What is Psychosis?
Manchester Mental Health &
Social Care Trust
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Aims & Objectives
 To provide an introduction to psychosis and
associated signs and symptoms.
 To develop an awareness of how the signs of
psychosis can be identified.
 For participants to be aware of vulnerable groups
 To provide a baseline of knowledge concerning
psychosis from which to develop.
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Terms We Use …
As a large group let us consider what
terms are used to describe someone
who has a mental illness…..
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Cast your minds back…
Think back to being at school or youth
club.
Try to recall someone who you thought
might have been experiencing some
difficulties in the way they related to you
or others.Consider their behaviour , what
was it that made you think they were a bit
‘odd’.
In a small group share some of these
thoughts.
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The Stigma of Mental Health
Health
Stigma can be the largest obstacle for those
who experience mental health problems
60% of young people admit to verbally
abusing people with mental health problems (
Mind 2000)
In a survey of young people 38% were unable
to name a mental illness (Corrado &
Carluccio 2001).
66% of all media coverage associated mental
illness with violence (Philo & Secker 1994)
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The Historical Background
 Kraepelin 1893 – Developed groups of
symptoms into catatonia, paranoia,
hebephrenic and simple. He also noted that
they did not all have a chronic progression.
 Bleuler 1911- Developed the term schizophrenia
as a ‘splitting of psychic function’.
 Schneider 1959 –Identified first & second rank
symptoms to assist in the development of a
diagnosis.
 Langfeldt 1961 – Made a distinction between true
schizophrenia and schizophrenic states.
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What is Psychosis?
The word ‘psychosis’ is used to describe
conditions that affect the mind, where there
has been some loss of contact with reality
When someone becomes ‘ill’ in this way it is
called a ‘psychotic episode’
It is most likely to occur in young people around 3 in every 100 young people (more
common than diabetes!)
Most recover fully - It can happen to anyone
& can be treated
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Symptoms of Psychosis
Psychosis can lead to changes in mood,
thinking and to abnormal ideas. This can
make it hard for even people who know the
person best to understand how the person
feels.
In order to try to understand the experience of
psychosis it can be useful to group together
some of the more characteristic symptoms
The next few slides describe these symptoms
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Confused Thinking
Everyday thoughts become confused or don’t
join up properly
Sentences are unclear or don’t make sense
A person may have difficulty concentrating,
following a conversation or remembering
things
Thoughts appear to be speeded up or slowed
down
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False Beliefs
It is common for someone experiencing a
psychotic episode to hold false beliefs
(delusions)
The person may be so convinced of these
beliefs that even the most logical counterarguments may not dissuade them from the
belief
For example, a person may be convinced that
the way that cars are parked outside his
house is irrefutable evidence that the police
are watching
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Hallucinations
In psychosis, a person may hear, see, smell,
taste or feel something that is not actually
there.
For example, they may hear voices when
there is no-one else around and there is
nothing else to explain them; or they may
see things that other people can’t see.
Things may taste or smell as if they are ‘bad’
or even poisoned
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Changed Feelings
In a psychotic episode, how someone is
feeling may change suddenly for no apparent
reason.
The person may feel ‘strange’ or cut off from
the world, with everything moving in slow
motion.
Mood swings are common, veering from
unusually excited to very depressed.
Peoples’ emotions can be dampened; they
feel less able to express their emotion.
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Changed Behaviour
People with psychosis often behave differently from
the way they usually do; they may be extremely
active or lethargic, sitting around all day.
They may laugh inappropriately or become upset and
angry for no apparent reason.
These changes can be explained by the symptoms
previously described - a person who believes they
are in danger may call the police; someone who
believes he is Jesus may want to preach in the street;
or someone may stop eating if they think that their
food is poisoned.
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Making a Diagnosis
Everybody’s experience is different and
unique to them. Attaching a specific name or
label to a psychotic illness is not always
useful initially.
However, a diagnosis is usually attempted
eventually, depending on the type of
symptoms displayed and how long the illness
lasts.
Although diagnosis in first-onset psychosis is
particularly tricky, the following slides
describe the most common terms in use.
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Drug-induced Psychosis
Use of, or withdrawal from, alcohol and
drugs can be associated with the
appearance of psychotic symptoms.
