Psychotic Disorders Flashcards
(77 cards)
1
Q
What is the strongest risk factor for developing a psychotic disorder?
A
Family history
2
Q
What is schizoaffective disorder?
A
A mental health condition that combines both symptoms of schizophrenia and a major mood disorder.
3
Q
What are RFs of schizoaffective disorder?
A
- Genetics
- FHx increases risk
> First-degree relatives have an increased risk for both mood disorders and schizophrenia
4
Q
What are the types of schizoaffective disorder?
A
Manic Type
- Both schizophrenic and manic symptoms prominent
- Develop at the same time
- Single episode, or recurrent disorder (majority manic episodes)
Depressive Type
- Both schizophrenic and depressive symptoms prominent
- Develop at the same time
- Single episode, or recurrent disorder (majority depressive episodes)
5
Q
What is the DSM-V criteria for diagnosis of schizoaffective disorder?
A
Requires 2 episodes of psychosis:
- Symptoms of psychosis without major mood disorder to persist for ≥2 weeks
- Major mood episode with schizophrenia symptoms uninterrupted to persist for ≥2 weeks
6
Q
What is the management of schizoaffective disorder?
A
1st line:
- BIO: Atypical antipsychotic e.g. olanzapine or quetiapine
- PSYCHO: CBT, psychoeducation
- SOCIAL: Social skills training
Consider:
- Lithium if inadequate response with antipsychotic or mania / mixed manic-depressive symptoms
- Antidepressant e.g SSRI if depressive symptoms
7
Q
What is psychosis?
A
A severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality.
Affects:
- Perception (e.g hallucinations)
- Beliefs (e.g. delusions)
- Functioning (e.g. loss of insight)
8
Q
What is delusional mood?
A
A change of mood preceeding a delusion. The mood is often one of perplexity in which the patient senses an unexplicable change in his/her environment.
- Experiences may solidify into beliefs
9
Q
What is acute psychosis?
A
Sudden onset psychosis, resolving in <3 months
10
Q
What are delusions?
A
An impression maintained despite being contradicted by reality or rational judgement, that is fixed, unshakable and out of keeping with cultural context.
11
Q
What are delusions of reference?
A
Person believes events are aimed at them
E.g. newspaper article directed at person
12
Q
What are grandiose delusions?
A
Person believes they have unique significance or power
E.g. person thinks they are the queen.
13
Q
What are paranoid delusions?
A
Person believes they are being harmed or watched
E.g. van outside the house is filled with people trying to spy on them.
> Can lead to patients not taking their meds
14
Q
What are delusions of control?
A
Person thinks their thoughts or actions are being controlled
E.g. person thinks an alien is controlling their thoughts.
15
Q
What are erotomanic delusions?
A
Person thinks someone is in love with them
E.g. thinks Justin Bieber is in love with them.
> Can lead to legal issues e.g. restraining orders
16
Q
What are hallucinations?
A
Perception in the absence of an external sensory stimulus
17
Q
What are auditory hallucinations?
A
> Most common
Second person = addressing patient directly
Third person = discussing patient in first person
E.g.
- Commands in their head
- Running commentary
- Random noises
- Thought echo: repeat patient’s thoughts
18
Q
What are visual hallucinations?
A
- Usually simple e.g. flashes of colour
- Can be clear / identifiable objects
19
Q
What age does acute psychosis usually occur?
A
The peak age of first-episode psychosis is around 15-30 years
20
Q
What are the S/S of acute psychosis?
A
Main features:
- Hallucinations
- Delusions
- Disorganised behaviour
- Disorganised thinking
Associated features:
- Agitation/aggression
- Neurocognitive impairment (e.g. in memory, attention or executive function)
- Depression
- Thoughts of self-harm
21
Q
Linking real words incoherently / nonsensical content ?
A
Word salad
22
Q
Putting words together because of how they sound instead of what they mean?
A
Clanging
23
Q
Answers diverge from topic and never return?
A
Tangentiality
24
Q
Little information conveyed by speech / difficulty with speaking / tendency to speak little ?
A
Alogia / poverty of speech
25
What conditions can acute psychosis occur in?
- **Schizophrenia** (most common psychotic disorder)
- **Affective disorders** - severe depression, BPAD
- **Organic** - dementia, delirium
- **Puerperal psychosis**
- **Brief psychotic disorder** (symptoms last <1 month)
- **Prescribed drugs** e.g. corticosteroids
- **Certain illicit drugs** e.g. cannabis, phencyclidine
26
What is the management of acute psychosis?
