psychosis + confusion Flashcards by Susannah Welch

classic characteristics of psychosis

hallucinations
delusions
disorder of form of thought

lack of insight

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primary vs secondary delusions

Primary = arrive fully formed in the consciousness without need for explanation

Secondary = are often attempts to explain anomalous experiences – hallucinations, passivity experiences, depression

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thought interferences

 Clanging + punning – ding dong bell, go to hell
 Loosening of associations
 Knight’s move thinking – came here in dads car, he’s got a blue car, the sea is blue
 Neologisms
 Tangentiality
 Word salad/verbigeration

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thought insertion

there are thoughts being put into my head that don’t belong to me – I haven’t thought them

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thought withdrawal

= they can extract the information from me using the internet, they take my thoughts out of my head

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thought broadcasting

it’s like everyone can know what I am thinking – my sky dish is beaming

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thought blocking

it’s like I get halfway through thinking something + the thoughts jut dry up and I cant think of anything for a while

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what do 3rd person auditory hallucinations suggest?

schizophrenia

(depression sometimes 2nd person hallucinations but never 3rd)

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management of psychosis

1 - 4-6weeks trial of atypical
2 - 4-6weeks trial of second atypical or typical

3 - 6month trial of clozapine titrated up to 900mh/day (best efficacy but super bad side effects)

4 - adjuvant medication/ECT (in addition to clozapine)

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drug induced psychosis

May be acute symptoms or more insidious + chronic
o Tend to be short is access to psychoactive substance is removed

Not the same as intoxication + withdrawal effects
Beware of comorbidity with schizophrenia + bipolar disorder

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depressive psychosis

Characterised by mood congruent content of psychotic symptoms
Delusions - worthlessness/guilt/hypochondriasis/poverty

Hallucination - accusing/insulting/threatening voices
o Typically 2nd person

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mania with psychosis

Delusions – grandeur, special ability, persecution, religiosity
Hallucinations – tend to be 2nd person + auditory
-  hearing God’s voice telling you you’re great

Flight of ideas

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delirium

Acute transient confusion state – last from hrs to weeks
Assoc with physical insult or injury or environmental factors
Rapid in onset, 1-2days from precipitating insult

Duration varies but often continues beyond resolution of original insult – often by weeks or months

Medical emergency
o 35-40% patients die within one year
o Barriers to treatment – too agitated for IV lines etc

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types of delirium

hypoactive - quiet, confused drowsy, fearful patient

hyperactive - driven, wandering, agitated, shouting out, aggressive

mixed - some periods of both of above

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risk factors for delirium

older age
previous history of delirium
underlying cognitive deficits

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delirium presentation

Clouding of consciousness
o Subtle drowsiness to unresponsiveness
o Disorientation in time, place + person
o Fluctuating severity over time – lucid intervals
o Worse at night
Impaired concentration/memory, especially for new information
Visual hallucinations/illusions +/- auditory – often threatening
Persecutory delusions
Agitation OR retardation
Insomnia

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causes of delirium

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I WATCH DEATH
- Infections
- Withdrawal
- Acute – electrolyte probs, acidosis
- Toxins – drugs, opiates
- CNS - Encephalitis, Stroke
- Hypoxia
- Deficiencies – thiamine, B12
- Endocrine – thyroid, adrenal, glycaemia
- acute vascular shock
- trauma - head injury, hypothermia
- heavy metals - lead, mercury

delirium investigations

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4AT

1 - alertness - normal/mild sleepiness
2 - AMT-4 = age, DOB, place, current tear
3` - attention = name months backwards
4 - acute or fluctuating course

delirium treatment

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treat underlying cause
reassurance + reorientation
low stimulus environment
use of appropriate legal measure to allow for treatment

pharma - assist with distress, agitation (supportive)
- consider low dose antipsychotic - haloperidol, quetiapine
–> NOT in PARKINSONS

post-ictal confusion

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abnormal condition following a seizure

begins when seizure ends + ends when patient has returned to baseline
usually resolves within 30 mins

post-ictal confusion presentation + management

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drowsiness, nausea, confusion, exhaustion

