Psychosis and Schizophrenia

Question 1

what is psychosis?

Answer 1

this is where judgement of reality is significantly disturbed
usually accompanied by a loss of insight- so the pt is unaware that they are unwell, they may be unwilling to accept tment as they don’t understand why they need it, and can’t make a rational decision about treatment.

Question 2

the 3 key psychotic symptoms?

Answer 2

hallucinations
delusions
thought disorder

Question 3

what is an hallucination?

Answer 3

a perception occurring in the absence of an external stimulus
this is believed to be real by the patient

Question 4

how is an hallucination different from a pseudohallucination?

Answer 4

a pseudohallucination is located inside the pt’s subjective/internal space e.g. they hear voices which are inside their head, like their own thoughts, rather than hearing somebody next to them talking to them.
shakeable- can be recognised by the pt as unreal
tend to occur at times of heightened emotion
tend to represent the pts own thoughts and feelings

Question 5

in which conditions are pseudohallucinations common?

Answer 5

personality disorders- pseudohallucinations can be a way in which the pt manifests their distress e.g. via the voices in their head.

Question 6

questions you need to consider to explore the presentation of hallucinations?

Answer 6

modality-auditory, visual, gustatory, olfactory, tactile and somatic
nature?- e.g. if auditory- what is being said? who by? more than 1 person? talking to you or about you? voice inside your head?-pseudohallucination.

Question 7

auditory hallucinations are common in which conditions?

Answer 7

schizophrenia- voices tend to talk in the 3rd person
mania
depression-voices tend to talk in the 2nd person

Question 8

visual hallucinations are common in which conditions?

Answer 8

delirium tremens-an acute organic brain syndrome that may develop 3-5 days after alcohol-dependent people stop drinking, hallucinations characteristically lilliputian (of small creatures or figures)
delirium
dementia
space occupying lesions (SOLs)

Question 9

causes of olfactory hallucinations?

Answer 9

depression

tumour

Question 10

causes of tactile hallucinations e.g. insects crawling over the skin or of heat/cold on skin?

Answer 10

cocaine intoxication

schizophrenia

Question 11

causes of somatic hallucinations e.g. of organs being pulled out or twisted?

Answer 11

schizophrenia

Question 12

what is an illusion?

Answer 12

a misperception of an external stimulus- so the stimulus is there but you don’t perceive it as what it actually is e.g. walking in the dark and thinking you can see a man when it’s a tree.

Question 13

what is a delusion?

Answer 13

a false unshakeable belief that is not in keeping with the person’s cultural and religious background.

Question 14

different types of delusions?

Answer 14

persecutory (paranoid)-somebody out to get them, cause harm to them, occur in schizophrenia and mania
delusion of reference- objects, events of people are in some way of personal significance to them e.g. crossword clues are trying to convey a message specifically to them. occur in schizohprenia.
passivity-pt believes an outer agency is controlling their thoughts and actions. occurs in schizophrenia.
grandiose-beliefs of exaggerate self-importance e.g. special powers, god. occurs in mania.
nihilistic-belief that something has ceased e.g. the world is about to end, they are dead or their bowels have stopped working. occurs in depression.
guilt-pt believes they are unduly responsible for something they can’t possibly have cause e.g. a tsunami. occurs in depression.
poverty-pt believes they have no money. occurs in depression and the elderly.

Question 15

how are overvalued ideas different from delusions?

Answer 15

these are ideas which tend to overly occupy a person and may affect their actions
overvalued ideas are shakeable and can be understood culturally e.g. body image.

Question 16

2 aspects of thought?

Answer 16

form- how is thought ordered. if disorder, may be disturbance in structure or flow.

content-what the pt is talking or writing about. a disorder may occur with delusions and obscessions.

Question 17

what is a formal thought disorder?

Answer 17

an abnormality in the structure of thinking
includes flight of ideas, loosening of associations-complete loss of normal structure of thinking-there is no logical link between ideas, and neologisms-words/phrases constructed by the pt, although not consciously, which are used with meaning in their conversation.

Question 18

pts with a formal though disorder may have a flight of ideas. what is this and what conditions might it be seen with?

Answer 18

ideas follow each other rapidly and are connected to one another but the associations appear to be due to chance-they are not expected, but may be explained by rhyming, puns, clangs or an environmental distraction.
seen in mania

Question 19

what would a pt with insight be able to do?

Answer 19

know that they are unwell
understand that they need treatment
will accept the treatment or be able to make a rational decision about the treatment

Question 20

positive symptoms of schizophrenia?

Answer 20

hallucinations
delusions
thought disorder

these happen often when the pt is acutely unwell, and an be gotten rid of with tment, but often the pt is left with their negative symptoms.

Question 21

negative symptoms of schizophrenia?

Answer 21

the pt doesn't engage with what they would have done previously:
apathy-loss of interest/enthusiasm
social withdrawal
loss of motivation
neglect

Question 22

what other name be used to describe the delusion a pt has where they think they are dead?

