WEEK 4 Flashcards
outline of an assessment
1) the individual’s history - the story
2) the “mental state” - the psychopathology
3) collateral information from third parties
4) physical investigation - important for psychiatrists
5) diagnosis or formulation
6) risk assessment - self and others
7) create a plan
format of the history
1) history of presenting complaint
2) past psychiatric history
3) past medical history
4) medications
5) family history
6) psychosocial history
= the patient’s story basically
format of the mental state
categories:
- appearance and behavior
- speech
- mood
- thoughts
- perception
- cognition
- insight
- risk - tho it’s not always included
history vs. mental state
- the lengths change: history is static, whereas mental state is dynamic
- the language use is different: the history contains the story, the mental state is the phenomenology
why we use history and mental state systems
1) it makes us systematic, more rigorous in defining psychopathology, and reduces risk of missing areas of assessment
2) communicate with other professionals
3) allows us to make provisional diagnosis and formulation
4) allows us to monitor change
how to classify delusions
- delusions must be fixed and demonstrably false
- some ideas may be difficult to disprove, but we need to investigate how pervasive these ideas are within the individual’s life
- delusions should be culturally inappropriate
common delusional types
1) paranoid: most common in psychosis, feelings of being persecuted, followed, or spied on.
2) nihilistic: sense of things not being real or dying, commonly linked with depression
3) grandiose: delusions which have a positive mood component to them, sense of having special powers or abilities
formal thought disorder
= difficulty conveying thoughts in a logical linear nature.
- ranges in severity, can reach a level of extremity where even words in the same sentence are jumbled.
- not a problem of the content, but a problem with the ability to convey it in a logical linear way.
- it is still possible to pull out tonal info and get a sense of the content, but it’s difficult because of disjointed expression
insight
= the ability to recognize one’s difficulties and limits
- not necessarily binary “present” or “absent”.
- we can inquire about insight via asking about: presence of mental illness, nature of mental illness, utility or need for treatment, risk to self/others
- recovering insight can sometimes lead to depression and self-harm, because they are seeing the extent of the damage the disorder has done
substances that cause psychosis
1) acute psychosis after a single use:
- synthetic cannabinoid
- k2
- LSD
- ketamine
2) acute psychosis after repeated use:
- metamphetamine
- crack cocaine
acute stage: treatment
- the priority is symptom relief
- antipsychotics are highly effective
- symptoms such as agitation, hallucinations, and delusions, can be addressed safely and efficiently
maintenance stage: treatment
- the priority is avoiding relapse
relapse and meds
- going off medication is the main factor resulting in relapse
- in the first year of recovery, relapse rates are at 77% for those off-meds, and 3% for those on meds.
- patients who quit meds have a FIVEFOLD chance of relapse
antipsychotic drugs: 2 requirements
1) wide safety window
2) proven effectiveness in large RCTs
Paul Janssen
studied the effects of amphetamines on cyclists who were taking the drug to reduce fatigue. they would experience acute psychoses similar to paranoid schizophrenia. he then researched how to reverse the effect of amphetamines and developed haloperidol, which is now in use for schizophrenia. in small does, it powerfully reduces hallucinations, delusions, and agitation.
conditioned avoidance
= an important test to see if a molecule would make for a good candidate for an antipsychotic
- both haloperidol and chlorpromazine inhibit learning in animals, facilitating conditioned avoidance
DA and the CNS
- DA neurons influence a large area of higher CNS territory
- DA neurons are found in brain stem nuclei such as the substantia nigra
- DA axons project subcortical structures and large areas of the frontal cortex
- DA neuron projections show massive arborization within the higher centers (striatum + PFC)
fast transmitters
- glutamate and GABA
- point-to-point communication between tethered pre and post synaptic elements
- optimized for fast signaling
slow neuromodulators
- DA
- diffuse, slower biochemical change in millions of target neurons
- not optimized for the fast dissemination of specific info, but instead for modulating the higher networks.
DA neurons: 3 modes of firing (Schulz)
1) spiking every second
- in the awake brain
- tonic concentration in areas like the striatum
- tonic concentration is important for well-rehearsed thoughts and motor patterns
2) burst firing
- when an animal encounters a new stimulus that carries reward
- this pattern adjusts the strength of point to point connections in the striatum - essential for learning
3) switching off
- for several seconds when an anticipated/predicted reward or outcome fails to materialize
antipsychotics and sedation
- all antipsychotics act as D2R blockers. they only differ in their propensity to act on additional receptors, producing effects that may be desirable or unwanted.
- sedation occurs through action on histamine receptors. both chlorpromazine and quetiapine are sedatives. arpripazole doesn’t act on histamine receptors, so it isn’t a sedative.
- sedation is wanted when an individual is agitated, but unwanted when psychosis is resolved. so selecting an antipsychotic depends on the stage of illness.
antipsychotics and phases
in the acute phase, symptom relief is the priority. in the maintenance phase, avoidance of side effects is the priority to ensure continued adherence to treatment and avoidance of relapse.
clozapine
- incredibly effective in treatment resistant patients. it is believed to work in a slightly different way: it has weak binding to the D2R, but seems to act on acetylcholine receptors instead.
- it also has an anti-suicidal effect, reduces aggression and violence, and has no motor side effects (parkinsonism).
- it’s only downside is that weekly and then monthly blood tests need to be taken. in 1% of patients, it can lead to a massive fall in white blood cells, necessary to fight infection.
- in severely disabled patients, clozapine needs to be taken alongside a package of rehabilitative psychosocial support to recover QoL. this is especially important for people with severe negative symptoms.
long-acting depot antipsychotic
- golden standard treatment for avoiding relapse in psychotic disorders. proven effectiveness over oral antipsychotics.
- it remains in the system for many weeks, which means there is sufficient time to carefully monitor and plan for patients who discontinue or miss a dose. conversely, the sign that someone discontinued with oral meds is a severe acute psychotic episode.
