The Psychotic State
Psychosis is characterized by an impaired relationship with reality.
Signs and Symptoms of Psychotic Episodes - Causes and Effects
People who are experiencing psychosis may have either hallucinations or delusions. Hallucinations are sensory experiences that occur within the absence of an actual stimulus. The person experiencing psychosis may also have thoughts that are contrary to actual evidence. These thoughts are known as delusions. Some people with psychosis may also experience loss of motivation and social withdrawal. These experiences can be frightening. They may also cause people who are experiencing psychosis to hurt themselves or others.
Delusions and hallucinations are two very different symptoms that are both often experienced by people with psychosis. Delusions and hallucinations seem real to the person who is experiencing them. There are delusions of paranoia , grandiose delusions , and somatic delusions. Someone with a grandiose delusion will have an exaggerated sense of importance.
A hallucination is a sensory perception in the absence of outside stimuli. There are certain illnesses that cause psychosis, however. There are also triggers like drug use, lack of sleep, and other environmental factors. In addition, certain situations can lead to specific types of psychosis developing. Some types of dementia may result in psychosis, such as that caused by:. However, research has shown that genetics may play a role. People are more likely to develop a psychotic disorder if they have a close family member, such as a parent or sibling, who has a psychotic disorder.
Children born with the genetic mutation known as 22q Some kinds of psychosis are brought on by specific conditions or circumstances that include the following:. Brief psychotic disorder, sometimes called brief reactive psychosis, can occur during periods of extreme personal stress like the death of a family member. Someone experiencing brief reactive psychosis will generally recover in a few days to a few weeks, depending on the source of the stress. Psychosis can be triggered by the use of alcohol or drugs, including stimulants such as methamphetamine and cocaine.
Some prescription drugs like steroids and stimulants can also cause symptoms of psychosis. People who have an addition to alcohol or certain drugs can experience psychotic symptoms if they suddenly stop drinking or taking those drugs. A head injury or an illness or infection that affects the brain can cause symptoms of psychosis. Psychotic disorders can be triggered by stress , drug or alcohol use, injury, or illness.
They can also appear on their own.
The following types of disorders may have psychotic symptoms:. When someone has bipolar disorder , their moods swing from very high to very low. Schizophrenia is one type of psychotic disorder. People with bipolar disorder may also have psychotic symptoms. Other problems that can cause psychosis include alcohol and some drugs, brain tumors, brain infections, and stroke.
Treatment depends on the cause of the psychosis. It might involve drugs to control symptoms and talk therapy. Hospitalization is an option for serious cases where a person might be dangerous to himself or others. Psychotic Disorders Also called: Could someone be behind this? Patients rarely complain of negative symptoms box 2 , but they may have lost ambitions at school or work and social networks and activities may have been curtailed. Three core mood symptoms—mood, energy, and interest or pleasure—are reduced in depression and raised in manic states.
The coexistence of psychosis and major alterations in mood may indicate bipolar or schizoaffective disorders. Many other aspects of the patient's history determine diagnosis and management:. The primary diagnosis may be revised weeks or years later box 3 , and thorough documentation improves diagnostic accuracy now and later. The patient's general appearance and behaviour may indicate overarousal and hostility as a result of positive symptoms or irritability suggestive of elevated mood.
Other motor signs catatonia and negativism are rare in Western settings. Altered consciousness is highly unusual in non-organic psychoses—intermittent clouding indicates delirium and this or other impairments require urgent medical investigation. Speech will be disorganised if thought disorder is present box 1 , and with predominant negative symptoms box 2 conversation will be stilted and difficult. Random changes of the subject loosening of associations and new words neologisms are best written down verbatim.
Fast or pressured speech suggests mania. Mood should be noted as normal, depressed, or elevated. Affect, the outward expression of mood, is unlikely to be normal in these patients: An anxious or perplexed affect may impact on actual behaviour. Cognitive impairment, tested at the bedside, can present in the early stages of psychosis, but gross abnormalities may alert the clinician to learning disability or organic pathology.
Concentration is subjectively normal patient unaware but objectively impaired for example, the patient cannot recite the months of the year backwards. Insight can change considerably over the course of a psychotic illness and its treatment. Taking a collateral history is the third core component of assessments.
Incomplete information can be gained from patients who are paranoid, and perhaps lack insight. Family and friends may have noticed them behaving strangely—responding to hallucinations or testing their delusions. Taking collateral details after clinical assessment is an opportunity to test the working diagnosis. The patient's family will clarify whether some beliefs are culturally sanctioned and are not therefore delusional.
Collateral history may identify a prodrome or negative symptoms box 2 as the main focus of carers' concerns.
Insidious onset and prolonged psychotic symptoms during the first two years are both strong predictors of poorer long term outcome. If the quality of collateral history is poor for example, the patient is brought in by the police or is homeless , seek out anyone with prior contact before concluding your assessment. Integrate new information into further assessments of your patient: Patients need to be given the results as soon as they are known. This reduces anxiety and paranoia, and it prevents excessive preoccupation with physical health. If the patient has organic psychosis, treat the underlying condition and unless the patient has epilepsy 8 consider symptomatic short term treatment of the psychotic symptoms.
