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Psychotic Disorders (Ch 3) Flashcards

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1
Q

Psychosis

A

distorted perception of reality

Poor reality testing may be accompanied by delusions, perceptual disturbances (illusions or hallucinations) and/or disorganized thinking/behavior.

Can be a symptom of schizophrenia, mania, depression, delirium, and dementia

it can be substance or medication induced

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2
Q

Delusions

A

fixed, false belief that remain despite evidence to the contrary and cannot be accounted for by cultural background of the individual

bizarre - false belief that is impossible
non bizarre - false belief that is plausible but not true

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3
Q

Delusions of persecution/paranoid delusions

A

irrational belief that one is being persecuted

“The CIA is after me and tapped my phone”

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4
Q

Ideas of reference

A

Belief that cues in the external environment are uniquely related to the individual

“The TV characters are speaking directly to me.”

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5
Q

Delusions of control

A

Thought broadcasting - belief thoughts can be heard by others

Thought insertion - belief other’s thoughts are being placed in one’s head

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6
Q

Delusions of grandeur

A

Belief that one has special powers beyond those of a normal person

“I am the all-powerful son of God and I shall bring down my wrath on you if I don’t get my way.”

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7
Q

Delusions of guilt

A

Belief that one is guilty or responsible for something

“I am response for all the world’s wars”

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8
Q

Somatic delusions

A

Belief that one is infected with a disease or has a certain illness

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9
Q

Illusion

A

misinterpretation of an existing sensory stimulus (mistaking a shadow for a cat)

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10
Q

Hallucinations (including types)

A

Sensory perception without an actual external stimulus

Auditory: Most commonly in schizophrenic pts
Visual: less common in schizophrenic pts, may accompany drug intoxication, drug and alcohol withdrawal, or delirium
Olfactory: aura associated with epilepsy
Tactile: secondary to drug use or alcohol withdrawal

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11
Q

Differential diagnosis of psychosis

A 
Psychotic disorder due to another medical condition
Substance/Medication-induced psychotic disorder
Delirium/Dementia
Bipolar disorder, manic/mixed episode
Major depression with psychotic features
Brief psychotic disorder
Schizophrenia
Schizophreniform disorder
Schizoaffective disorder
Delusional disorder
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12
Q

Medical causes of psychosis - CNS

A

Cerebrovascular disease, MS, neoplasm, Alzheimer’s dz, Parkinson’s dz, Huntington’s dz, tertiary syphilis, epilepsy (often temporal lobe), encephalitis, prion dz, neurosarcoidosis, AIDS

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13
Q

Medical causes of psychosis - endocrinopathies

A

Addison/Cushing dz, hyper/hypothyroidism, hyper/hypocalcemia, hypopituitarism

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14
Q

Medical cases of psychosis - Nutritional/vitamin deficiency

A

B12, folate, niacin

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15
Q

Medical cases of psychosis - other systemic

A

connective tissue disease - SLE, temporal arteritis

porphyria

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16
Q

DSM5 criteria for psychotic disorder d/t another medical condition

A

Prominent hallucinations or delusions
Sxs do not occur only during an episode of delirium
Evidence from hx, physical, or lab data to support another medical (non psychiatric) cause

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17
Q

Medications known to induce psychosis

A 
anesthetics
anticholinergics
anticonvulsants
antihistamines
antihypertensives
antimicrobials
antiparkinsonian agents
chemotherapeutic agents
corticosteroids
digitalis
methylphenidate
NSAIDs
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18
Q

Substances known to induce psychosis

A 
Alcohol
barbiturates
benzodiazepines
cannabis
cocaine
hallucinogens (LSD, ecstasy)
inhalants
phencyclidine (PCP)

caused by intoxication or withdrawal

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19
Q

DSM5 criteria for substance/medication-induced psychotic disorder

A

Hallucinations and/or delusions
Sxs do not occur only during episode of delirium
Evidence from hx, physical, or lab data to support a medication or substance induced cause
Disturbance is not better accounted for by a psychotic disorder that is not substance/medication induced

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20
Q

delusion vs illusion, vs hallucination

A

Delusion: false belief
Illusion: misinterpretation of external stimulus
Hallucination: perception in absence of an external stimulus

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21
Q

Positive symptoms of schizophrenia

A

ADDED onto normal behavior

Hallucinations, delusions, bizarre behavior, disorganized speech

Respond more robustly to antipsychotic medications

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22
Q

Negative symptoms of schizophrenia

A

SUBTRACTED or missing from normal behavior

Flat or blunted affect, anhedonia, apathy, logia, lack of interest in socialization

