PSYCHOSIS

Dr Niall Boyce
ST3 Psychiatry Research
Dr Claudia Cooper
MRC Research Training Fellow in Health Services
Research
Locum Consultant Old age Psychiatry

Management of psychosis
Treat acute episode

Reduce risk of relapse

Promote long term recovery

Intervene early: prompt
treatment associated
with better outcome

ANTIPSYCHOTICS
Lowest effective dose
Usually oral (occasionally
depot, im)
Monitor side effects
Adherence
PSYCHOLOGICAL
THERAPY
Self help to come to
terms with
symptoms/illness
SOCIAL SUPPORT
Focus on engagement,
hope, reduce stigma

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

Maintenance treatment

Family therapy to reduce

expressed emotion

CBT to help manage residual symptoms

Art therapy helps negative symptoms

Support to reduce substance

misuse

Support employment and study

Appropriate accommodation

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

Types of primary delusions

Autochthonous delusions
Delusional perceptions
a normal perception is interpreted with delusional meaning
objects or persons take on new delusional personal significance

VIDEO 2

Types of primary delusions

Autochthonous delusions
Delusional perceptions
Delusional atmosphere / mood
experiencing surroundings as sinister, apprehensive & peculiar in a vague
way
something funny is going on

VIDEO 3

Types of primary delusions

Autochthonous delusions
Delusional perceptions
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

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

because I was hungry.

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.

VIDEO 6

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

horoscope

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...

The diagnostic hierarchy

Includes delirium, dementia, medical
causes of psychosis, drug and
alcohol related psychoses

Organic disorders

Psychotic disorders

Includes schizophrenia, delusional

disorder

Mood disorders
Anxiety disorders
Personality disorders

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

abuse

? epilepsy, substance

Delusions / hallucinations + altered level of consciousness = delirium

General pointers (2)

Bizarre delusions and hallucinations
disorders

Mood congruent delusions and hallucinations

? Mood disorders

? Schizophrenia spectrum

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

Life time prevalence of psychosis

Any psychotic
Illness: 3%

Includes:
Schizophrenia (1%)
Schizoaffective disorder (0.2%)
Delusional disorder (0.03%)
Acute & transient psychotic disorders
Induced delusional disorder

(Bipolar affective disorder (1%))

psychotic symptoms, not clinically relevant: > 17%

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 (3 rd 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

Positive symptoms

Hallucinations
Delusions
Ideas of reference

Under-activity
Few leisure interests
Negative
symptoms
Lack
of convention
Social withdrawal
speech
motivation
emotional responsiveness (flat affect)

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
Auditory Hallucinations
Ideas of reference
Suspiciousness
Flat Affect
Delusions of Persecution

97 %
74 %
70 %
66 %
66 %
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
Identical twin
Non-identical twin
Children
Sibling
Parent
Grandchild
Niece/ nephew
1st cousin
General population
0

10

20

30
40
%

50

60

Genetics of schizophrenia
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

Genetics of schizophrenia
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

Aetiology of schizophrenia

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

Perinatal factors

Aetiology
of schizophrenia
School problems

neurodevelopmental

genetics

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

Perinatal factors

Aetiology
of schizophrenia
School problems
cannabis

neurodevelopmental

genetics

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.

Neurodevelopmental
hypothesis
School
problems,
abuse

Perinatal factors

Developmental delay

Expressed
emotion

cannabis
genetics
Life event,
deprivation,
adversity,
migration

Final
common
pathway is
Dopamine
5HT
glutamate

Migration
In the UK, the incidence of all psychoses is significantly higher in AfricanCaribbean 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).

Perinatal factors

Aetiology
of schizophrenia
School problems
cannabis

neurodevelopmental

genetics

Expressed emotion

migration
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:
Antipsychotic medication
+ low EE family

12%

Antipsychotic medication
+ high EE family (<35 hours a week)

42%

Antipsychotic medication
+ 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