Introduction

Psychosis is an acute mental health state, resulting in delusional beliefs and hallucinations. It is commonly associated with Schizophrenia, although there can be several causes, including:

• Other mental health disorders
  • Depression
  • Bipolar disorder
• Drug and alcohol abuse – particularly amphetamines (especially methamphetamine), but also marijuana and other hallucinogens (e.g. LSD)
• Neurological disorders

Definitions

Delusion

• Fixed, strange or irrational belief, which is firmly held, and out of context for the individuals cultural background. Types can include:
  • Delusions of grandeur – exaggerated ideas of importance – e.g. belief that they are an important historical figure
  • Paranoia – e.g. belief in a plot against them
  • Somatic – belief that they have a terrible incurable illness

Hallucination

• A sensory perception – which can be auditory, visual, touch or smell based – without an obvious real-world stimulus
  • e.g. hearing voices, seeing animals or figures which are not present
• Hallucinations are seen in other disorders – particularly delirium

Epidemiology

• 80% of patients present between the ages of 16-30
• Incidence of about 50 per 100 000 per year
• M > F

Presentation

• Typically patient is brought to the doctor or emergency department by a third party – e.g. police, or relative or friend

A history and assessment should include:

• Drug and alcohol history
• Onset and duration of symptoms
• Any recent major life events or stressors
  • In particular – the death or psychosis event of a relative or friend
• Personal history of mental illness
• Family history of mental illness
• Assessment of delusions and hallucinations
  • ‘I want to ask you if you have had any unusual experiences that people often feel. Do you ever think that people are talking about you, or taking special notice of you?’ if yes – ask more about it. Why do they think this? Do they have any evidence?
  • E.g. this may be perfectly logical if for example, the family have been involved with the police.
  • Is anyone trying to harm you? – persecutory delusions
  • Do you have any special powers? – grandiose delusions
  • Do you ever feel someone is controlling you in some way? – passivity experiences
  • Have you ever had thoughts put into your head that are not your own? – thought insertion
• Assessment of insight
  • Some patients may realise that these are hallucinations or probable delusions
  • Others may really believe the things they see or hear are real, and have no insight that there delusions may not real be true
• Assess suicide risk
  • Perhaps also homicide risk

Mental state exam

• Appearance & behaviour – may show self neglect, restlessness or odd, or lack of movements, and odd appearance(e.g. hair / makeup / clothes)
• Speech – Tangential speech – one though is unrelated to the next. Often neologisms, may be incoherent, jumps from subject to subject.
• Mood – suspicious, may often seem deep in though and perplexed/confused
• Thoughts – delusions,though disorder, persecutory
• Perceptions – hallucinations – most commonly auditory
• Cognition – poor attention span and concentration, unshakable beliefs (‘concrete thinking’)

Investigations

• LFTs and FBC
  • Deranged LFTs and macrocytosis (enlarged RBCs) are suggestive of alcohol abuse
• Infectious disease
  • Screen for serology for syphilis and HIV
• Drug screening – to rule out amphetamines and cannabis as the cause
  • Typically a urinary drug screen
• EEG – to rule out epilepsy
• Fasting glucose – to rule out diabetes
• CT/MRI – looks for atrophy of the lateral ventricles. Also space occupying lesions can cause schizophrenia, but these are rare!
• Full neuro exam – checking for an organic cause

