Problem 33-hallucinations2

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Hallucinations/Disordered thinking
Hallucination
A false perception arising without an external stimulus: it is experienced as real and vivid
and occurring in external space
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Auditory
Visual
Somatic
Olfactory and gustatory
Hypnagogic- when a person goes asleep
Extracampine- occurs outside the limit of person’s normal sensory field
Functional- a normal sensory stimulus is required to precipitate the hallucination
Illusion
Misperceptions of real external stimuli e.g. mistaking a dressing gown for a person in a dark
room
Pseudohallucination
Is a perceptual experience which differs from a hallucination, in that it appears to arise in
the subjective inner space of the mind, not through one of the external sensory organs.
Delusion
An unshakeable false belief that is not accepted by other members of the patient’s culture.
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To the patient they are true
The delusion is false because of faulty reasoning
The belief is out of keeping with the patient’s social and cultural background
Classified as:
 Primary- do not occur in response to any previous psychopathological state, occur
typically in schizophrenia and other primary psychotic disorders
 Secondary- consequences of pre-existing psychopathological states usually mood
disorders
 Mood congruent or mood incongruent
 Bizarre or non-bizarre
 According to the content of the delusion, see table
Overvalued ideas
A plausible belief that a patient becomes preoccupied with to an unreasonable extent. Key
feature- the pursuit of this idea causes considerable distress to the patient or those living
around them
Circumstantial and tangential thinking
Circumstantial- over-inclusion of details however if allowed to finish person comes the
original starting point
Tangential- speaker diverts from the initial train of thought but never returns to the orginal
point
Flight of ideas
Thinking is markedly accelerated resulting in a stream of connected concepts, links can be
normal or through a pun or clang association or through a vague idea
Loosening of association
When the patients train of thought shifts suddenly from one very loosely or unrelated idea
to the next
Neologisms and idiosyncratic word use
New words created by the patient, often combining syllables of other known words.
Patients can use words idiosyncratically by attributing them with unrecognized meaning.
Thought blocking
A sudden cessation to their flow of thought, often in mid-sentence (observe sudden breaks
in speech). Patients have no recollection of this and continue on a different topic.
Perservation
Patients unnecessarily repeat a word or phrase they have previously expressed-highly
suspicious of organic brain disease.
Echolalia
When patients senselessly repeat words or phrases spoken around them by others-parrot
like.
Irrelevant answers
Give answers completely unrelated to the question
Negative symptoms
Indicate a clinical deficit and include- marked apathy, poverty of thought and speech,
blunting of affect, social isolation, poor self-care and cognitive deficits.
Able to differentiate psychotic illness from other causes
Bloods- FBC, ESR, U+E, LFTs, thyroid function, glucose, calcium, syphilis serology
Urine drug screen
EEG, CT
ECG- check ok to take anti-psychotics because they prolong QT interval
Medical conditions
Cerebral neoplasm, infarcts, trauma,
infection including HIV, CJD,
neurosyphilis, herpes encephalitis
Endocrine- thyroid, parathyroid, adrenal
disorders
Epilepsy- temporal lobe
Huntingtons disease
SLE
Acute intermittent porphyria
Vitamin B12 and thiamine deficiency
Substances
Alcohol
Amphetamines
Anticholinergics
Antiparkinsonian drugs
Cocaine
Corticosteroids
Hallucinogens
Inhalants/solvents
Organophosphates
Phencyclidine
Basic pharmacology of antipsychotic drugs
Antipsychotics are thought to work by their ability to block dopamine D2 receptors on
the mesolimbic dopamine pathway
Typical antipsychotics- chlorpromazine, promazine, thioridazine, pipotiazine,
trifluoperazine, fluphenazine, haloperidol, flupentixol, zuclopenthixol, sulpiride,
pimozide
Atypical antipsychotics- clozapine, olanzapine, risperidone, quetiapine,
amisulpride
Common index conditions
Schizophrenia
Prevalence- approximately 1%
Mid-teens- late thirties, women have later onset
First-rank symptoms
 Delusional perception
 Delusions of thought control:insertion, withdrawal, broadcast
 Delusions of control: passivity experiences of affect (feelings), impulse,
volition and somatic passivity (influence controlling the body)
 Hallucinations: audible thoughts (first person or thought echo), voices arguing
or discussing the patient, voices giving a running commentary
Mood disorders-see other core problems
Steroid psychosis- teroid psychosis is a psychotic disorder caused by the use of
corticosteroid medications. Affected people develop psychiatric symptoms such as
depression and mania. The treatment options vary depending on the patient's preexisting medical condition.
Corticosteroids are drugs that mimic cortisol, a hormone produced by the body. They
reduceinflammation and suppress the immune system. Doctors prescribe
corticosteroid medications such as cortisone and prednisone to treat autoimmune
disorders such as lupus and rheumatoid arthritis.
Researchers believe steroid psychosis occurs when high doses of corticosteroids
cause an increase in dopamine levels in the brain. Increased dopamine levels lead
to symptoms such as depression, mood swings and psychosis. Corticosteroids also
lower the serotonin levels in the brain, worsening the patient's depressive symptoms.
Most patients who develop steroid psychosis begin to manifest symptoms between
three and 11 days after starting corticosteroid therapy. Many people become overly
excited, irritable or depressed. Others have rapid mood swings, and some become
suicidal. Severely affected patients may hallucinate or lose contact with reality.
Gender may play a role in determining who develops steroid psychosis. Studies
indicate that women are somewhat more likely to develop the condition than men.
This may have to do with the fact that women are more likely than men to develop
conditions such as lupus that require corticosteroid treatment.
Able to specify type of psychotic illness- see flow chart
Knows relevant aspects of common law which may need to be applied when
managing mentally ill patients, Knows when and how to employ the Mental
Health Act- SEE powerpoint on Minerva- search mental health act Jan 2011
Able to manage acutely disturbed or violent patient (e.g. physical restraint,
drug therapy)
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