Psychosis

Question 1

Which questions should you ask regarding a suspected psychosis?

Answer 1

• When did the patient last feel themselves?
• How have things changed recently?
• Ask about normal life, friends/family, hobbies and interests
• Auditory halluncations
• Strange or frightening experiences
• Hearing things when nobody else is present
• TV/radio speaking TO them
• Feeling others are against them/want to harm them
• Ideas of special powers

Question 2

What are some differential diagnoses for psychosis?

Answer 2

• Brain tumours: accompanied by disorientation, memory loss, neurological features
• High-dose steroids
• Temporal lobe epilepsy
• Thyroid disease
• Encephalitis
• Acute confusion
• Dementia
• Metabolic disorders

Question 3

Which mental disorders can cause psychotic symptoms?

Answer 3

• Severe depression
• Drug-induced psychosis
• Manic phase of a bipolar disorder
• Dementia

Question 4

What is the first line treatment for psychosis?

Answer 4

• CBT
• Antipsychotics:

Nice guidance says patients should be offered antipsychotics + CBT

Question 5

What are the common side-effects of antipsychotic medication?

Answer 5

• Sedation
• Diabetes
• Raised prolactin

Question 6

Which baseline investigations should be performed before starting an anti-psychotic medication?

Answer 6

• Weight (on chart)
• Waist circumference
• Pulse and BP
• Fasting BMs, HbA1c, blood lipid profile and prolactin levels
• Assessment of movement disorders
• Assessment of nutritional status, diet, and physical activity
• ECG

Question 7

What are the criteria for a section 2 of the MHA?

Answer 7

• The patient is suffering from a mental disorder of a nature/degree which warrants hospital detention for assessment +/- treatment
• The patient ought to be detained in the interests of their own health/safety, or to protect others
• The patient will not agree to other forms of appropriate treatment/cannot consent

Question 8

What is a section 135?

Answer 8

Section 135:

• Can be used once
• Allows access to a premises to remove a patient to place of safety
• Does not allow for treatment
• Requires one doctor, AMHP and police
• Allows for further assessment

Question 9

What is a section 136?

Answer 9

Section 136:

• Can be used once
• Allows police to remove person from public place to safety
• Does not allow treatment
• Requires police

Question 10

What is a section 2?

Answer 10

Section 2:

• Lasts up to 28 days
• Admission for assessment
• Treatment can be given for mental disorder itself or condition directly as a result of it
• Requires application of AMHP or nearest relative, and 2 doctors
• Patient can appeal and be discharged
• Application is made for a section 3 if more detention needed

Question 11

What is a section 3?

Answer 11

Section 3:

• Lasts for 6 months
• Admission for treatment
• Treatment can be given for the first 3 months, then consent/second opinion needed
• Requires application by AMHP/nearest relative, and 2 doctors
• Patient can appeal and be discharged

Question 12

What is a section 4?

Answer 12

Section 4:

• Emergency admission for assessment
• Treatment can only be given under common law
• Requires application by AMHP/nearest relative, and any doctor
• Patient cannot appeal, only be discharged by responsible clinician

Question 13

What is a section 5(2)?

Answer 13

Section 5(2)

• Lasts for 72 hours
• Emergency holding order (patient already admitted on an informal basis)
• Treatment can only be given under common law
• Requires recommendation from doctor or approved clinician
• Cannot appeal

Question 14

What is a section 5(4)?

Answer 14

Section 5(4):

• 6 hours
• Emergency holding order when patient already admitted informally
• Treatment can only be given under common law
• Requires recommendation from a registered nurse
• Patient cannot appeal

Question 15

When are anti-psychotics indicated?

Answer 15

• Schizophrenia
• Schizoaffective disorder
• Severe depression with psychosis
• Augmenting agent in treatment resistant depression/anxiety
• Dementia

Question 16

What are typical antipsychotics?

Answer 16

Examples:

• Haloperidol
• Sulpiride
• Pimozide
• Chlorpromazine
• D2 dopamine receptor antagonists, and therefore have extrapyramidal side effects (Parkinsonian symptoms)

Question 17

What are atypical antispsychotics?

Answer 17

• Serotonin-dopamine 2 antagonsists (SDAs)
• Affect dopamine AND serotonin transmission

Examples:

• Risperidone (tablets, IM and immediate release)
• Olanzapine (tablets, IM and immediate release)
• Quetiapine (tablets), commonly causes orthostatic hypotension and weight gain
• Apiprazole (tablets and IM), D2 partial agonist, noQT prolongation

SE: weight gain and prolactinaemia, hyperglycaemia, hypercholesterolaemia, hypertrigyceridaemia

Question 18

How does Clozapine work?

Answer 18

• Atypical antipsychotic
• Regular tablets only
• Reserved for treatment resistant patients
• Associated with agranulocytosis
• Weekly bloods for first 6 months, then every fortnight for 6 months

- Increased risk of seizures (especially with lithium)
Side effects: 
- Sedation
- Weight gain
- Deranged LFTs
- Hypertriglyceridaemia
- hypercholesterolaemia
- Hyperglycaemia

Question 19

What is neuroleptic malignant syndrome?

Answer 19

Potentially life-threatening

Presents with autonomic dysfunction:

• Hyperthermia
• Hypertension
• Hyperreflexia
• Tachycardia
• Tremor
• Agitation
• Irritability
• Sweating

Complications:

• Rhabdomyolysis
• Hyperkalaemia
• Renal failure
• Seizures

Treatment:

• Discontinue medication
• ICU, ventilatory and circulatory support
• Treat hyperthermia with cooling
• Dantrolene/Bromocriptine/Amantadine for rigidity
• Benzodiazepines for agitation
• IV hydration for diuresis

Question 20

Following discharge from hospital, what should be done for the patient?

Answer 20

They should be managed in the community, with a Care Programme Approach:

Liaise early intervention in psychosis team

• Should include details of how to get help in a crisis
• Patients should receive a written care plan
• Updated and reviewed every 6-12 months