If the underlying condition cannot be cured for example, Alzheimer's dementia , consider giving low dose antipsychotics, but be aware that the benefits of these drugs in this situation may be outweighed by their adverse effects. Even in agitated patients who lack insight into their bizarre behaviour, mental health law allows for compulsory treatment of the mental disorder only, and physical treatments antibiotics, intravenous fluids, surgery cannot be forced on patients under this legislation.
From this point on, I will consider only psychiatric diagnoses. Post-traumatic stress disorder and obsessive compulsive disorder have prominent anxiety symptoms, driven by understandable non-psychotic processes. The last three possibilities are lifelong disorders, identified by collateral history.
All can have episodes of psychosis, but residual disabilities of the underlying disorder persist beyond the treatment episode. I find that having psychosis is horrible, but unless I'm acting strangely no one knows and I'm expected to seem normal. I hear very distressing voices all the time and occasionally get weird delusions and see things in a way that other people say are not real.
I've been admitted to hospital and sectioned several times because of it. When I first arrive at the hospital I hate the fact that my liberty has been curtailed, but after a while it's a relief not to have the responsibility of trying to take care of myself. I know it's time to go home when I start resenting the hospital again. Finding the right medication can be difficult—I have the misfortune of getting terrible side effects from many of them. However, by trial and error I have eventually found something that doesn't make me too uncomfortable and makes the voices quieter.
Now of course I'm reluctant to try the new ones in case they cause problems or don't work properly. The most complicated thing in day to day life is trying to work out what sensory input is real without having to keep asking people. I also have to try to make sure I don't get tired or stressed.
Non-organic psychoses are best treated by mental health services in the least restrictive setting. Open discussion can achieve consensual admission. Patients with psychosis who decline further treatment are assessed under mental health legislation on the grounds of danger to self suicide, unsafe behaviours, exploitation by others or danger to others overarousal, risk of acting on delusions, potential harm to others.
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In England and Wales, the Mental Health Act requires two independent doctors and an approved social worker to agree on involuntary committal to a psychiatric hospital. Accreditation for acute inpatient mental health services www. Older adults, adolescents, and postpartum women have complex needs and require admission to specialist units. Early detection, perhaps through specialised teams with allied strategies public education, liaison with schools and general practitioners have the potential to reduce admissions.
It is safer to achieve sedation with benzodiazepines as required , rather than antipsychotics. Choosing a highly sedating antipsychotic drug at this stage can impede discharge later box 4. All hospitals and trusts have clear guidelines on rapid tranquillisation of patients with psychosis; these monitor for side effects and complications. Typical antipsychotics have greater anticholinergic dry mouth, tachycardia, urinary obstruction, etc and antiadrenergic postural hypotension, impotence effects.
All antipsychotics cause sedation to varying degrees and lower seizure threshold, especially clozapine.
What Are the Types of Psychotic Disorders?
All antipsychotics, except for ziprasidone not available in the UK and aripiprazole, 10 cause weight gain and impaired glucose tolerance. Typical and atypical antipsychotics probably increase the risk of thromboembolic disease equally.
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- Psychosis: Causes, symptoms, and treatments?
The metabolic syndrome box 5 is often seen in people with chronic psychoses given their unhealthy life styles, 14 and is linked to all antipsychotics, most notably atypicals. They could not conclude that haloperidol failed to prevent volume loss, or caused it, or that olanzepine halted loss. Clozapine should be considered earlier in patients who do not respond to two antipsychotics, but many patients decline clozapine because weekly blood tests are needed to detect early signs of a low white blood cell count.
Fish oils are a worthwhile option, but only as an addition to standard treatment. Evidence supporting psychological interventions is strong enough to recommend their use in all treatment guidelines.
What is psychosis?
Practitioners of cognitive behaviour therapy have challenged traditional assumptions about delusions to gain a shared understanding of the origins of beliefs and explore alternative explanations: Family interventions have the advantage of benefits for other family members and greater acceptability and than drug treatments drop-out rates are lower. Psychoeducational interventions are brief, cheap, and require less staff training. Most patients with a first episode of psychosis have misused substances; abstinence improves their prognosis, and if they continue to abstain their outcomes at 18 months are better than those for patients who have never misused substances.
Box 6 shows possible outcomes of standard care, on the basis of two reviews. Early intervention teams provide phase specific treatments, integrated case management, and cognitive behaviour therapy interventions. Early intervention teams reduce the duration of untreated psychosis.
Treatment of a first episode is recommended for one year, followed by gradual cessation in asymptomatic patients at low risk. Risk of relapse is indicated by residual disability, family history of psychosis, or current substance misuse. Patients at risk and those with multiple psychotic episodes require longer prophylaxis. Patients with a history of violence need more intensive case management to reduce risk, and this may include prolonged medication under supervision. Given the high personal and health service costs of relapse, decisions about discontinuation and prophylaxis should be agreed with early intervention teams.
Several early models for intervention teams have been described, with varying resource implications. Early intervention teams accommodate diagnostic uncertainty in some patients, and for most patients coordinated interventions maximise functioning and prevent relapse. Trials of cognitive behaviour therapy and family interventions, with more sophisticated treatments than used heretofore, will identify specific components that improve recovery and reduce relapse further.
Provenance and peer review: National Center for Biotechnology Information , U.