More often treatment resistant and contribute significantly to social isolation or schizophrenic patients

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23
Q

Cognitive symptoms of schizophrenia

A

impairment in attention, executive function, working memory

may lead to poor work and school performance

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24
Q

Three phases of schizophrenia

A

Prodromal: decline in functioning precedes first psychotic episode - e.g.: socially withdrawal, irritable, physical complaints, declining school/work performance, new found interest in religion or the occult

Psychotic - perceptual disturbances, delusions, disordered thought process/content

Residual - following episode of active psychosis. marked by mild hallucinations or delusions, social withdrawal, negative symptoms

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25
DSM5 Criteria for Schizophrenia
Two or more of the following present for at least 1 month: 1. Delusions 2. Hallucinations 3. Disorganized speech 4. Grossly disorganized or catatonic behavior 5. Negative symptoms (at least 1, 2, or 3) Must cause significant social, occupational, or self-care functional deterioration Duration of illness for at least 6 month - including prodromal or residual periods in which the above criteria may not be met Symptoms not due to effects of a substance or another medical condition
26
Catatonia
stereotyped movement, bizarre posturing, and muscle rigidity can be seen in schizophrenic patients
27
Clozapine
considered for treating schizophrenia when fail typical and other atypical antipsychotics Rare adverse event: agranulocytosis - need WBC and ANC counts regularly
28
5 A's of schizophrenia negative symptoms
``` Anhedonia Affect - flat Alogia - poverty of speech Avolition - apathy Attention - poor ```
29
Echolalia vs Echopraxia
Echolalia - repeats words or phrases | Echopraxia - mimics behavior (practices behavior)
30
Typical psychiatric exam findings in schizophrenic patients
``` Disheveled appearance flat affect disorganized thought process Intact procedural memory and orientation Auditory hallucinations Paranoid delusions Ideas of reference Lack of insight into their disease ```
31
Epidemiology of Schizophrenia
Men early-mid 20s Women late 20s Men more negative sis, poorer outcome Rarely presents before 15 or after 55 Strong genetic predisposition Substance use: over 50% nicotine, alcohol, cannabis, cocaine Post psychotic depression
32
Downward drift hypothesis in schizophrenia
schizophrenic pos unable to function well in society, end up in lower socioeconomic groups - many become homeless
33
Dopamine hypothesis - schizophrenia
Increased dopamine activity in certain neuronal tracts cause schizophrenia Evidence: dopamine receptor antagonists successful in treating Cocaine and amphetamines increased dopamine activity and can lead to schizophrenic like symptoms
34
Prefrontal cortical dopamine pathway (schizophrenia)
inadequate dopaminergic activity responsible for negative symptoms
35
Mesolimbic dopamine pathway (schizophrenia)
Excessive dopaminergic activity responsible for positive symptoms
36
Tuberoinfundibular dopamine pathway
blocked by antipsychotics -> hyperprolactinemia -> gynecomastia, galactorrhea, sexual dysfunction, menstrual irregularities
37
Nigrostriatal dopamine pathway
blocked by antipsychotics -> Parkinsonism/extrapyramidal side effects: tremor, rigidity, slurred speech, akathisia, dystonia, and other abnormal movements
38
Serotonin abnormality in schizophrenia
Elevated serotonin some second gen (atypical) antipsychotics (risperidone and clozapine) antagonize serotonin and wearing antagonize dopamine
39
Norepinephrine abnormality in schizophrenia
Elevated norepinephrine Long term use of antipsychotics shown to decrease activity of noradrenergic neurons
40
GABA abnormality in schizophrenia
Decreased GABA Decreased expression of the enzyme necessary to create GABA in the hippocampus of schizophrenic pts
41
Glutamate receptor abnormality in schizophrenia
Decreased levels of glutamate receptors Schizophrenics have fewer NMDA receptors, corresponds with psychotic sis with NMDA antagonists like ketamine
42
Prognostic factors associated with a better prognosis in schizophrenia
``` later onset good social support positive sxs mood sxs acute onset female few relapses good premorbid functioning ```
43
Prognostic factors associated with a worse prognosis in schizophrenia
``` Early onset poor social support negative symptoms family history gradual onset male many relapses poor premorbid functioning (social isolation, etc) Comorbid substance use ```
44
First generation (typical) antipsychotic medications
