PSYCHOSISPSYCHOSIS

20072007

SummarySummary

Common psychiatric emergency may present to Common psychiatric emergency may present to health services other than mental health team.health services other than mental health team.

Co-morbidities are common - increase with ageCo-morbidities are common - increase with age First episodes best treated by specialist First episodes best treated by specialist

multidisciplinary teams delivering psychosocial multidisciplinary teams delivering psychosocial interventions as well as drugs.interventions as well as drugs.

Treatment achieves complete remission without Treatment achieves complete remission without relapse in 25%relapse in 25%

Use of low dose well tolerated atypical Use of low dose well tolerated atypical antipsychotic increases compliance and reduces antipsychotic increases compliance and reduces future relapsesfuture relapses

TerminologyTerminology

PsychosisPsychosis disorder of thinking and perception where disorder of thinking and perception where

typically patients do not ascribe their symptoms typically patients do not ascribe their symptoms to a mental disorderto a mental disorder

Positive symptomsPositive symptoms Delusions, hallucinations, thought disorderDelusions, hallucinations, thought disorder

Negative symptomsNegative symptoms A deficit state – what is not thereA deficit state – what is not there

DelusionDelusion False unshakeable belief out of keeping with the False unshakeable belief out of keeping with the

patients cultural educational and social patients cultural educational and social backgroundbackground

TerminologyTerminology

HallucinationHallucination

A sensory perception experienced in A sensory perception experienced in the absence of a real stimulusthe absence of a real stimulus

ProdromeProdrome

A definable period before the onset A definable period before the onset of psychotic symptoms during of psychotic symptoms during which functioning becomes which functioning becomes impaired.impaired.

FrequencyFrequency

1 yr prevalence of non organic psychosis is 1 yr prevalence of non organic psychosis is 4.5/1000 community residents.4.5/1000 community residents.

Commonest age of presentation men < 30 Commonest age of presentation men < 30 women < 35 and people >60.women < 35 and people >60.

Schizophrenia has a 1 yr prevalence of Schizophrenia has a 1 yr prevalence of 3.3/1000 and life time morbidity of 3.3/1000 and life time morbidity of 7.2/10007.2/1000

Psychotic symptoms have a 10.1% Psychotic symptoms have a 10.1% prevalence in non demented community > prevalence in non demented community > 85yrs85yrs

Disorders in which psychotic Disorders in which psychotic symptoms occurssymptoms occurs

SchizophreniaSchizophreniaBipolar disorderBipolar disorderDepressionDepressionSubstance misuse particularly Substance misuse particularly

cannabiscannabisDementiaDementiaParkinson’s diseaseParkinson’s disease

Other causes of psychosisOther causes of psychosis

NeurologicalNeurologicalEpilepsyEpilepsyHead injuryHead injuryCVACVAInfectionInfectionTumoursTumours

Most causes of deliriumMost causes of delirium

SchizophreniaSchizophrenia

Incidence increased byIncidence increased byEthnic originEthnic originMigrationMigrationEconomic inequality in areas of Economic inequality in areas of

high deprivationhigh deprivation

DiagnosisDiagnosis

Diagnosis based on clinical findingsDiagnosis based on clinical findings No confirmatory testsNo confirmatory tests Investigations might be required to rule out Investigations might be required to rule out

organic psychosis.organic psychosis. Most information gained on first assessmentMost information gained on first assessment Antipsychotic treatment can reduce strength Antipsychotic treatment can reduce strength

of delusionof delusion Patients learn quickly that disclosing Patients learn quickly that disclosing

symptoms can lead to implications for drugs symptoms can lead to implications for drugs and libertyand liberty

HistoryHistory

Important to gain patients trust byImportant to gain patients trust by Recording presenting complaints firstRecording presenting complaints first Listening empathicallyListening empathically

Open questionsOpen questions How have things been for you latelyHow have things been for you lately Do you think something funny has been going Do you think something funny has been going

onon Have you heard unusual noises or voicesHave you heard unusual noises or voices Could someone be behind thisCould someone be behind this

HistoryHistory

Enquire about 3 core mood Enquire about 3 core mood symptomssymptomsMoodMoodEnergyEnergyInterest and pleasureInterest and pleasure

Psychosis + major alterations in Psychosis + major alterations in mood may indicate bipolar or mood may indicate bipolar or schizoaffective disorders.schizoaffective disorders.

