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Psych Rotation > Psychotic Disorders (Ch 3) > Flashcards

Psychotic Disorders (Ch 3) Flashcards

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
Q

DSM5 Criteria for Schizophrenia

A

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

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26
Q

Catatonia

A

stereotyped movement, bizarre posturing, and muscle rigidity

can be seen in schizophrenic patients

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27
Q

Clozapine

A

considered for treating schizophrenia when fail typical and other atypical antipsychotics

Rare adverse event: agranulocytosis - need WBC and ANC counts regularly

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28
Q

5 A’s of schizophrenia negative symptoms

A 
Anhedonia
Affect - flat
Alogia - poverty of speech
Avolition - apathy
Attention - poor
29
Q

Echolalia vs Echopraxia

A

Echolalia - repeats words or phrases

Echopraxia - mimics behavior (practices behavior)

30
Q

Typical psychiatric exam findings in schizophrenic patients

A 
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
Q

Epidemiology of Schizophrenia

A

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
Q

Downward drift hypothesis in schizophrenia

A

schizophrenic pos unable to function well in society, end up in lower socioeconomic groups - many become homeless

33
Q

Dopamine hypothesis - schizophrenia

A

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
Q

Prefrontal cortical dopamine pathway (schizophrenia)

A

inadequate dopaminergic activity responsible for negative symptoms

35
Q

Mesolimbic dopamine pathway (schizophrenia)

A

Excessive dopaminergic activity responsible for positive symptoms

36
Q

Tuberoinfundibular dopamine pathway

A

blocked by antipsychotics -> hyperprolactinemia -> gynecomastia, galactorrhea, sexual dysfunction, menstrual irregularities

37
Q

Nigrostriatal dopamine pathway

A

blocked by antipsychotics -> Parkinsonism/extrapyramidal side effects: tremor, rigidity, slurred speech, akathisia, dystonia, and other abnormal movements

38
Q

Serotonin abnormality in schizophrenia

A

Elevated serotonin

some second gen (atypical) antipsychotics (risperidone and clozapine) antagonize serotonin and wearing antagonize dopamine

39
Q

Norepinephrine abnormality in schizophrenia

A

Elevated norepinephrine

Long term use of antipsychotics shown to decrease activity of noradrenergic neurons

40
Q

GABA abnormality in schizophrenia

A

Decreased GABA

Decreased expression of the enzyme necessary to create GABA in the hippocampus of schizophrenic pts

41
Q

Glutamate receptor abnormality in schizophrenia

A

Decreased levels of glutamate receptors

Schizophrenics have fewer NMDA receptors, corresponds with psychotic sis with NMDA antagonists like ketamine

42
Q

Prognostic factors associated with a better prognosis in schizophrenia

A 
later onset
good social support
positive sxs
mood sxs
acute onset
female
few relapses
good premorbid functioning
43
Q

Prognostic factors associated with a worse prognosis in schizophrenia

A 
Early onset
poor social support
negative symptoms
family history
gradual onset 
male
many relapses
poor premorbid functioning (social isolation, etc)
Comorbid substance use
44
Q

First generation (typical) antipsychotic medications

A

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
Q

Second generation (atypical) antipsychotic medications

A 
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
Q

Extrapyramidal symptoms - side effect

A

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
Q

Anticholinergic symptoms - side effect

A

especially low-potency first gen antipsychotics and atypical antipsychotics)

Dry mouth, constipation, blurred vision, hyperthermia

tx: per symptom - eye drops, stool softeners, etc

48
Q

Metabolic syndrome - side effect

A

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
Q

Tardive dyskinesia - side effect

A

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
Q

Neuroleptic malignant syndrome - side effect

A

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
Q

Thioridazine side effect

A

irreversible retinal pigmentation at high doses

52
Q

Chlorpromazine side effect

A

deposits in lens and cornea

53
Q

DSM5 criteria for schizophreniform disorder

A

same criteria as schizophrenia

sis last between 1-6 months

54
Q

DSM5 criteria for schizoaffective disorder

A

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
Q

Medical Treatment of schizoaffective disorder

A

Second gen antipsychotics may target both psychotic and mood symptoms
mood stabilizers
antidepressants
electroconvulsive therapy (ECT)

56
Q

DSM5 criteria for Brief Psychotic Disorder

A

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
Q

Prognosis and treatment of brief psychotic disorder

A

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
Q

Delusional Disorder

A

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
Q

Erotomanic type (delusion)

A

delusion that another person is in love with them

60
Q

Grandiose type (delusion)

A

Delusions of having great talent

61
Q

Somatic type (delusion)

A

physical delusions

62
Q

Persecutory type (delusion)

A

delusions of being persecuted

63
Q

Jealous type (delusion)

A

delusions of unfaithfulness

64
Q

Koro

A

Southeast Asia - Singapore

Intense anxiety that the penis will recede into the body, possibly leading to death

65
Q

Amok

A

Malaysia

Sudden unprovoked outbursts of violence, often followed by suicide

66
Q

Brain fag

A

Africa

Headache, fatigue, eye pain, cognitive difficulties, and other somatic disturbances in male students

67
Q

Schizotypal

A

personality disorder

paranoid, odd or magical beliefs, eccentric, lack of friends, social anxiety

criteria for overt psychosis not met

68
Q

Schizoid

A

personality disorder

solitary activities, lack of enjoyment from social interactions, no psychosis

Psych Rotation (9 decks)

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