenia, get altered reward (DA) signalling in the mesolimbic pathway leading to distorted salience of stimuli
- in a non-addicted person, the PFC can inhibit drive while conditioned clues and saliency can stimulate it
- in an addicted person, saliency can override the PFC and will no longer be inhibited by it
35
Gambling disorder DSM-5
Tx?
- 12 months
- at least 4 of:
- increased amounts, restless, cant quit, preoccupied, distressed, lying about extent, affects life, rely on other for $
- CBT, motivational interviewing, no meds approved
- Screen with South Oaks Gambling Screen/ LIE/ BET
36
How does gambling disorder affect other things? Possible etiology?
- affects SUD tx (often coincide), increases intimate partner violence
- though to have DA basis --> increased bottom-up ventral striatal DA release to cues/gambling tasks/reward prediction, decrease of top down orbitofrontal influence
- increased compulsivity with DA agonists
37
What is the pathophysiology behind addiction?
- dopamine!
- mesolimbic system involved in behavioural reinforcement/ drive
- reward pathway: VTA --> NA --> PFC
- amygdala activates when seeing craved substance
- D2 receptors are LOWER in addiction, more likely to find methylphenidate pleasant
- more stress = better response to drugs
- new environments can lead to overdose
38
Role of serotonin
Role of glutamate
Serotonin - mood, sleep, memory, cognition
- raphe nucleus/NA/HC/PFC
- seen to decrease in the cerebral cortex after ecstasy
Glutamate - craving, learning, memory
39
Effect of:
Nicotine
Opioids
Alcohol
Cocaine
Methamphetamine
Cannabis
Nicotine --> increases DA and NE
Opioids --> increase DA and decrease NE
Alcohol --> increases GABA (inhibitory) and decreases glutamate (excitatory), also increases DA and 5HT
Cocaine --> reuptake inhibitor of NE, DA, 5HT
Methamphetamine --> dumps NE, DA, 5HT into the cleft by reversing transport
Cannabis --> increase DA and 5HT
*withdrawal is the opposite
40
Impulsivity vs compulsivity?
Impulsivity --> effort to obtain arousal/ gratification (NE and DA)
Compulsivity --> effort to reduce anxiety (5HT)
41
SUD DSM-5
What is considered remission?
Which substance is most addictive?
- 12 months, 2 of the typical criteria
- 3-12 months is early remission, 12+ months is sustained remission (can still have cravings)
- tobacco is most addictive (nicotine is a gateway drug)
- earlier age = higher risk of addiction
*this exact criteria is same for Cannabis use disorder and OUD
42
Treatments for SUD?
- Agonists --> methadone for OUD, nicotine patch for smoking
- Partial agonists --> buprenorphine for OUD, varenciline for smoking
- Antagonists --> naltrexone for OUD
- Aversion --> disulfiram for AUD
- Sx Mitigators --> benzos for alcohol withdrawal
- Behavioural --> CBT, MI, SMART, mindfulness
43
What is considered high risk for drinking? What causes flushing/tachycardia/HTN/nausea? Chronic consequences?
- 7+ drinks a week
- acetaldehyde
- hepatosplenomegaly, caput medusa, macro anemia, hepatitis
44
What does alcohol withdrawal look like?
What is delirium tremens?
What is Wernicke Korsacoff?
- insomnia, irritability, anxiety
- high BP and HR, tremor, hyperreflexia
Delirium tremens --> hallucinations, tremor, seizures, disorientation, anxiety 3-4 days after, EMERGENCY
Wernicke Korsacoff --> encephalopathy, ataxia, hallucinations, psychosis, memory impairment, low vitamin B, EMERGENCY
45
THC vs CBD
THC --> psychoactive, lipophilic, partial agonist of CB1
- euphoria, relaxation, psychomotor and memory deficits, increased appetite, tachycardia, analgesia
- slower onset and longer lasting if ingested
CBD --> non-intoxicating, low affinity for CB1/2
- somnolence, lethargy, insomnia, suicidal thoughts, GI
- approved for epilepsy
46
Where are CB1 and CB2 expressed?
CB1 --> widely expressed in CNS/PNS, psychotropic effects (THC)
CB2 --> expressed in immune tissues (macrophages, B and T cells, GI), cytokine release
47
Side effects of weed
- acute --> nausea, vomitting, transient psychosis, anxiety, paranoia
- higher risk with polysubstance use and ingestion, young males
- chronic --> increased risk of developing schizophrenia, impaired learning/ attention/ working memory/ coordination, poor social functioning, potentially IQ decline but could be due to SES
48
Evidence of benefit for weed?
