What is Psychosis?

1. What is Psychosis? Manchester Mental Health & Social Care Trust

2. 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.

3. Terms We Use … As a large group let us consider what terms are used to describe someone who has a mental illness…..

4. 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.

5. 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)

6. The Historical Background • Kraepelin 1893 – Developed groups of symptoms into catatonia, paranoia, hebephrenic and simple. He alsonoted 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.

7. 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

8. 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

9. 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

10. 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 counter-arguments 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

11. 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

12. 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.

13. 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.

14. 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.

15. 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.

16. 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)

17. 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.

18. 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

19. 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

20. 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.

21. 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.

22. 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.

23. 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

24. 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

25. 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 .

26. 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.

27. 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 .

28. 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.

29. 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

30. 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.

31. 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.

32. 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)

33. Incidence & Prevalence - How many people does psychosis affect? • The average incidenceof 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)

34. 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)

35. 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)

36. Patterns of course of Schizophrenia Single episode, little social function deficit 22% Multiple episode, little social function deficit 35% Multiple episode , static social function deficit 8% 35% Multiple episode, incremental social function deficit Adapted from Shepard et al 1989

37. 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

38. 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.

39. 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 .