01.2 Psychosis

PSYCHOSIS

Dr Niall Boyce

ST3 Psychiatry Research

Dr Claudia Cooper

MRC Research Training Fellow in Health Services

Research

Locum Consultant Old age Psychiatry

Treat acute episode

Intervene early: prompt treatment associated with better outcome

Reduce risk of relapse

Promote long term recovery

ANTIPSYCHOTICS

Lowest effective dose

Usually oral (occasionally depot, im)

Monitor side effects

Adherence

Maintenance treatment

reduced relapse rate if continued > 1-2 years after acute episode

Maintenance treatment

PSYCHOLOGICAL THERAPY

Self help to come to terms with symptoms/illness

Family therapy to reduce expressed emotion

CBT to help manage residual symptoms

Art therapy helps negative symptoms

SOCIAL SUPPORT

Focus on engagement, hope, reduce stigma

Support to reduce substance misuse

Support employment and study

Appropriate accommodation

Management of psychosis

Timetable What is psychosis?

Abnormal thought content and form

Abnormal perceptions

BREAK

Making a diagnosis

Diagnostic hierarchy

Vignettes

Video

LUNCH

Schizophrenia and other psychotic disorders

Management

MCQ

Summary

Objectives

Define psychosis and recognise hallucinations, delusions and thought

disorder

Identify which patients have psychosis

Know the diagnostic criteria for schizophrenia and schizoaffective disorder

Use a framework to make a diagnosis in a psychotic patient

Know about the aetiology and treatment of schizophrenia

What is psychosis?

A severe mental illness that prevents people from being able to

distinguish between the real world and the imaginary world. Symptoms

include:

Hallucinations (seeing or hearing things that aren't really there)

Delusions ( believing things that arent true)

Thought content

Initiation of ideas

After a perception

Following a memory

Arise out of an atmosphere or mood state

Autochthonous

False beliefs

Primary and secondary delusions

Overvalued ideas

Sensitive ideas of reference

Delusions

An idea or belief that is:

false

unshakeable and firmly held

despite clear evidence to contrary, and

out of keeping with educational, cultural and social background

Content of delusions

Delusions of persecution

belief that someone or something is interfering with the person in a malicious or destructive way

Examples:

Someone (or an organisation e.g. MI5) is trying to kill or harm them

The neighbours are harassing them

People are monitoring their movements or following them

VIDEO 1

Asking about delusions of persecution

Are there times when you worry that people are against you/ trying to

harm you?

Do you have any concerns for your safety?

Grandiose delusions

belief of being a famous, having supernatural powers, having

enormous wealth

Suggestions for interview: Do you have any exceptional abilities or

talents?

Delusions of reference

belief that actions of other people, events, media etc. are either directly referring to the person or are communicating a message

Suggestions for interview:

Have there been times when you have overheard people talking about you?

Do you ever see things on the TV or hear things on the radio which you think are about you?

Delusions of misidentification

Capgras syndrome

someone close has been replaced by an identical looking impostor

Fregolis syndrome

belief that strangers are actually familiar people in disguise

Delusions of control

passivity phenomena: made actions, feelings or impulses

the boundaries between self and the world are broken

thoughts, actions or feelings are subject to outside influences

thought insertion, withdrawal, broadcasting

often accompanied by delusional explanations

VIDEO 9

Asking about delusions of control

Thought interference: Have you ever felt that your thoughts were being

directly interfered with or controlled by another person?

Was this just because people were distracting you or being persuasive, or did it

come about in a way many people would find hard to believe, for instance

through telepathy?

Passivity: Have you ever felt that another person was able to control what

you did directly, as if they were pulling the strings of a puppet?

Religious delusions:

Beliefs about having contact with God, having religious powers,

being a religious leader

Delusions of love

Morbid jealousy

a strong feeling of jealousy coupled with a sense that the loved person belongs to

me

Erotomania

a preoccupation with the belief that a person is in love with them

usually the person is a stranger of unattainable status or position

Delusions of guilt, unworthiness, poverty and

nihilism

e.g. beliefs that they are dead or rotting inside would be nihilistic

delusions

Somatic delusions

beliefs about body,

including

illnesses (hypochondriacal delusions)

infestations (Ekboms syndrome).