Mx = supportive, seizure prevention

chronic illnesses which cause confusion

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Encephalitis
Hypoglycaemia
Hypothyroidism/hyperthyroidism
Vit B12 deficiency
Anaemia
Electrolyte disturbances

schizophrenia

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self-disorder due to perceptual incoherence

genetically determined neurodevelopmental vulnerability later triggered by environmental stressors

78% heritability, polygenic inheritance

onset of schizophrenia

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young adults

men - 12-25yrs

women - 25-35yrs

schizophrenia risk factors

stress drugs - heavy regular cannabis, cocaine social adversity neuro - enlarged ventricles, thinner cortices neurochemical - altered dopamine signalling genetics birthcomplications

which gene alterations are risk factors for schizophrenia?

neuregulin dysbindin DISC-1

genetic risk in schizophrenia

o MZ twins 40-60% o Both parents 50% o One parent 15% o Some mutations – 22q11 o Higher in African-Caribbean

birth complications that increase risk of schizophrenia

Prenatal exposure to viral infections – 2nd trimester o Maternal stress, malnutrition o Higher rates of perinatal complications than controls – prematurity, prolonged labour., fetal hypoxia, pre-eclampsia o Winter/spring births – due to viral illness o Risk increases by 50% by childhood viral CNS infection

pathophysio of schizophrenia

drugs which release dopamine in brain (amphetamine) or D2 receptor agonists (apomorphine) produce a psychotic state -> it is assumed schizophrenia is related to overactivity of dopamine pathways in the brain (dop receptor antagonist used to treat symptoms of schiz) amphetamine can make symptoms of schizophrenia worse

physical pathology of schizophrenia

enlarged lateral ventricles - non-progressive reduced frontal-temporal lobe volume reduced frontal lobe grey matter reduced activation of prefontal areas on specific tasks - impairment of executive function (Stroop test - can only read words)

first rank/Schneider's symptoms of schizophrenia

delusions auditory hallucinations - thoughts, voices thought interference - passivity of thought, withdrawal, insertion, broadcasting passivity phenomena - affect, impulse, volition, somatic

schizophrenia presentation

positive - hallucinations delusions passivity phenomena disorder of form of thought negative - reduced speech reduced motivation/drive (avolition) reduced interest/pleasure (anhedonia) apathy blunting of affect

sub-types of schizophrenia

paranoid hebephrenic catatonic persistent delusional disorder

most common type of schizophrenia

paranoid - 80% of diagnoses - first rank symptoms dominate

hebephrenic schizophrenia

shallow + inappropriate emotional responses bizarre behaviour

catatonic schizophrenia

movement disorder predominates

management of schizophrenia

1st = Risperidone, olanzapine -> 2nd gen oral (atypical) antipsychotics – 6-8weeks 2nd = haloperidol -> 1st or 2nd gen – 6-8weeks 3rd line – check diagnosis, optimise social supports, check compliance o Compliance -> depot (long term) – IM weekly to 3 monthly -> haloperidol o Consider clozapine – weekly blood tests tho o Consider combining 2 antipsychotics CBT to all

treatment of schizophrenia side effect considerations

- Medication induced weight gain -> cardiac problems - Falls due to EPSE - Cognitive effects of anticholinergic - Osteoporosis due to raised prolactin - Sedation leading to immobility cardio risk modification - linked to antiosychotics + high smoking rates

indicators of poor prognosis in schizophrenia

poor premorbid adjustment - prodromal phase of social withdrawal insidious (slow, not obvious) onset early onset - child/teen long duration of untreated psychosis cognitive impairment enlarged ventricles strong fam Hx, low IQ

indicators of good prognosis in schizophrenia

females marked mood disturbance especially elation fam Hx of mood disorders older age onset shorter time of untreated psychosis

schizophrenia prognosis

Suicide o 10-15% suicide rate o May occur following recovery of insight o High risk time = first week of discharge from hospital o Need to ensure adequate medical follow up as well as psychological + social support Homicide by people with schizophrenia is rare o Note in command hallucinations + delusions of jealousy

psychosis + confusion Flashcards

(41 cards)