Psychosis

• What is psychosis?

  Term used to describe a person experiencing things differently from those around them

  Collection of symptoms

  Impaired assessment of reality with significant alterations in Perception, Thoughts, Mood & Behaviours
• Give 3 psychotic features.

  Hallucinations

  Delusions

  Thought disorganisation
• What are the different types of thought disorganisation?

  Alogia - little info conveyed by speech

  Thought block - pt abruptly stops for a minute of so, and then continue like nothing has happened

  Tangentiality - answers diverge from topic

  Clanging - linking words based on rhymes or how they sound

  Word salad - linking real words incoherently
• What are the associated features of psychosis?

  Agitation/aggression

  Neurocognitive impairment (e.g. memory, attention, executive function)

  Depression

  Thoughts of self-harm
• What conditions have psychotic symptoms?

  Schizophrenia (most common)

  Depression (psychotic depression, common in elderly patients)

  Bipolar disorder

  Puerperal psychosis

  Brief psychotic disorder (symptoms < 1 month)

  Neurological conditions (Parkinson's, Huntington's)

  Medication (corticosteroids)

  Illicit drugs (cannabis, phencyclidine)
• What is the peak age for an initial psychotic episode?

  15-30 years
• What is the strongest RF for developing a psychotic disorder?

  FH
• What are the RFs for developing psychotic disorders?

  FHx

  Stressful life events

  Childhood adversity

  Migration (esp from developing country)

  Urban living

  Cannabis use

  Other substance use (amphetamines, cocaine, LSD)

  Medication use (high dose corticosteroids)

  Early life factors (exposure in utero, maternal stress, birth trauma)

  Exposure to parasite, Toxoplasma gondii
• What are the complications of psychotic disorders?

  Premature death -> increased risk of suicide

  Increased risk of...

  • CVD
  • T2DM
  • Smoking-related illness
  • Cancer
  • Infections (HIV, Hep C & TB)

  Social exclusion

  Substance misuse
• What are the DDx of psychotic disorders?

  Severe mood disorders w/psychotic symptoms

  Drug-induced psychosis

  Sepsis

  Underlying medical condition (cerebral tumours, epilepsy)

  PTSD

  OCD

  Autism spectrum disorder or communication disorders
• What is the management of psychosis?

  Assess risk (to self, to others & from others)

  • high risk -> same day specialist mental health assessment
  • low risk -> refer for specialist assessment to early intervention in psychosis service without delay
  • Do not start antipsychotic drug treatment whilst waiting for specialist assessment

  Antipsychotic medications

  ->Monitor response & adverse effects (close attention to CV)

  Psychoeducation to pt & family

  Inform about support available

  CBT and/or family intervention

  Care plan -> crisis plan, advance statement, key clinical contacts in emergency
• What is the prodromal period for psychosis?

  Increasing distress & decline in personal & social functioning

  Can last from a few days to 18 months
• What are the symptoms of prodromal period of psychosis?

  Transient, low intensity psychotic symptoms

  Reduced interest in daily activities

  Problems with mood, sleep, memory, concentration, communication, affect & motivation

  Anxiety, irritability or depressive features

  Incoherent or illogical speech
• What are positive symptoms?

  Symptoms which ADD to a patient's experience of illness

  Examples:

  • hallucinations
  • delusions
  • thought disorganisation
  • possession of thought
  • passivity phenomena
• Define hallucinations.

  Perception of a sensory stimulus in the absence of a real stimulus
• Define a delusion.

  Unusual or bizarre fixed beliefs (e.g. persecutory)

  Out of character for that person
• What is passivity phenomena?

  External control of bodily movements
• What is important information to obtain about hearing voices (auditory hallucinations)?

  Heard internally/externally

  How many voices?

  Are they recognisable? (often related to trauma)

  What is the content of their speech (derogatory/neutral/affirming)?

  Commanding? (if so, has the pt acted on commands or are they likely to?)

  Third person? (inc. running commentary)
• Other than auditory hallucinations, what are the other types of hallucinations?

  Visual -> typically of figures (either recognised or disturbing/contorted)

  Tactile
• What is the most common type of hallucination?

  Auditory
• Define illusion.

  Misperception of real external stimulus
• What is apophenia?

  Tendency to perceive meaningful connections between unrelated things
• Apophenia is a normal trait, but can sometimes be overactive in (developing) psychosis & self-referential, and can lead to delusional beliefs (can start to make connections between unrelated things, and can start to believe them in a fixed way).

  Not a true hallucination, but misinterpretation of real stimuli.
• What is a delusional belief?

  False (but not necessarily wrong) -> do not have the evidence to show that it is true

  Fixed & unshakeable (ask to rate as a percentage of certainty maybe?)

  Out of keeping with social & religious context (out of character for person)
• What is an overvalued idea?

  A comprehensible idea pursued beyond the bounds of reason
• What are the different types of delusions?

  Grandiose delusions (seen in mania)

  Delusions of jealousy

  Persecutory (paranoid) delusions

  Erotomanic delusions (uncommon)

  Somatic delusions (hypochondriacal delusional disorder)

  Nihilistic delusion (typically in severe depression)
• What are erotomanic delusions?

  Fixed, unshakeable belief that someone else (often someone in the public eye) is in love with them
• What are somatic delusions?

  False beliefs about their body (e.g. body rotting, no blood)
• What is passivity phenomena?

  Belief that one's (voluntary) action is actually caused by an external entity

  • 'made action' -> patient experiences their own movement like a passive observer
  • 'made emotions' -> pt attributes an emotion to having been placed within them by an external source, rather than being an emotional response to an external event
• What are negative symptoms?

  Symptoms that DETRACT from a patient's ability to function

  Examples:

  • flattened/restricted affect - unreactive to situations (need to differentiate from depression)
  • cognitive impairments (attention & executive function)
  • Decreased volition/apathy
  • Deterioration in social function & activities of daily living
• What are the 2 main types of anti-psychotics?

  Typical (1st generation)

  Atypical (2nd generation)
• What is the difference between typical & atypical antipsychotics?

  Typical -> act primarily on D2 receptors

  Atypical -> act on range of receptors

  Can cause extra-pyramidal symptoms (EPS), atypical have fewer

  Atypical have more metabolic side effects
• What are some of the adverse effects of antipsychotics?

  Extrapyramidal symptoms (dystonic reactions & pseudoparkinsonism, akathisia, tardive dyskinesia)

  Weight gain

  Reduced seizure threshold

  QT prolongation

  Postural hypotension

  HTN

  Abnormal LFTs
• Give 3 examples of typical antipsychotics.

  Haloperidol

  Flupentixol

  Chlorpromazine
• Give 3 examples of atypical antipsychotics.

  Olanzapine

  Amisulpride

  Clozapine
• How can acute dystonia from antipsychotics be managed?

  Procyclidine
• What is the difference between 'hearing voices' and auditory hallucinations?

  Hearing voices -> internal (mood disorder)

  Auditory hallucinations -> external (schizophrenia/psychosis)