Primary and secondary delusions

A primary delusion is a delusion which arises "out of the blue".

Secondary delusions are secondary to a morbid event, such as a change

in mood, an hallucination, or another delusion.

Types of primary delusions

Autochthonous delusions

arising de novo



Delusional perceptions

a normal perception is interpreted with delusional meaning

objects or persons take on new delusional personal significance

VIDEO 2




Delusional atmosphere / mood

experiencing surroundings as sinister, apprehensive & peculiar in a vague

way

something funny is going on

VIDEO 3




Delusional atmosphere / mood

Delusional memory

fictitious event is remembered as really having occurred

Overvalued ideas

acceptable and comprehensible ideas

pursued beyond the bounds of reason

preoccupy & dominate the persons life.

similar quality to passionate political, religious or ethical convictions

But not fulfilling criteria for delusion

Sensitive ideas of reference

in a rigid, suspicious person

interpreting information as pertaining to themselves

in a critical, derogatory way.

But not fulfilling criteria for delusion

Disturbances in form of thought

Normal thought form

I went to the shop.to buy a loaf of bread

because I was hungry.

Meaning link

Meaning link

In flight of ideas, there are links between phrases but they are

clang associations.

Clang associations are associations of words similar in sound

but not in meaning. Links may be rhymes or puns

This occurs in mania and hypomania and usually with

pressure of speech.

You come in here swinging your stethoscope.telling me about my

horoscope

VIDEO 6

In loosening of association there is no link between phrases.

Knights move thinking is a type of loosening of association

where there is an abrupt jump from one idea to another

midway through the first thought e.g.

Inferior schools! Inferior schools! Preferably Dr Sims? Your tablets have

been a miserable failure. I have had to sit with these mad surgeries. With

regard to these tablets it will depend what the lord wants. With these

women it is certainly destiny humph

A Simms1988

In word salad, there is no link between words.

Blue does runs shaky lovely very

VIDEO 8

Neologism

New word created by the patient which only has meaning to them

E.g. a patient believed that his thoughts were being influenced by a

process called telegony

Circumstantiality

Overinclusion of details and parenthetical remarks

Takes a long time to get to the desired point

Tangentiality

Inability to have goal-directed associations of thought

Never gets from desired point to desired goal

Echolalia

Repeating of words or phrases of another person

Can occur in schizophrenia, mental retardation or dementia

Perseveration

Persisting response to a prior stimulus after the new stimulus has been

presented

Thought block

Abrupt interruption in train of thinking before a thought or idea is finished

After a brief pause the person indicates no recall of what was being said

or what was going to be said

May be explained by the patient as thought withdrawal

VIDEO 7

PERCEPTIONS

Imagery or fantasy

complex experience

created voluntarily

based on perceptions, memories, wishes

can easily tell the difference between fantasy and reality

Abnormal perceptual experiences

Sensory distortions (the quality, intensity or feeling associated with a

perception is altered)

E.g. hyperacusis (things seem louder)

Visual hyperaesthesia (colours seem more vivid)

Derealisation/depersonalisation (loss of usual feelings of familiarity with self and

surroundings)

VIDEO 4

False perceptions

Illusions

Completion

Affect

Pareodolic

Hallucinations

Pseudohallucinations

Completion Illusions

An incomplete perception is filled

in from previous experience

Rely on inattention

Affect illusions

Pareidolic illusions

2. Hallucinations

occur spontaneously

not distortions of real perceptions

indistinguishable from normal perceptions

can occur in any sensory modality

Auditory hallucinations

Occasionally elementary sounds (e.g. in organic states)

Rarely music

Usually voices

VIDEO 5

Asking about voices

Have there been times when you heard or saw things others couldnt?

Have you ever heard a voice when there was no one around to account

for it?

Could you tell me what it said?

Has the voice ever told you what to do?

How do you feel when you hear the voice?