**Immediate:**
*If patient severely agitated*
- 1st line = de-escalation techniques
- 2nd line = oral BZN e.g. lorazepam
- 3rd line = rapid tranquillisation e.g. lorazepam
**Antipsychotics:**
- Refer to specialist
- Atypical antipsychotic e.g. olanzapine
- Procyclidine as required for SE of antipsychotics
**Long-term:**
- CBTp to all patients
- +/- Family interventions
- Social care and support
- Support for carers
27
What is delusional disorder?
Persistent / life-long delusions without other psychotic symptoms (no / few hallucinations).
Otherwise function normally e.g. socially / at work.
28
How is delusional disorder classified based on timescale?
**<3 months** = temporary
**≥3 months** = persistent
29
What is the DSM-V diagnostic criteria for delusional disorder?
- Delusions present for at least 1 month
- No other psychotic symptoms (e.g. cannot include: clear auditory hallucinations, Schizophrenic symptoms)
- Functioning not affected
- Other causes ruled out e.g. no evidence of organic/brain disease
NOTE: the presence of an occasional or transitory auditory hallucination does NOT rule out the diagnosis
30
What is the aetiology/RFs of delusional disorder?
- Old age
- Social isolation
- Group delusions
- Low socioeconomic status
- Premorbid personality disorder
- Sensory impairment
- Immigration
- FHx
- Head injury
- Substance abuse
- Neurological lesions to temporal lobe, limbic system, BG
- Cortical damage (persecutory delusions)
- Distrust, suspicion, jealousy, low self-esteem
31
What are the S/S of delusional disorder?
- **Non-bizarre delusions, rarely hallucinations**
- Process unimpaired, content preoccupied, single theme of thoughts
- Insight impaired (delusions affect thought and behaviour)
- Cognition intact
32
Delusion where they believe partner is unfaithful?
Othello syndrome / delusional jealously
33
Delusional belief that one or more familiar persons repeatedly change their appearance?
Fregoli syndrome
34
Shared delusions/hallucinations between people?
Folie á deux
35
Consciously pretending you have a medical illness?
Factitious disorder
Patient wants to be sick
Will falsify symptoms
36
What are the investigations for delusional disorder?
- Full history and collateral history + MSE
- Exclude organic causes
37
What is thought withdrawal / thought broadcasting?
Withdrawal = stolen thoughts
Broadcasting = everyone can hear thoughts
38
What are the differentials for delusional disorder?
- Substance-induced
- Mood disorder with delusions
- Schizophrenia
- Dementia + delirium
- Body dysmorphia
- OCD
- Hypochondriasis
- Paranoid (personality disorder)
39
What is the management of delusional disorder?
**Biological** (limited evidence)
- Antipsychotics (poor evidence)
- SSRI (cover other potential missed differentials)
- BDZ (for anxiety)
**Psychological:**
- Individual CBT
- Psychoeducation
**Social:**
- Social skills training
- Family therapy
40
What is the Early Intervention in Psychosis (EIP) Service?
**Psychosis is toxic:**
The longer a patient is psychotic, the more it will affect their cognitive abilities, insight and social situation. Sooner effective treatment started = better prognosis.
- Service aims to engage patients with very early symptoms, from adulthood till ~35 years
- Patients are offered antipsychotics and psychosocial interventions with the aim of keeping the duration of untreated psychosis (DUP) under 3 months
- 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
41
What is the management for schizophrenia?
**BIO:**
- 1st line = atypical antipsychotic (e.g. olanzapine)
- Procyclidine as required for SE of antipsychotics
- ECT may be required in patients resistant to pharmacological management / need rapid reduction of symptoms
- Offer combined healthy eating and physical activity programme
- Offer interventions for metabolic complications of antipsychotics (e.g. weight gain, high cholesterol)
- Help with smoking cessation
**PSYCHO:**
- CBTp offered to all patients (can aid compliance)
- Family therapy
**SOCIAL:**
- Social skills training (targeting accommodation, finances, and daily activities)
- Support for carers (including education/support programmes, inform them of their right to a formal carer’s assessment)
- Specialist teams e.g. EIP, assertive outreach, rehab, CC
N.B. 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)
42
Describe typical and atypical antipsychotics
**Typical Antipsychotics (FGAs)**
- Older drugs
- Examples = Chlorpromazine, Haloperidol, Flupentixol decanoate
- Cause EPSEs at normal doses
- Effective, cheap and provide depot options
- SEs include sedation
**Atypical Antipsychotics (SGAs)**
- Examples = Olanzapine, Risperidone (available as depot), Quetiapine, Aripiprazole, Clozapine, Amisulpride
- SEs include weight gain, dyslipidaemia, glucose metabolism
**Start atypical antipsychotic when:**
- Choosing 1st line treatment in newly diagnosed schizophrenia
- There are unacceptable SEs from typical antipsychotics
- Relapse occurs on a typical antipsychotic
**NOTE: Avoid using more than 1 antipsychotic**
43
How do atypical antipsychotics work?