Other aspects of historyOther aspects of history

Symptoms in other systems especially Symptoms in other systems especially neurological and endocrineneurological and endocrine

Past psychiatric symptomsPast psychiatric symptoms Past medical history and medicationPast medical history and medication Family history of mental health and suicideFamily history of mental health and suicide Alcohol and substance misuseAlcohol and substance misuse Allergies and adverse drug reactionsAllergies and adverse drug reactions

Mental state examinationMental state examination

Thorough documentation improves Thorough documentation improves accuracy now and in later yearsaccuracy now and in later years

General behaviour General behaviour over arousal and hostility suggestive of over arousal and hostility suggestive of

positive symptoms.positive symptoms. Irritability suggestive of elevated moodIrritability suggestive of elevated mood Catatonia and negativism rare Catatonia and negativism rare Altered consciousness unusual in non organic Altered consciousness unusual in non organic

psychosispsychosis Intermittent clouding suggests deliriumIntermittent clouding suggests delirium

Mental state examinationMental state examination

General behaviourGeneral behaviourDisorganised speech indicates thought Disorganised speech indicates thought

disorderdisorderStilted and difficult conversation occurs Stilted and difficult conversation occurs

with negative symptomswith negative symptomsNew words – neologisms best written New words – neologisms best written

downdownRandom changes in conversationRandom changes in conversationFast or pressured speech suggests maniaFast or pressured speech suggests mania

Mental State ExaminationMental State Examination

MoodMoodDepressed or elevatedDepressed or elevated

AffectAffectNormal or flatNormal or flat

Asses suicidal riskAsses suicidal riskCognitive impairmentCognitive impairment

Grossly abnormal indicates learning Grossly abnormal indicates learning disability or organic disorderdisability or organic disorder

Differential diagnosisDifferential diagnosis

Bipolar affective disorderBipolar affective disorder Schizoaffective disorderSchizoaffective disorder Severe depression with psychotic featuresSevere depression with psychotic features Delusional disorderDelusional disorder Post traumatic stress disorderPost traumatic stress disorder Obsessive compulsive disorderObsessive compulsive disorder Schizotypal or paranoid personality Schizotypal or paranoid personality

disorderdisorder AspergersAspergers ADHDADHD

Collateral historyCollateral history

Important as family or friends may Important as family or friends may have noted strange behaviourhave noted strange behaviour

May identify a prodromeMay identify a prodromeAcute stress causing symptomsAcute stress causing symptomsGain information about premorbid Gain information about premorbid

personalitypersonalityAre beliefs culturally sanctioned and Are beliefs culturally sanctioned and

not delusionalnot delusional

Positive psychotic symptomsPositive psychotic symptoms

Paranoid delusionParanoid delusion Any delusion that refers back to selfAny delusion that refers back to self

Delusions of thought interferenceDelusions of thought interference Delusions that others can hear read insert or Delusions that others can hear read insert or

steal one’s thoughtssteal one’s thoughts Passivity phenomenaPassivity phenomena

Beliefs that others can control your will, limb Beliefs that others can control your will, limb movements, bodily functions or feelings.movements, bodily functions or feelings.

Thought echoThought echo Hearing own thoughts spoken out loudHearing own thoughts spoken out loud

Positive psychotic symptomsPositive psychotic symptoms

Third person auditory hallucinationsThird person auditory hallucinations Voices speaking about the patient, running Voices speaking about the patient, running

commentaries – common in non affective psychosiscommentaries – common in non affective psychosis Hallucinations without affective contentHallucinations without affective content Second person auditory hallucinationsSecond person auditory hallucinations

Voices speaking to patient - may give commandsVoices speaking to patient - may give commands Thought disorderThought disorder

Thought block, over inclusive thinking, difficulties Thought block, over inclusive thinking, difficulties in abstract thought – can’t explain proverbsin abstract thought – can’t explain proverbs

Negative symptomsNegative symptoms

Apathy – disinterest blunted affectApathy – disinterest blunted affect Emotional withdrawal – flat affectEmotional withdrawal – flat affect Odd or incongruous affect Odd or incongruous affect

Smiling when recounting sad eventsSmiling when recounting sad events Lack of attention to personal hygieneLack of attention to personal hygiene Poor rapportPoor rapport

Reduced verbal and non verbal communication Reduced verbal and non verbal communication no eye contactno eye contact

Lack of spontaneity and flow of Lack of spontaneity and flow of conversationconversation

Which treatment settingWhich treatment setting

Best treated in least restrictive Best treated in least restrictive settingsetting

70% of first episodes end up in 70% of first episodes end up in hospitalhospital

Older adults, adolescents and Older adults, adolescents and post partum women have post partum women have complex needs and require complex needs and require admission to specialist units.admission to specialist units.

