Psychosis

Question 1

What is psychosis?

Answer 1

A group of mental illnesses that features a difficulty perceiving and interpreting reality

Question 2

Which type of mental illnesses are associated wit psychosis?

Answer 2

Schizoaffective disorder
Bipolar I
Schizophrenia (1%) 
Delusional disorder
Depression with psychotic features 
Due to other medical condition 
Substance related

Question 3

What are the three domains of psychosis symptoms?

Answer 3

Positive symptoms
Negative symptoms
Disorganisation

Question 4

What are the two main positive symptoms of psychosis?

Answer 4

Hallucinations

Delusions

Question 5

What are hallucinations in psychotic patients?

Answer 5

Percepts in absence of a stimulus
Auditory
Voices commenting on you 
Voices talking to each other
Visual
Somatic/tactile
Olfactory

Question 6

What are delusions in psychotic patients?

Answer 6

Fixed, false beliefs, out of keeping with social/cultural background.

Persecutory
Control
Reference
Mind reading
Grandiosity
Religious
Guilt/sin
Somatic

Thought broadcasting
Thought insertion
Thought withdrawal

Question 7

What are the four main negative symptoms of psychosis?

Answer 7

Alogia
Avolution/apathy
Anhedonia
Affective flattening

Question 8

What term describes a poverty of speech?

Answer 8

Alogia

Question 9

What is alogia?

Answer 9

Is concerned with paucity of speech, little content and the individual is slow to respond.

Question 10

What is avolution/apathy?

Answer 10

Poor self-care
Lack of persistence at work/education
Lack of motivation

Question 11

What is anhedonia/asociality?

Answer 11

Disengaged interest and pleasure within conducting activities.

• Few close friends
• Few hobbies/interests
• Impaired social functioning

Question 12

What is affective flattening?

Answer 12

Unchanging facial expressions
Few expressive gestures
Poor eye contact
Lack of vocal intonations
Inappropriate affect

Question 13

What are the two main forms of disorganisation symptoms?

Answer 13

Bizarre behaviour

Thought disorder

Question 14

What is bizarre behaviour?

Answer 14

Bizarre social behaviour
Bizarre clothing/appearance
Aggression/agitation
Repetitive/sterotyped behaviours

Question 15

What is thought disorder?

Answer 15

Derailment
Circumstantial speech
Pressured speech
Distractibility
Incoherent/illogical speech

Question 16

What is the peak onset of psychosis?

Answer 16

Peak incidence in adolescence/early 20s.

Peak later in women

Question 17

What is taken in a psychiatric history?

Answer 17

• History of presenting concern- nature, severity, onset, worsening factors, and treatment received
• Past psychiatric history (diagnosis, treatment, community team, previous admissions?)
• Background history (family, personal, social- abuse, alcohol/drug misuse)
• Past medical history and medicine
• Corroborative history

(Educational, occupational history, relationships, separation, childhood illness)

Question 18

What things are considered when conducting a social history?

Answer 18

• Living arrangements
• Financial issues
• Alcohol and illicit drug use
• Forensic history

Question 19

What type of history requires consent?

Answer 19

Corroborative history

Question 20

What 7 key features are assessed in a mental state examination?

Answer 20

Appearance and behaviour 
Speech
Mood
Thoughts
Perceptions
Cognition 
Insight

Question 21

How can appearance change in patients with psychosis?

Answer 21

Neglect : Alcoholism, drug addiction, dementia, depression and schizophrenia

Weight loss: Anorexia nervosa, depression, cancer, hyperthyroidism, financial issues/homelessness.

Facial: Depressive, anxious, wooden Parkinsonian

Question 22

What type of movements are assessed in psychosis patients?

Answer 22

Overactive, restless- manic

Inactive, slow - depressive

Immobile, mute - stupor

Tremors, ticks, choreiform movements, dystonia, tardive dyskinesia
Mannerisms, stereotypes

Question 23

What four factors are assessed when looking at speech?

Answer 23

Quantity - less, more, mutism
Rate- slow, fast, pressure of speech.
Spontaneity - latency
Volume - quiet, loud

Question 24

What are primary delusions?

Answer 24

Occurs suddenly

Question 25

What are secondary delusions?

Answer 25

Arises from previous abnormal idea/experience

Question 26

What is an illusion?

Answer 26

Misperception of a real external stimulus

Question 27

What is a hallucination?

Answer 27

= perception in the absence of external stimulus true perception + 2) coming from outside the head pseudohallucination = 1) OR 2) hypnagogic, hypnopompic ``` auditory – second person, third person visual – Charles Bonnet syndrome olfactory gustatory tactile, of deep sensation ```

Question 28

What features are assessed when considering mood in individuals with suspected pyschosis?