They block dopamine receptors and serotonin 5-HT2 receptors
44
What is the management of acute dystonia?
Procyclidine
45
What are the SEs of antipsychotics?
**Extrapyramidal Side-Effects (EPSEs):**
- Acute dystonia
- Akathisia
- Parkinsonism
- Tardive dyskinesia
**Hyperprolactinaemia:**
- Galactorrhoea, amenorrhoea, gynaecomastia and hypogonadism
- Sexual dysfunction
- Increased risk of osteoporosis
**Also:**
- Sedation
- Hypotension
- Weight gain (especially olanzapine and clozapine)
- Anticholinergic (dry mouth, blurred vision, constipation, urinary retention, tachycardia)
- Impaired glucose tolerance - increased risk of diabetes
46
What is acute dystonia?
Sustained muscle contraction e.g.
- Torticollis - twisting of the neck that causes the head to rotate and tilt at an odd angle
- Oculogyric crisis - involuntary upward deviation of both eyes
47
What is tardive dyskinesia?
Sudden, irregular movements which you cannot control:
- Lip-smacking, chewing, pouting of jaw, excessive blinking, tongue-poking
48
What needs to be monitored during schizophrenia management?
**Baseline Measurements before starting an antipsychotic:**
- Weight, waist circumference
- HR and BP
- Fasting BM, HbA1c, lipid profile, prolactin
- Assessment of any movement disorders
- Assessment of nutritional status, diet and physical activity
- ECG (if cardiovascular RFs present or recommended by chosen medication)
**Monitoring:**
- Response to treatment and SEs
- Emergence of movement disorders
- Waist circumference
- Adherence
- Overall physical health
- Weight: Weekly for 6w > At 12w > At 1y > Annually
- HR and BP: At 12w > 1y > Annually
49
Describe treatment resistance in schizophrenia
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
- **1st line = Clozapine**
- Requires weekly blood tests to detect early signs of neutropaenia
- If there is a lack of response to clozapine, consider augmentation with another antipsychotic
50
What is Schizophrenia?
Schizophrenia is a serious mental condition that affects a persons ability to think, feel and behave clearly.
- Loss of insight
51
What are the S/S of Schizophrenia?
**Positive symptoms**
- Delusions
- Hallucinations
- Disorganised speech e.g. word salad
- Disorganised behaviour e.g. wearing loads of layers on a hot day
- Catatonic behaviour (strange movements / responses)
**Negative symptoms**
Reduction/removal of normal processes e.g. decrease in emotions they can express or loss of interests
- Flat effect (inappropriate response)
- Alogia (lack of info in speech)
- Avolition (decreased motivation)
**Cognitive symptoms**
Affects memory / learning / understanding
- Subtle / difficult to notice
- E.g. unable to keep track of several things at once
**+Insomnia**
52
Describe the phases of Schizophrenia
**Prodromal**
- Withdrawn
- Seems similar to depression / anxiety
**Active**
- Severe psychotic symptoms
**Residual phase**
- Cognitive symptoms / become withdrawn again
53
What is the DSM-V diagnostic criteria for Schizophrenia?
**1. Two of the following symptoms:**
- Delusions
- Hallucinations
- Disorganised speech
- Disorganised / catatonic behaviour
- Negative behaviour
**2. At least 1 of them has to be delusions, hallucinations or disorganised speech**
**3. Must be ongoing for at least 6m, with at least 1m of the active phase symptoms**
**4. Symptoms can't be attributable to another condition** e.g. substance abuse
54
What is the aetiology of Schizophrenia?
