Psychosis - Diagnosis and Management

• A delusion is a false, fixed, strange, or irrational belief that is firmly held. The belief is not normally accepted by other members of the same culture or group. It is important to look at culture, especially with ethnic issues, to decide if strange beliefs are really psychotic. There are delusions of paranoia (plots against them), delusions of grandeur (exaggerated ideas of importance or identity), and somatic delusions (false belief in having a terminal illness).
• An hallucination is sensory perception (seeing, hearing, feeling, smelling) without an appropriate stimulus, like hearing voices when no one is talking. Not all hallucination suggests psychosis.

• About 3% of the population will experience psychosis at some time in their lives, the age of onset is usually between 15 and 30.
• Women tend to present at a slightly older age than men and they are more susceptible at certain times, such as when pre-menstrual, the puerperium and the menopause.

• The patient is often brought to the doctor by a third party. This might be because the patient lacks insight but, more likely, because psychosis is a very distressing condition, both for the patient and for those around, and a degree of support is required.
• Occasionally the first contact may be with family members who have with concerns about a member of their family. If the patient cannot be persuaded to come to the surgery, a home visit may be necessary. ²
• Where the patient may behave aggressively, consider a joint visit with an experienced community psychiatric nurse and/or the police.

Question the patient directly to discover the symptoms and to ascertain the degree of insight. The accompanying person may be extremely valuable in terms of giving history.

Follow the guidance for psychiatric assessment but history should cover the following ground (the accompanying person may be a very valuable source of information):

• What is the nature of the hallucination or delusion?
  • What is the time span?
  • Is there a recurring theme?
  • Is there insight into it being unreal?
• Have there been any recent major life-events?
• Is there a history of substance abuse (alcohol or drugs)?³
• Does the patient's past behaviour suggest psychological vulnerability, e.g. irritability, uneasiness, suspiciousness, and withdrawn mood?²
• Is there a family history of mental illness?
• During the taking of the history it is possible to make an assessment of the patient's mental state.
  • Is there loss of touch with reality, delusions or bewildered mood?
  • Is thought or speech disorganised, abstract or vague?
  • Is emotion normal and appropriate? Remember that such experiences will naturally cause extreme anxiety, but are there inappropriate emotional outbursts?
  • Is there excitement or confusion?
  • Is there depression or suicidal ideation? ³Depression can cause psychosis and all forms of mental illness have a risk of suicide, not just depression. There are a number of forms of self-harm assessment.
• Physical examination is unlikely to be rewarding in the younger patient but in the older one there may be physical signs of alcohol abuse, neurological features and/or other signs of systemic disease. Always look for evidence of poor personal hygiene or self-neglect.

Psychosis will usually require referral to mental health services but there are some investigations that can be undertaken in the practice. The management of schizophrenia in primary care is well established but most doctors will want a specialist opinion at the outset.

• Abnormal LFTs and macrocytosis on FBC are highly suggestive of alcohol abuse.
• Serological tests for syphilis should not be forgotten. Screening for AIDS should be preceded by counselling.
• Urine screen for drugs of abuse. Light recreational use of cannabis can produce a positive test for the next fortnight. Heavy and chronic use can produce a positive results for months after the last use.
• Brain scan may show a space occupying lesion or cerebral atrophy.

• The history should help distinguish between schizophrenia, bipolar disorder and depression but history can be misleading.
• Abnormal behaviour in the puerperium suggests a puerperal psychosis.
• Duration and intercurrent illness will differentiate between psychosis and acute confusional state.
• Alcohol abuse can cause Korsakoff's psychosis but alcohol withdrawal (delirium tremens), may also present with psychosis.
• Psychosis is not a major feature of dementia but it can occur.
• Hallucinations and psychosis can occur in other neurological and degenerative disorders including Parkinson's disease¹ and multiple sclerosis. Hallucinations can occur in up to 40% of patients with Parkinson's disease and this may be due to the disease or the medication.⁴
• Brain tumours and epilepsy⁵ can produce psychosis but they may also produce hallucinations per se. Temporal lobe epilepsy is especially liable to produce hallucinations of smell.
• Hypnogogic hallucinations can occur alone or be part of narcolepsy.
• Many forms of drug abuse can cause psychosis. There may be a dual diagnosis of mental illness and substance abuse.
  • Drugs not usually associated with abuse like mefloquine, other antimalarials⁶ and buproprion have been implicated. A full drug history is essential - including herbal⁷ and "natural remedies" that have not been adequately tested for toxicity whilst a gullible public believes that they are incapable of producing adverse effects.
  • Drugs of abuse: Many drugs of abuse can cause psychosis. Sometimes those who are psychologically vulnerable and perhaps on the verge of mental illness may attempt self-medication with illicit substances. This may lead to debate as to whether it was the drug that caused the mental illness or the mental illness that lead to the drug abuse. What does seem certain is that those on the edge of mental illness who abuse drugs do themselves only harm and recent research has shown that such people who take cannabis are more likely to precipitate schizophrenia. A national study of the British prison population⁸ concluded that severe dependence on cannabis and psychostimulants is associated with a higher risk of psychosis and is in contrast to severe dependence on heroin, which has a negative relationship with psychosis.
    • Hallucinogen perception disorder usually refers to abuse of lysergic acid diethylamine (LSD). It is not as popular as it was in the 1960s but it is still available. The amounts involved are tiny and it is not detected by routine urine screens for drugs.
    • Amphetamine abuse includes MDMA or Ecstasy.⁹ Paranoia tends to be a prominent feature. Amphetamine is often abused along with other substances but in Japan it is often the sole drug of abuse. A study from there concluded that amphetamine psychosis has 3 core components. They are progressive qualitative alteration in mental symptoms from a nonpsychotic to a prepsychotic to a severely psychotic state, enhanced vulnerability to relapse of psychosis and very long duration of the vulnerability to relapse.¹⁰
    • Cocaine addiction also causes psychosis. There may be features of hypomania. Urine test is positive for only a matter of days.
    • Cannabis is no longer seen as a harmless drug. It may be that it is comparatively innocuous if taken occasionally in moderation, rather like alcohol, but stronger varieties are now available than the traditional grass. A form called skunk can be 30 times as potent as the traditional forms. Cannabis moderately increases the risk of psychotic symptoms in young people but has a much stronger effect in those with a predisposition for psychosis.¹¹ The risk of psychosis also seems to be dose related.¹²
    • Mushrooms, khat,¹³ mescaline and many other drugs and substances of abuse may also be involved.

