Summary Final year MD notes - psychosis in psychiatry
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Course
Institution
Macquarie University (MQ
)
A collection suite of final psychiatric and mental health MD notes to ace your penultimate and final year exams!
Look no further and save the stress of accessing multiple resources as this PDF collates and summarises information from several resources including but not limited to:
-Talley and...
SCHIZOPHRENIA “divided in the mind”
< 1% of population (20 /100 000 or 16000 new cases in NSW) DDX
Ø 1/3RD do NOT becoming lifelong Ø Drug-induced psychosis (e.g. from recent steroid usage)
Epi Ø 20 year shorter life expectance Ø Psychotic disorder = disorders manifesting with delusional beliefs
ranging from è brief psychotic disorder è psychosis
Ø Higher rates in low SES, ATSI, pacific islanders
• NO specific biological marker
• Strong inheritance – FHx (e.g. specific deletions – 22q11) ® of schizophrenia, substance abuse
• Pregnancy / birth complications (e.g. malnutrition, toxin or viral exposure ante-natal period)
RF • Use of psychoactive drugs during teens and young adulthood (Nb: persistent drug use predicts re-admission BUT does NOT increase risk of
being diagnosed with schizophrenia)
• Childhood trauma
Schizophrenia = neurodegenerative manifestation group of disorders [AS AVERAGE BRAIN VOL lower at diagnosis)
PP • LOSS OF GRAY MATTER + ENLARGED VENTRICLE + LOSS OF SYNAPSES
• Abnormal dopamine pathways (NOT imbalance of dopamine) ® causes Movement disorders
• Has prodrome (period between onset of premorbid mood changes (e.g. irritable, communication issue, social isolation) AND
symptoms of psychosis – acute manic episode, hallucinations, delusions
o Often incorrectly diagnosed as ADHD
Define Ø DSMV criteria for schizophrenia = 2 -for-6-ophrenia (> 2 symptoms for 6 months) ® AT LEAST ONE MUST BE 1,2 OR 3
/Sx
Positive (1st rank) Schneider symptoms Negative symptoms (5 A’s)
Increased mesolimbic and nigrostriatal pathway (XS dopamine) Hypoactive mesocortical pathway
Good
prognosis 1) Delusion = firm fixed beliefs (MAIN) Ø AFFECT / APATHY – BLUNTED
signs: a. Delusion of thought interference (thought insertion, Ø AMBIVALENCE – self-neglect (poor hygiene)
withdrawal or broadcasting – someone knows their Ø ALOGIA - Poverty of speech – naturally quiet (due to
• Acute thoughts OR thought control) voices in head)
onset b. Delusional perception (e.g. picking up coin make me Ø ANHEDONIA
• Catatonia the son of God) Ø ASOCIALITY - social withdrawal / isolation
• Low mood 2) Hallucinating (visual, somatic, olfactory, auditory – voices in 3rd Ø impaired cognitive function (memory, attention)
person or running commentary) OFTEN more disabling than positive symptoms AND less
3) Disorganised speech, (e.g. clanging, word salad, neologisms) responsive to treatment
• Disorganised or catatonic behavior (motor symptoms) *Negative Sx makes schizophrenic a chronic condition
• Delusional disorder [does NOT meet criteria A of schizophrenia)
o ≥ 1x delusions >1/12
o Does NOT impair social/occupational function
o Manic, MDD are brief and related to delusion
• Schizophreniform disorder = schizophrenia syndrome <6/12 duration
o Has episode of mood disturbance occurs in the presence of 1-3 above, AND
o mood symptoms present in both the active and residual phase of the illness
• Brief psychotic disorder = schizophrenia syndrome <1/12 duration ® delusion remit
with return of insight
• Schizo-affective disorder = distinct episodes of mania or severe depression (mood
changes) >2 weeks PLUS schizophrenia syndrome
DDx. • Psychosis NOT otherwise specified (NOS)
SUBSTANCE-induced psychosis (SIP) = TOXIC DELIRIUM Substance exposed schizophrenia (SES)
• Prolonged and heavy substance use • Small doses need
• Prolonged insomnia • 1st rank symptoms – auditory hallucinations,
• Illusions NOT hallucinations thought broadcasting
• Normal thought and behaviour (e.g. fear) • Schizophrenic disorder of form of thought
• Ideas NOT delusions of reference (e.g. believing people in passing city bus • Basis of Beliefs often bizarre
are talking about them) • Residual negative symptoms
• Plausible persecutory beliefs
• High level of arousal and anxiety
• Other psychiatric conditions (anxiety, depression) Poor prognosis
• Social impairment (work, finances, relationships) Ø No trigger ® Gradual onset with prodrome of social withdrawal
Comp. • Substance abuse (e.g. alcohol, nicotine) Ø Low IQa
Ø FHx
• Suicide risk ® RoSH to others and community
Ø prodro
• Physical exam (neurological) Specific tests for encephalitis • ECG
• FBC, EUC, LFT, • Anti-NMDAR - autoimmune encephalitis • MRI brain – smaller brain volume
Ix • Fasting BSL, lipids, • Anti-VGKC - Limbic autoimmune encephalitis, • Urine drug screen
• TFT epilepsy, neuromyotonic (Isaac’s syndrome) • EEG
• HIV and Hepatitis screen • Anti-GAD – T1DM • STI screen (if indicated – neurosyphilis)
Non-Pharm Pharmacological
• De-escalate verbally if possible • Anti-psychotics (Dopamine antag)
• CBT or psychodynamic psychotherapy o 1st line = PO risperidone OR
• MDT (best) = (1) rehab then provide (2) social support o PO clozapine (weak D2 blocker) for Rx resistant schizo
to meet residual disability (e.g. case management) o reduce/abolish both +ve symptoms [mainly] and -ve symptoms
Mx o SANE Australia
*Olanzapine taken the longest by sufferers BUT wt gain
• Generate insight of illness and need for treatment NB:
• Treat comorbid substance use (S/A/D) • 1/3rd of patients are resistant to medications –
(most are smokers!!!)
• Fast vs slow metabolisers = start slow and titrate up
• Treat depression (6% die from suicide)
• Become less responsive with time
• ECT (last resort)
, STAGING OF SCHIZOPHRENIA
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