PSYCHOSIS

1. PSYCHOSIS 2007

2. Summary • 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

3. Terminology • Psychosis • disorder of thinking and perception where typically patients do not ascribe their symptoms to a mental disorder • Positive symptoms • Delusions, hallucinations, thought disorder • Negative symptoms • A deficit state – what is not there • Delusion • False unshakeable belief out of keeping with the patients cultural educational and social background

4. 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.

5. 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

6. Disorders in which psychotic symptoms occurs • Schizophrenia • Bipolar disorder • Depression • Substance misuse particularly cannabis • Dementia • Parkinson’s disease

7. Other causes of psychosis • Neurological • Epilepsy • Head injury • CVA • Infection • Tumours • Most causes of delirium

8. Schizophrenia • Incidence increased by • Ethnic origin • Migration • Economic inequality in areas of high deprivation

9. Diagnosis • 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

10. History • Important to gain patients trust by • Recording presenting complaints first • Listening empathically • Open questions • 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

11. History • Enquire about 3 core mood symptoms • Mood • Energy • Interest and pleasure • Psychosis + major alterations in mood may indicate bipolar or schizoaffective disorders.

12. Other aspects of history • 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

13. Mental state examination • Thorough documentation improves accuracy now and in later years • General behaviour • 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

14. Mental state examination • 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

15. Mental State Examination • Mood • Depressed or elevated • Affect • Normal or flat • Asses suicidal risk • Cognitive impairment • Grossly abnormal indicates learning disability or organic disorder

16. Differential diagnosis • 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

17. 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

18. Positive psychotic symptoms • Paranoid delusion • Any delusion that refers back to self • Delusions of thought interference • Delusions that others can hear read insert or steal one’s thoughts • Passivity phenomena • Beliefs that others can control your will, limb movements, bodily functions or feelings. • Thought echo • Hearing own thoughts spoken out loud

19. Positive psychotic symptoms • Third person auditory hallucinations • Voices speaking about the patient, running commentaries – common in non affective psychosis • Hallucinations without affective content • Second person auditory hallucinations • Voices speaking to patient - may give commands • Thought disorder • Thought block, over inclusive thinking, difficulties in abstract thought – can’t explain proverbs

20. Negative symptoms • Apathy – disinterest blunted affect • Emotional withdrawal – flat affect • Odd or incongruous affect • Smiling when recounting sad events • Lack of attention to personal hygiene • Poor rapport • Reduced verbal and non verbal communication no eye contact • Lack of spontaneity and flow of conversation

21. 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.

22. Treatment • 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

23. Special Groups • Groups requiring special units • Older Adults • Adolescents • Post- partum women

24. Management • 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

25. Management • 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

27. Typical antipsychotic drugs • Cause more • Extrapyramidal sideffects • Raised prolactin – sexual dysfunctions and galactorrhoea • Anticholinergic sideffects – dry mouth tachycardia urinary obstruction • Antiadrenergic – postural hypotension impotence

28. Management • Psychosocial with strong evidence for benefit • CBT reduces impact of symptoms • Family interventions prevent relapse • Psycho educational interventions • Supported employment

29. 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

30. Prognosis • Relapse at one year • Placebo treatment no psychosocial intervention • 61% with first psychotic episode • 87% with 5th or more psychotic episodes

31. Prognosis • Relapse at one year • Antipsychotic treatment with psychosocial interventions • 19% with family education • 20% with social skills training • 0% with both interventions

32. Prognosis • Recovery at 15-25 years defined as global assessment of function >60 • 37.8% with schizophrenia • 54.8% with other psychosis

33. Maintenance • 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

34. Risk of Relapse • Indicators of relapse are • Residual disability • Family history of psychosis • Current substance misuse