TreatmentTreatment

Patients declining treatment need Patients declining treatment need assessment under the mental health assessment under the mental health actactDanger to self –suicide, unsafe Danger to self –suicide, unsafe

behaviour, exploitation by othersbehaviour, exploitation by othersDanger to others – over arousal, Danger to others – over arousal,

potential to harm, risk of acting on potential to harm, risk of acting on delusiondelusion

Special GroupsSpecial Groups

Groups requiring special Groups requiring special unitsunitsOlder AdultsOlder AdultsAdolescentsAdolescentsPost- partum womenPost- partum women

ManagementManagement

Listen to patients relatives to catch Listen to patients relatives to catch relapse early and identify harmful relapse early and identify harmful components of ward environmentcomponents of ward environment

Consult with early intervention teamConsult with early intervention team Identify and change environmental factors Identify and change environmental factors

that perpetuate psychosisthat perpetuate psychosis When new symptoms occur consider drug When new symptoms occur consider drug

side effectsside effects Start psychosocial interventions earlyStart psychosocial interventions early Test for substance misuseTest for substance misuse

ManagementManagement

All antipsychotics cause All antipsychotics cause SedationSedationWeight gainWeight gainImpaired glucose tolerance – metabolic Impaired glucose tolerance – metabolic

syndrome insulin resistance increased syndrome insulin resistance increased risk cardiovascular events measure risk cardiovascular events measure waist circ.waist circ.

Lower seizure thresholdLower seizure threshold? Increased risk of thromboembolism? Increased risk of thromboembolism

Typical antipsychotic drugsTypical antipsychotic drugs

Cause moreCause moreExtrapyramidal sideffectsExtrapyramidal sideffectsRaised prolactin – sexual dysfunctions and Raised prolactin – sexual dysfunctions and

galactorrhoeagalactorrhoeaAnticholinergic sideffects – dry mouth Anticholinergic sideffects – dry mouth

tachycardia urinary obstructiontachycardia urinary obstructionAntiadrenergic – postural hypotension Antiadrenergic – postural hypotension

impotenceimpotence

ManagementManagement

Psychosocial with strong Psychosocial with strong evidence for benefitevidence for benefitCBT reduces impact of symptomsCBT reduces impact of symptomsFamily interventions prevent Family interventions prevent

relapserelapsePsycho educational interventionsPsycho educational interventionsSupported employmentSupported employment

PrognosisPrognosis

Relapse at one yearRelapse at one yearAntipsychotic treatment but on Antipsychotic treatment but on

psychosocial interventionpsychosocial intervention40% but 62% if in stressful 40% but 62% if in stressful

environmentenvironment27% of patients with first psychotic 27% of patients with first psychotic

episodeepisode48%when 548%when 5thth or more psychotic or more psychotic

episodeepisode

PrognosisPrognosis

Relapse at one yearRelapse at one yearPlacebo treatment no Placebo treatment no

psychosocial interventionpsychosocial intervention61% with first psychotic episode61% with first psychotic episode87% with 587% with 5thth or more psychotic or more psychotic episodesepisodes

PrognosisPrognosis

Relapse at one yearRelapse at one yearAntipsychotic treatment with Antipsychotic treatment with

psychosocial interventionspsychosocial interventions19% with family education19% with family education20% with social skills training20% with social skills training0% with both interventions0% with both interventions

PrognosisPrognosis

Recovery at 15-25 years defined Recovery at 15-25 years defined as global assessment of function as global assessment of function >60>60

37.8% with schizophrenia37.8% with schizophrenia54.8% with other psychosis54.8% with other psychosis

MaintenanceMaintenance

After recoveryAfter recoverySingle antipsychotic for one year after Single antipsychotic for one year after

first episode followed by gradual first episode followed by gradual withdrawal in asymptomatic patientswithdrawal in asymptomatic patients

Multiple psychotic episodes require Multiple psychotic episodes require longer prophylaxsislonger prophylaxsisThere are high personal and health service There are high personal and health service

costs for relapse so decisions need to be costs for relapse so decisions need to be made carefullymade carefully

Risk of RelapseRisk of Relapse

Indicators of relapse areIndicators of relapse areResidual disabilityResidual disabilityFamily history of psychosisFamily history of psychosisCurrent substance misuseCurrent substance misuse