Psychotic Disorders Flashcards
(32 cards)
Describe some examples of delusions
- Delusions are false fixed beliefs despite conflicting evidence
Persecutory: belief that one is going to be harmed or harassed by someone else
Referential: belief that certain gestures, comments, environmental cues are directed to one self
Grandiose: believe of possessing exception abilities
Erotomanic: belief that another person is in love with them
Somatic: preoccupation with health and organ function
Jealous: belief spouse is unfaithful
Delusions of control: behaviour and thought are not controlled by self
Thought broadcasting: others can hear own thoughts
Describe different types of hallucinations
- perception like experiences that occur without external stimulus
Auditory hallucination
Touch hallucination
Olfactory or gustatory hallucinations (rare - require metabolic or neurological work up)
Describe different severeties of disorganized thinking
Mild
- circumstantialy or over-inclusive: too much detail but stays on topic
Moderate
- tangentiality: answer question at first then steers to something obliquely or imcompletely related
Severe
- loose association: thoughts are not linked but syntax from switches in intact
Extreme
- word salad
- incoherence
Other
- echolalia
- flight of ideas: increased speed of thoughts
- thought blocking: stops mid-sentence and does not return
- poverty of thought: lack of thought
- poverty of content: convey little information
Describe some of the negative symptoms
- Affective flattening or blunting: reduction in expression of emotions
- Avolition: decrease in self-initiated activities
- Alogia: diminished speed
- Anhedonia: decrease pleasure from positive stimuli
- Asociality: lack of interest in social interaction
- Ambilivence: difficult making decision
What is the lower life expactancy in schizophrenia
- 20 years
- most due to suicide but also chronic conditions
Risk for suicide - depression
- young age
- high IQ
- high premorbid function
- awareness of loss of function
- command auditory hallucinations
Discuss the possible pathophysiology and risks for schizophrenia
Stress-diathesis model
- caused by vulnarability/susceptibility of brain cted on stessor event
- have structural and functional abnormalities in the brain
- dopamine overactivity in mesolimbic causing positive symptoms
- dopamine depletion in mesocortical causing negative symptoms
Risks
- low socioeconomic status
- indistrualized nation
- family history
Discuss the natural course of schizophrenia
Prodrome
- start in adolescences and last one year (average onset in males is 21 and females is biphasic with 27 or 50s)
- nonspecific with depression and anxiety, substance misuse with attenuated positive symptoms
- have deterioration of school/work performance and change in relationships
Active
- mood episodes and symptoms
- cognitive deficits in vocational and functional impairement
Residual
- attenuated positive and negative symptoms with inappropriate behaviour and poor insight
- want to treat early in first episode as have greatest opportunity for response
- relapse have increase resistance to treatment, longer duration of psychotic symptoms, and less chance of return to baseline
List some good and poor prognosis factors for schizophrenia
Good - late and acute onset - obvious precipitating factor - high functioning baseline - married, good support - more positive symptoms Poor - male - early and insidious - poor pre-mormid function - negative symptoms - poor support - family history - no remission in 3 years - multiple relapses
List the diagnostic criteria for schizophrenia
> =2 of the following for >=1 month where at least one is delusion, hallucination or disorganized speed
- delusion
- hallucination
- disorganized speech
- grossly disorganized or catatonic behaviour
- negative symptoms
Social/occupational dysfunction
Continuous disturbance for >=6 months which include >=1 month of symptoms as well as prodromal, residual and negative
No other psychotic disorder or substance use
If autism or communication disorder then have delusion or hallucination
List the specifiers for catanoia
> =3 of
- stupor (no psychomotor activity)
- cataplesy (passive induction of posture held against gravity
- waxy flexibility
- mutism
- negativism (no response to instructions or external stimuli)
- posturing
- mannerism
- stererotypy
Discuss the treatment for schizophrenia
Susbtance use
- stop using substances
- harm reduction
Psychosocial
- family therapy and support in acute
- psychotherapy in stabilization
- stable begin social and life skills training
Service delivery
- acute crisis line and community treatment orders
Medication
- should be begun immediately as have best prognosis
