PSYCHOSIS 2007

Summary Common psychiatric emergency may present to health services other than mental health team. Common psychiatric emergency may present to health services other than mental health team. Co-morbidities are common - increase with age Co-morbidities are common - increase with age First episodes best treated by specialist multidisciplinary teams delivering psychosocial interventions as well as drugs. First episodes best treated by specialist multidisciplinary teams delivering psychosocial interventions as well as drugs. Treatment achieves complete remission without relapse in 25% Treatment achieves complete remission without relapse in 25% Use of low dose well tolerated atypical antipsychotic increases compliance and reduces future relapses Use of low dose well tolerated atypical antipsychotic increases compliance and reduces future relapses

Terminology Psychosis Psychosis disorder of thinking and perception where typically patients do not ascribe their symptoms to a mental disorder disorder of thinking and perception where typically patients do not ascribe their symptoms to a mental disorder Positive symptoms Positive symptoms Delusions, hallucinations, thought disorder Delusions, hallucinations, thought disorder Negative symptoms Negative symptoms A deficit state – what is not there A deficit state – what is not there Delusion Delusion False unshakeable belief out of keeping with the patients cultural educational and social background False unshakeable belief out of keeping with the patients cultural educational and social background

Terminology Hallucination A sensory perception experienced in the absence of a real stimulus Prodrome A definable period before the onset of psychotic symptoms during which functioning becomes impaired.

Frequency 1 yr prevalence of non organic psychosis is 4.5/1000 community residents. 1 yr prevalence of non organic psychosis is 4.5/1000 community residents. Commonest age of presentation men 60. Commonest age of presentation men 60. Schizophrenia has a 1 yr prevalence of 3.3/1000 and life time morbidity of 7.2/1000 Schizophrenia has a 1 yr prevalence of 3.3/1000 and life time morbidity of 7.2/1000 Psychotic symptoms have a 10.1% prevalence in non demented community > 85yrs Psychotic symptoms have a 10.1% prevalence in non demented community > 85yrs

Disorders in which psychotic symptoms occurs Schizophrenia Schizophrenia Bipolar disorder Bipolar disorder Depression Depression Substance misuse particularly cannabis Substance misuse particularly cannabis Dementia Dementia Parkinson’s disease Parkinson’s disease

Other causes of psychosis Neurological Neurological Epilepsy Epilepsy Head injury Head injury CVA CVA Infection Infection Tumours Tumours Most causes of delirium Most causes of delirium

Schizophrenia Incidence increased by Incidence increased by Ethnic origin Ethnic origin Migration Migration Economic inequality in areas of high deprivation Economic inequality in areas of high deprivation

Diagnosis Diagnosis based on clinical findings Diagnosis based on clinical findings No confirmatory tests No confirmatory tests Investigations might be required to rule out organic psychosis. Investigations might be required to rule out organic psychosis. Most information gained on first assessment Most information gained on first assessment Antipsychotic treatment can reduce strength of delusion Antipsychotic treatment can reduce strength of delusion Patients learn quickly that disclosing symptoms can lead to implications for drugs and liberty Patients learn quickly that disclosing symptoms can lead to implications for drugs and liberty

History Important to gain patients trust by Important to gain patients trust by Recording presenting complaints first Recording presenting complaints first Listening empathically Listening empathically Open questions Open questions How have things been for you lately How have things been for you lately Do you think something funny has been going on Do you think something funny has been going on Have you heard unusual noises or voices Have you heard unusual noises or voices Could someone be behind this Could someone be behind this

History Enquire about 3 core mood symptoms Enquire about 3 core mood symptoms Mood Mood Energy Energy Interest and pleasure Interest and pleasure Psychosis + major alterations in mood may indicate bipolar or schizoaffective disorders. Psychosis + major alterations in mood may indicate bipolar or schizoaffective disorders.

