PSYCHOSIS
2007
Summary
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Common psychiatric emergency may present to health
services other than mental health team.
Co-morbidities are common - increase with age
First episodes best treated by specialist multidisciplinary
teams delivering psychosocial interventions as well as
drugs.
Treatment achieves complete remission without relapse
in 25%
Use of low dose well tolerated atypical antipsychotic
increases compliance and reduces future relapses
Terminology
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Psychosis
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Positive symptoms
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Delusions, hallucinations, thought disorder
Negative symptoms
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disorder of thinking and perception where typically
patients do not ascribe their symptoms to a mental
disorder
A deficit state – what is not there
Delusion
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False unshakeable belief out of keeping with the
patients cultural educational and social background
Terminology
Hallucination
A sensory perception experienced in the
absence of a real stimulus
Prodrome
A definable period before the onset of
psychotic symptoms during which
functioning becomes impaired.
Frequency
1 yr prevalence of non organic psychosis is
4.5/1000 community residents.
 Commonest age of presentation men < 30
women < 35 and people >60.
 Schizophrenia has a 1 yr prevalence of 3.3/1000
and life time morbidity of 7.2/1000
 Psychotic symptoms have a 10.1% prevalence in
non demented community > 85yrs
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Disorders in which psychotic
symptoms occurs
 Schizophrenia
 Bipolar
disorder
 Depression
 Substance misuse particularly
cannabis
 Dementia
 Parkinson’s disease
Other causes of psychosis
Neurological
 Epilepsy
 Head injury
 CVA
 Infection
 Tumours
 Most causes of delirium
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Schizophrenia
 Incidence
increased by
 Ethnic origin
 Migration
 Economic inequality in areas of high
deprivation
Diagnosis
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Diagnosis based on clinical findings
No confirmatory tests
Investigations might be required to rule out
organic psychosis.
Most information gained on first assessment
Antipsychotic treatment can reduce strength of
delusion
Patients learn quickly that disclosing symptoms
can lead to implications for drugs and liberty
History
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Important to gain patients trust by
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Recording presenting complaints first
Listening empathically
Open questions
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How have things been for you lately
Do you think something funny has been going on
Have you heard unusual noises or voices
Could someone be behind this
History
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Enquire about 3 core mood symptoms
 Mood
 Energy
 Interest
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and pleasure
Psychosis + major alterations in mood
may indicate bipolar or schizoaffective
disorders.
Other aspects of history
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Symptoms in other systems especially
neurological and endocrine
Past psychiatric symptoms
Past medical history and medication
Family history of mental health and suicide
Alcohol and substance misuse
Allergies and adverse drug reactions
Mental state examination
Thorough documentation improves accuracy
now and in later years
 General behaviour
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over arousal and hostility suggestive of positive
symptoms.
Irritability suggestive of elevated mood
Catatonia and negativism rare
Altered consciousness unusual in non organic
psychosis
Intermittent clouding suggests delirium
Mental state examination
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General behaviour
 Disorganised speech indicates thought
disorder
 Stilted and difficult conversation occurs with
negative symptoms
 New words – neologisms best written down
 Random changes in conversation
 Fast or pressured speech suggests mania
Mental State Examination
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Mood
 Depressed
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or elevated
Affect
 Normal
or flat
Asses suicidal risk
 Cognitive impairment
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 Grossly
abnormal indicates learning disability
or organic disorder
Differential diagnosis
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Bipolar affective disorder
Schizoaffective disorder
Severe depression with psychotic features
Delusional disorder
Post traumatic stress disorder
Obsessive compulsive disorder
Schizotypal or paranoid personality disorder
Aspergers
ADHD
Collateral history
Important as family or friends may have
noted strange behaviour
 May identify a prodrome
 Acute stress causing symptoms
 Gain information about premorbid
personality
 Are beliefs culturally sanctioned and not
delusional
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Positive psychotic symptoms
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Paranoid delusion
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Delusions of thought interference
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Delusions that others can hear read insert or steal
one’s thoughts
Passivity phenomena
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Any delusion that refers back to self
Beliefs that others can control your will, limb
movements, bodily functions or feelings.
Thought echo
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Hearing own thoughts spoken out loud
Positive psychotic symptoms
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Third person auditory hallucinations
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Voices speaking about the patient, running
commentaries – common in non affective psychosis
Hallucinations without affective content
 Second person auditory hallucinations
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Voices speaking to patient - may give commands
Thought disorder
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Thought block, over inclusive thinking, difficulties in
abstract thought – can’t explain proverbs
Negative symptoms
Apathy – disinterest blunted affect
 Emotional withdrawal – flat affect
 Odd or incongruous affect
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Smiling when recounting sad events
Lack of attention to personal hygiene
 Poor rapport
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Reduced verbal and non verbal communication no eye
contact
Lack of spontaneity and flow of conversation
Which treatment setting
 Best
treated in least restrictive setting
 70% of first episodes end up in
hospital
 Older adults, adolescents and post
partum women have complex needs
and require admission to specialist
units.
Treatment
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Patients declining treatment need
assessment under the mental health act
 Danger to self –suicide, unsafe
behaviour, exploitation by others
 Danger to others – over arousal,
potential to harm, risk of acting on
delusion
Special Groups
Groups
Older
requiring special units
Adults
Adolescents
Post- partum women
Management
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Listen to patients relatives to catch relapse early
and identify harmful components of ward
environment
Consult with early intervention team
Identify and change environmental factors that
perpetuate psychosis
When new symptoms occur consider drug side
effects
Start psychosocial interventions early
Test for substance misuse
Management
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All antipsychotics cause
 Sedation
 Weight
gain
 Impaired glucose tolerance – metabolic
syndrome insulin resistance increased risk
cardiovascular events measure waist circ.
 Lower seizure threshold
 ? Increased risk of thromboembolism
Typical antipsychotic drugs
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Cause more
 Extrapyramidal
sideffects
 Raised prolactin – sexual dysfunctions and
galactorrhoea
 Anticholinergic sideffects – dry mouth tachycardia
urinary obstruction
 Antiadrenergic – postural hypotension impotence
Management
 Psychosocial
for benefit
 CBT
with strong evidence
reduces impact of symptoms
 Family interventions prevent relapse
 Psycho educational interventions
 Supported employment
Prognosis
 Relapse
at one year
 Antipsychotic
treatment but on
psychosocial intervention
 40%
but 62% if in stressful environment
 27% of patients with first psychotic episode
 48%when 5th or more psychotic episode
Prognosis
 Relapse
at one year
 Placebo
treatment no psychosocial
intervention
61%
with first psychotic episode
87% with 5th or more psychotic
episodes
Prognosis
 Relapse
at one year
 Antipsychotic
treatment with
psychosocial interventions
19%
with family education
20% with social skills training
0% with both interventions
Prognosis
 Recovery
at 15-25 years defined as
global assessment of function >60
 37.8%
with schizophrenia
 54.8% with other psychosis
Maintenance
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After recovery
 Single
antipsychotic for one year after first
episode followed by gradual withdrawal in
asymptomatic patients
 Multiple psychotic episodes require longer
prophylaxsis
 There
are high personal and health service costs
for relapse so decisions need to be made carefully
Risk of Relapse
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Indicators of relapse are
 Residual
disability
 Family history of psychosis
 Current substance misuse