Sometimes these symptoms will rapidly
resolve and disappear once the effects
of the substance wears off.
Sometimes the symptoms last longer
although they appear to have clearly
begun with substance use.
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Organic Psychosis
Sometimes psychotic symptoms may appear
as a result of a head injury or a physical
illness that disrupts brain functioning
(encephalitis, AIDS or a tumor may all
produce psychotic-like symptoms)
These psychotic symptoms are usually
accompanied by other difficulties, such as
memory loss or confusion. Physical tests can
often confirm these diagnoses (MRI, CAT
scans etc)
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Brief Reactive
Psychosis
Psychotic symptoms may arise suddenly in
response to a major stress in the person’s
life.
These stressors may include a death in the
family, a sudden change in life circumstances
or a particularly traumatic personal event
(getting mugged, being sent to prison).
Symptoms may initially be severe but the
person makes a full recovery in a few days.
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Delusional Disorder
The main symptom here is a strong
belief in things that are not true.
These ‘delusions’ may be restricted to
one area or a limited number of areas.
There is no other evidence of psychosis
(hallucinations, problems with language)
but this does not stop this condition
from being distressing & disruptive to
the person and those around them
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Schizophrenia
This term refers to a psychotic illness in which
the changes in behaviour or symptoms have
been present for at least 6 months.
Symptoms and length of illness vary between
patients
Contrary to popular belief and previous views
amongst professionals, many people with
schizophrenia can lead full and happy lives,
with many making a full and sustained
recovery
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Schizophreniform Disorder
This is just like schizophrenia. However,
the difference is that the symptoms
have not lasted for longer than 6
months.
If all symptoms clear up before 6
months, a retrospective alternative
diagnosis may be made.
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Bi-polar (manic-depressive)
disorder
In bi-polar disorder, psychosis occurs in the
context of a more general disturbance in
mood.
Extreme highs (mania) or lows (depression)
Psychotic symptoms, when present, tend to fit
in with the person’s mood - i.e. someone who
is depressed might hear a voice telling them
to harm themselves; someone who is high
may believe they are special and can perform
amazing feats.
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Schizoaffective Disorder
This diagnosis is made when a person
has concurrent or consecutive
symptoms of both a mood disorder
(such as depression or mania) and
psychosis.
In other words, the picture is not typical
of a mood disorder or a psychosis, but
displays various elements of both.
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Psychotic Depression
This is a severe depressive illness with
psychotic symptoms mixed in, but
without periods of mania or highs
occurring at any point during the illness.
It is this last point that distinguishes a
psychotic depression from a bi-polar
illness
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Schizophrenia – Positive & Negative
Symptoms
You will often hear mental health
professionals referring to the ‘positive’ and
‘negative’ symptoms of schizophrenia.
Positive symptoms refer to those
symptoms that are ‘more than’ normal
experiences
Negative symptoms refer to those
symptoms or changes in behaviour that are
‘less than’ a normal range of experiences
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What are ‘Negative
Symptoms’?
 This term was developed to describe those
symptoms which cause a person to function at a level
below those who are mentally healthy.
 They are used to describe such symptoms as:
flattened emotions, poor motivation and social
withdrawal.
 ‘Secondary’ features of these negative symptoms
may include sleep disturbance, agitation, low mood,
social isolation .
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Some symptoms you might
notice……
‘Positive’ symptoms - Talking to oneself or to
‘someone else’ who can’t be seen; appearing
perplexed or distracted; expressing strange or
bizarre beliefs about themselves, others or the
world e.g. “ I wrote all the Beatles hits”
“ The TV is talking about me”
Other way of recognizing positive symptoms is
that the person may use unusual words or their
conversation is hard to follow.
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Some symptoms you might
notice……
‘Negative’ symptoms - Often friends or
family have more problems coping with
these as they are often regarded as ‘bad’
behaviour. The person might just stop
going out, stop meeting up with friends,
they may stay in bed all day, self care
might be getting worse or they may
smoke more .
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ICD – Classification of
Schizophrenia
Any ONE of the following for a
month or more on most days,
not due to organic brain disease or
alcohol / drug intoxication.
