Psychosis Tutorial Flashcards
(26 cards)
What is Psychosis?
What disorders have psychosis?
Difficulty perceiving and interpreting reality
e.g. Bipolar disorder, schizophrenia, drug induced episode, severe depression
What are the 3 symptom domains in psychosis?
Positive
Negative
Disorganisation
What are the 2 main positive symptoms?
- Hallucinations - perceptions in absence of a stimulus:
2. Delusions - fixed, false beliefs, out of keeping with social/cultural background:
What are the 4 main negative symptoms?
- Alogia - poverty of speech:
Paucity of speech, little content
Slow to respond - Anhedonia - loss of enjoyment:
Few close friends
Few hobbies/interests
Impaired social functioning - Avolition / apathy - poor self care:
Poor self-care
Lack of persistence at work/education
Lack of motivation
4. Affective flattening - unchanging facial expressions: Unchanging facial expressions Few expressive gestures Poor eye contact Lack of vocal intonations Inappropriate affect
What are 2 main disorganisation symptoms?
- Bizarre behaviour:
Bizarre social behaviour
Bizarre clothing/appearance
Aggression/agitation
Repetitive/sterotyped behaviours
- Thought disorder:
Derailment Circumstantial speech Pressured speech Distractibility Incoherent/illogical speech
What is the onset, course, morbidity and mortality of psychosis?
Onset = can occur at any age, although often during adolescence / early 20s (later peak in women)
Course = often chronic and episodic; very variable
How do you take Psychiatric history?
History of presenting concern - why now? nature, severity, onset, course, worsening factors, treatment received
Past psychiatric history - any known diagnosis, treatment, known to community team, previous admissions to hospital
Background history (family, personal, social) - parents, siblings, relationships, atmosphere at home, drug abuse, suicide, mother’s pregnancy and birth, early development, education, intimate relationships, financial issues, living arrangements, alcohol / drug abuse
Past medical history and medicines - regular medications, compliance, over-the-counter medications, interactions
Corroborative history - informants, confidentiality
What is the MSE?
Mental state examination
What do you look at during an MSE?
Appearance and behaviour - general appearance, facial expression, posture, movements, social behaviour
Speech - quantity, rate, spontaneity, volume
Mood - subjective, objective, predominant mood, constancy, congruity (e.g. cheerful when describing sad experiences)
Thoughts - stream, form, content, preoccupations, morbid thoughts, suicidality, delusions, overvalued ideas, obsessional symptoms
Perceptions - illusions, hallucinations, distortions
Cognition - consciousness, orientation, attention, concentration, memory, language functioning, visuospatial functioning
Insight - awareness of oneself, recognition that they are unwell, acceptance, awareness treatment is required
Case Study: Andy
New lecturer works for MI5, drafted in his roommates and now they’re after him
Duration - 2 months
Auditory hallucinations of his 3 housemates - they’re always talking about him, commenting on everything he is doing, but they never talk to him directly
His housemates are putting different thoughts into his brain
Convinced there is a chip put in his head, can feel it - tracking device
Physically fine
What else would you like to know about Andy?
What is his current mood?
Does your family have a history of similar symptoms he is experiencing?
Ask his mum about any behaviour changes?
Do he take any other medications?
Does he have any history of alcohol or drug abuse?
Has he been to the GP / hospital about these before?
Other friends he trusts?
Other social history - friends, family, siblings, support system?
Any visual hallucinations?
If he is aware these thoughts are abnormal?
How is uni going? Struggling with grades?
What do you do to keep yourself safe?
Has he tried removing the chip himself / seen other doctors etc.?
Case Study: Andy, additional points -
6 month history of social withdrawal
8 month history of poorer functioning at uni
Problems with anxiety as a teen but no diagnosis
no previous psychotic symptoms
What are prodomal symptoms?
Non-specific symptoms that predate the psychosis - loss of enjoyments, anxiety, social withdrawal etc.
