Psychotic disorders Flashcards

Question

What is the differential diagnosis of schizophrenia?

Answer 1

**Organic** * Dementia or Delirium * Epilepsy (temporal lobe epilepsy) * Medication side effect e.g. steroids, dopamine agonists * Cerebral pathology: brain tumour, stroke, HIV, syphilis * Systemic Illness e.g. Wilson's, porphyria * Drug use: amphetamine, cocaine/ crack cocaine, LSD, ecstasy, ketamine, GHB (gamma-hydroxybutrate)/ GBL (gamma- butyrolactone), phencyclidine (PCP) and many NPS. * Alcohol. Heavy use can cause: * Alcohol hallucinosis * Delirum tremens **Non-organic** * Schizophrenia - symptoms should be present for at least 1 month and affect multiple areas of the mental state * Acute and Transient Psychotic Episode - symptoms peak within 2 weeks and resolve within a month * Can resolve completely within a few months * Linked to stress * Schizoaffective disorders * Picture of schizophrenia and a mood disorder simultaneously * Delusional disorder * Delusions lasting more than 3 months without clear mood disturbance or other schizophrenia symptoms * Schizotypal disorder * enduring state lasting several years or more. * Eccentricity: people may dress, behave, think,and speak oddly. * They may be suspicious, aloof, and struggle to make close relationships. * Puerperal (post-partum) psychosis * occurs within a few weeks of delivery **Other** * Personality disorder * Paranoid PD * Schizoid PD * Borderline personality pattern

Answer 2

* Paranoid * Most common * Acute phase description * Main symptoms = delusions and hallucinations * Catatonic * Psychomotor disturbance * Stupor: state of being immobile, mute and unresponsive despite appearing to be conscious (eyes open and follow you around the room) * Excitement: periods of extreme and purposeless motor hyperactivity * Posturing: assuming and maintaining bizarre or inappropriate positions * Rigidity * Waxy flexibility: patient’s limbs offer minimal resistance to being placed in odd positions which are maintained for unusually lengthy periods (cataplexy) * Automatic obedience * Perseveration: inappropriate repetition of words or movements * Hebephrenic * Onset aged 15-25 years * Disorganised and chaotic mood, behaviour and speech * Affect is shallow and inappropriate * Delusions/hallucinations *not* prominent * Simple * Negative features only * No psychotic symptoms * Residual * Prominent negative symptoms are all that remain after delusions and hallucinations subside

Answer 3

• Bloods: FBC, TFTs, U&Es, LFTs, CRP, fasting G o HIV & syphilis serology may be considered o Check lipids before starting long-term antipsychotics MSU Urine drug screen CT head if organic pathology suspected EEG is epilepsy or organic cause suspected Symptom rating scales to assess severity and monitor response to tx OT assessment of ADLs Social work assessment of housing, finances and carers’ needs Collateral hx

Answer 4

Use a Biopsychosocial model * Biological therapies - mainly antipsychotics * Psychological therapies * Social Interventions * Early Intervention in Psychosis (EIP) service * Other … * Consider Tx resistance

Answer 5

**Early Intervention in Psychosis (EIP) Service** o Psychosis is toxic: the longer a patient is psychotic, the more it will affect their cognitive abilities, insight and social situation o The sooner effective treatment can be started the better the prognosis o The service aims to engage patients with very early symptoms, from adulthood till ~35 years o Patients are offered antipsychotics and psychosocial interventions with the aim of keeping the **duration of untreated psychosis (DUP)** under 3 months o The service can be used in children \>14 years old * CAMHS can manage psychosis in children up to 17 years old • **Note**: if urgent intervention is necessary, use the **crisis resolution team** and **home treatment team**

Answer 6

• **Antipsychotics** Dopamine antagonists (block post-synaptic D2 receptors) Where possible, medications should be chosen with the person, using the lowest dose that controls symptoms without causing unpleasant side effects. Lower doses may be possible during remission, but the general advice is to continue medication for up to 3 years after a ﬁrst episode of psychosis; longer periods are often needed with recurrent psychosis. **First Generation Antipsychotics (FGA)/Typical Antipsychotics** o Older drugs o Examples: * Chlorpromazine * Haloperidol * Sulpiride * Triﬂuoperazine, * Zuclopenthixo * Flupentixol decanoate o Cause EPSEs and/or hyperprolactinaemia at normal doses o Effective, cheap and provide depot options Some are available as long- acting injections (‘depots’) → useful when people have difﬁculties taking daily tablets consistently, e.g. ﬂupentixol decanoate, ﬂuphenazine decanoate, haloperidol decanoate, zuclopenthixol acetate. **Second Generation Antipsychotics (SGA)/Atypical Antipsychotics** o In addition to dopamine receptors, these also block **serotonin 5-HT2 receptors** (different side effect profile to FGAs) * They cause fewer EPSEs and generally don’t increase prolactin levels, but are more likely to cause metabolic side effects: * hypertension * central obesity * raised fasting plasma glucose * hypertriglyceridaemia * low high density lipoprotein cholesterol. o Examples: Olanzapine (available as depot) Risperidone (available as depot) Quetiapine Aripiprazole (available as depot) Clozapine Amisulpride Lurasidone **o Consider starting an atypical antipsychotic when:** * Choosing 1st line treatment in newly diagnosed schizophrenia * There are unacceptable side-effects from typical antipsychotics * Relapse occurs on a typical antipsychotic o Avoid using more than 1 antipsychotic