Answer 22

cotard delusion

Question 23

most common type of schizophrenia?

Answer 23

paranoid

Question 24

what name is given to a group of symptoms which can help in diagnosing schizophrenia as they are thought to be rarely found in other disorders?

Answer 24

schneider’s first rank symptoms:
3 hallucinations: 3rd person, running commentary, thought echo
3 thought possession delusions: thought withdrawal, broadcasting or insertion
3 ‘made’ phenomena or delusions: actions, impulses or feelings are controlled by external agency.
delusional perception

Question 25

what is a delusional perception?

Answer 25

a normal perception e.g. traffic lights changing colour, which is interpreted with delusional meaning.

Question 26

how can psychosis in schizophrenia be distinguished from that in mood disorders?

Answer 26

psychosis in mood disorder is congruent with mood e.g. grandiose delusions in mania and nihilistic delusions in depression.

Question 27

possible presentations of psychosis which are NOT due to a psychiatric cause?

Answer 27

drug induced
high steroids e.g. cushing's disease
metabolic/endocrine disorder
epilepsy 
neurosyphilis
delirium

Question 28

causes of delirium?

Answer 28

drug induced-intoxication e.g. steroids, or digoxin, or withdrawal e.g. alcohol or opioids.
sepsis/infection
hypo/hyperglycaemia
organ failure-cardiac, hepatic
constipation
biochemical derangement

Question 29

why avoid lorazepam in treating elderly pt with suspected delirium?

Answer 29

high falls risk-4 times

Question 30

What is word salad and when is it seen?

Answer 30

A random unintelligible mix of words see in advanced schizophrenia. thought and speech totally incoherent.

Question 31

What is thought broadcasting?

Answer 31

Belief that others aware of or can hear a person’s thoughts.

Question 32

What is neurosis?

Answer 32

A mild form of mental illness where patients retain their ability to judge what is reality but have symptoms of stress such as anxiety and depression, and is not the result of an organic disorder.

Question 33

common features of acute schizophrenia?

Answer 33

hallucinations
persecutory delusions
delusions of reference
social withdrawal
impaired performance at work

Question 34

3 main kinds of mood abnormalities in the acute syndrome of schizophrenia?

Answer 34

mood change such as depression, anxiety, irritability or euphoria. depressive symptoms may develop as an integral part of the disorder, as a response to insight into nature of illness and problems to be faced, or as side effects of antipsychotic med.

reduction in normal variations of mood-flattening/blunting of affect.

emotion not in keeping with the situation-incongruity of affect.

Question 35

delusions of greater diagnostic value in acute schizophrenia?

Answer 35

delusions of reference
delusions of control (passivity)-pt being controlled by an outside agency
delusions about thought possession-thought insertion, withdrawal or broadcast.

Question 36

what ‘negative’ symptoms characterise the chronic syndrome of schizophrenia?

Answer 36

social withdrawal
emotional apathy
thought disorder
cognitive impairment
lack of drive
underactivity or disorganised behaviour

Question 37

movement disorders in chronic schizophrenia?

Answer 37

catatonic movement disturbances: stupor-immobile, mute, unresponsive.
stereotypies-repeated movements that do not appear goal directed, mannerisms if goal directed
waxy flexibility-pt placed in awkward posture can maintain this for much longer than a healthy person could without severe discomfort.

Question 38

thought content in chronic schizophrenia?

Answer 38

delusions- often held with little emotion e.g. pts convinced being persecuted but show no fear or anger.
and may be ‘encapsulated’

Question 39

problems with cognitive function in chronic schizophrenia?

Answer 39

working and semantic memory
attention
executive functioning
verbal fluency and motor functioning to a lesser extent

Question 40

prescribed drugs that may cause psychotic reactions?

Answer 40

steroids

dopamine agonists used in tment of Parkinson’s

Question 41

what is the incidence and prevalence of schizophrenia, and why is the prevalence much higher than the incidence?

Answer 41

incidence=10 and 20 per 100,000 of population
prevalence= 4 per 1000

and as disorder is chronic

Question 42

RFs for schizophrenia?

Answer 42

predisposing factors:
genetic-FH-child, twin or sibling of a schizophrenic pt
environmental- abnormalities of pregnancy and delivery, maternal influenza (2nd trimester), fetal malnutrition, urban birth, migration-afrocaribbean immigrants, winter birth.
precipitating factors: early cannabis consumption
stressful life events

Question 43

perpetuating factors in schizophrenia?

Answer 43

high emotional expression-strongly expressed feeling, espec. critical comments, among family members
can increase relapse rates and can be modified by family therapy.

Question 44

2 important indications for ECT in schizophrenia?

Answer 44

when severe depressive symptoms accompanying schizophrenia

in rare cases of catatonic stupor

Question 45

lifetime risk of schizophrenia?