Differential Diagnosis

• Schizophrenia
• Bipolar disorder – often may present with symptoms of schizophrenia, such as Schneider’s first rank symptoms. Usually can be distinguished, due to the elation, erratic behaviour, grandiose delusions (usually schizophrenia is persecutory) and increased activity.
• Alcoholic Hallucinations – alcohol withdrawal may mimic schizophrenia for a short period (up to 2 weeks, usually less) may have second person hallucinations.
• Drugs – The drugs that cause these symptoms can be stimulants or hallucinogens. Examples include:
  • Cannabis
  • Steroids – These two drugs produce symptoms particularly consistent with schizophrenia
  • Cocaine
  • Ecstasy
  • LSD
  • Magic mushrooms (psilocybin)
  • Mescaline
  • Phencyclidine
• Organic disorders
  • Epilepsy – particularly temporal lobe seizures
  • Dementia
  • B12 def
  • Hypoglycaemia
  • Trauma/head injury
  • In trauma and head injury, the patient may hear voices that they can ‘talk to’. In psychiatric disease, this does usually not occur (or if the patient claims it does occur, it is often fictitious)
• Other mental health disorders
  • Brief Psychotic disorder – symptoms are present for less than a month, then disappear. Often sudden onset, and in some cases a precipitating factor (e.g. severe psychological stress) may be identified.
  • Delusional disorder – basically, might appear like schizophrenia, but, there are only hallucinations and /or delusions, and no other signs of schizophrenia. We say that delusional disorder exists when an individual has a complex and logical system of beliefs that are based on one or more delusional beliefs. There may also be auditory hallucinations, but there are usually no other schizophrenia-like symptoms. The delusions are usually either persecutory or grandiose. Three particularly common delusions are:
  • Dysmorphophobia – a delusion that their body is particularly deformed (e.g. they think they have a massive nose when they clearly don’t), to that it is always giving off a particularly foul smell
  • Morbid Jealousy – a delusion that the patient’s partner is cheating on them, despite very little evidence – e.g. they were late home one night
  • Erotomania – this is where the patient loves another individual, and believes the other individual also loves them – but that they are unable to show it
  • Often these patients have a history of paranoid personality, particularly sensitive to criticism, have a very rigid belief system, or a history of sensory depravation or temporal or parietal lobe defects.

Management

• Most cases of acute psychosis require admission to a mental health facility
  • There is a high likelihood that may require a compulsory admission
  • Some patients may go voluntarily but many do not
• Prompt recognition and treatment is associated with a better long-term outcome
• Often there is a dual diagnosis of drug abuse with schizophrenia
• Most cases are treated acutely with antipsychotic medication
  • Atypical antipsychotics are usually first line – e.g. olanzapine, quetipaine or risperidone
  • Haloperidol – a typical antipsychotic may also still be used in certain circumstances

Schizophrenia

Epidemiology

• 1% of the population will have a diagnosis of schizophrenia at some point in their lives
  • Prevalence – 200 per 100 000
  • Incidence – 20 per 100 000
• The incidence is roughly the same around the globe, however, the course of the disease varies according to location. In the western world, it is less likely to be ‘cured’.
  • Higher incidence in inner city, low socioeconomic environments. However it is thought that schizophrenia itself may cause this socioeconomic depravation – because the average patient has a lower than average status, but the parents of the patient usually have an ‘average’ socioeconomic status.
  • This is sometimes referred to as downward drift / social drift
• Peak incidence:
  • 18-25 in men
  • 25-30 in women
• Equal incidence in both men and women

Aetiology

• Loss of interest
• Social withdrawal
• Self-neglect
• Depression
• Anxiety
• Brief psychotic episodes
• This period is known as the prodromal period. A long prodromal period usually means that the diagnosis is delayed, and in these situations the prognosis is poor.

Genetic factors

• General risk – 1%
• If sibling has condition – 9%
• If parent has condition – 13%
• If both parents have condition – 45%

Environmental factors thought to be negligible – studies have shown that children kept away from their schizophrenic mothers are at the same risk of developing the condition as those who grew up with their birth mother.
Obstetric complications – are found in increased incidence in those who go on to develop the condition. This suggests that some kind of developmental abnormality may be present.
‘Sensitive’ personalities – some people have a tendency to perceive critiscm harshly, and to interpret non-critical comments as criticism. These people have an increased likelihood of developing schizophrenia.

Predisposing factors

• Periods of increased stress
• Periods of intense emotion (both positive and negative) – e.g. losing your job, winning the lottery
• Increased levels of criticism from friends and family members
• Drugs – particularly hallucinogens, stimulants, including amphetamines, alcohol and cannabis

Symptoms

• Many cognitive functions remain intact
• Only some functions affected
• Perceived loss of boundaries between the individual and the outside world
  • E.g. thoughts/acts/emotions may be perceived to be controlled by outside influences.
• Preoccupied with thoughts about the self

Typically the symptoms of depression are divided into:

• Positive symptoms
• Negative symptoms
• Cognitive impairment
• Mood disturbance

Positive symptoms

• Delusions
• Hallucinations
• Thought disorder
• Disorganised speech and behaviour

• Auditory Hallucinations – the most common symptom, and often the easiest to elicit. These can take several forms:
  • Third person – talking about the individual who hears them. May be single or multiple voices. These are the most common type of auditory hallucination in schizophrenia. The voices are often critical of the individual. With treatment, these voices may not go away, but they may become quieter, and contain more positive content
  • Thought echo – the individual hears their thoughts spoken aloud, either simultaneously (as thinking the thought) or just afterwards.
  • Second person – talking to the individual – can still occur in schizophrenia, but also present in lots of other mental disorders.
  • NOTE – auditory hallucinations in which the person talks to the voice they hear are most commonly the result of TRAUMA or are fictitious.
• Other hallucinations – e.g. visual, olfactory etc. again, can occur in schizophrenia, but also common to other disorders. These are most common in organic conditions. If these symptoms are present then they have to be medically investigated.
  