Other aspects of history Symptoms in other systems especially neurological and endocrine Symptoms in other systems especially neurological and endocrine Past psychiatric symptoms Past psychiatric symptoms Past medical history and medication Past medical history and medication Family history of mental health and suicide Family history of mental health and suicide Alcohol and substance misuse Alcohol and substance misuse Allergies and adverse drug reactions Allergies and adverse drug reactions

Mental state examination Thorough documentation improves accuracy now and in later years Thorough documentation improves accuracy now and in later years General behaviour General behaviour over arousal and hostility suggestive of positive symptoms. over arousal and hostility suggestive of positive symptoms. Irritability suggestive of elevated mood Irritability suggestive of elevated mood Catatonia and negativism rare Catatonia and negativism rare Altered consciousness unusual in non organic psychosis Altered consciousness unusual in non organic psychosis Intermittent clouding suggests delirium Intermittent clouding suggests delirium

Mental state examination General behaviour General behaviour Disorganised speech indicates thought disorder Disorganised speech indicates thought disorder Stilted and difficult conversation occurs with negative symptoms Stilted and difficult conversation occurs with negative symptoms New words – neologisms best written down New words – neologisms best written down Random changes in conversation Random changes in conversation Fast or pressured speech suggests mania Fast or pressured speech suggests mania

Mental State Examination Mood Mood Depressed or elevated Depressed or elevated Affect Affect Normal or flat Normal or flat Asses suicidal risk Asses suicidal risk Cognitive impairment Cognitive impairment Grossly abnormal indicates learning disability or organic disorder Grossly abnormal indicates learning disability or organic disorder

Differential diagnosis Bipolar affective disorder Bipolar affective disorder Schizoaffective disorder Schizoaffective disorder Severe depression with psychotic features Severe depression with psychotic features Delusional disorder Delusional disorder Post traumatic stress disorder Post traumatic stress disorder Obsessive compulsive disorder Obsessive compulsive disorder Schizotypal or paranoid personality disorder Schizotypal or paranoid personality disorder Aspergers Aspergers ADHD ADHD

Collateral history Important as family or friends may have noted strange behaviour Important as family or friends may have noted strange behaviour May identify a prodrome May identify a prodrome Acute stress causing symptoms Acute stress causing symptoms Gain information about premorbid personality Gain information about premorbid personality Are beliefs culturally sanctioned and not delusional Are beliefs culturally sanctioned and not delusional

Positive psychotic symptoms Paranoid delusion Paranoid delusion Any delusion that refers back to self Any delusion that refers back to self Delusions of thought interference Delusions of thought interference Delusions that others can hear read insert or steal one’s thoughts Delusions that others can hear read insert or steal one’s thoughts Passivity phenomena Passivity phenomena Beliefs that others can control your will, limb movements, bodily functions or feelings. Beliefs that others can control your will, limb movements, bodily functions or feelings. Thought echo Thought echo Hearing own thoughts spoken out loud Hearing own thoughts spoken out loud

Positive psychotic symptoms Third person auditory hallucinations Third person auditory hallucinations Voices speaking about the patient, running commentaries – common in non affective psychosis Voices speaking about the patient, running commentaries – common in non affective psychosis Hallucinations without affective content Hallucinations without affective content Second person auditory hallucinations Second person auditory hallucinations Voices speaking to patient - may give commands Voices speaking to patient - may give commands Thought disorder Thought disorder Thought block, over inclusive thinking, difficulties in abstract thought – can’t explain proverbs Thought block, over inclusive thinking, difficulties in abstract thought – can’t explain proverbs

Negative symptoms Apathy – disinterest blunted affect Apathy – disinterest blunted affect Emotional withdrawal – flat affect Emotional withdrawal – flat affect Odd or incongruous affect Odd or incongruous affect Smiling when recounting sad events Smiling when recounting sad events Lack of attention to personal hygiene Lack of attention to personal hygiene Poor rapport Poor rapport Reduced verbal and non verbal communication no eye contact Reduced verbal and non verbal communication no eye contact Lack of spontaneity and flow of conversation Lack of spontaneity and flow of conversation

Which treatment setting Best treated in least restrictive setting Best treated in least restrictive setting 70% of first episodes end up in hospital 70% of first episodes end up in hospital Older adults, adolescents and post partum women have complex needs and require admission to specialist units. Older adults, adolescents and post partum women have complex needs and require admission to specialist units.