Answer 45

1%

Question 46

NICE recommendations regarding physical health management and general considerations in psychosis and schizophrenia?

Answer 46

mental healthcare provider should offer a combined healthy eating and physical activity programme
ensure tment given in line with guidance if rapid or excssive weight gain, abnormal lipid levels or blood glucose management problems
consider help with smoking cessation-*be aware of potential increased risk of toxic ADRs with olanzapine and clozapine if smoking reduced as loss of CYP450 induction effect so reduced drug metabolism, offer nicotine replacement therapy, or bupropion if schizophrenia diagnosis or varenicline if schizophrenia or psychosis- latter 2 must monitor regularly espec. over 1st 2-3wks, warn about increased risk of neuropsychiatric symptoms.
routinely monitor weight, CVS and metabolic morbidity indicators
consider peer support to help improve service user experience and QOL
consider a manualised self-management programme
offer supported employment programmes

Question 47

treatment options to prevent psychosis?

Answer 47

in those considered at increased risk(person distressed with decline in social functioning and any 1 of transient or attenuated psychotic symptoms, other experiences or behaviour suggestive of possible psychosis or 1st degree relative with psychosis or schizophrenia) offer individual CBT with or without family intervention and offer interventions recommended for anxiety, depression, emerging PD or substance misuse.

Question 48

management of 1st episode psychosis?

Answer 48

early intervention in psychosis services for assessment, if can’t provide urgent intervention refer to crisis resolution or home tment team.
AP medication should NOT be started in primary care unless done in consultation with a consultant psychiatrist.
secondary care: offer oral AP tment along with psychological interventions-family intervention-at least 10 planned sessions and individual CBT-over at least 16 planned sessions.

Question 49

possible ADRs to be discussed when determining choice of AP medication?

Answer 49

metabolic-weight gain and diabetes
CVS-QTc prolongation
EP-dystonia, akathisia, dyskinesia
hormonal-raised prolactin
unpleasant subjective experiences

Question 50

warning to be given if prescribing the typical antipsychotic chlorpromazine?

Answer 50

potential to cause skin photosensitivity

advise using sunscreen if necessary

Question 51

tment of acute episodes of psychosis or schizophrenia?

Answer 51

crisis resolution and home tment team as 1st line if severity of episode, or level of risk to self or others, exceeds capacity of early intervention in psychosis services or other community teams to effectively manage it. consider acute community tment with them before IP admission.
oral AP medication or r/v current med. in conjunction with psychological interventions-offer CBT in acute phase or later, and family intervention to all those families who live with or are in close contact with the service user. arts therapies for alleviation of -ve symptoms-psychotherapeutic techniques with promotion of creative expression. can experience themselves differently, develop new ways of relating to others, express themselves and understand their feelings.

after acute episode, encourage pt to write an account of their illness in their notes.
advise about high relapse risk if stop med. in next 1-2yrs
monitor of symptoms and signs of relapse for at least 2 yrs post WD of AP medication.
ensure AP med. reviewed annually

when relapse or re-referral to secondary care, refer to crisis section of care plan

Question 52

interventions for those whose illness has not responded adequately to tment?

Answer 52

r/v diagnosis
r/v treatment adherence
assess if illicit drug use, alcohol, prescrib med. or coexisiting physical illness
offer family intervention if only tried CBT, or CBT if only tried family intervention
offer clozapine in schizophrenia if illness has not responded to at least 2 different antipsychotic drugs given sequentially at adequate dose, and at least 1 of which is a non-clozapine atypical AP.
if clozapine not working, r/v illicit drug use and co-morbid physical illness, before checking therapeutic drug levels and considering augmenting with a 2nd antipsychotic-adequate trial may need up to 8-10 weeks.

Question 53

How to decide if what a pt is telling you is actually a delusion?

Answer 53

Is their response out of proportion to the situation?

Is it in keeping with the patients social, religious or cultural background?

Question 54

what is hebephrenic schizophrenia?

Answer 54

A form of schizophrenia in which affective changes are prominent, delusions and hallucinations fleeting and fragmentary, behaviour irresponsible and unpredictable, and mannerisms common. often childlike in facial expressions and behaviour. The mood is shallow and inappropriate, thought is disorganized, and speech is incoherent. There is a tendency to social isolation. Usually the prognosis is poor because of the rapid development of “negative” symptoms, particularly flattening of affect and loss of volition. Hebephrenia should normally be diagnosed only in adolescents or young adults.

Question 55

what is catatonic schizophrenia?

Answer 55

Catatonic schizophrenia is dominated by prominent psychomotor disturbances that may alternate between extremes such as hyperkinesis and stupor, or automatic obedience and negativism. Constrained attitudes and postures may be maintained for long periods. Episodes of violent excitement may be a striking feature of the condition. The catatonic phenomena may be combined with a dream-like (oneiroid) state with vivid scenic hallucinations