Answer 28

``` Subjective Objective Predominant mood Constancy Congruity (Cheerful while describing sad events). ``` Emotional lability/incontinence/reduced reactivity/blunting/flattening/irritability.

Question 29

What features of thought are examined when assessing thoughts in individuals with suspected psychosis?

Answer 29

``` Stream Form Content Preoccupations Morbid thoughts, suicidality Delusions, overvalued ideas Obsessional symptoms ```

Question 30

What is insight in terms of assessing a patient's mental state?

Answer 30

Awareness of onself as presenting phenomena that other people consider abnormal Recognition that these phenomena are abnormal Acceptance that these abnormal phenomena are caused by mental illness Awareness that treatment is required

Question 31

What type of symptoms typically precede psychosis?

Answer 31

Prodromal symptoms | Changes in social behaviour, social withdrawal and impairments in functioning

Question 32

What are the environmental risk factors for psychosis?

Answer 32

Cannabis and drug use Maternal infections Migrant status Socioeconomic deprivation Childhood trauma Prenatal/birth complications

Question 33

What are the genetic risk factors for psychosis?

Answer 33

Schizophrenia is highly heritable | Highly polygenic

Question 34

What additional sources of information are available to support a diagnosis of psychosis?

Answer 34

Collateral history from family, friends and work. Healthcare records: GP, Mental health services.

Question 35

What difficulties are encountered when treating someone with very poor insight into their psychosis?

Answer 35

Concordance with treatment Attendance at follow-up Would not stay in hospital

Question 36

What are the differentials for psychosis?

Answer 36

``` Delirium Schizophrenia Personality disorder Dementia Drugs Encephalitis (behavioural changes) ```

Question 37

What are the three types of psychosis management?

Answer 37

Pharmacological Psychological (CBT and avatar therapy) Social support

Question 38

Which neurotransmitter system is most implicated in the mechanism of antipsychotics?

Answer 38

Dopamine

Question 39

Which hormone activity is increased in psychosis?

Answer 39

Increased dopamine activity is implicated in causing reality distortion in psychosis post-mortem studies reveal elevated presynaptic dopamine in striatum.

Question 40

How do most antipsychotics work?

Answer 40

They are dopamine antagonists. Aripirazole is a partial agonist

Question 41

Why can Parkinson's be a risk factor for psychosis?

Answer 41

Dopamine agonists which are used in the treatment can cause psychotic symptoms.

Question 42

What are the common side effects associated antipsychotic medication?

Answer 42

Extrapyramidal side effects - Parkinsonism - Acute dystonia - Tardive dyskinesia - Akathisia Antipsychotics can cause post-synaptic dopamine blockade in the extrapyramidal system Parkinsonism is a common effect

Question 43

What parkinsonism features are associated with antipysychotic drug use?

Answer 43

Rigidity- Characteristic cog-wheeling Slow and shuffling gait Lack of arm swing in gait- early sign Pill rolling tremor - slow movement of the thumb across other fingers

Question 44

What is acute dystonia?

Answer 44

Increased motor tone --> Sustained abnormal posture Can occur shortly after taking dopamine antagonist

Question 45

What is tardive dyskinesia?

Answer 45

Repeated oral/facial/buccal/lingual movements. Initially subtle- can progress to tongue involvement, lip smacking. increased risk: Long term antipsychotics, female

Question 46

What is akathisia?

Answer 46

Inner restlessness (hand streotypy) Feel compelled to move, but does little to alleviate Can lead to overt, relentless movement. Legs most commonly affected

Question 47

What are 'typical' antipsychotics?

Answer 47

Commonly cause extrapyramidal side effects at therapeutic doses, definition is NOT based on pharmacology/drug target.

Question 48

What is the main difference between atypical and typical antipsychotics?

Answer 48

Atypical drugs are less likely to cause ESPEs.

Question 49

What is the management of extra-pyramidal side effects in patients receiving antipsychotics?

Answer 49

Avoid them in the first place: Atypical antipsychotics usually first-line. Change medication, anticholinergic medications can help e.g procyclidine.

Question 50

What are the haematological side effects of antipsychotics?

Answer 50

Agranulocytosis | Neutropenia

Question 51

What are the metabolic side effects of antipsychotics?

Answer 51

Increased appetite Weight gain Diabetes

Question 52

What are the cardiac side effects of antipsychotics?

Answer 52

Dysrhythmia | Long QTc,

Question 53

What are the pituitary side effects of antipsychotics?

Answer 53

Increased prolactin release

Question 54

What are the gastrointestinal side effects of antipsychotics?

Answer 54

Constipation