Case Study: Andy, more history -
Family history of SZ
Cannabis use - started 1 year ago
Early life stress - separation from dad (Estrangement), though good relationship with mum
What do we know about SZ, what are some risk factors for SZ development? (psychology)
Corcordance rates of 46% Highly polygenic Environmental risk factors: drug use, esp. cannabis Prenatal / birth complications Socioeconomic deprivation
Perform an MSE on Andy using:
Appearance and Behaviour Speech Mood Thoughts Perceptions Cognition Insight
Appearance and Behaviour - 21 Caucasian male, average build, well kempt, appropriate clothes, little eye contact, monotone face (congruity), slouchy but sitting, looks suspicious, able to establish rapport
Speech - slightly quiet, monotone
Mood - objectively - not distressed, anxious, blunted affect, concerned about his experiences
Thoughts - paranoid and persecutory delusions; thought insertion, denies thought broadcasting and blocks
Perceptions - auditory hallucinations - 3rd person running commentary, tactile hallucinations - thinking the chip was implanted in him, denies command hallucinations
Cognition - oriented to time and place
Insight - thinks the psychiatric thinks his delusions are stupid, recognises his experiences are odd, but thinks there is nothing wrong with his delusions and does not believe he has a mental illness, minimal insight
What is derailment?
What is word salad?
Spontaneous speech that ends up off the track
Ideas loosely related or unrelated
Patient says string of words that make no sense
What is a pseudohallucination?
Experienced during personality disorders e.g. being a different character / personality
Voices in their heads, louder than their own thoughts
Not external sounds (hallucinations are perceived external sounds, not voices in the head)
What are some cognitive impairments associated with SZ?
Working memory impairments
Lower scores on cognitive testing
Poorer educational attainment from childhood
Cognitive impairments stay stable over time and independent of psychotic symptoms
What are some difficulties with treating someone with poor insight into their psychosis?
Concordance with treatments - esp. medications
Attendance to follow up sessions
Would not stay in hospital
What would be the working diagnosis for Andy?
Acute psychotic episode
Not a straight away diagnosis to SZ because many people with first psychosis episode do not go on to develop more
Also many disadvantages come alongside being given a diagnosis like SZ, and have it turn out be wrong - stigma, incorrect treatment, labeling a patient, etc.
What are all the possible differentials for a psychotic episode?
Drugs: Recreational e.g. cocaine, LSD, cannabis, alcohol; or medications e.g. L-dopa, steroids, anticholinergics
Metabolic: Ca2+, Mg2+, Cu2+, Vit B12
Endocrine: Thyroid, Cushing’s, Addison’s
Infections: Encephalitis, syphilis
Delirium
Head trauma, brain injury, stroke, encephalopathy
SZ, mania depression
Personality disorder
Dementia
What would be the treatment options for Andy?
Pharmacological: Anti-psychotic medications
Psychological: CBT for psychosis
Social support: Supportive environments, structures and routines; housing, benefits, support with budgeting / employment
What neurotransmitter system do most anti-psychotics target?
Do they act as agonists or antagonists? Why?
Dopamine, but can also act on serotonin, acetylcholine, histamine
Dopamine antagonists - increased dopamine causes psychosis
Some are partial dopamine agonists but they can cause Parkinsonian symptoms
Case Study: Andy follow-up
Andy agrees to take an antipsychotic medication and go to psychological therapy. A few months later, Andy’s symptoms are under control but he develops some new symptoms:
Rigidity
Shuffled, slow walking / gait
Loss of arm swing in gait
‘Pill-rolling’ tremors
Why have these new symptoms arisen?
They are Parkinsonian symptoms
Due to extra-pyramidal side effects
Antipsychotics can cause post-synaptic dopamine blockade in the extrapyramidal system (parts of the brain that enable us to maintain posture and tone)
What are 4 extrapyramidal side effects of antipsychotics?
Parkinsonianism - rigidity, shuffled walking / gait, loss of arm swing in gait, ‘pill-rolling’ tremors
Dystonia - increased motor tone = sustained abnormal posture, laryngeal dystonia = fatal, can be acute and painful
Tardive dyskinesia - usually after long term use in females, repeated oral / facial / buccal / lingual movements e.g. lip smacking, tongue movement, etc.
Akathisia - inner restlessness, feels compelled to move, relentless movement, legs commonly affected
What are typical VS atypical antipsychotics?
Typical = older generation, often leads to extrapyramidal side effects
Atypical = second generation, newer psychotics, fewer if not no extrapyramidal side effects