Treatment Patients declining treatment need assessment under the mental health act Patients declining treatment need assessment under the mental health act Danger to self –suicide, unsafe behaviour, exploitation by others Danger to self –suicide, unsafe behaviour, exploitation by others Danger to others – over arousal, potential to harm, risk of acting on delusion Danger to others – over arousal, potential to harm, risk of acting on delusion

Special Groups Groups requiring special units Groups requiring special units Older Adults Older Adults Adolescents Adolescents Post- partum women Post- partum women

Management Listen to patients relatives to catch relapse early and identify harmful components of ward environment Listen to patients relatives to catch relapse early and identify harmful components of ward environment Consult with early intervention team Consult with early intervention team Identify and change environmental factors that perpetuate psychosis Identify and change environmental factors that perpetuate psychosis When new symptoms occur consider drug side effects When new symptoms occur consider drug side effects Start psychosocial interventions early Start psychosocial interventions early Test for substance misuse Test for substance misuse

Management All antipsychotics cause All antipsychotics cause Sedation Sedation Weight gain Weight gain Impaired glucose tolerance – metabolic syndrome insulin resistance increased risk cardiovascular events measure waist circ. Impaired glucose tolerance – metabolic syndrome insulin resistance increased risk cardiovascular events measure waist circ. Lower seizure threshold Lower seizure threshold ? Increased risk of thromboembolism ? Increased risk of thromboembolism

Typical antipsychotic drugs Cause more Cause more Extrapyramidal sideffects Extrapyramidal sideffects Raised prolactin – sexual dysfunctions and galactorrhoea Raised prolactin – sexual dysfunctions and galactorrhoea Anticholinergic sideffects – dry mouth tachycardia urinary obstruction Anticholinergic sideffects – dry mouth tachycardia urinary obstruction Antiadrenergic – postural hypotension impotence Antiadrenergic – postural hypotension impotence

Management Psychosocial with strong evidence for benefit Psychosocial with strong evidence for benefit CBT reduces impact of symptoms CBT reduces impact of symptoms Family interventions prevent relapse Family interventions prevent relapse Psycho educational interventions Psycho educational interventions Supported employment Supported employment

Prognosis Relapse at one year Relapse at one year Antipsychotic treatment but on psychosocial intervention Antipsychotic treatment but on psychosocial intervention 40% but 62% if in stressful environment 40% but 62% if in stressful environment 27% of patients with first psychotic episode 27% of patients with first psychotic episode 48%when 5 th or more psychotic episode 48%when 5 th or more psychotic episode

Prognosis Relapse at one year Relapse at one year Placebo treatment no psychosocial intervention Placebo treatment no psychosocial intervention 61% with first psychotic episode 61% with first psychotic episode 87% with 5 th or more psychotic episodes 87% with 5 th or more psychotic episodes

Prognosis Relapse at one year Relapse at one year Antipsychotic treatment with psychosocial interventions Antipsychotic treatment with psychosocial interventions 19% with family education 19% with family education 20% with social skills training 20% with social skills training 0% with both interventions 0% with both interventions

Prognosis Recovery at years defined as global assessment of function >60 Recovery at years defined as global assessment of function > % with schizophrenia 37.8% with schizophrenia 54.8% with other psychosis 54.8% with other psychosis

Maintenance After recovery After recovery Single antipsychotic for one year after first episode followed by gradual withdrawal in asymptomatic patients Single antipsychotic for one year after first episode followed by gradual withdrawal in asymptomatic patients Multiple psychotic episodes require longer prophylaxsis Multiple psychotic episodes require longer prophylaxsis There are high personal and health service costs for relapse so decisions need to be made carefully There are high personal and health service costs for relapse so decisions need to be made carefully

Risk of Relapse Indicators of relapse are Indicators of relapse are Residual disability Residual disability Family history of psychosis Family history of psychosis Current substance misuse Current substance misuse