Visual hallucinations

characteristically occur in organic states

Asking about visual hallucinations:

Have you ever seen a vision?

Have you ever seen something that others couldnt see?

Somatic hallucinations

Also called tactile / haptic hallucinations

These may be sensations of being:

touched or strangled

feeling that insects are crawling beneath the skin (formication) e.g. occurs in cocaine users

feelings of sexual stimulation.

They can be classified as superficial (skin), kinaesthetic (involving joints/ muscles) or visceral (inner organs)

Olfactory and gustatory hallucinations

involve smell and taste respectively.

often have strong affective component.

3. Pseudohallucinations

These are similar to hallucinations but differ in some important aspects, either:

they do not appear to the patient to be real and instead located in the mind (i.e. in subjective inner space)

e.g. visual pseudohallucinations - seen by inner eye

Auditory pseudohallucinations - voice in my head

Or they seem to occur in the outside world but patient views it as unreal.

They may occur in, for example, borderline personality disorder, fatigue, bereavement

Why make a diagnosis?

Importance of diagnosis

Wrong diagnosis =

wrong treatment

wrong risk assessment

wrong prognosis etc etc...

Organic disorders

Psychotic disorders

Mood disorders

Anxiety disorders

Personality disorders

The diagnostic hierarchy Includes delirium, dementia, medical causes of psychosis, drug and

alcohol related psychoses

Includes schizophrenia, delusional

disorder

Includes bipolar affective

disorder, psychotic depression

Medical conditions can cause:

Delirium

(which may include psychotic symptoms)

Psychosis

Definition of Delirium

Generalized impairment of cognitive functions (perception, thinking

memory, orientation), emotion, psychomotor activity and sleep-wake

cycle

NB: impaired consciousness/ attention

Characterized by confusion, perceptual disturbances and disordered

thinking and behaviour => easily mistaken for psychosis

Medical disorders presenting with psychotic symptoms

Psychoactive drug use

Alcohol: withdrawal, intoxication, hallucinosis

Infection: sepsis, encephalitis

Cerebral neoplasm, trauma, stroke

Neurological disorders: Parkinsons, epilepsy

Dementia

Lewy body, Alzheimers etc.

And many more..........

Psychiatric disorders presenting with psychotic symptoms

Schizophrenia spectrum disorders

Schizophrenia, delusional disorder, schizoaffective disorder etc

Mood disorders

Bipolar disorder

Depression

Disorders whose symptoms can appear psychotic

Obsessive compulsive disorder

Post traumatic stress disorder

Borderline personality disorder

Schizoid personality disorder

Hypochondriasis

Factitious disorder, malingering

Approach to making a diagnosis

Similar principles to any other branch of medicine

history and examination etc.....

Detailed account of the psychotic symptoms

nature

onset

degree

longitudinal course

previous episodes

collateral information

Further history

Other symptoms and signs ?

Sleep, appetite

Context of the symptoms?

Drug use, bereavement

Family history of mental illness

Examination

Mental state

level of consciousness

cognition

hallucinations, delusions, thought disorder

mood incongruent or bizarre

Physical examination

Investigations

General pointers (1) Elementary hallucinations (noises), visual or olfactory hallucinations

? organic conditions

Episodic delusions and hallucinations ? epilepsy, substance

abuse

Delusions / hallucinations + altered level of consciousness = delirium

General pointers (2)

Bizarre delusions and hallucinations ? Schizophrenia spectrum

disorders

Mood congruent delusions and hallucinations

? Mood disorders

Vignettes

Case 1

A 52 year old man in brought to A&E by the police, after he was found

shouting in the street. He is sweating and appears terrified.

He can see rats running around

This has never happened before

Case 1 What will you ask about?

Alcohol

Drugs

How long ?

Urine drug screen

FBC

Temperature

(Glucose)

Case 2

An 84 year old woman is referred by social services. She has been

shouting at her neighbours, neglecting herself and has started to refuse

meals on wheels as she believes they are poisoned

Case 2

Her explanation

Medical problems

Mood

Alcohol

Collateral

MMSE

FBC

Case 3

A 30 year old woman attends A&E having made superficial cuts to her

forearms with a razor. She has numerous scars on her arms and casualty

records show past overdoses. She cant remember ever feeling happy or

normal. She cut herself because she heard voices in her head telling her

to.