List some susbtances/medications and medical disorders that can lead to psychotic disorders
Substances - marijuana - cocaine - alcohol Medications - L-dopa Medical - Lewy-body dementia - Wernike-Korsakoff syndrome - Wilson's disease
List the diagnostic criteria for schizophreniform disorder
- same diagnostic criteria as schizophrenia but lasts between 1-6 months
- brief psychotic disorders is same but only 1 day to 1 month
List the diagnostic criteria for schizoaffective disorder
- schizophrenia with major pervasive mood episode (MDD or manic)
- delusion or hallucination for >=2 weeks in absence of major mood episode
- symptoms that meet critieria for Major mood episode
- not due to substances
List the diagnostic criteria for delusional disorder
- delusions for >=1 month that are non-bizzare
- does not meet critieria for schizophrenia
- no impact on behaviour nor functioning
- manic or depressive episode, if present, is brief
- not due to substance or other condition
Discuss the four dopaminergic pathways in Schizophrenia
Mesolimbic
- from the ventral tegmentum area to amydala, hippocampus and medial prefrontal cortex
- in schizophrenia excess dopamine produce positive symptoms
Mesocortical
- from ventral tegmentum area to prefrontal cortex
- in schizophrenia loss of dopamine result in cognitive dulling, flat affect and amotivation
Nigrostriatal Pathway
- from substantial nigra to striatum
- dopamine release inhibit post-synaptic cholinergic interneuron from releasing ACh in striatum
- not affected in schizophrenia
- with antipsychotics have blockage resulting in extra-pyramidal side effects
Tuberoinfundibular Pathway
- from hypothalamus to infundibulum
- not affected in schizophrenia
- antipsychotics cause dopamine blockade resulting in prolactenemia and sexual dysfunction
Discuss the mechanism of action and provide examples of typical antipsychotics
Mechanism
- are dopamine (D2) receptor antagonist therefore reduce amount of dopamine in mesolimbic to decrease positive symptoms
- highest risk for extra pyramidal symptoms due to nigrostriatal blockade by increasing ACh (can use anticholinergic to decrease effects)
- blockage in tuberoinfundibular result in prolactenemia and gynecomastic, erectile dysfunction in men and galatorrhea, delayed or no orgasm, menstrual changes in women
- no benefit for negative symptoms
Examples
- Haloperidol (Haldol)
Discuss the risk, onset, presentation and treatment for dystonia
- Young male
- Within minutes to hours to days
- Sustained muscle contraction
- laryngeal adductor spasm
- oculogyric crisis
- Anticholinergic (benzotropine)
Discuss the risk, onset, presentation and treatment for parkinsonism
- Old female
- Within days to weeks
- TRAP
- tremor
- rigidity
- akinesia
- posture abnormality
- anticholinergic (benzotropine)
Discuss the risk, onset, presentation and treatment for akathisia
- Middle aged female
- within days to weeks
- restlessness
- pacing,
- rocking
- Beta blocker (propanalol) or benzodiazepine (clonazepam)
Discuss the risk, onset, presentation and treatment for tardive dyskinesia
- Old female, African
- After 3 months
- Repetitive involuntary choreoathetoid movement
- oral buccal lingual dyskinesia
- Tetrabenazine
Discuss the risks, presentation and treatment for neuroleptic malignant syndrome
Risks
- male
- rapid antipsychotic dose increase or IM use
- extreme psychomotor abnormalities
- dehydration
- affective disorder
- medical illness
Clinical Presentation (FRAME)
- onset within 2-4 weeks
- fever
- rigidity
- autonomic instability (increase HR, BP, sweating)
- mental status change
- extra lab changes with increase CK and WBC
- can lead to PE, DIC, renal failure, death (10-20%)
Management
- discontinue antipsychotics
- give D2 agonist (bromocriptine or amantadine)
- supportive antipyretics, hydration, muscle relaxant
Discuss the mechanism of action of atypical antipsycotics and provide examples
- all are dopamine D2 and serotonin 5HT2A receptor antagonists
- 5HT2A blockage increase dopamine release in mesocortical pathway resulting in increased dopamine improving negative symptoms
- have dopamine blockade by D2 in nigrostriatal and tuberoinfundibular but also 5HT2A blockade which increases dopamine so less risk of extra pyramidal side effects
Examples - Risperidone (risperdal)
- Olanzapine (Zyprexa)
- Quetiapine (seroquel)
- Clozapine (Clozaril)
- Aripiprazole (Abilify)
Discuss the general side effects of atypical antipsychotics
Weight gain
- most weight gain with clozapine and olanzapine
- moderate with risperidone and quetiapine
- neutral with aripiprazole
Hyperglycemia and Diabetes
- clozapine highest risk
- risperidone lowest risk
Prolonged QTc
Anticholinergic effects
Adrenergic effects
- sexual dysfunction and postural hypotension