Substantial - chronic pain, antiemetic in chemo, MS spasticity, decreasing opioid use (enhances the analgesic effects of opioids)
Moderate - sleep
Meh - tourette's, anxiety, PTSD, increase appetite in HIV
49
What causes tolerance and withdrawal?
- over time receptors become less sensitive
- body can no longer produce enough endogenous opioids
50
How does pupil size vary in relation to drugs?
- Dilated if withdrawal
- Constricted if opioid overdose
51
Risk factors for OUD
- 40+, male, current or past Hx of SUD, family hx, depression/ anxiety/ PTSD/ ADD, chronic pain and being prescribed an opioid for it, trauma, ACEs (alter the HPA axis)
- 5-15% of chronic pain patients on opioids have OUD
52
Social vs structural vs self stigma
Social --> negative labels/images, ignoring
Structural --> barriers to care (witholding until better managed)
Self --> u hate urself
53
Ways to avoid OUD
- don't dispense more than 30 days at a time
- do not co-Rx with benzodiazepines
- assess for other SUD
- supervised injection sites, OAT, support programs
- don't use alone, don't mix, don't inject
*if overdose --> ventilation BEFORE chest compressions (respiratory issue)
54
Demographics of suicide
- starts at 10, increases until 24 and remains high, peaks at 50 and then decreases until 70
- continued decline in women, severe rebound in men
- overrepresented in indigenous (but NOT a risk factor)
- immigrants commit less suicide
55
Unintentional Self-Injury
Self-Injurious Behaviour
Non-Suicidal Self-Injury
Suicide Gesture
Suicide Attempt
Suicide
USI --> risky behaviour (alcohol overdose, firearms)
SIB --> hair pulling, skin picking, intellectual disabilities
NSSI --> intentional but not wanting to die, cutting/burning/purging
Gesture --> suicidal behaviour/ communication, doesn't need intent
Attempt --> intent of death w action
Suicide --> resulting in death
56
Etiology behind NSSI
- genetic susceptibility --> TRAUMA --> increased opioid release and decreased sensitivity --> NSSI to release opioids
- those with a history of suicidality and NSSI have less endorphins in spinal fluid
- those who self-injure report greater euphoria when given opioids
- those who self-injure have lower stress/ cortisol levels
57
4 Cs of Suicide
Collateral --> ask other people about history, perception of reality, distortion of time, reactionary nature
Confidence --> how well do you know the patient, patient is confident in themself, poor enagement
Common Sense --> careful history taking, active vs passive ideation
Changeability --> NOT: age, sex, fam hx, prior attempts
YES: access, mental health, support, meds
58
Risks of Suicide (SAD PERSONS)
- sex: male
- age under 19 or over 45
- depression
- previous attempts/ psychiatric care
- excessive alcohol/ drugs
- single/ widowed/ divorced
- no support
- organized/ serious attempt (2)
- stated future intent (2)
- rational thinking loss (2)
8+ --> hospital admission
0-5 --> maybe discharge
+ASARI - assessment of suicide and risk inventory
59
Motivations for Suicide
1. Isolated (egoistic) --> LGBT, trauma, divorced
2. Hopeless (fatalistic) --> chronic illness, hardship
3. For others (socioistic) --> remorse, shame, revenge, protecting others
4. Pressure (anomic) --> school/social pressure, family loss/change
*most suicide interventions address anomic ideation
60
What should you also test for to rule out secondary causes of psychosis?
- syphilis - neurosyphilis can cause psychotic-like symptoms
- urinalysis for drugs that could be induced psychosis
61
BC Mental Health Act
- allows patients to be admitted involuntarily
1. Have a mental disorder
2. Require tx in a facility to prevent deterioration/ protect themselves and others
3. Cannot suitably be admitted voluntarily
62
Substance Induced Psychotic Disorder
- delusions and/ or hallucinations
- evidence of onset after use/ withdrawal
- not better explained by another illness
63
Stimulant Withdrawal
- dysphoria and 2 of:
- fatigue, unpleasant dreams, insom/hypersomnia, increased appetite, pyschomotor agitation and retardation
