Psychosis Tutorial Flashcards
1
Q
What is psychosis?
A
broad descriptive term for difficulty interpreting and perceiving reality
2
Q
What are the different symptom domains in psychosis?
A
- Positive symptoms
- Negative symptoms
- Disorganisation
3
Q
What is the prevalence of psychotic disorders?
A
- prevalence ~3.5%, of which ~1% is schizophrenia
- Schizophrenia has taken a lot of focus both in terms of research and cultural perception of psychosis but this is changing
4
Q
What is a hallucination?
A
Percepts in absence of a stimulus
5
Q
What are positive hallucination symptoms?
A
- Auditory
- Voices commenting on you
- Voices talking to each other
- Visual
- Somatic/tactile
- Olfactory (rare)
6
Q
What are delusions?
A
Fixed, false beliefs, out of keeping with social/cultural background
7
Q
What are positive delusion symptoms?
A
- Persecutory
- Control
- Reference
- Mind reading
- Grandiosity
- Religious
- Guilt/sin
- Somatic
- Thought broadcasting
- Thought insertion
- Thought withdrawal
8
Q
What are positive symptoms?
A
- Hallucinations
- Delusions
9
Q
What are negative symptoms?
A
- Alogia
- Avolition/apathy
- Anhedonia/asociality
- Affective flattening
10
Q
What are disorganisation symptoms?
A
- Bizarre behaviour
- Thought disorder
11
Q
What is alogia?
A
-Poverty of speech
•Paucity of speech, little content
•Slow to respond
12
Q
What is avolition/apathy?
A
- Poor self-care
- Lack of persistence at work/education
- Lack of motivation
13
Q
What is anhedonia/asociality?
A
- Few close friends
- Few hobbies/interests
- Impaired social functioning
14
Q
What is affective flattening?
A
- Unchanging facial expressions
- Few expressive gestures
- Poor eye contact
- Lack of vocal intonations
- Inappropriate affect
15
Q
What is bizarre behaviour?
A
- Bizarre social behaviour
- Bizarre clothing/appearance
- Aggression/agitation
- Repetitive/sterotyped behaviours
16
Q
What is thought disorder?
A
- Derailment
- Circumstantial speech
- Pressured speech
- Distractibility
- Incoherent/illogical speech
17
Q
What is the onset of psychosis like?
A
- Can occur at any age
- Peak incidence in adolescence/early 20s
- Peak later in women
18
Q
What is the course of psychosis like?
A
- Often chronic & episodic
* Very variable
19
Q
What is morbidity of psychosis like?
A
- Substantial, both from disorder itself and increased risk of common health problems e.g. heart disease
- Significant impact on education, employment and functioning
20
Q
What is the mortality of psychosis like?
A
- Substantial
- All-cause mortality 2.5x higher, ~15 years life expectancy lost
- High risk of suicide in schizophrenia – 28% of excess mortality
21
Q
What is the psychiatric history?
A
- History of Presenting Concern
- Past Psychiatric History
- Background History (Family, Personal, Social)
- Past Medical History and Medicines
- Corroborative History
- The patient’s description of the presenting problem – nature, severity, onset, course, worsening factors, treatment received
- Circumstances leading to arrival to hospital
22
Q
What would you ask for past psychiatric history?
A
- Any known diagnosis?
- Any treatment?
- Known to a community team?
- Any previous admissions to hospital?
23
Q
What would you ask for family history?
A
- Age of parents, siblings, relationship with them
- Atmosphere at home
- Mental disorder in the family, abuse, alcohol/drugs misuse, suicide
24
Q
What would you ask for personal history?
A
- Mother’s pregnancy and birth
- Early development, separation, childhood illness
- Educational and occupational history
- Intimate relationships
25
What would you ask for social history?
* Living arrangements
* Financial issues
* Alcohol and illicit drug use
* Forensic History
26
What would you ask for past medical history and medicines?
Medical problems = a cause or consequence of
mental disorder or psychiatric treatment
•Regular medications?
•Compliance?
•Over the counter medications?
•Interactions?
27
What is a corroborative history?
-Need for consent
•Informants: relatives, friends, authority
•Confidentiality
28
What is in a mental state examination (MSE)?
* Appearance and Behaviour
* Speech
* Mood
* Thoughts
* Perceptions
* Cognition
* Insight
29
What are you looking for in appearance and behaviour?
- General appearance
- Facial expression
- Posture
- Movements
- Social behaviour
30
What are you looking for in general appearance?
1. neglect: alcoholism, drug addiction, dementia, depression, schizophrenia
2. weight loss: anorexia nervosa, depression, cancer, hyperthyroidism, financial issues/homelessness
31
What are you looking for in facial expression?
depressive, anxious,
| “wooden” parkinsonian
32
What are you looking for in posture?