  • Passivity experiences – the patient believes that their movements, emotions or will is being altered in a similar way to the thought issues, for examples, they believe their movements are being controlled.
    
  • Incongruity of affect – the patient may burst out laughing or become very angry for no apparent reason, or they may have inappropriate emotional reactions – e.g. laughing at bad news.
    
• Thought and speech disorders – their thought processes may be altered, for example, their speech may be totally fragmented (word salad), or they may have some sort of thought disorder – e.g. they can speak in normal sentences, but their ideas are linked in strange ways, e.g. not by content, but because the words rhyme.
  • Neologism – this is a phenomenon that may occur with some patients. They may make up a new word, or give an existing word a new meaning that is only apparent to the individual, and does not make sense. They may keep repeating this word. E.g. “I like to sprong”
  • Word salad – the form of the sentences makes no sense at all. Words are mixed up, in the wrong place.
  • Flight of thought – this is where the patient moves quickly from one idea to another, often half-way through a sentence, with no apparent association between ideas.
  • Knight’s move thinking (aka Derailment)- patient moves from one idea to another with strage illogical associations between the ideas.
  • Pressure of speech – the patient speaks at a rate faster than normal
  • Circumstantiality – excessive ‘long-windedness’ – the patient takes forever to reach the point when they talk.
• Mannerisms – strange and pointless movements. This is often repeated frequently, and accompanied by a strange facial expression.
  
• Catatonia – a state where the person may not respond to stimuli and exhibits strange physical behaviour. The state may involve a particular movement or posture that a patient often performs. Can be associated with any mental health condition. Examples can include
• Stupor – the patient is unable to move or speak except for moving their eyes.
• Strange postures – that are normally very difficult to hold
• Negativism – the patient does the exact opposite of what they are asked
• Automatic obedience
• Waxy flexibility – the patient has strange muscle tone that allows the doctor to put the patient into physical position that would otherwise be very difficult and/or painful.

Schneider’s First Rank Symptoms of Schizophrenia

• Primary delusions – these appear with no apparent precipitating event. The individual may enter a state of being ‘perplexed’ for several days or months, and as the perplexity disappears, the delusion develops.
• Persistent delusions – these arise with the period of perplexity. If other symptoms of schizophrenia are present, this can be diagnostic for schizophrenia. If they are not, then it can be diagnostic for delusional disorder.
• Secondary delusions – these arise when other symptoms of schizophrenia have been present for a period just before the delusion, and arise from strange experiences the individual has as a result of their schizophrenia.

Thought issues

• Thought insertion – the patient believessomebody or something is ‘planting’ thoughts into their mind. This happens against the person’s will.
• Thought broadcast – the patient believes their thoughts are ‘broadcast’ to others against their will
• Thought withdrawal – the patient believes thoughts are being removed from their mind against their will, and this leaves the mind ‘blank’.

Negative symptoms

• Weight change
• Sleep problems
• Guilt / hopelessness / low self worth
• Social withdrawal

• Alogia – this is a general impoverished level of thinking, usually seen in the form of poverty of speech – whereby the patient will give very short answers, and will not voluntarily give any input to a conversation. They are unable to elaborate on their thoughts. The patient feels as though their ‘mind is empty’.
• Poverty of content of thoughts – is a less extreme version. The patient is able to answer questions, but their thought process is not properly utilised and they cannot explain their answers.
• Blunting of Affect – the person has a lack of emotion
• Avolition (loss of volition) – the patient has a general lack of interest in life, self care, social activities and motivation.
• Slowness of thought an movement

