Mgh Handbook Psychosis

Front 1

psychosis

Back 1

- gross impairment of reality testing
- thought disorder

Front 2

psychosis in Huntington's

Back 2

- psychotic sx may precede motor and cognitive sx

Front 3

psychosis in Parkinson's

Back 3

- look for bradykinesia, tremor, rigidity

Front 4

psychosis in Wilson's idsease

Back 4

- look for tremor, dysarthria, rigidity, gait disturbance, Kayser Fleischer rings
- measure ceruloplasmin

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psychosis in intermittent porphyria

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- acute episodes of abdominal pain, weakness, peripheral neuropathy
- measure delta-aminolevulinic acid and porphobilinogen in urine

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schizophrenia criteria

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- 4 weeks of active phase (bizarre delusions or typical auditory hallucinations)
- or 4 weeks of two of the following: nonbizarre delusions, less typical hallucinations, disorganized speech, disorganized behavior, negative sx
- illness present for 6 months

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negative sx

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- two main clusters:
1. reduced affective experience or expression i.e. affective blunting and alogia
2. amotivation cluster: avolition, anhedonia, asociality

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time period for psychotic d/o

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- schizophrenia 6 months
- schizophreniform 1-6 months
- brief psychotic d/o <4 wks

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schizotypal personality

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- chronic, bizarre, or idiosyncratic thoughts or behaviors
- don't meet active phase criteria for schizophrenia

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schizoaffective versus MD w/ psychotic features

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- psychosis occurs with MD = MD w/ psychotic fx
- psychosis occurs when patient was euthymic = schizoaffective

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clusters of schizophrenia sx

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1. reality distortion (delusions, hallucinations
2. disorganization (formal thought disorder and inappropriate affect)
3. negative symptoms (apathy, anhedonia, social withdrawal, alogia, flat affect)
4. cognitive deficits

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do patients with psychosis have capacity?

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- they may have capacity to make certain decisions even when their judgment is impaired in other realms e.g. delusions

Front 13

which schizophrenia type may go unnoticed?

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- paranoid schizophrenia because they fail to exhibit bizarre appearance and speech
- may not have overt disorganization and negative sx

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partial joining of perspectives

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- when you neither agree nor attempt to reality-test a patient's delusions, but intstead show impartial interest or concern

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schizophrenic patient that is masturbating or disrobing in public, stealing food, smoking in restricted areas is what kind of behavior?

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- disorganized

Front 16

behaviors of which type of schizophrenic patient may be dangerous?

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- disorganized type if agitated-- may have occasional violent or self-injurious behaviors
- require aggressive pharmacotherapy and may require restraints

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schizophrenic with poor hygiene or soiled clothing in hospital may be what type?

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- prominent negative symptoms
- withdrawn and unmotivated and lack of interpersonal skills

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short term behavioral control of mania?

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- antipsychotics and benzos
- but must work on getting mood stabilizer to therapeutic level

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features of psychotic depression

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- ruminative concerns about guilt, worthlessness
- hopeless, guilt
- may have persecutory delusions: but beliefs tend to be less bizarre and seem believable
- ECT or antipsychotic w/ anti-dp

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delusions in elderly

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- very common
- called late paraphrenia
- at risk for organic causes of psychosis, dementia, depression, med toxicity

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late onset schizophrenia

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- occurs after age 45
- usually occurs in women and appears as paranoid psychosis

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will organic psychosis respond to antipsychotics?

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- yes, psychotic sx and agitation usually improve regardless of cause

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which type of antipsychotic has its strongest support for short-term tx of medically compromised agitated patient?

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- high potency, first generation agents

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which antipsychotics are available in long acting depot

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- haldol, fluphenazine, risperidone

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which antipsychotics have good tolerability?

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- perphenazine and molindone

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benefit of molindone?

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- does not seem to cause weight gain

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tx of exacerbations in otherwise stable patients?

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- usually improve without altering medications

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dose of haldol for elderly

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- 0.5 to 2mg at night

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greatest risk for acute dystonia?

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- younger patients (<40 y.o) started on high-potency first generation antipsychotics during first week of tx

Front 30

which antipsychotics is dystonia most unlikely to occur?

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- quetiapine or clozapine

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tx of akathisia?

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- acute: diazepam 10mg
- long term: propranolol 10-20mg BID to QID
- switch to second gen antipsychotic or lower dose

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tx of antipsychotic-induced parkinsonism?

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- reduce neuroleptic
- add benztropine 1-2mg BID or amantadine 100mg BID to TID
- avoid long term use b/c can impair attention and memory
- switch to second generation

Front 33

when do you see tardive dyskinesia?

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- after 6 months of treatment
- may be irreversible

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describe TD

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- involuntary choreiform movements of mouth, tongue, upper extremities

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risk of developing TD

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- first gen: 5% per year of exposure, lifetime risk of 50-60%
- second gen: 0.8% per year; highest in risperidone when higher than 6mg/day

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second gen with highest risk of hyperprolactinemia

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- risperidone and paliperidone
- abilify lowers prolactin

Front 37

which second gen antipsych have few or no cardiac effects?

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- olanzapine and abilify

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which second gen have alpha-adrenergic effects that need titration to avoid orthostatic hypotension?

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- clozapine, risperidone, quetiapine, ziprasidone (but not paliperidone)

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which second gen produces most hypotension and tachycardia?

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- clozapine

Front 40

which antipsych prolongs QTc most?

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- thioridazine and then ziprasidone

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is there a difference between risk of sudden cardiac death in first vs second?

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- no
- both have a dose related increase

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side effect of clozapine?

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- agranulocytosis, sialorrhea, weight gain, hypotension, tachycardia, seizures, impairment of esophageal and bowel motility, urinary incontinence, cardiomyopathy, pericarditis, pulmonary embolism

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clozapine withdrawal

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- acute worsening of psychosis with cholinergic rebound
- if d/c'd for more than 4 days, it should be reintroduced at low dose

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treating agitation

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- 1mg ativan, 5mg haldol
- standing haldol with benzo PRN BID or TID

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which second gen are available IM?

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- abilify, olanzapine, geodon

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NMS

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- hyperthermia, rigidity, confusion, diaphoresis, autonomic instability, elevated CPK and leukocytosis
- see more in t

Front 47

what looks like NMS without hx of antipsychotic use?

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- malignant hyperthermia (general anesthesia) and lethal catatonia

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when to restart antipsychotic after NMS?

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- two weeks after resolution

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when might you see NMS without rigidity?

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- with second generation antipsych

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what interacts with clozapine?

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- fluvoxamine, erythromycin --> elevates clozapine --> obtundation and CV effects

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which meds should be used with low-potency agents with much care?

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- other highly anticholinergic drugs b/c of anticholinergic activity --> confusion, urinary retention, constipation

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which antipsych should be used in patients with high risk for violence or suicide?

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- clozapine - protective on violence and suicide

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what should you r/o in violent patient?

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- encephalitis