**Unknown**
- Likely genetic basis
- Early/prenatal infection and autoimmune disorders have been linked
- RF = cannabis use
55
Describe the epidemiology of Schizophrenia
- More common in males, less severe sx in females
- M onset = mid-twenties
- F onset = late-twenties
> May relate to oestrogen regulation of dopamine
56
What is the prognosis of Schizophrenia?
- Relapses are common (esp if not on antipsychotics)
- Baseline gets worse after relapse
57
Which factors are associated with poor prognosis in schizophrenia?
- Strong family history
- Gradual onset
- Low IQ
- Prodromal phase of social withdrawal
- Lack of obvious precipitant
- Male
- Earlier onset
58
What are the SEs of clozapine?
- Agranulocytosis (1%), neutropaenia (3%)
- Reduced seizure threshold - can induce seizures in up to 3% of patients
- Constipation/intestinal obstruction
- Myocarditis (CP): a baseline ECG should be taken before starting treatment
- Hypersalivation
59
If someone on antipsychotics has intolerable SEs, which drug should they be switched too?
Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
60
The repetition of someone else's speech including the questions being asked?
Echolalia
61
What are the risks of using antipsychotics in elderly patients?
- Stroke
- VTE
62
What is the management of tardive dyskinesia?
**Tetrabenazine**
(if moderate/severe TD)
or switch to an atypical
63
What are the first rank symptoms of schizophrenia?
*If any symptom is present most of the time for at least 1 month = diagnosis*
**1. Auditory hallucinations**
- Third person
- Running commentary
- Thought echo
**2. Passivity of thought**
- Thought withdrawal
- Thought insertion
- Thought broadcasting
**3. Delusions of control**
- Actions/feelings/impulses under external control
- Bodily sensations due to external influence
**4. Delusional perception**
- Normal perception of common place object/sight leads to sudden, intense, self-referential delusion e.g. see red car = I knew I had 2 souls
64
What are in investigations for schizophrenia?
**Clinical diagnosis based on criteria**
- History, MSE, & collateral history
- Urine drug screen
- Bloods (FBC, U&Es, HbA1c, lipids, endocrine tests)
- +/- CT/MRI (rule out masses/changes associated with dementia)
65
What are Long Acting Injectable Antipsychotics (LAIs)?
Also known as **“depots”**
- Antipsychotics that are given via a long acting IM injection rather than as an oral tablet
- Beneficial for patients with poor oral compliance
- Loss of insight is a core feature of psychosis, patients can therefore be unwilling to engage in treatment planning as they do not believe they are unwell
- Not all oral tablets are available as depots
66
What dose of antipsychotic should be used?
- Start at low doses to minimise side effects, especially in those who are antipsychotic naïve as they are at higher risk of experiencing EPSEs
- Doses are significantly lower in elderly populations
67
What is rapid tranquillisation?
**IM administration of antipsychotics use to help manage acutely agitated patients (often undertaken with the use of restraint)**
- Olanzapine and haloperidol are most commonly used
*Typically antipsychotics are 3rd line choices after benzodiazepines and promethazine have been tried*
68
What is the main cardiac SE of antipsychotics?
**QTc Prolongation**
- Typically should be <440ms in male, <470ms in females
- QTc prolongation is a RF for developing cardiac arrhythmia's - specifically Torsade de Pointes
*Relative risk:*
- High = haloperidol
- Moderate = chlorpromazine
- Low = olanzapine, risperidone
- Nil = aripiprazole
69
What is the management of drug-induced Parkinsonism?
- Switch medication
- Procyclidine
70
What can cause a rise in clozapine blood levels?
Stopping smoking
Alcohol binging
71
What can reduce clozapine blood levels?
- Starting smoking / smoking more
- Stopping drinking
- Omitting doses
72
What is the best course of action to address missed doses of Clozapine?
If clozapine doses are missed for more than 48 hours the dose will need to be restarted again slowly
73
What is used to treat hyper-salivation?
hyoscine
74
When a patient thinks a closely related person, usually their loved one, has been replaced by an exact double?
Capgras syndrome
75
What is a PET scan likely to show in someone with schizophrenia / any major psych disorder?
- Hypoactivity of prefrontal lobes
- Enlarged cerebral ventricles
76
Belief that his/her body, mainly their skin, is infested by small organisms or bugs?
Ekbom syndrome (delusional parasitosis)
77
What is Munchausen’s syndrome?
Purposefully causing symptoms e.g. hypoglycaemia
Aka factitious disorder