Case 3

Why unhappy

Why now

Anything else to harm themselves

Characteristics of voices

Anhedonia

Blood drug levels (paracetamol/salicylate)

Review medical records

Case 4

45 year old man presents to A&E saying that his life is in danger. He is

dishevelled, and appears suspicious and anxious. He confides in you that

he believes MI5 are following him.

He has previously be sectioned under the MHS (section 2) for a drug

induced psychosis.

Case 4

Why is life in danger?

Substances?

How long?

Collateral from nurse

Orientation

FBC

Glucose

(U&E, Drug screen)

Psychotic disorders

psychotic symptoms, not clinically relevant: > 17%

Any psychotic

Illness: 3%

Life time prevalence of psychosis

Includes:

Schizophrenia (1%)

Schizoaffective disorder (0.2%)

Delusional disorder (0.03%)

Acute & transient psychotic disorders

Induced delusional disorder

(Bipolar affective disorder (1%))

Psychosis - diagnoses

Schizophrenia

Schizoaffective disorder

Delusional disorder

Acute and Transient psychotic disorders

Schizophrenia

First-rank symptoms of schizophrenia

Strongly suggestive of schizophrenia if present:

auditory hallucinations:

hearing thoughts spoken aloud

hearing voices discussing him/her or giving a running commentary (3rd person)

thought withdrawal, insertion and broadcast

somatic hallucinations

delusional perception

Made feelings, impulses or actions (passivity)

Kurt Schneider (1959)

ICD-10 Schizophrenia

At least one of: thought echo, insertion, withdrawal, and broadcast

delusions of control, influence, or passivity

voices giving a running commentary or discussing

persistent delusions of other kinds

or at least two of: other hallucinations

thought disorder

catatonic behaviour,

"negative" symptoms

a significant and consistent change in behaviour

for at least a month, in absence of intoxication, brain disease or extensive manic / depressive symptoms

Under-activity

Few leisure interests

Lack of convention

Social withdrawal

speech

motivation

emotional responsiveness (flat affect)

Positive symptoms Negative symptoms Hallucinations

Delusions

Ideas of reference

Sub-types 1. Paranoid schizophrenia

Stable delusions, usually + hallucinations

2. Hebephrenic schizophrenia

Fleeting delusions & hallucinations Behaviour & thought disorganized

3. Residual schizophrenia after a period of positive symptoms, negative

symptoms predominate

4. Simple schizophrenia negative symptoms, no initial positive symptoms

(rare)

5. Catatonic schizophrenia

Rare

Disturbances of voluntary motor activity

including

Stupor

Periods of over-activity

Rigidity

Posturing

Waxy flexibility (maintenance of limbs

and body in externally imposed positions)

WHO: International Pilot Study

Lack of insight 97 %

Auditory Hallucinations 74 %

Ideas of reference 70 %

Suspiciousness 66 %

Flat Affect 66 %

Delusions of Persecution 64 %

WHO: International Pilot Study

Social withdrawal 74 %

Under-activity 56 %

Lack of convention 54 %

Few leisure interests 50 %

Slowness 48 %

Over-activity 41 %

Function

Schizophrenia can have a devastating effect on :

interpersonal relationships

work

self-care

other goal directed behaviours

DSM-IV

This classifies schizophrenia in a broadly similar way

Main difference is that it requires symptoms to have been present for 6

MONTHS

Aetiology of schizophrenia

Genetics of schizophrenia

Strong evidence of a genetic component from

Epidemiological studies

Molecular genetic studies

Genetic epidemiology: Risk of developing

schizophrenia

0 10 20 30 40 50 60

General population

1st cousin

Niece/ nephew

Grandchild

Parent

Sibling

Children

Non-identical twin

Identical twin

%


Molecular genetic studies

Linkage studies: eg regions of chromosomes 5 and 8 replicated

Genes found to be associated with schizophrenia in genetic association studies

(typically case control) include 8 and 13


The mechanism for genetic component of schizophrenia may be:

1) solely genetic

2) gene-gene interaction

3) gene-environment interaction

4) A combination

Evidence for 1 and 3 at the moment


genetics

Neurodevelopmental hypothesis

result of an early brain insult

affects brain development leading to abnormalities which are

expressed in the mature brain

Perinatal risk factors

Spring birth. Seems to be related to greater exposure to viruses in utero

(in winter months)

birth complications

Childhood risk factors Developmental delay

Children aged 2 who later became schizophrenic

responsiveness

positive affect

eye contact

75% of people who develop schizophrenia have 'soft' neurological signs as children (abnormal gaits, dysgraphaesthesia, proprioceptive errors; tics and epilepsy)

Poor academic performance

Radiological changes

Volume lateral ventricles

Volume brain

Especially Temporal lobe, Amygdala / hippocampal complex

Same changes found in newly diagnosed patients as chronic

schizophrenics

Appear to be non-progressive

Neuropathological changes suggestive of neuronal degeneration

Males with schizophrenia

Earlier onset

More negative symptoms

More structural brain abnormalities

More susceptible to neurodevelopmental disorders


neurodevelopmental

genetics

Perinatal factors School problems

Cannabis and schizophrenia

People who smoke cannabis are more likely to develop schizophrenia

The younger a person smokes/uses cannabis, the higher the risk for schizophrenia, and the worse the schizophrenia is when the person does develop it.

A gene-environment interaction between COMT (catechol-O-methyl transferase) gene and cannabis suggested and finding replicated, but no primary association of schizophrenia with alleles at the COMT locus has been demonstrated


neurodevelopmental

genetics

cannabis Perinatal factors

School problems

Life events

Increased incidence of events in 3 weeks prior to onset

46 % Vs. 14 % in control group

Family Interaction

Higher relapse rates for :

Families with high Expressed Emotion

critical comments

hostility

over-involvement

Social class and urbanicity

Schizophrenia is more common in people from lower social classes and

urban areas.

Developmental delay

genetics

Expressed

emotion

cannabis

Perinatal factors School

problems,

abuse

Life event,

deprivation,

adversity,

migration

Neurodevelopmental hypothesis

Final common

pathway is Dopamine

5HT glutamate

Migration

In the UK, the incidence of all psychoses is significantly higher in African-

Caribbean and Black African populations compared with the White British

population

Incidence rates of schizophrenia in Caribbean countries are similar to those

found in the indigenous UK population.

The rate for schizophrenia in second-generation AfricanCaribbean people

born in the UK appears to be higher than in the first generation.

This pattern is strongly suggestive of an environmental effect (? Social

adversity ? Discrimination).


neurodevelopmental

genetics

Expressed emotion migration

cannabis Perinatal factors

School problems

Life event

Neurotransmitter changes

We dont yet know exactly how these aetiological factors actually

result in psychosis. The answer is very likely to include

neurotransmitters.

In schizophrenia there is:

dopamine activity (amphetamine is a dopamine agonist)

glutamate activity (PCP blocks glutamate receptors)

5-HT activity (LSD is a serotonin agonist)

Schizophrenia

After 10 years, of the people diagnosed with schizophrenia:

25% Completely Recover

25% Much Improved, relatively independent

25% Improved, but require extensive support network

15% Hospitalized, unimproved

10% Dead (Mostly Suicide)

Poor Prognostic Indicators

Male

Insidious onset

Long duration of untreated psychosis

Drug use

Family environment

Non-compliance

Neuro-cognitive deficits

Risk of relapse after first episode of psychosis

(schizophrenia or schizoaffective disorder)

90% of people experiencing a first psychotic episode will be well within a

year

About 80% will have a further episode within 5 years

Those who discontinue antipsychotic medication may be 5 times more

likely to relapse over this time

Schizoaffective disorder

Both affective and psychotic symptoms are prominent within illness

episode, simultaneously or within a few days of each other

Therefore criteria for schizophrenia and depressive/ manic episode not met

Usually less impairment between episodes and social impairment than for

schizophrenia (but more than in bipolar affective disorder)