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ICD – Classification of
Schizophrenia
1. Thought echo, withdrawal or broadcasting
2. Delusions of control, influence or passivity.
3. Third person auditory hallucinations,either
commentary or voices conversing.
4. Persistent delusions culturally inappropriate
and completely impossible
OR
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ICD – Classification of
Schizophrenia
Any TWO of the following for one month or
more:
1. Persistent hallucinations with partial or
overvalued ideas.
2. Breaks in train of thought, incoherence,
neologisms, irrelevance.
3.Catatonia, posturing, mutism
4. Negative symptoms –apathy,blunting of
affect, social withdrawal,paucity of speech.
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DSM – Classification of
Schizophrenia
Presence of any of (1), (2) or (3) for at least ONE
WEEK
(1) 2 of the following :- delusion, prominent
hallucinations, incoherence,catatonia,flat or
inappropriate affect.
(2) Bizarre delusions
(3) Prominent hallucinations commentary or
conversing.
Also marked social function defect for 6
months and No manic or depressive syndrome.
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How the definition of a ‘delusion’ has
changed over time?
 A ‘false unshakeable belief which arises out
of an internal morbid process out of keeping
with a persons educational and cultural
background’(Hamilton 1978).
 ‘Delusions involve a misinterpretation.. , the
distinction between a delusion and strongly held
idea is difficult to make and depends on degree
of conviction, can be modifiable.’( DSM IV 1994)
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Incidence & Prevalence - How many
people does psychosis affect?
 The average incidence of psychosis is 15 per
100,000 new cases per annum (DOH 2001)
 ‘Point prevalence rate’ ( the number of people with a
‘psychotic’ diagnosis at a single point in time rather
than lifetime prevalence) - 5 per 1000 (Singleton et al
2001) this means 212,000 in UK (177,000 in
England).
 10,000 to 50,000 people in UK are likely to have
been given a diagnosis of schizophrenia (Kinderman
& Cooke 2000)
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Local Incidence &
prevalence
All areas of Manchester have admission rates for
mental health needs above the national average
(Griffiths 1998).
There are over 65,000 students Manchester.Their
sexual and mental health needs have been
established as priority areas (Stronach & Walker
2004)
The city of Manchester is the second most deprived
area in England with an associated higher rate of
mental health problems (Griffiths 1998)
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What groups of people are likely to get a
diagnosis of schizophrenia?
 This varies among minority ethnic communities - from
6 per 1000 amongst Bangladeshis to 16 per 1000
amongst black African-Caribbean people (Nazroo
and King 2002).
 The reasons for this difference are highly
controversial! (see Jenkins 1998)
 People in inner city areas are more likely to be given
a diagnosis than suburban areas ( Freeman 1994)
 Young people in their late teens and early twenties
are more commonly diagnosed ( Cooper 1987)
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Patterns of course of Schizophrenia
22%
35%
8%
Single episode, little social function deficit
Multiple episode, little social function deficit
Multiple episode , static social function deficit
35% Multiple episode, incremental social function deficit
Adapted from Shepard et al 1989
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The course and outcome of
schizophrenia
In a study by Ciompi in 1976, 228 patients with a diagnosis
of schizophrenia were followed up over 37 years.
27% Complete remission
22% Minor residual symptoms remained
24% Intermediate course – symptoms arose
episodically
22% Severe – continued to be symptomatic
9% Unstable / uncertain or were not classified
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Group Work – Concluding Exercise
 As a small group, write a short description of a
person as if you were outlining a ‘character’ in a
play.
 The only thing you know about this person before
you begin is that he/she MIGHT be exhibiting
signs of a psychotic illness
 What positive and/or negative symptoms may the
person be experiencing?
 What might the person be saying or doing with
those close to them or strangers?
 Be creative and try and make the person as
‘alive’ as possible.
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To Conclude…………
 Although the nature of psychosis has been
under examination for over a century, psychiatry
is still a ‘young science’.
 The symptoms of a psychotic illness involve both
‘positive’ symptoms and ‘secondary’, less
obvious symptoms.
 There are specific groups of the population that
are more vulnerable to receiving a diagnosis of
schizophrenia .
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