Session 04 - Psychotic Disorders

Question 1

What is psychosis?

Answer 1

The misinterpretation of thoughts and perceptions that originate from a patient’s own mind which are experienced as reality.

Question 2

What are the biological causes of psychosis?

Answer 2

Genetics: twin studies have shown schizophrenia has 50% concordance rate in MZ twins.

Dopamine: antipsyhotics block D2 receptors, whereas L-Dopa induces psychosis.

Neurodevelopmental: higher in people with lower birth weight, developmental delay etc.

Question 3

What are the psychological causes of psychosis?

Answer 3

Prodrome: often preceded by patients exhibiting anxiety, depression and ideas of reference.

These people can be offered CBT to reduce the risk of progression to full psychosis.

Question 4

What are the social causes of psychosis?

Answer 4

Stress: linked to social deprivation, urbanisation and stressful life events.

Question 5

What are the four dopaminergic pathways in the brain?

Answer 5

1) Mesolimbic (VTA > NAc)

2) Mesocortical (pre-frontal cortex)

3) Nigrostriatal (SNr to Basal Ganglia)

4) Tuberoinfundibular (to anterior pituitary)

Question 6

What is the link between the mesolimbic pathway and schizophrenia?

Answer 6

Involved in the reward pathway and attributing salience to a stimulus.

Excessive dopamine activity here is thought to give positive symptoms: delusions, hallucinations etc.

Question 7

What is the link between the mesocortical pathway and schizophrenia?

Answer 7

Dopamine here is important for executive functioning, emotion and speech.

Underactive dopamine here is thought to give negative symptoms: alogia, anhedonia, blunted affect.

Question 8

What is the link between the nigrostriatal pathway and schizophrenia?

Answer 8

Dopamine here increases voluntary motor movements.

Explains why anti-psychotics (D2-blockers) lead to extrapyramidal side effects.

Question 9

What is the link between the tuberoinfundibular pathway and schizophrenia?

Answer 9

Dopamine here is responsible for reducing prolactin output.

Explains why antipsychotics (D2-blockers) elevate prolactin release giving hyperprolactinaemia.

Question 10

What are the positive symptoms of schizophrenia?

Answer 10

Symptoms that is present through its presence:

• hallucinations
• delusions
• thought disorder
• catatonia
• passivity phenomena

Question 11

What is a hallucination?

Answer 11

A perception that the patient experiences as coming from the outside world, in the absence of an external stimulus.

The most common are 3rd person auditory hallucinations, or voices giving a running commentary.

Question 12

What is Charles-Bonnet hallucination?

Answer 12

Visual hallucination in a person with partial or severe blindness.

Visual impairment promotes sensory deafferentation, leading to disinhibition, thus resulting in sudden neural firings of the visual cortical regions.

Question 13

What is a delusion?

Answer 13

A false belief out of keeping with the patient’s sociocultural background, which is held with unshakeable conviction even in the face of contradictory evidence.

Question 14

What is a persecutory delusion?

Answer 14

The belief that people are conspiring against you.

Question 15

What is a delusion of reference?

Answer 15

The belief that people on TV / radio are talking to or about you.

Question 16

What is Cotard syndrome?

Answer 16

A delusion characterised by the false belief of death.

The patient believes that they are dead, or a part of their body is non-existent.

It is associated with psychotic depression, and can lead to extreme neglect as patients believe they no longer need to eat or drink.

Question 17

What is De Clerambault’s syndrome?

Answer 17

A delusion about love.

Often seen in young women, who falsely believe that a famous person has fallen in love with her.

Question 18

What is Orthello delusion?

Answer 18

The patient believes that their spouse is being unfaithful, despite no real evidence.

Question 19

What is Folie à deux?

Answer 19

When symptoms of a delusion belief are transmitted from one individual to another.

Question 20

What is thought disorder?

Answer 20

An impaired capacity to sustain coherent discourse, in written or spoken language.

Question 21

What is catatonia?

a) wavy flexibility

b) catatonic stupor

Answer 21

Abnormal movements experienced by some patients.

a) you can move a patient into a position and they will remain frozen there.

b) this is where a patient suddenly stops and stays there.

Question 22

What is passivity phenomena?

Answer 22

The belief that your thoughts and actions are no longer your own.

This includes thought insertion, broadcasting and withdrawal.

Question 23

What are the negative symptoms of schizophrenia?

Answer 23

Symptoms that are present through its absence.

5As:
- affect blunted (restriction emotion, with poor emotional display).
- alogia (paucity of speech)
- asociality (social isolation)
- anhedonia (lack of pleasure)
- avolition (lack of motivation)

Question 24

How is schizophrenia diagnosed?

Answer 24

The presence of >2 symptoms experienced for longer than one month:
1. Delusions
2. Hallucinations
3. Disorganised speech
4. Disorganised or catatonic behaviour
5. Negative symptoms

Question 25

What is the most common type of schizophrenia?

Answer 25

Paranoid schizophrenia - the prominent hallucinations and delusions, with mostly normal intellectual functioning and emotion.

The person feels very suspicious and persecuted.

Question 26

What is catatonic schizophrenia?

Answer 26

An uncommon type that is characterised by prominent psychomotor disturbances.

Patients display rigidity, posturing and abnormalities of voluntary movement.

Question 27

What is disorganised schizophrenia?

Answer 27

A subtype of schizophrenia with early onset, unpredictable behaviour and speech.

Affect and mood is inappropriate with giggling, mannerisms and pranks.

Patients can also have fleeting hallucinations and delusions.

Question 28

What is residual schizophrenia?

Answer 28

A long-term subtype where most symptoms have gone, but the negative symptoms remain.

Question 29

What is undifferentiated schizophrenia?

Answer 29

Schizophrenia that cannot be classified as:
- paranoid
- residual
- catatonic
- disorganised

Question 30

Biopsychosocial management of schizophrenia.

Answer 30

Bio: Antipsychotics in a stage wise approach.

Psycho: CBT is offered to all patients, to challenge delusions and develop coping strategies.

Social: need for social support for appropriate housing, financial advice.

Question 31

What is the medical management of schizophrenia?

Answer 31

First line is oral atypical antipsychotics (quetiapine, olanzapine, respiridone).

Second line is oral typical antibiotics (haloperidol, chlorpromazine).

Third line is clozapine.

Question 32

What prescribing considerations should be made with antipsychotics?

Answer 32

• regularly monitor weight, lipids, glucose and ECGs
• start at minimum dose with monotherapy then titrate up
• minimum length of treatment is six months

Question 33

How long should antipsychotics be prescribed for the

a) first episode

b) second episode

c) third episode

of schizophrenia?

Answer 33

a) 6-24 months

b) 5 years

c) life-long medication

Question 34

What is delusional disorder?

Answer 34

A rare mental illness in which a patient experiences delusion, but with no accompanying hallucinations, thought disorder, mood disorder or flattening of affect.

Question 35

How is delusional disorder diagnosed?

Answer 35

Delusions in the absence of any other psychotic symptoms or reversible causes (e.g. drugs).

Question 36

What is the management of delusional disorder?

Answer 36

Psychotherapy (CBT) is main line, plus antipsychotics.