It is very important to recognise and manage a first episode of psychosis correctly as delay in diagnosis may adversely affect ultimate prognosis.¹⁴If there is an external cause like substance abuse this must be addressed. Remember that psychosis in substance abuse can be part of dual diagnosis.

• Prompt assessment - Admission to a psychiatric unit is often required at the outset. Compulsory admission and possibly enforced treatment under the Mental Health Act may be required but the condition is so distressing that most patients go voluntarily. The family also tends to prefer the patient to be in a safe environment.
• Psychological input
  • Education.
  • Cognitive-behavioural therapy.
  • Family interventions (management usually involves the family as well as the patient).
  • Modify stress and vulnerability factors.
  Counselling will be required to help the patient gain insight into the disease and a realistic appraisal of the prognosis.
  A case manager or therapist can provide emotional support, education about the illness and its management, and practical assistance with day-to-day living. They may also recommend programmes in the community and provide supportive psychotherapy and vocational counselling.
• Drug treatment
  • First-line treatment in suspected schizophrenia now involves the use of the newer atypical antipsychotics¹⁵ e.g. risperidone or olanzapine is first line, but haloperidol is still used.^16,17
  • Depot formulations may be needed, especially if patient is not co-operating. However, oral medication is preferred as depot may have unpredictable effects and duration of onset.¹⁸
  • Benzodiazepines may be needed acutely - such as lorazepam.
  • Rapid tranquilisation may be required if the patient is violent or aggressive and refuses admission.
  • Other drugs may be required to deal with the problems of substance abuse.
  There is some data to suggest that antipsychotics are most useful as monotherapy and that the role of benzodiazepines may be limited. Furthermore, addition of benzodiazepines may just add to side effects.¹⁹
  A Cochrane review noted that current guidelines and clinical practice for the use of antipsychotic drugs in women with non-affective disorders during pregnancy and postpartum are not based on evidence from randomised controlled trials.²⁰
  In the elderly lower doses should be given and time allowed for the effect.²¹

This is highly variable. Sometimes symptoms resolve swiftly and people resume their regular life with little delay. Other people may need several weeks or months to recover. Some people will need medication and support for the rest of their lives. Psychosis is treatable and many people will make an excellent recovery. The old picture of a steady psychological and social decline is no longer appropriate, partly because of improved medication. The first episode of psychosis tends to occur at a time when decisions about a career still need to be made, yet at that time it is usually impossible to give an accurate prognosis. The better educational establishments are often very understanding about those with mental health problems and will give them a chance to recover and resume their studies. The Disability Discrimination Act encourages employers to take a more enlightened view of those with mental illness. Nevertheless, occupations where unexpected, irrational actions may have disastrous consequences like clinical medicine, airline pilots and driving a bus, are probably best avoided.

It must not be forgotten that psychosis can lead to disastrous consequences. Suicide can occur in any form of mental illness. A study of young people in Sweden, followed up for 10 years showed that 2.5% had killed themselves and 25% had attempted suicide.²² Delusional concern for loved ones may lead to the decision to kill them too. Paranoia may lead to the "self-defence" of killing an innocent person. In puerperal psychosis it is necessary to strike a balance between bonding between mother and baby and the risk of harm to the baby. The law on Infanticide acknowledges that a mentally deranged woman may kill her baby up to a year old. It is an old law that sees the woman as a victim of mental illness rather than a heinous murderer.

With any episode of psychosis the DVLA states that driving must cease for at least 3 months. It may be resumed if conditions are met and there is a favourable specialist's report.