Psychosis refers to patients suffering a loss of contact with reality. It affects 3 out of 100 people in their lifetime. Psychosis is a constellation of symptoms and signs rather than a diagnosis itself.
Contents
Causes of psychosis
Psychiatric
- Schizophrenia
- Mood disorders:
- Bipolar affective disorder
- Severe depression with psychosis
- Schizoaffective disorder
- Delusional disorder
- Post-partum psychosis
- Unspecified nonorganic psychosis (considered if organic causes excluded and does not fit criteria for other conditions)
Drug-induced
- Medicinal: corticosteroids, Parkinsonian medication, anti-malarials
- Recreational: psychedelics (LSD, psilocybin), stimulants (cocaine, MDMA), cannabis, alcohol
Organic
- Acute: delirium, encephalitis
- Degenerative: Parkinson’s, Alzheimer’s
- Structural: SOL
- Endocrine: thyrotoxicosis, Addison’s
- Temporal lobe epilepsy
Features
- Positive:
- Hallucinations: auditory, visual, olfactory, tactile
- Delusions
- Thought disorder: derailment, poverty, circumstantiality, perseveration, blocking
- Negative:
- Social withdrawal
- Alogia (poverty of speech)
- Apathy
- Amotivation
- Emotional blunting
- Catatonic behaviour
- Cognitive
Pathophysiology
- Multifactorial and dependent on the cause
- Primary psychiatric disorders are strongly linked to interactions between genes and environment
- ‘Positive’ symptoms in psychiatric disorders associated with excess activity of neurotransmitter dopamine at D2-like receptors in the mesolimbic pathway (this forms basis of psychotropic therapy to treat ‘positive’ symptoms
Schizophrenia
Chronic mental disorder usually developing in early life with 0.5% lifetime risk
Negative symptoms can be indicative of a prodrome
First rank symptoms – last ≥1 month:
– Auditory hallucinations – usually 3rd person in form of running commentary with negative statements
– Thought interference
– Delusions of control
– Delusional perceptions
Negative symptoms can be indicative of a prodrome
First rank symptoms – last ≥1 month:
– Auditory hallucinations – usually 3rd person in form of running commentary with negative statements
– Thought interference
– Delusions of control
– Delusional perceptions
Questions to consider in a psychosis history
- Open question: “Has anything odd or unusual been happening recently?”
- Delusions (ask onset and fixity – how sure they are):
- Persecutory: “Is anyone out to get you?” “Is anyone plotting against you?”
- Reference: “Do you feel people are talking about you?”
- Passivity: “Do you feel you are not in control?”
- Thought disorder:
- Form of thought: “Are you able to think clearly?”
- Thought insertion: “Do you have any thoughts which are not your own?”
- Thought withdrawal: “Are any thoughts being taken from your mind?”
- Thought broadcasting; “Can anyone access your thoughts?”
- Hallucinations:
- Auditory:
- “Are you hearing any voices?”
- “Who are they?”
- “Can you hear them like you can hear me?”
- Visual: “Can you see things that others cannot?”
- Auditory:
- Insight: “If I were to say I thought you were unwell, how would you feel?”
Management
1. Refer to on-call psychiatric team
2. Full psychiatric assessment (including MSE) and collateral history
3. Rule out organic causes
- Full physical examination
- Bloods: FBC, U&Es, LFTs, TFTs, vitamin B12/folate, serology
- Urine drug screen
- Imaging: CT/MRI head
- Lumbar puncture
- EEG
4. If psychiatric cause:
- Consider sectioning under Mental Health Act or consider Early Intervention Services if 1st episode (dependent on local services)
- Bio:
- 1st line – atypical antipsychotic (PO or IM depot)
- 2nd – trial another antipsychotic
- 3rd – clozapine
- 4th – combination
- Electroconvulsive therapy (ECT) if catatonic
- Psycho: psychoeducation, psychotherapy
- Social: social support, advocacy
Written by Dr Muhammad Zain Haq, Psychiatry Lead (F2)
Reviewed by Dr Patrick Ezeani (Consultant Psychiatrist)
