Transcript PSYCHOSIS
PSYCHOSIS
2007
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
Terminology
Psychosis
Positive symptoms
Delusions, hallucinations, thought disorder
Negative symptoms
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
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
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
Schizophrenia
Incidence
increased by
Ethnic origin
Migration
Economic inequality in areas of high
deprivation
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
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
History
Enquire about 3 core mood symptoms
Mood
Energy
Interest
and pleasure
Psychosis + major alterations in mood
may indicate bipolar or schizoaffective
disorders.
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
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
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
Mental State Examination
Mood
Depressed
or elevated
Affect
Normal
or flat
Asses suicidal risk
Cognitive impairment
Grossly
abnormal indicates learning disability
or organic disorder
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
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
Positive psychotic symptoms
Paranoid delusion
Delusions of thought interference
Delusions that others can hear read insert or steal
one’s thoughts
Passivity phenomena
Any delusion that refers back to self
Beliefs that others can control your will, limb
movements, bodily functions or feelings.
Thought echo
Hearing own thoughts spoken out loud
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
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
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
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
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
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
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
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
Indicators of relapse are
Residual
disability
Family history of psychosis
Current substance misuse