Psychosis Flashcards
What is psychosis?
Psychosis is a severe mental health problem in which there is extreme impairment of ability to think clearly, respond with appropriate emotion, communicate effectively, understand reality and behave appropriately.
What is a delusion?
A delusion is a false, fixed, strange, or irrational belief that is firmly held. The belief is not normally accepted by other members of the same culture or group. It is important to look at culture, especially with ethnic issues, to decide if strange beliefs are really psychotic.
There are delusions of paranoia (plots against them), delusions of grandeur (exaggerated ideas of importance or identity) and somatic delusions (false belief in having a terminal illness).
What is an hallucination?
An hallucination is sensory perception (seeing, hearing, feeling, smelling) without an appropriate stimulus, like hearing voices when no one is talking. Not all hallucination suggests psychosis.
How should a person with psychosis be assessed?
Follow the guidance for psychiatric assessment but history should cover the following ground (the accompanying person may be a very valuable source of information):
- What is the nature of the hallucination or delusion?
-What is the time span? - Is there a recurring theme?
- Is there insight into it being unreal?
- Have there been any recent major life events?
- Is there a history of substance misuse (alcohol or drugs)?
- Does the patient’s past behaviour suggest psychological vulnerability - e.g., irritability, uneasiness, suspiciousness and withdrawn mood?
- Is there a family history of mental illness?
What are the investigations for a person presenting with psychosis?
Psychosis will usually require urgent referral to mental health services but there are some investigations that can be undertaken in the practice. The management of schizophrenia in primary care is well established but most doctors will want a specialist opinion at the outset.
Differential diagnoses suggest the following tests may be useful:
- Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol misuse
- Serological tests for syphilis
- Screening for AIDS.
- Urine screen for recreational drugs. Light recreational use of cannabis can produce a positive test for the subsequent fortnight. Heavy and chronic use can produce a positive result for months after the last use
- CT brain scan could exclude a space-occupying lesion or cerebral atrophy if focal signs are present - but not routinely.
What are the organic causes of psychosis?
Organic psychoses can be caused by a variety of conditions including strokes, brain injury, encephalitis, Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, temporal lobe epilepsy or brain tumours.
What is the management of psychosis?
It is very important to recognise and manage a first episode of psychosis correctly, as delay in diagnosis may adversely affect prognosis. If there is an external cause like substance misuse this must be addressed. Remember that psychosis in substance misuse can be part of dual diagnosis
Aims of treatment
- Reduce time between appearance of symptoms and initiating therapy (ie 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.
Admission to a psychiatric unit is often required at the outset. Compulsory admission and possibly enforced treatment under the Mental Health Act may be required. The condition is so distressing that some patients may go voluntarily.
First-line treatment in suspected schizophrenia now involves the use of the newer atypical antipsychotics - eg, risperidone or olanzapine is first-line but haloperidol is still used.
Drugs used for mania and hypomania include atypical antipsychotics, benzodiazepines - to aid sleep or reduce agitation - and mood stabilisers such as lithium and carbamazepine (usually under specialist supervision).
What is schizophrenia?
Schizophrenia is the most common form of psychosis. It is a lifelong condition, which can take on either a chronic form or a form with relapsing and remitting episodes of acute illness. It is a disorder which not only affects patients but also family and close friends.
What is the aetiology of schizophrenia?
Multiple factors are involved in schizophrenia - eg, genetic, environmental and social. Short-lived illnesses similar to paranoid schizophrenia are associated with cocaine, amphetamines and cannabis.
Cannabis use especially has been noted to be a culprit in both established schizophrenia and in enhancing future risk of schizophrenia in those who have not yet developed psychotic symptoms
What are the risk factors for schizophrenia?
Family history - specific genetic variants and pathways that increase susceptibility to schizophrenia have been identified.
Intrauterine and perinatal complications - e.g., premature birth, low birth weight.
Intrauterine infection, particularly viral.
Abnormal early cognitive/neuromuscular development.
Social isolation, migrants. The higher level of schizophrenia in migrants probably reflects a mixture of environmental and social factors.
Abnormal family interactions - e.g., hostile or overly critical parents.
What is the presentation of schizophrenia?
The hallmark symptoms of a psychotic illness are:
- Delusions
- Hallucinations
- Thought disorder
- Lack of insight
What are the positive symptoms of schizophrenia?
These ‘first rank’ or ‘positive’ symptoms of schizophrenia are rare in other psychotic illnesses (eg, mania or organic psychosis).
The presence of only one of the following symptoms is strongly predictive of the diagnosis:
- Lack of insight.
- Auditory hallucinations, especially the echoing of thoughts, or a third person ‘commentary’ on one’s actions - eg, ‘Now he’s putting on his coat.’
- Thought insertion, removal or interruption - delusions about external control of thought.
- Thought broadcasting - the delusion that others can hear one’s thoughts.
- Delusional perceptions (ie abnormal significance for a normal event) - eg, ‘The rainbow came out and I realised I was the son of God.’
- External control of emotions.
- Somatic passivity - thoughts, sensations and actions are under external control.
What are the negative symptoms of schizophrenia?
Underactivity - which also affects speech. Low motivation. Social withdrawal. Emotional flattening. Self-neglect.
What are the signs of schizophrenia?
In the mental state examination, be alert for:
- Appearance and behaviour - withdrawal, suspicion, or (rarely) stereotypical behaviours (repetition of purposeless movements) and mannerisms (eg, saluting).
- Speech - interruptions to the flow of thought (thought blocking), loosening of associations/loss of normal thought structure (knight’s move thinking).
- Mood/affect - flattened, incongruous or ‘odd’.
- Abnormal beliefs - delusional percepts, delusions concerning thought control or broadcasting, passivity experiences.
- Abnormal experiences - hallucinations, especially auditory.
- Cognition - attention, concentration, orientation and memory should be assessed (significant impairment suggests delirium or severe dementia).
What are the differentials for schizophrenia?
Organic disorders:
- Drug-induced psychosis- amfetamine, LSD, cannabis
- Temporal lobe epilepsy
- Encephalitis
- Alcoholic hallucinosis
- Dementia
- Delirium due to infection, metabolic or toxic disturbance.
- Cerebral syphilis (rare)
Psychiatric conditions
- Mania
- Psychotic depression
- Panic disorders
- Personality disorders
- Dissociative identity disorder
