Psychosis

Question 1

What is psychosis?

Answer 1

• Patient cannot tell the difference between subjective experience and objective reality
• Lack of insight

Question 2

Is reality always perceived in the same way by people without psychosis?

Answer 2

No
Our brains filter information differently, but cant process fast enough
Everyone makes different shortcuts to avoid information overload

Question 3

What are the two main types of psychosis?

Answer 3

Paranoid - e.g. schizophrenia

Affective - Bipolar, unipolar depression

Question 4

What organic causes are there for psychosis?

Answer 4

Delirium
Dementia
Brain Injury
Stroke

Question 5

How can substance misuse cause psychosis?

Answer 5

Intoxication (e.g. Delirium Tremens in alcohol)

Withdrawal

Question 6

What symptoms indicate a patient is having a psychotic experience?

Answer 6

• Hallucinations
• Ideas of Reference
• Delusions
• Formal thought disorder
• Thought interference
• Passivity phenomena
• Loss of insight

Question 7

Describe the difference in normal brain processing of a stimulus, and how patients with hallucination process a stimulus.

Answer 7

Normal Brain:
Stimulus -> sensory organ -> brain processing -> perception of object

Hallucination
Aberrant brain processing (without stimulus) -> perception of object that is not there

Question 8

Hallucinations can take the form of what sensory modalities?

Answer 8

Visual
Auditory
Olfactory
Gustatory
Tactile (physical contact with imaginary object e.g. bugs)

Question 9

Describe what the brain thinks when it is trying to interpret psychotic symptoms

Answer 9

Hallucinations - brain cannot consider it is an internal perception

Thought insertion - someone else is putting these thoughts in my head, they are not my own

Passivity of action - someone else is moving my arm rather than myself

Question 10

What is meant by ideas of reference?

Answer 10

• Words/ messages jumping out at them
• Has a different meaning to them, often persecutory towards them
• usually from TV, radio, newspapers

Question 11

What is paranoia?

Answer 11

• The belief that external events are related to oneself

- Can be brief OR can have delusions of reference - e.g. patient thinks they are the second coming of Christ etc

Question 12

What is a delusion?

Answer 12

• falsely held belief
• patient is adamant regardless of contrary evidence
• usually held outwith the social, cultural and educational background of the patient
• Can be bizarre or impossible

Question 13

What is the difference between a primary and secondary delusion?

Answer 13

Primary - fully formed whilst patient is conscious and they require no explanation for it

Secondary - patient is trying to explain another experience e.g. hallucination

Question 14

Give examples of types of delusion

Answer 14

• Paranoid
• Persecutory
• Grandiose
• Religious (pt often thinks they are religious figure)
• Misidentification
- Capgrass - pt thinks certain people = spying on them
- Fregoli - pt thinks people are changing their appearance to spy on them
• Guilt
• Sin - pt is worried about something they have done in the past
• Poverty
• Nihilistic
• Erotomanic - pt thinks celebrity/incorrect person is in love with them
• Jealousy - “othello syndrome” - believe infidelity in significant other

Question 15

What does it mean that the content of delusions is culturally defined?

Answer 15

e.g. by a disease prevalent at that time in history

Nowadays by technology/ satellites

Question 16

What symptoms heard in a patients speech, would indicate they had a thought disorder?

Answer 16

• Neologisms (new words that pt has created)
• Tangentiality
• Clanging and punning
• Loosening of associations
• Knight’s move thinking
• Word Salad

Question 17

What are the main types of thought interference and what do patients complain of in each?

Answer 17

Thought insertion - thoughts being put into my head

Thought withdrawal - take my thoughts out of my head

Thought broadcasting - everyone knows what I am thinking

Thought blocking - I get halfway through thinking something and the thoughts just dry up

Question 18

What are the different types of passivity that patients may experience?

Answer 18

• action (someone else made them make an action)
• feelings (someone else made them feel something)
• urge
• influence on body (other person made them move)

Question 19

How should you challenge/confront patients about their psychotic symptoms?

Answer 19

CLARIFY:
“I just want to check that I am understanding this correctly, I don’t want to misunderstand you, I think what you are saying is that ……”

Creative ways to challenge:
• “What would you say if someone said to you that [these beliefs] are not true?”

“Explain to me how this is possible?”

IF ALL ELSE FAILS
“agree to disagree”

Question 20

What are the possible differential diagnoses for psychosis?

Answer 20

Drug induced
Depressive
Mania with Psychosis
Delirium

Question 21

How is a depressive psychosis noticed?

Answer 21

• content of delusions are usually depressive themes e.g. guilt/worthlessness
• auditory hallucinations are 2nd person, directed at depressed patient

Question 22

What differences from normal psychosis are seen in an episode of drug-induced psychosis?

Answer 22

• acute onset and short duration

- especially if psychoactive substance removed

Question 23

What symptoms are typical of mania with psychosis?

Answer 23

• Content of delusions = grandeur / special ability / persecution / religiosity
• Hallucinations: auditory (e.g. God’s voice)
• Flight of ideas

Question 24

What symptoms would indicate psychosis is potentially due to a delirium?

Answer 24

• Clouding of consciousness
• ranges from drowsiness to unresponsive
• disorientation in time, place and person
• lucid intervals
• worse at night
• Impaired concentration / memory (e.g. new info)
• agitation or psycho-motor retardation may be present