1. hunched shoulders, downcast head and eyes – depressive
| 2 sitting upright, head erect, hands gripping the chair – anxious
33
What are you looking for in movements?
1. overactive, restless – manic
2. inactive, slow - depressive
3. immobile, mute – stupor
tremors, tics, choreiform movements, dystonia, tardive dyskinesia
mannerisms, stereotypies
34
What are you looking for in social behaviour?
disinhibited, overfamiliar
withdrawn, preoccupied
signs of impending violence: raised voice, clenching fists, pointed fingers, intrusion into personal space
35
What are you looking for in speech?
```
1. Quantity:
less, more, mutism
2. Rate:
slow, fast, pressure of speech
3. Spontaneity:
latency
4. Volume:
quiet, loud
```
36
What are you looking for in mood?
```
Subjective
Objective
Predominant mood
Constancy
Congruity
```
37
What is constancy?
emotional lability/incontinence
reduced reactivity/blunting/flattening
irritability
38
What is congruity?
cheerful while describing sad events
39
What are you looking for in thoughts?
1. Stream: pressure, poverty, blocking
2. Form: flight of ideas, loosening of associations, perseveration
3. Content:
40
What type of content are you looking for?
- Preoccupations
- Morbid thoughts, suicidality
- Delusions, overvalued ideas
- Obsessional symptoms
41
What are some delusions/overvalued ideas?
```
1. primary – occurs suddenly
secondary – arises from previous abnormal idea/experience (hallucination/mood/delusion)
2. delusional mood/perception/memory
shared delusion = folie à deux
3. paranoid
of reference
grandiose/ expansive
of guilt/ worthlessness
hypochondriacal
of jealousy
sexual/ amorous
religious
of control
concerning the possession of thought (insertion, withdrawal, broadcast)
```
42
What are some obsessional symptoms?
1. obsessional thoughts: dirt and contamination, aggressive actions, orderliness, disease, sex, religion
2. compulsions: checking, cleaning, counting, dressing rituals
43
What are you looking for in perceptions?
1. Illusions
2. hallucinations
3. Distortions
44
What is an illusion?
= misperception of a real external stimulus
| Hallucinations
45
What is a hallucination?
= perception in the absence of external stimulus
1. true perception + 2) coming from outside the head
pseudohallucination = 1) OR 2)
1. hypnagogic, hypnopompic
2. auditory – second person, third person
3. visual – Charles Bonnet syndrome
4. olfactory
5. gustatory
6. tactile, of deep sensation
46
What are you looking for in cognition?
1. Consciousness
2. Orientation
3. Attention and concentration
4. Memory
5. Language functioning
6. Visuospatial functioning
47
What are you looking for in insight?
1. Awareness of oneself as presenting phenomena that other people consider abnormal
2. Recognition that these phenomena are abnormal
3. Acceptance that these abnormal phenomena are caused by mental illness
4. Awareness that treatment is required
5. Acceptance of the specific treatment recommendations
48
What is psychosis often preceded by?
- ‘prodromal’ symptoms
| - Changes in social behaviour, like social withdrawal, and impairments in functioning, often precede onset
49
What did people at high-risk of developing psychosis usually have?
psychosis often have/had another mental disorder like affective disorders earlier in life
50
What are genetic risk factors for psychosis?
1. Schizophrenia is highly heritable: ~46% concordance in MZ twins
2. Highly polygenic – lots of genes of small effect sizes, but ones found so far account for ~20% of known genetic risk
51
What are environmental risk factors for psychosis?
1. Drug use, especially cannabis
2. Prenatal/birth complications
3. Maternal infections
4. Migrant status
5. Socioeconomic deprivation
6. Childhood trauma
52
What are additional sources of information?
- Collateral history
1. Family
2. Friends
3. Work/education
- Healthcare records
1. GP
2. Mental health services
53
What else might you look for in appearance and behaviour in someone with psychosis?
1. Bizarre or inappropriate clothing e.g. no shoes
2. Agitation/aggression
3. Poor personal hygiene or neglect of self-care – negative symptoms
4. Injuries/wounds – people with psychosis are far more likely to be victims of violence
54
Why is it important to assess for mood in people with psychosis
1. Some affective disorders can cause psychosis (e.g. bipolar disorder, depression) with implications for treatment
2. Depression comorbid with schizophrenia in ~30% of cases (Li et al, 2020)
3. People at high-risk of psychosis often have another mental disorder
4. Lifetime risk of suicide 5% in schizophrenia
55
What is derailement?
- Spontaneous speech that tends to slip off track
| - Ideas are loosely related or unrelated
56
What. is loosening of association?