Other symptoms seen in schizophrenia

• Depression
• Anxiety
• Agitation
• Withdrawal
• Inappropriate eating behaviour – e.g. stuffing themselves in an ‘uncivilised’ way, and then vomiting.
• Incontinence
• Self harm
• Destruction of possessions
• Massive intake of water – causing water intoxication – which can lead to hyponatraemia. This can inturn cause delirium, coma, and even death! In these cases the person will drink all/any water they can find –even out of toilets.
• Post psychotic depression –this is a prolonged depressive episode that occurs on resolution of the psychosis. This can be distinguished from the negative symptoms of schizophrenia because:
  • In schizophrenia – negative symptoms increase/decrease in conjunction with the severity of positive symptoms
  • In post psychotic depression – the depressive type symptoms do not change in concordance with any positive symptoms
  • This case can be extremely difficult to distinguish from the normal negative symptoms of depression – but it requires different treatment – and so if you suspect it, you should make the extra effort to try and find out. Patients with post psychotic depression are at high risk of suicide, and they have a particular feeling of hopelessness. In post-psychotic depression the patient often has a good degree of insight – because the depression is often in response to their diagnosis. It can also be a result of neuroleptic medication.

Diagnosis

• Two or more of the following, present for at least one month, for most days
  • Hallucinations
  • Delusions
  • Disorganised speech
  • Negative symptoms
  • Grossly disorganised or catatonic behaviour
• At least one of the first three must be present, PLUS
• Social or occupational dysfunction
• No evidence of other causes for psychosis
• Not attributable to medication (illicit or otherwise)

Risk

• Thoughts of suicide
• Plans for suicide
• Auditory hallucinations relating to suicide

Self-neglect – this can occur to such a great degree, that the patient’s health can be put at risk, and even death can result.
Risk to others – the risk of a violent attack on another individual is relatively low, but in those with a history of impulsive behaviour and violence, you should be careful. Particular symptoms that might put others at risk include:

• Passivity experiences
• Morbid jealousy
• Persecutory delusions directly involving others

Pathology

• Most anti-psychotic drugs block dopaminergic transmission, and are able to reduce symptoms
• Many dopamine agonists have psychotic side effects (e.g. in Parkinson’s disease)

Nueroimaging (CT or MRI) may show:

• Increased size of lateral ventricles
• Reduced brain size (usually in temporal lobes)
• Negative symptoms – often correlated with reduced blood flow and other abnormalities in the frontal cortex.
• Reduced connections between different brain areas can often be deduced from EEG’s.

Management

Acute attack

• First line – antipsychotics (aka neuroleptics) – typical or atypical.
  • Drug choice depends on individual circumstance
  • The atypical antipsychotics (risperidone, olanzapine, queitpaine, aripiprazole) are now recommended first line
  • Can be given in oral tablet form, or oral liquid, or IM injection. There is no need to ever give one IV. If adherence is an issue, consider depot preparation given IV every 2-4 weeks
  • Main side effects include sedation, and extrapyramidal side effects (e.g. Parkinsonism). These effects are reduced in atypical antipsychotics (which are newer), but atypical agents can cause weight gain, and increased risk of diabetes
  • Typical antipsychotics include haloperidol and chlorpromazine
  • Both typical and atypical agents are effective for reducing the positive symptoms, but atypical agents in particular are also effective at improving the negative symptoms
  • Typically, start with a low dose and titrate upwards for effect
• Second line – Clozapine – atypical antipsychotic – this is not included as a first line treatment, as requires close monitoring as it has a tendency to cause aplastic anaemia, which can be fatal. If two other anti-psychotics have not been effective, then clozapine should be considered. It is highly effective in 30% of patients.
  • CPMS – Clozepine monitoring system. A national service in the UK, that gives advice on the drug dosage to use, depeninding on the blood test results you send to them. Compulsory for anyone on clozepine. Only consultant psychiatrists can prescribe clozapine

Psychological therapies

Social care

Impact on society

• Very expensive to treat
• If not diagnosed, can cause harm to others

Prognosis

• 20% of patients will make a full recovery with drug and supportive treatments
• A further 35% have long periods of remission
• 35% will have persistent mild positive and negative symptoms, that can be managed in the community
• 10% have severe schizophrenia that is unresponsive to treatment, and these people will often require institutionalised care.
• A small number of patients may require forensic care, due to high risk
• Lifetime suicide risk is about 2%

• Delayed diagnosis and management
  • Prompt diagnosis and management is associated with an improved outcome
• Pre-morbid factors – e.g. poor educational background, poor achievement at work, social problems
• Drug and alcohol abuse
• Features of the condition – long slow onset, delay of first treatment, catatonic symptoms, strong negative symptoms, thought disorder
• Current social / living situation – e.g. lack of structure to daily living, lack of social network, exposure to stress and high emotions at home.

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