What is Psychosis?
- Perceptual disorder, disconnection with surroundings
- Hallucinations
- Delusions
- Negative symptoms
- Disorganised behaviour/speech
- “Grossly impaired understanding of reality
What are the types of psychosis?
- First episode psychosis
- Schizophreniform disorder
- Brief psychotic disorder
- Substance-induced psychosis
- Schizophrenia
- Psychosis in other disorders –Bipolar, Depression with psychotic features
- Schizoaffective disorder
- Delusional disorder
- Shared psychotic disorder
- Psychotic disorder due to general medical disorder
What are psychotic features?
- Positive symptoms -distortion or exaggeration of normal function
- Negative symptoms -restricted range and/or intensity of emotional expression (speech, fluency/productivity of thought, decreased goal directed behaviour (alogia)
What are positive symptoms of Psychosis?
Positive symptoms
–Hallucinations
–Delusions
–Disorganized thought
What are negative symptoms of Psychosis?
Negative symptoms –Affective blunting –Alogia –Avolition –Anhedonia
What are the components of psychosis?
- Cognition
- New learning
- Memory
- Mood symptoms
- Insight
- Demoralization
- Anxiety & depression
- Suicide
- All the above effect level of functioning
What is Schizophrenia: DSMIV tr diagnosis?
- Two or more active phase symptoms:
- Delusions
- Hallucinations
- Disorganised speech
- Grossly disorganised or catatonic behaviour
- Duration of at least 6/12 with at least 1/12 active phase symptoms
- Negative symptoms
- Various sub-types
What is the prevalence of Schizophrenia?
- Has been observed worldwide
- Prevalence estimates commonly vary in the range of 0.5 -1.5%
- More than 2,000,000 new cases worldwide per annum
- Evidence to suggest that more than 200,000 people in Australia have Schizophrenia
What is the prognosis of Schizophrenia?
22% have one episode & no residual impairment
•35% have recurrent episodes & no residual impairment
•8% have recurrent episodes & develop significant non-progressive impairment
•35% have recurrent episodes & develop significant progressive impairment
•The majority therefore do not recover fully, but can be managed with medication
•Suicide rate is up to 13%
•Little evidence that antipsychotics have altered the course of illness for most patients
•However, evidence that prolonged psychosis which is untreated has a bad prognosis
Prognosis - what is a good outcome with psychosis associated with?
- Female
- Older age of onset
- Married
- Living in a developing (as opposed to developed) country
- Functional premorbid personality
- No previous psychiatric history
- Good education and employment record
- Acute onset, affective symptoms, good compliance with medications
What are the biochemical theories?
Main theories are dopamine, serotonin and excitatory amino acid hypotheses
What causes Psychosis?
Psychotic symptoms occur as a result of a disturbance in how the brain functions
•Different parts of the brain communicate with each other using chemical messengers (neurotransmitters)
•Psychotic illnesses develop when people have an imbalance of these chemical messengers
•When there is excessive Dopamine –causes positive symptoms (hallucinations, delusions).
•Not enough Dopamine –causes negative symptoms (lack of motivation)
Genetic predisposition
•Early development –birth trauma
•Stressors –substance use, biological factors, stressful events, unknown triggers
What are the acute treatment goals?
Reduce likelihood of harm: •Self •Staff • Family •Others •Reduce distress and disability associated with acute symptoms •Planning for further interventions •Engage family/partners/caregivers
Assessment of Schizophrenia
- Predisposing, Precipitating, Perpetuating & Protective factors
- Stressors
- Presenting problems
- Reasons for presentation to service
- Patient’s & others perception of the problem
- History –psychiatric, physical, medical, behavioural, abuse, financial, legal, occupational, substance use, cultural, personal development, previous level of functioning
- Premorbid personality, coping mechanisms & resilience
- Family history –of physical & mental illness, interpersonal relationships, genogram
- Collateral history
- Treatment history
- MSE, MMSE, physical assessment & organic screen, risk assessment
What are the typical medications types for Psychosis?
- First generation –Phenothiazines i.e. Chlorpromazine is a low potency mediation with high sedation factor 200mgs daily up to 500mgs max dose
- Alternative to first generation- Haloperidol 1.5mgs daily up to 7.5mgs daily, Pimozide are both high potency with low sedation factors
- Pericyazine 10mgs with a max dose of 20mgs daily (therapeutic guidelines 2008)
What are the atypical medications for psychosis?
•Clozapine 12.5mgs max dose 900mgs •Risperidone 0.5mgs up to 6mgs at night •Olanzapine 5mgs up to 20mgs •Quetiapine 100mgs up to 400mgs •Aripiprazole 10mgs up to 30mgs –(therapeutic guidelines 2008)
What are the general adverse affects from anti psychotics?
Parkinsonism •Dystonias •Akathisia •Tardive dyskinesia •Neuroleptic malignant syndrome •Metabolic dysregulation •Hyperprolactinaemia •Cardiac & other effects
Parkinsonism
- More likely with typicals
- Usually reversible
- More likely after weeks or even months of continuous therapy
- Major negative influence on compliance
What are the long acting medications - depot medications?
- Fluphenazine deconate 12.5-50mgs 2-4 weekly
- Flupenthixol deconate 20-40mgs 2-4 weekly
- Haloperidol deconate 50-200mgs 4 weekly
- Risperidone consta 25-50mgs 2 weekly
- Zulcopentixol deconate 200-400 mgs 2-4 weekly
- Olazapine Deconate 45-300mgs 2-4 weekly
- These medications are used to ensure that clients are adherent to medication, reducing the need to oral medication daily (therapeutic guidelines 2008)
What are the dystonias?
- Range from inconvenient to medical emergency:
- Torticollis
- Retrocollis
- Trismus
- Oculogyric crisis
- Laryngeal dystonia
- Opisthotonus
- Most commonly acute and early (24-48 hrs)
Metabolic dysregulation
- Weight gain
- Often > 7%
- Combined with smoking, poor lifestyle & lack of exercise ,poor nutrition, and substance use
- Can be rapid
Hyperprolactinaemia
Gynaecomastia, Gallactorhea Sexual dysfunction, disturbance of menses, osteoporosis
Akathisia
Severe subjective sensation of motor restlessness •Often in first 2-3 days of treatment •Propranolol (caution) and/or BZD •Benztropine less helpful •Differentiate from psychotic agitation •Negative influence on compliance
Tardive dyskinesiaWh
- Common, severe abnormal involuntary movement syndrome
- Potentially irreversible
- Cumulative exposure to drug
- More common with typicals
- May emerge after withdrawal or dose reduction
- High dose vitamin E