Spectrum

Bipolar Affective Schizoaffective Schizophrenia

Functioning between episodes:

Good Poor

Prognosis:

Poor Good

Delusional Disorder

Delusions constitute the most conspicuous or the only clinical

characteristic

Often function well outside area of delusion

Present for at least 3 months

Acute and Transient psychotic disorders

the onset of psychotic symptoms must be acute (2 weeks or less from a

nonpsychotic to a clearly psychotic state);

If the schizophrenic symptoms last for more than 1 month, the diagnosis

should be changed to schizophrenia.

ATPD - prognosis

Diagnosis less stable than for schizophrenia. A year later:

15% schizophrenia

28% affective disorder

Psychosocial functioning maintained

10 years after diagnosis:

A third had been medication free with no relapse for at least two years

79% had experienced at least one relapse

Management

Risk assessment

Care Programme Approach

Treatment

DVD

Risks to consider

Self harm and suicide

Self-neglect

Harm to others

UK Deaths per year

Suicides 5,000

Road Traffic Accidents 4,000

Homicides 6-700

Dangerous driving / drunk driving 300

Homicides + contact with mental health services in past year

40

Homicides by stranger + contact with mental health services in past

year 3-4

Self report violence in previous year

2% of non mentally ill

12 % of mentally ill

25 % of people with substance abuse problems

60 % of people with substance abuse problems + schizophrenia /

depression / mania.

Risk assessment

Identify risk

Assess risk

How can risk be altered ?

Assess risk

Past including precedents

Current

Other factors e.g.drugs

From patient and other sources

How can risk be altered ?

Treatment strategy

Planned response

Review date

Care Programme Approach

Assess health & social needs

Agreed care plan

Assess carer needs

Named Care co-ordinator

Regular monitoring & review (CPA) meetings

Interagency & multi-disciplinary working

Early Intervention in Psychosis services

These are being set up in many areas

Specialist teams who treat people experiencing their first episode of

psychosis (aged 18-35)

Aim to reduce the Duration of Untreated Psychosis, because shorter

time to treatment associated with better outcome

Therefore focus on early detection and treatment and maintaining contact

to try to prevent relapse

Management : General Principles

Biological

Psychological

Social

Antipsychotic medication

Typical antipsychotics

Chlorpromazine

Haloperidol

Atypical antipsychotics

Risperidone

Olanzapine

Quetiapine

Amisulpiride

Aripiprazole

Antipsychotic medication (2)

Antipsychotic medication are started at low dose and increased gradually

They take affect after 1-6 weeks

They should be continued for a minimum of a year after a person is

asymptomatic. There is probably benefit in continuing for up to 5 years,

but many people are reluctant to do so.

Adherence to medication is key.

Psychological

Family therapy

CBT for psychosis

Family Interaction

Higher relapse rates for :

Families with high Expressed Emotion

critical comments

hostility

over-involvement

Family Intervention

Relapse rates 9 months post discharge:


+ low EE family 12%


+ high EE family (35 hours) 92%

CBT for psychosis

Recommended by NICE as a treatment in addition to medication for

people with persistent positive symptoms of psychosis.

Typically, around 50-65% of people who receive therapy benefit in some

way.

CBT for psychosis (2)

Identify a clients main difficulties, how they arose, and what they

understand about them.

The aim is not necessarily to get rid of symptoms, but to alleviate distress

and disability, by helping them find:

New ways to reframe their experiences

New strategies to cope with their symptoms

Social

Support

Socialisation

Any Questions ?

Objectives (recap)

Define and recognise psychosis, hallucinations, delusions and thought

disorder

Know the diagnostic criteria for schizophrenia and schizoaffective

disorder

Distinguish between positive and negative symptoms of schizophrenia

Use a framework to make a diagnosis in a psychotic patient

Be able to outline the aetiology of schizophrenia

Be able to discuss the setting and types of treatment for psychosis

Documents

01.2 Psychosis