A patient identifies his family as ‘mother, father, son, Holy Ghost’ (Bleuler, 1911/1950)
57
What cognitive impairments are associated with schizophrenia?
1. Working memory impairments
2. Lower scores on cognitive testing (from childhood)
3. Poorer educational attainment (from childhood)
58
What difficulties might you have treating someone with very poor insight into their psychosis?
1. Concordance with treatment
2. Attendance at follow-up
3. Would not stay in hospital
59
What are some differentials?
1. Delirium
2. Schizophrenia
3. Encephalopathy, acquired brain injury, stroke etc
4. Dementia (Alzheimer's, vascular, Parksinons/Lewy body, Huntingtons)
5. Personality disorder
6. Mania depression / Schizoaffective disorder / peurperal psychosis / other psychotic disorders
7. Drugs: Cocaine, LSD, Cannabis, Alcohol
L-Dopa, Steroids, Anticholinergics
8. Metabolic: Ca2+, MG2+, Cu2+, Vit B12
9. Endo: thyroid, Cushings , Addisons
10. Infections: Encephalitis, syphilis,
any
60
What is pharmacological management?
1. Antipsychotic medications
| 2. Often mainstay of treatment
61
What is psychological management?
1. CBT for psychosis
| 2. Newer therapies like avatar therapy
62
What is social. support management?
1. Supportive environments, structures and routines
2. Housing, benefits
3. Support with budgeting /employment
63
What neurotransmitter system is most implicated in the mechanism of antipsychotics?
- Dopamine
| - but antipsychotics act on many neurotransmitters including serotonin, acetylcholine, histamine
64
What elevated level is implicated in causing reality distortion in psychosis?
- Dopamine
| - Evidence from imaging + drug models + post-mortem studies -> elevated presynaptic dopamine in striatum
65
What type of drugs are antipsychotics?
1. Most antipsychotics are dopamine antagonists
2. Aripirazole is a partial agonist
3. Dopamine agonists like those used in Parkinson’s disease can cause psychotic symptoms
66
What are extrapyramidal side effects (EPSEs)?
Antipsychotics can cause post-synaptic dopamine blockade in the extrapyramidal system (parts of the brain that enable us to maintain posture and tone)
67
What are examples of ESPEs?
- Parkinsonism
- Acute Dystonia
- Tardive Dyskinesia
- Akathisia
68
What is parkinsonism?
1. rigidity - characteristic ‘cog-wheeling’
2. slow and shuffling gait
3. Lack of arm swing in gait – early sign
4. ‘pill-rolling’ tremor - slow (4-6Hz) movement of the thumb across the other fingers:
69
What is dystonia?
1. Increased motor tone -> sustained abnormal posture
2. Can occur shortly after taking dopamine antagonist
3. Can be acute, frightening, painful, even fatal (laryngeal dystonia)
70
What is tardive dyskinesia?
1. repeated oral/ facial/ buccal/ lingual movements
2. Initially subtle – can progress to tongue involvement, lip smacking
3. Increased risk: long-term antipsychotics, female
71
What is akathisia?
1. Inner restlessness
2. Feel compelled to move, but does little to alleviate
3. Can lead to overt, relentless movement
4. Legs most commonly affected
72
What makes something a ‘typical’ versus an ‘atypical’ antipsychotic?
1. ‘Typical’ antipsychotics commonly cause extrapyramidal side effects at therapeutic doses
2. Definition is NOT based on pharmacology/drug target
73
Can newer antipsychotics cause EPEEs?
1. Newer, atypical antipsychotics (e.g. olanzapine) – less likely to cause EPSEs
2. But can be caused by all antipsychotics
74
What is the management of EPSEs?
1. Avoid them in the first place: atypical antipsychotics usually first-line
2. Change medication
3. Anticholinergic medications can help e.g. procyclidine
4. Patients need to be fully-informed about risks
75
What are other side effects of antipsychotics?
1. CNS: EPSEs, sedation
2. Haematolgoical: Agranulocytosis, neutropenia
3. GI: constipation
4. Pituitary: increase prolactin (release suppressed by dopamine)
5. Metabolic: increase appetite, weight gain, diabetes
6. Cardiac: dysrhythmia, long QTc
76
What is the long term management in psychosis?
1. Community follow-up
2. Managing antipsychotic side effects e.g. weight, diabetes
3. Health promotion: reducing risk factors e.g. smoking, diet
4. All-cause mortality 2.5x higher in schizophrenia: ~14 years lost
77
Do people have another psychotic episode?
- Some people after an episode of psychosis recover completely and remain well
- Majority follow an episodic course, with periods of wellness and relapses