Answer 7

**Side-Effects of Antipsychotics** o **Extrapyramidal Side-Effects** Dystonia Akathisia Parkinsonism Tardive dyskinesia **Hyperprolactinaemia** o Galactorrhoea, amenorrhoea, gynaecomastia and hypogonadism o Sexual dysfunction o Increased risk of osteoporosis Weight gain (especially olanzapine and clozapine) Sedation Increased risk of diabetes (olanzapine) Dyslipidaemia Anticholinergic side-effects (dry mouth, blurred vision, constipation, urinary retention, tachycardia) Arrhythmias Seizures (reduces seizure threshold) Neuroleptic malignant syndrome

Answer 8

**1st line: Clozapine** **Treatment Resistance**: *failure to respond to **two or more** antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks* **NB**: there is a small but significant risk of **agranulocytosis** (0.7%) Requires weekly blood tests to detect early signs of neutropaenia The sooner an effective treatment is started, the better the person’s prognosis. Hence, if other treatments fail, a trial of clozapine should follow promptly. If there is a lack of response to clozapine, consider augmentation with another antipsychotic

Answer 9

• **CBT** o CBT has not been shown alone to improve outcomes, but combined with other therapies can be helpful in treating schizophrenia In CBT, the therapist aims to gently challenge the person’s beliefs, helping them to spot illogical thinking, e.g. ‘I’m a bit confused by that. If the Prime Minister’s stalking you all day, how do they ﬁnd the time to run the country and appear on TV?’ The person is encouraged to think about the evidence for and against a belief and to consider alternative explanations o CBT has been shown to help positive symptoms o Social skill training better in helping negative symptoms **Cognitive remediation therapy (CRT**) is particularly helpful in negative symptoms: it aims to improve neurocognitive skills such as concentration, memory, and problem- solving— often using computer- based programmes • **Family Therapy** Can reduce relapse rates o Effects of high expressed emotion can be ameliorated through communication skills, education about schizophrenia, problem-solving and helping patients expand their social network o Can offer respite for the families Family intervention is a type of therapy that works with the patient and their family or cohabitees. It can reduce the effects of high EE through communication skills training, education about psychosis, and problem- solving techniques. • **Duration** o CBT: at least 16 sessions o Family therapy: at least 10 sessions • **Arts therapies** -Allows pts to discover new forms of expression

Answer 10

**Multidisciplinary approach:** * Social workers, * beneﬁts advisors * occupational therapist Practical needs should be addressed, e.g. beneﬁts, housing, training, and education Befriending and peer support may help develop social conﬁdence. Mental health organizations such as Rethink and Mind provide a wealth of patient resources, as well as carrying out important work in promoting social inclusion and helping tackle stigma at a personal and societal level **Psychoeducation** is vital to reduce relapse. This a collaborative approach where people are encouraged to ask and ﬁnd out more about their illnes Needs to address ``` o Education, training and employment o Skills (e.g. budgeting, cooking) o Housing (e.g. supported accommodation, independent flats) ``` o Accessing social activities o Developing personal skills (e.g. creative writing) May include admission to hospital for observation, treatment or refuge • **Support for Carers** oOffer support for carers (including education and support programmes) o Inform them of their right to a formal **carer’s assessment** (available for free through social services) o Consider peer support (support from someone who has recovered from psychosis) **Rehabilitation**

Answer 11

**Physical Health** oOffer combined healthy eating and physical activity programme o Offer interventions for metabolic complications of antipsychotics(e.g.weight gain, high cholesterol) o Help with smoking cessation (consider nicotine replacement therapy or bupropion or varenicline) * Bupropion and varenicline have an increased risk of adverse neuropsychiatric symptoms so should be monitored closely for the first 2-3 weeks o Regularly monitor weight and other cardiovascular/metabolic parameters • **Monitoring** o **Baseline Measurements** before starting an antipsychotic: * Weight * Waist circumference * Pulse and BP * Fasting BM, HbA1c, lipid profile, prolactin * Assessment of any movement disorders * Assessment of nutritional status, diet and physical activity * ECG (if cardiovascular risk factors present or recommended by the chosen medication) * **Children** should also have height measured every 6 months o **Monitoring** * Response to treatment and side-effects * Emergence of movement disorders Waist circumference Adherence * Overall physical health * **Weight** * Weekly for 6 weeks * At 12 weeks * At 1 years * Annually thereafter * **Pulse and blood pressure** * At 12 weeks * 1 year * Annually

Answer 12

**1st line: atypical antipsychotic (e.g. quetiapine)** CBT should be offered to all patients Close attention should be paid to cardiovascular risk factor modification due to the high rates of cardiovascular disease in schizophrenic patients (due to medication and high smoking rates)

Answer 13

* ¼ recover and experience no further diffculties after a single psychotic episode * ⅔ develop schizophrenia, which can relapse whenmedication is stopped. * 1/10 will be seriously and continuously disabled * ⅓ tx resistant illness

Psychotic disorders Flashcards

(38 cards)