Psychosis and schizophrenia 2 Flashcards
(18 cards)
What are some of the other differentials for a patient presenting with psychosis ?
- Drug induced psychosis
- Depressive psychosis
- Mania with psychsosis
- Schizoaffective disorder - This is the presence of schizophrenic disorder and affective disorder (either manic or depressive) Can be schizo-manic or schizo-depressive or both
- Delirium
Describe the key features suggestive of drug induced psychosis
- Symptoms tend to be short lasting if access to the psychoactive substance is removed.
- Particularly in young people esp cannabis
- occur from taking too much of a certain drug, having an adverse reaction after mixing substances, during withdrawal from a drug, or if the individual has underlying mental health issues.
- Beware comorbidity of substance use in schizophrenia & bipolar disorder
What are the 3 typical features suggesting depressive psychosis ?
- Mood congruent - so their emotions match the type of delusion/ hallucinations they are experiencing i.e. depressive mood with delusions and hallucinations as below:
- Delusions of worthlessness / guilt / hypochondriasis / poverty
- Hallucinations of accusing / insulting / threatening voices – typically 2nd person
What are the typical features of mania with psychosis ?
- Typified by mood congruent (i.e. again there mood matches the delusions/ hallucinations they are having) content of psychotic symptoms
- Delusions of grandeur / special ability / persecution / religiosity
- Hallucinations: auditory (e.g. God’s voice)
- Flight of ideas
Define schizoaffective disorder
Schizoaffective disorder is a mental disorder in which a person experiences a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania.
What are the features suggestive more of delirium
- Acute onset e.g. in alcohol withdrawal, infection, medical / surgical in-patients,
- septicaemia, organ failure (cardiac, renal, hepatic), hypoglycaemia, post-op hypoxia, post-ictal, encephalitis, space occupying lesion, drug intoxication (e.g. steroids, digoxin, diuretics, anticholinergics), drug withdrawal (e.g. benzodiazepines)
- Often older patients
- inattention with fluctuating course
- disorganised thinking (impaired concentration/ memory)
- altered consciousness.
- visual hallucinations / illusions
- ± auditory hallucinations
- irritability
- insomnia
- psychomotor disturbance - agitation or retardation
What is the main mechanism of action of typical anti-psychotics and give some examples of them
- Main action is D2 inhibiton (dopamine antagonist)
- Chlorpromazine or haloperidol
What is the main mechanism of action of atypical anti-psychotics and give some examples of this class of drug
- Main mechanism of action is D2 and 5-HT2 antagonists
- Olanzapine, risperidone, quetiapine, clozapine
What is the main differences between typicals and atypical anti-psychotics ?
Atypicals are:
- Less likely to induce Extra-Pyramidal side-effects (EPSE) + less likely for dopamine blockade with hyperprolactinaemia/sexual dysfunction
- They are worse for metabolic syndrome and sedation
- High 5-HT2A to D2 ratio
- Better efficacy against negative symptoms (schizophrenia)
- Effective in patients unresponsive to typical drugs
What is metabolic syndrome ?
A cluster of conditions; Increased blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels
Describe the main side effects cause by typical anti-psychotics
EPSE and hyperprolactinaemia
EPSE symptoms:
- acute dyskinesias and dystonicreactions, - intermittent spasmodic or sustained involuntary contractions
- tardive dyskinesia, - stiff, jerky movements of your face and body that you can’t control
- Parkinsonism - signs similar to parkinsons (covered in neuro)
- akinesia, - loss or impairment of the power of voluntary movement.
- akathisia - feeling of inner restlessness and inability to stay still
- neuroleptic malignant syndrome. - life-threatening idiosyncratic reaction fever, altered mental status, muscle rigidity, and autonomic dysfunction.
Hyperprolactinaemia signs:
- sexual dysfunction
- galactorrhoea,
- amenorrhoea,
- infertility.
What drug should be used to treat EPSE in patients on typical anti-psychotics ?
procyclidine
What are the side effects of atypical anti-psychotics ?
Sedation, weight gain (mainly mediated through increased hunger), metabolic syndrome, EPSE (extra-pyramidal side effects), constipation, QTc prolongation, neuroleptic malignant syndrome.
Before starting an anti-psychotic medication what needs to be done ?
Record the following baseline investigations:
- Weight
- waist circumference
- Pulse and BP
- Fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile and prolactin levels
- Assessment of any movement disorders
- Assessment of nutritional status, diet and level of physical activity
- an ECG (if cardiac risk factors or personel history of CVD)
What is the treatment for psychosis and schizophrenia ?
1st line = Oral anti-psychotic + psychological intervention (CBT + family intervention)
Choice of anti-psychotic:
- 1st line = atypical anti-psychotics (olanzapine usually first
- 2nd line = typical
- 3rd line = clozapine if used at least 2 or more anti-psychotics (at least one being an atypical) and both failed
What drug is used for treatment resistant schizophrenia and what is the key side effect that you need to be careful of?
Clozapine (atypical)
Agranulocytosis, also known as agranulosis or granulopenia, is an acute condition involving a severe and dangerous leukopenia (lowered white blood cell count), most commonly of neutrophils causing a neutropenia ==> be wary of patients increase susceptibility to infection
Sore throat in patient on clozapine = get a full blood count
Also causes - gastroparesis, sedation, weight gain, hypersalivation and potentially myocarditis (basically want to start a patient on this in hospital so can monitor)
What monitoring is required for patients on clozapine ?
FBC:
- Weekly for the first six months
- Fortnightly for the next six months
- Every four weeks thereafter
- For one month after cessation of clozapine
What does the use of anti-psychotics in elderly patients increase the risk of ?
Stroke & VTE
