Psychiatry - Psychosis

Question 1

Psychosis?

Answer 1

• Severe mental disorder: Extreme impairment of ability to think clearly, respond with appropriate emotion, communicate effectively, understand reality and behave appropriately
• Functional impairment and debilitating
• Psychosis occurs in a number of serious mental illnesses, some neurological and drugs not associated with abuse
• Delusions and hallucinations

Question 2

Psychosis?

Epidemiology?

Answer 2

• 80% of patients present between the ages of 16-30
• Women tend to present at a slightly older age than men
• Women more susceptible when premenstrual, during the puerperium and the menopause
• UK studies: Higher prevalence of psychosis in the black and minority ethnic (BME)

Question 3

Psychosis?

Presentation?

Answer 3

• Brought in by third party - lack of insight
• First contact may be with family members - home visit may be necessary
• Home visit: If there is risk - joint visit with an experienced community psychiatric nurse and/or the police
• Psychiatric Hx and MSE
• Physical examination is unlikely to be rewarding in the younger patient. In older patient there may be physical signs of alcohol abuse, neurological features and/or other signs of systemic disease. Always look for evidence of poor personal hygiene or self-neglect

Question 4

Psychosis?

Investigations?

Answer 4

Usually referral to mental health services if presenting with psychosis

Some investigations to do before:

• FBC & LFTs: Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse
• Syphilis testing
• AIDS screening
• Urine drug screens
• CT brain scan may be

Question 5

Psychosis?

Differentials and Management?

Answer 5

Hx should aid with distinguishing between schizophrenia, BPAD and depressions

Management:

• PROMPT diagnosis and management of first episode is key
• Cause ?substance abuse
• Dual diagnosis
• Family intervention
• NICE: Treat all patients who have psychosis with respect throughout the whole care plan, including the experience of compulsory hospitalisation where necessary

Question 6

Psychosis?

Aims of Treatment?

Answer 6

• Reduce duration of untreated psychosis
• Accelerate remission and prevent relapse
• Use both biological and psychological measures
• Maximise the patient’s ability to get back to normal life
• Prompt secondary care assessment – psychiatric unit
• Rapid tranquilisation – for patient’s safety or safety of others

Question 7

Psychosis?

Management of Psychosis?

Answer 7

Schizophrenia:

• 1st line: Newer atypical antipsychotics e.g. risperidone or olanzapine is first-line but haloperidol is still used

Mania and hypomania:

• Atypical antipsychotics, benzodiazepines (to aid sleep or reduce agitation), mood stabilisers

Depression:

• Psychosis in depression is usually part of the spectrum of bipolar disorder

Question 8

Psychosis?

Prognosis?

Answer 8

• Not as bleak now due to early intervention and better treatment
• Can be disastrous consequences
• Factors from one study that determined five-year prognosis after a first episode of psychosis included Global Assessment of Functioning (GAF) score during the year before first admission, education level, actual GAF score at first admission, gender and social network
• Another study found 20% of patients were in symptomatic and functional remission within two years
• Education is important to develop insight
• Psychosis appears to deteriorate rapidly in the early stages before reaching a level of stability