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Flashcards in Psychosis Deck (55):
1

Psychiatric differential of psychosis

Schizophrenia

Schizoaffective disorder: Prominent mood symptoms

Schizotypal personality disorder: Chronic nature

Manic episode (e.g. of bipolar): Other features of mania

Postpartum psychosis: Acute postpartum onset

Delusional disorders: absence of other features of schizophrenia

Psychotic depression

2

Non-psychiatric differentials of psychosis

Iatrogenic: Anti-malarials, L-DOPA, steroids

Substance misuse: Esp. amphetamine

Complex partial epilepsy: other evidence of seizures (e.g. post-ictal grogginess)

Huntington's: Family history, choreiform movements

Syphilis:

SLE: renal and skin involvement

Dementia: Age, cognitive impairment

Delirium: Acute onset, clouding of consciousness

3

Schneider's first-rank symptoms of schizophrenia

Delusional perception (e.g. delusions of reference)

Auditory hallucinations: Third-person, running commentary, thought echo

Passivity: Thought, feeling, action

Thought interference: Withdrawal, insertion, broadcasting

Somatic hallucinations

Can occur in 10-20% of manic episodes

4

Difference between primary and secondary delusion

Secondary delusions arises understandably from aother mental state (e.g. guilt in depression)

5

Features of catatonic schizophrenia

Waxy flexibility

Posturing

Negativism

Echopraxia

Automatic obedience

Ambitendency

6

Appearance and behaviour in schizophrenia

Idiosyncratic dress

Mannerisms and stereotypies

EPSEs

Suspicious/distracted/uninterested behaviour

7

Mood in schizophrenia

Flattened affect

Incongruency between mood and thought content

8

Thought in schizophrenia

Formal thought disorder (e.g. loosening of associations)

Delusional beliefs

Thought block/echo/interference

Neologisms

9

Perceptions in schizophrenia

Hallucinations esp. auditory

Check for content (esp risk to self/others)

10

Duration criterion for schizophrenia

1 month

11

Negative symptoms of schizophrenia (particularly in chronic)

Flattened affect

Apathy and avolition

Social withdrawal

Poor self-care

Cognitive, attentional, and memory impairment

Poverty of speech

12

Short-term management of first-episode psychosis

Admission (and possible detention)

Antipsychotic (low-dose if first episode, may not have schizophrenia!)

Benzodiazepine if necessary for sedation

Establish context/precipitating factors for illness

Screen for autoantibodies causing autoimmune encephalitis/psychosis if first episode

Referral to EIS if first episode

13

Long-term management of schizophrenia

Bio:

  • Monitor drug levels/SEs (esp EPSEs, prolactin, ECG, clozapine FBC)
  • Regular medical review (esp weight, BP, glucose, HbA1c, lipids)

Psycho:

  • Involve family for therapy and psychoeducation
  • Post-schizophrenic depression --> antidepressants
  • CBT for persistent delusions
  • Regular monitoringof mental state

Social:

  • CPA planning: Assigned key worker/care coordinator
  • Accommodation, benefits, employment support
  • Address risks to self/others

 

14

Time to assess response to antipsychotic

6 weeks (although early response can be noted at 2-4 weeks)

15

When to administer clozapine

After failure of 2 antipsychotics at treatment dose for 6w each

16

Psychological treatments for schizophrenia

Family therapy: To lower expressed emotion and educate about early warning signs/management (difficult + modest effect)

CBT: for residual symptoms (modest effect + minimal engagement); ?VR trial

Cognitive remediation therapy: to improve memory deficits

17

Social interventions for schizophrenia

Supported accommodation

Employment support

Assertive outreach for patients with chaotic lifestyles

Regular f/u with named key worker/care coordinator

18

Poor prognostic factors: demographic

Onset <25y

Isolated, unmarried

Male

Poor work record

Substance misuse

Psychiatric Hx

Social isolation

19

Poor prognostic factors: illness

Insidious onset

Prolonged untreated psychosis

Hebephrenic subtype

Poor treatment compliance

Early negative symptoms

Poor insight into disease

No mood symptoms (schizoaffective better prognosis)

20

Main causes of mortality and morbidity

Life expectancy 12-15 years shorter

Cardiovascular illness and diabetes

Suicide (5-10%)

Exploitation/victims of violent crimes from others (40%)

21

Age of incidence of schizophrenia

20-28 for men

More equal distribution in females (26-32) with second peak post-menopause

22

ICD-10 diagnostic criteria for schizophrenia, at least one of:

