Psychosis

Question 1

Psychosis is a term used to describe

Answer 1

a person experiencing things differently from those around them.

Question 2

Psychotic features include:

Answer 2

hallucinations (e.g. auditory)
delusions
thought disorganisation

agitation/aggression
neurocognitive impairment (e.g. in memory, attention or executive function)
depression
thoughts of self harm

Question 3

Psychotic thought features

Answer 3

alogia: little information conveyed by speech
tangentiality: answers diverge from topic
clanging
word salad: linking real words incoherently → nonsensical content

Question 4

Psychotic symptoms may occur in a number of conditions:

Answer 4

schizophrenia
depression (psychotic depression, a subtype more common in elderly patients)
bipolar disorder
puerperal psychosis
brief psychotic disorder: where symptoms last less than a month
neurological conditions e.g. Parkinson’s disease, Huntington’s disease
prescribed drugs e.g. corticosteroids
certain illicit drugs e.g. cannabis, phencyclidine

Question 5

The peak age of first-episode psychosis is around

Answer 5

15-30 years

Question 6

The atypical antipsychotics were developed due to

Answer 6

the problematic extrapyramidal side-effects which are associated with the first generation of typical antipsychotics.

Question 7

Typical antipsychotics

Mechanism of action

Answer 7

Dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways

Question 8

Typical antipsychotics

Adverse effects

Answer 8

Extrapyramidal side-effects and hyperprolactinaemia common

Question 9

Typical antipsychotics

Examples

Answer 9

Haloperidol

Chlopromazine

Question 10

Atypical antipsychotics

Mechanism of action

Answer 10

Act on a variety of receptors (D2, D3, D4, 5-HT)

Question 11

Atypical antipsychotics

Adverse effects

Answer 11

Extrapyramidal side-effects and hyperprolactinaemia less common
Metabolic effects

Question 12

Atypical antipsychotics

Examples

Answer 12

Clozapine
Risperidone
Olanzapine

Question 13

typical antipsychotics Extrapyramidal side-effects (EPSEs)

Answer 13

Parkinsonism
acute dystonia
akathisia
tardive dyskinesia

Question 14

acute dystonia is

Answer 14

sustained muscle contraction (e.g. torticollis, oculogyric crisis)

Question 15

acute dystonia mx

Answer 15

procyclidine

Question 16

akathisia is

Answer 16

severe restlessness

Question 17

tardive dyskinesia is

Answer 17

late onset of choreoathetoid movement
abnormal, involuntary
may occur in 40% of patients
may be irreversible

most common is chewing and pouting of jaw

Question 18

The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:

Answer 18

increased risk of stroke

increased risk of venous thromboembolism

Question 19

reduced seizure threshold less/greater with atypicals

Answer 19

greater

Question 20

which drug particularly prolong QT

Answer 20

haloperidol)

Question 21

neuroleptic malignant syndrome tetrad

Answer 21

pyrexia

muscle rigidity

autonomic lability: typical features include hypertension, tachycardia and tachypnoea

agitated delirium with confusion

Question 22

S/E antipsychotics?

Answer 22

antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin
may result in galactorrhoea
due to inhibition of the dopaminergic tuberoinfundibular pathway
impaired glucose tolerance

Question 23

Antipsychotics frequency of monitoring

Full blood count (FBC), urea and electrolytes (U&E), liver function tests (LFT)

Answer 23

at the start of therapy
annually
clozapine requires much more frequent monitoring of FBC (initially weekly)

Question 24

Antipsychotics frequency of monitoring

Lipids, weight

Answer 24

at the start of therapy
at 3 months
annually

Question 25

Antipsychotics frequency of monitoring | Fasting blood glucose, prolactin

Answer 25

at the start of therapy at 6 months annually

Question 26

Antipsychotics frequency of monitoring | Blood pressure

Answer 26

baseline | frequently during dose titration

Question 27

Antipsychotics frequency of monitoring | Electrocardiogram

Answer 27

baseline

Question 28

Antipsychotics frequency of monitoring | Cardiovascular risk assessment

Answer 28

annually

Question 29

typical/Atypical antipsychotics should now be used first-line in patients with schizophrenia

Answer 29

Atypical antipsychotics should now be used first-line in patients with schizophrenia

Question 30

Adverse effects of atypical antipsychotics

Answer 30

weight gain | clozapine is associated with agranulocytosis hyperprolactinaemia

Question 31

Examples of atypical antipsychotics

Answer 31

``` clozapine olanzapine risperidone quetiapine amisulpride aripiprazole ```

Question 32

Which atypical antipsychotics higher risk of dyslipidemia and obesity

Answer 32

Olanzapine

Question 33

Which atypical antipsychotics generally good side-effect profile, particularly for prolactin elevation

Answer 33

aripiprazole

Question 34

Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment.

Answer 34

true

Question 35

Clozapine should be introduced if schizophrenia is

Answer 35

not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.

Question 36

Adverse effects of clozapine

Answer 36

agranulocytosis (1%), neutropaenia (3%) reduced seizure threshold - can induce seizures in up to 3% of patients constipation myocarditis: a baseline ECG should be taken before starting treatment hypersalivation

Question 37

Dose adjustment of clozapine might be necessary if what is started or stopped during treatment.

Answer 37

smoking

Question 38

ICD10 definition of hallucination:

Answer 38

false sensory perception in the absence of an external stimulus. Maybe organic, drug-induced or associated with mental disorder.

Question 39

generally accepted definition that a pseudohallucination is

Answer 39

a false sensory perception in the absence of external stimuli when the affected is aware that they are hallucinating.

Question 40

An example of a pseudohallucination is a hypnagogic hallucination which occurs when transitioning from wakefulness to sleep. These are experienced vivid auditory or visual hallucinations which are fleeting in duration and may occur in anyone

Answer 40

true

Question 41

The relevance of pseudohallucinations in practice is that patients may need reassurance that these experiences are normal and do not mean that they will develop a mental illness.

Answer 41

true

Question 42

Pseudohallucinations commonly occur in people who are

Answer 42

grieving

Question 43

Charles-Bonnet syndrome (CBS) is characterised by

Answer 43

persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.

Question 44

Charles-Bonnet syndrome (CBS) Risk factors include:

Answer 44

``` Advanced age Peripheral visual impairment Social isolation Sensory deprivation Early cognitive impairment ```

Question 45

Charles-Bonnet syndrome (CBS) The most common ophthalmological conditions

Answer 45

associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract Well-formed complex visual hallucinations are thought to occur in 10-30 per cent of individuals with severe visual impairment. Prevalence of CBS in visually impaired people is thought to be between 11 and 15 per cent.

Question 46

CBS is equally distributed between sexes and does not show any familial predisposition.

Answer 46

true

Question 47

CBS generally not a transient experience

Answer 47

true

Question 48

CBS ?% find the hallucinations themselves an unpleasant or disturbing experience

Answer 48

a third

Question 49

Cotard syndrome is

Answer 49

rare mental disorder where the affected patient believes that they (or in some cases just a part of their body) is either dead or non-existent. This delusion is often difficult to treat and can result in significant problems due to patients stopping eating or drinking as they deem it not necessary.

Question 50

Cotard syndrome is associated with

Answer 50

severe depression and psychotic disorders.

Question 51

De Clerambault's syndrome

Answer 51

also known as erotomania, is a form of paranoid delusion with an amorous quality. The patient, often a single woman, believes that a famous person is in love with her.

Question 52

Othello's syndrome is

Answer 52

Othello's syndrome is pathological jealousy where a person is convinced their partner is cheating on them without any real proof. This is accompanied by socially unacceptable behaviour linked to these claims.