Chlorpromazine Fluphenazine Haloperidol Perphenazine D2 antagonists Treat positive sis with minimal impact on negative sis Side effects: extrapyramidal sis, neuroleptic malignant syndrome, tardive dyskinesia
45
Second generation (atypical) antipsychotic medications
``` Aripiprazole Asenapine Clozapine Iloperidone Lurasidone Olanzapine Quetiapine Risperidone Ziprasidone ``` 5-HT2 antagonist, as well as D4>D2 receptors Lower incidence of extrapyramidal side effects, increased risk for metabolic syndrome
46
Extrapyramidal symptoms - side effect
especially seen in high potency first gen antipsychotics Dystonia (spasms) of face, neck, and tongue Parkinsonism - resting tremor, rigidity, bradykinesia Akathisia - feeling of restlessness Tx: anticholinergics (benztropine, diphenhydramine), benzodiazepines/beta-blockers(specifically for akathisia)
47
Anticholinergic symptoms - side effect
especially low-potency first gen antipsychotics and atypical antipsychotics) Dry mouth, constipation, blurred vision, hyperthermia tx: per symptom - eye drops, stool softeners, etc
48
Metabolic syndrome - side effect
Second gen antipsychotics Elevated BP, blood glucose excess body fat around waist Abnl cholesterol levels combined -> increased risk of CV disease, stroke, T2DM Tx: switch to first get or a more "wt neutral" second generation antipsychotic like aripiprazole or ziprasidone Monitor lipids and blood glucose PCP for hld, DM, etc Encourage diet, exercise, smoking cessation
49
Tardive dyskinesia - side effect
first gen antipsychotics Choreoathetoid movements - face, tongue, head Tx: dc or reduce medication, consider substituting an atypical antipsychotic if appropriate Benzodiazepines, Botox, Vit E Movements may persist despite withdrawal of drug
50
Neuroleptic malignant syndrome - side effect
high potency first gen antipsychotics, any antipsychotic, initiation of tx and at higher IV/IM dosing of high potency neuroleptics Change in mental status, autonomic instability (high fever, labile BP, tachycardia, tachypnea, diaphoresis), "lead pipe" rigidity, elevated CPK, leukocytosis, metabolic acidosis Medical emergency - requires prompt withdrawal of all antipsychotic meds and immediate medical assessment and tx
51
Thioridazine side effect
irreversible retinal pigmentation at high doses
52
Chlorpromazine side effect
deposits in lens and cornea
53
DSM5 criteria for schizophreniform disorder
same criteria as schizophrenia | sis last between 1-6 months
54
DSM5 criteria for schizoaffective disorder
Either a major depressive or manic episode during which psychotic sxs consistent with schizophrenia also met Delusions or hallucinations for 2 weeks in absence of mood disorder sxs Mood sxs present for majority of psychotic illness Sis not due to effects of a substance or other medical condition
55
Medical Treatment of schizoaffective disorder
Second gen antipsychotics may target both psychotic and mood symptoms mood stabilizers antidepressants electroconvulsive therapy (ECT)
56
DSM5 criteria for Brief Psychotic Disorder
psychotic sxs as in schizophrenia lasting from 1 day to 1 month with eventual full return to premorbid level of functioning not due to effects of a substance or other medical condition May be seen in reaction to extreme stress such as bereavement, sexual assault, etc
57
Prognosis and treatment of brief psychotic disorder
High rates of release, almost all completely recover Brief hospitalization (workup, safety, stabilization), supportive tx, course of antipsychotics for psychosis, and/or benzodiazepines for agitation
58
Delusional Disorder
middle-aged or older patients (after 40 yo) DSM5: one or more delusions for at least 1 month Does not meet criteria for schizophrenia Functioning in life not significantly impaired, behavior not obviously bizarre
59
Erotomanic type (delusion)
delusion that another person is in love with them
60
Grandiose type (delusion)
Delusions of having great talent
61
Somatic type (delusion)
physical delusions
62
Persecutory type (delusion)
delusions of being persecuted
63
Jealous type (delusion)
delusions of unfaithfulness
64
Koro
Southeast Asia - Singapore Intense anxiety that the penis will recede into the body, possibly leading to death
65
Amok
Malaysia Sudden unprovoked outbursts of violence, often followed by suicide
66
Brain fag
Africa Headache, fatigue, eye pain, cognitive difficulties, and other somatic disturbances in male students
67
Schizotypal
personality disorder paranoid, odd or magical beliefs, eccentric, lack of friends, social anxiety criteria for overt psychosis not met
68
Schizoid
personality disorder solitary activities, lack of enjoyment from social interactions, no psychosis

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