Thought: insertion, withdrawal, broadcast, echo

Delusion: Of control, passivity, or persistent culturally inappropriate

Hallucinations: Auditory, third-person, giving running commentary or discussing among themselves

23

Features of delusional disorders

No hallucinations or other symptoms of schizophrenia

Persistent systematized, less bizarre delusions, MSE otherwise unremarkable

Acute self-limiting often in response to stressors

24

Management of schizoaffective disorder

Manage mood and psychotic elements on their own merits

25

Management of delusional disorders

Antipsychotics if peristent (>3 months), otherwise spontaneous recovery

26

Heritability of schizophrenia

80%

27

Risk of developing schizophrenia if one parent affected

12%

28

Risk of schizophrenia if identical twin affected

48%

29

Biological risk factors for schizophrenia

Family history

Obstetric complications - incl. fetal malnutrition, maternal influenza

Early cannabis use

Advancing paternal age

30

Social/psychological risk factors for schizophrenia

Urban living

Life stressors (may be precipitating)

Migrant population

Family with high expressed emotion

Poverty

Cannabis use (esp <15)

31

Most common structural abnormality in schizophrenia

Enlargement of lateral ventricles (but not diagnostically useful)

32

Most common first-gen antipsychotics

Haloperidol

Chlorpromazine

33

Extrapyramidal side effects of first-gen antipsychotics (in order of appearance)

Dystonia

Akathisia

Parkinosnism

Tremors

Tardive dyskinesia

34

Emergency treatment of acute dystonia

Anticholinergic procyclidine

35

Life-threatening adverse events of typical antipsychotics

Neuroleptic malignant syndrome

Torsade de pointes following Q-T prolongation

36

Features of neuroleptic malignant syndrome

Increased stiffness

Autonomic instability, sweating

Raised creatine kinase, white cell count, metabolic acidosis

37

Side effects of atypical antipsychotics

sedation (anti-histamine effect)

weight gain

T2DM

Possible increased risk of stroke

Neutropenia (esp pines)

38

Non-EPSEs of typical antipsychotics

Hyperprolactinaemia

Constipation, urinary retention (anti-muscarinic)

Postural hypotension (anti-alpha 1)

Sedation, weight gain (but usually not T2DM)

39

Most common atypical antipsychotics

Risperidone

Olanzipine

Quetiapine

Amisulpride

Clozapine

40

Side effects of clozapine

Agranulocytosis (weekly blood tests)

Myocarditis/cardiomyopathy

Seizures

Metabolic syndrome

Hypersalivation

!!constipation (clozapine-induce gut hypomotility, most fatal)!!

41

Drug that is affected by smoking

Clozapine, olanzapine - cessation reduces plasma levels

42

Antipsychotics available as depots

Haloperidol

apriprazole

olanzapine

risperidone

43

Mechanism of action of typical antipsychotics

D2 antagonism --> reduce +ve symptoms

44

Mechanism of action of atypical antipsychotics

D2 antagonism + 5-HT2a antagonism --> increase DA slightly in nigrostriatal pathway --> reduced EPSEs In mesocortical pathway --> reduced-ve symptoms

45

Advantages of risperidone

Most tolerable SE profile

46

Advantages of olanzapine

Sedative effect

47

Other condition for quetiapine

Bipolar depression

48

Benefits of clozapine

Most efficacy + anti-suicide drug --> for Rx-resistant

49

Antipsychotics by propensity for weight gain

Olanzipine > clozapine > quetiapine > risperidone

50

Antipsychotics by sedative effect

Clozapine > olanzipine > quetiapine > haloperidol > risperidone

51

ICD-10 diagnostic criteria for schizophrenia, at least two of:

Negative symptoms

Persistent hallucinations of any modality

Catatonic behaviour

Neologisms or breaks in thought --> incoherent speech

52

Differentiating schizophrenia from mood disorder

In mood disorder mood symtpoms precede psychosis + psychosis is mood congruent

53

Indications for antipsychotics in bipolar

For mania

If presenting euthymic, use mood stabiliser

54

Physical health monitoring for antipsychotics

Weight, BP, ECG, HbA1c, blood glucose/lipids, smoking cessation advice

Weekly for first 3/12

Monthly for 6/12

55

Prognosis for schizophrenia

Acute illness, complete recovery: 20%

Recurrent illness, some persistent deficit: 50%

Chronic illness, severe functional disability: 20%

Suicide: 10% (esp if younger, more insight)