Psychosis

Question 1

What is psychosis?

Answer 1

Involves inability to distinguish between subjective experience and reality
Characterised by lack of insight
Harmful to individuals functioning of interpersonal relationships

Question 2

What are some psychotic experiences?

Answer 2

Hallucinations
Delusions
Passivity
Formal thought disorder
Emotional disturbance
Physical symptoms

Question 3

What are some of Schneider’s first rank symptoms?

Answer 3

Auditory hallucinations: voices arguing, thought echo, running commentary
Delusions of thought interference: thought insertion/withdrawal/broadcasting
Delusions of control: passivity of affect/impulse/volitions, somatic

Question 4

What is in the ddx of psychotic symptoms?

Answer 4

Schizophrenia
Psychoactive Substance Use
Mania
Depression
Schizoaffective Disorder
Delirium
Dementia
Other organic cause

Question 5

Define simple schizophrenia

Answer 5

A disorder in which there is an insidious but progressive development of oddities of conduct, inability to meet the demands of society, and decline in total performance. The characteristic negative features of residual schizophrenia (e.g. blunting of affect and loss of volition) develop without being preceded by any overt psychotic symptoms.

Question 6

What are self referential experiences?

Answer 6

The belief that external events are related to oneself
Can vary in intensity from a brief thought, to frequent & intrusive thoughts to delusional intensity (self-referential delusions or delusions of reference)

Question 7

Describe the symptoms in drug induced psychosis

Answer 7

May be florid symptoms or chronic symptoms but tend to be short lasting if access to the psychoactive substance is removed.

Question 8

Describe depressive psychosis

Answer 8

Psychosis is a marker of severity in depression
Typified by mood congruent content of psychotic symptoms
Delusions of worthlessness / guilt / hypochondriasis / poverty
Hallucinations of accusing / insulting / threatening voices – typically 2nd person

Question 9

Describe mania with psychosis

Answer 9

Typified by mood congruent content of psychotic symptoms
Delusions of grandeur / special ability / persecution / religiosity
Hallucinations: auditory (e.g. God’s voice)
Flight of ideas

Question 10

How commonly is a symptom of first rank present in a manic episode?

Answer 10

About 20%

Question 11

How is schizoaffective disorder characterised?

Answer 11

Presence of both symptoms typical of schizophrenia and affective disorder
Any specific episode may be schizo-manic or schizo-depressed

Question 12

What is delirium?

Answer 12

Acute confusion-transient global disturbance, common and related to many underlying conditions

Question 13

What conditions are related to delirium?

Answer 13

Alcohol Withdrawal
Infection-septicaemia
Medical/surgical in-patients
Organ failure-cardiac, renal, hepatic
Hypoglycaemia
Post-op hypoxia
Post-ictal
Encephalitis
SOL
Drug intoxication- steroids, digoxin, diuretics, anticholinergics
Drug withdrawal- benzos

Question 14

What happens in delirium?

Answer 14

Clouding of consciousness
-Ranges from subtle drowsiness to unresponsive
-Disorientation in time, place & person
-Fluctuating severity over time (lucid intervals)
-Worse at night
Impaired concentration / memory
-Especially for new information

Question 15

What symptoms occur in delirium?

Answer 15

Visual hallucinations/illusions +- auditory (often threatening)
Persecutory delusions
Psychomotor disturbance-agitation or retardation
Irritability
Insomnia

Question 16

How is the ddx of psychosis decided on?

Answer 16

Nature of psychotic experiences
3rd person auditory hallucinations suggest schizophrenia
Mood related delusions suggest affective disorder
Associated psychiatric symptoms
Natural history of the symptoms – presentation over time
Other features of history - FH, PH, DH etc

Question 17

What is the definition of violence?

Answer 17

The intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation

Question 18

What does the immediate treatment of aggression include?

Answer 18

Management of substance withdrawal phenomena and management of acutely disturbed or aggressive behaviour

Question 19

Under the Scottish Mental Health act, what is the definition of a patient?

Answer 19

A person who has or appears to have a mental disorder

Question 20

What is covered by the term ‘mental disorder’?

Answer 20

Any mental illness
Personality Disorder
Learning Disability
‘However caused or manifested’

Question 21

When should emergency detention be used, and who can use it?

Answer 21

‘Where it is necessary as a matter of urgency to detain the patient in hospital for the purpose of permitting a full assessment of the person’s mental state; and where if the patient were not detained in hospital there would be a significant risk to either themselves or others’
Any registered medical practioner

Question 22

How long does an emergency detention last?

Answer 22

Max 72 hrs

Question 23

What treatment is allowed under an emergency detention?

Answer 23

None-except emergency care

Must be reported to MWC on form T4

Question 24

Who can apply a short term detention?

Answer 24

Approved Medical Practitioner

Must have MHO consent

Question 25

Does a short term detention allow treatment?

Answer 25

Yes-treatment authorised

Question 26

How long does a short term detention last?

Answer 26

Max 28 days

Question 27

When should a STD be used?

Answer 27

The patient has mental disorder
The patient’s ability to make decisions about the provision of medical treatment is significantly impaired as a result of that mental disorder (Significantly Impaired Decision Making Ability)
It is necessary to detain the patient in hospital for the purpose of determining what medical treatment should be given to the patient or of giving them medical treatment
There would be a significant risk to the health, safety or welfare of the patient or to the safety of any other person if the patient were not detained in hospital

Question 28

Who can apply for a compulsory treatment order?

Answer 28

MHO- supported by two medical reports
One must be AHP
Other usually patient’s GP

Question 29

Does a CTO authorise treatment?

Answer 29

Yes

Question 30

Is a tribunal hearing required in a CTO?

Answer 30

Yes

Question 31

How long can a CTO last?

Answer 31

Up to 6 months

Question 32

What is the rapid tranquilisation policy for a patient with either/some of: history unknown, cardiac history, no history of typical antipsychotics, current illicit drug use?

Answer 32

Consider oral therapy- Lorazepam 1-2mg
If unsuccessful/need effect within 30 mins
Lorazepam 1-2mg IM (1:1 in water or 0.9% NaCl)
Wait 30 mins
Repeat injection once if necessary

Question 33

What is the rapid tranquilisation policy for a patient with confirmed history of significant typical antipsychotic exposure (not just PRN)?

Answer 33

Consider oral therapy- Lorazepam 1-2mg and/or haloperidol 5mg
If unsuccessful/need effect within 30 mins
Lorazepam 1-2mg IM (1:1 in water or 0.9% NaCl)
In extreme cases, combination of lorazepam and haloperidol 5mg IM (not in same syringe)
Monitor RR, HR, BP every 5/10mins for 1hr
Wait 30 mins
Repeat injections once if necessary

Question 34

What should be used for sedation in psychosis?

Answer 34

Use BDZ rather than increase antipsychotics, or use sedating antipsychotics

Question 35

How do you decide which antipsychotic to use?

Answer 35

Patient and carer preference (Advance statements if available)
Patient characteristics (age, weight, physical health etc)
Usually Atypical is first line
Depot – issues with compliance, patient preference
Clozapine – treatment resistant illness

Question 36

What is available for use in psychosis with mood disorder?

Answer 36

Mood stabilisers e.g. lithium, sodium valproate, carbamazepine, lamotrigine
Antidepressants
ECT