++
Acute psychosis is the presence of the mental state where appreciation of reality is impaired as evidenced by the presence of typical psychotic symptoms such as delusions, hallucinations, mood disturbance and bizarre behaviour.7 Refer to the diagnostic strategy for hallucinations in TABLE 45.7.
++
++
The differential diagnoses of patients presenting with psychoses is presented in TABLE 45.8.
++
++
Early recognition of a psychosis, particularly schizophrenia, is extremely important, as early intervention leads to improved outcomes. Early or prodromal symptoms include the following:
++
social withdrawal
reduced attention and concentration
reduced drive and motivation
depressed mood
anxiety
irritability/agitation
suspiciousness
sleep disturbance
deterioration in role functioning
++
It is appropriate to ask the correct questions in order to elicit psychotic symptoms. These are presented in TABLE 45.9.
++
++
DSM-5 key diagnostic criteria5—schizophrenia
+++
Schizophrenia and associated disorders
++
The term ‘schizophrenia’ (Bleuler 1911) refers to a group of severe psychiatric illnesses characterised by severe disturbances of emotion, language, perception, thought processes, volition and motor activity. The causes of schizophrenia disorders are unknown, but genetic factors and drug abuse are implicated.
+++
Signs and symptoms of schizophrenia
++
Positive
Negative
— flat affect
— poverty of thought
— lack of motivation
— social withdrawal
— reduced speech output
Cognitive
Mood
— mania (elevation)
— depression
++
++
bizarre behaviour
subject to tension, anxiety or depression
deterioration in work and study performance
peak incidence 15–25 years8—smaller peak at 40 years
lifetime prevalence 1 in 100
equal sex incidence
high risk of suicide
+++
Differential diagnosis
++
Organic factors need to be excluded, especially drugs:
++
amphetamines
hallucinogens (e.g. LSD)
marijuana
++
Also consider complex partial seizures and a personality disorder. Other psychoses are presented in TABLE 45.8.
++
A comparison of delirium, dementia and functional psychosis is presented in TABLE 45.10.
++
++
Drug treatment is only a part of total management. Explanation and appropriate reassurance to the family with patient and family supportive care is obviously essential. Supportive psychotherapy is important in all phases. A team approach is necessary to cope with the disorder, which usually has a devastating effect on the family. Referral for specialist care is appropriate.
++
++
Drug treatment may include the first-generation (typical or conventional) antipsychotics such as haloperidol and chlorpromazine, which are effective for managing the ‘positive’ symptoms, or the second generation (atypical) antipsychotics such as risperidone, olanzapine, quetiapine, clozapine, amisulpride and aripiprazole, which in addition are more effective at treating the ‘negative’ and other symptoms of schizophrenia.9
++
The usual practice rule is to start with a second-generation antipsychotic at a low dose and titrate upwards at a rate and to a level that is optimal for the patient. Patients with a first psychotic episode may respond to lower than usual doses.5
++
When oral medication is possible, first-line treatment (for the first episode) is one of (with starting doses):1,10,11
amisulpride 100 mg nocte
asenapine 5 mg sublingual bd
aripiprazole 10 mg once daily
lurasidone 40 mg once daily
olanzapine 5 mg nocte
paliperidone 3 mg nocte
quetiapine 50 mg bd → 200 mg bd (by day 5)
risperidone 0.5–1 mg nocte → 2 mg nocte
ziprasidone 40 mg bd → 80 mg bd (risk of ↑ QT)
zuclopenthixol 20 mg nocte Practice tips
Typical initial oral therapy:
olanzapine 5 mg
or
risperidone 0.5 mg
If response is inadequate in 3 weeks increase the dose according to prescribing guidelines.
If no response after 4–6 weeks consider a change to:12
Parenteral medication should be avoided if possible in acute care, but if required:1,11
haloperidol 2.5–10 mg IM, initially, up to 20 mg in 24 hours, depending on the response
or
olanzapine 5–10 mg IM initially (do not use with benzodiapines concurrently)
add
benztropine 1–2 mg (o) bd (to avoid dystonic reaction)
or
zuclopenthixol acetate 50–150 mg IM as a single dose
If dystonic reaction:
If very agitated use:
++
Long-term antipsychotic medication is recommended to prevent relapse.1
++
Examples of oral medication regimens:11,12
Aim for lowest possible dose to maintain control.
Chlorpromazine is not recommended for long-term use because of photosensitivity reactions.
Use depot preparations if compliance is a problem (usually test dose first):1,10
fluphenazine decanoate 12.5 mg IM, initially then 12.5–50 mg every 2–4 weeks
or
haloperidol decanoate 50 mg IM, initially then 50–200 mg every 4 weeks
or
flupenthixol decanoate 10 mg IM, initially then 20–40 mg every 2–4 weeks
or
risperidone 25–25 mg IM initially then every 2 weeks, titrated to clinical response
or
zuclopenthixol 100 mg IM, initially then titrated to 200–400 mg every 2–4 weeks
++
Tips with depot preparations:
++
Start with IM test doses and then titrate to recommended controlling levels (half or full starting dose).
May take 2–4 months to produce a stable response, so oral supplements may be necessary.
Not as effective as oral therapy.
Give as deep IM injection with 21 gauge needle in buttock.
Use lowest possible dose to avoid tardive dyskinesia.
Reassess at least every 3 months.
Closely monitor patient for movement disorders.
+++
Drug-resistant schizophrenia13,14
++
Consider other causes (e.g. substances abuse). ECT may help the agitated patient, especially if catatonic. Consider a trial of clozapine (12.5 mg (o) bd initially increasing to 200–600 mg daily), with strict monitoring for blood dyscrasias and cardiotoxicity, or olanzapine (5–20 mg daily). A trial of adjunctive ECT should be considered in patients who fail to respond to clozapine.
+++
Movement disorders from antipsychotic medication1
++
Usually bizarre muscle spasms affect face, neck, tongue and trunk
Oculogyric crises, opisthotonos and laryngeal spasm
Treatment:
++
++
++
reduce dosage until akathisia less troublesome or substitute thioridazine
can use oral propranolol, diazepam or benztropine as a short-term measure
++
++
++
use lower dose or substitute a phenothiazine in low dosage
alternatively, use benztropine or benzhexol
++
Tardive dyskinesia is a syndrome of abnormal involuntary movements of the face, mouth, tongue, trunk and limbs. This is a major problem with the use of long-term antipsychotic drugs and may occur months or years (usually) after starting treatment and with drug withdrawal. Avoid prolonged use of metoclopramide.
++
++
++
If drug withdrawal is ineffective, use tetrabenazine 12.5 mg (o) daily, increasing as necessary.12 The risks and benefits of continuing therapy have to be weighed.
++
Note: Because of the difficulty with managing tardive dyskinesia, prevention in the form of using the lowest possible dosage of antipsychotic medication is essential. This involves regular review and adjustment if necessary.
+++
Neuroleptic (antipsychotic) malignant syndrome
++
This is a potentially fatal adverse effect that can develop at any time. It develops in hours to days.
++
Syndrome: high temperature, muscle rigidity, altered consciousness. Milder variants can occur (refer to CHAPTER 53).
++
++
++
Various psychotrophic agents, particularly the phenothiazines, are prone to cause the adverse effect of prolongation of the QT interval with potential severe outcomes.
++
The mood disorders are divided into depressive disorders and bipolar disorders. Bipolar is a broad term to describe a recurrent illness with episodes of either mania or depression with return to normal function in between. The swing in moods in bipolar disorders (manic depressive disorders) is illustrated in FIGURE 45.1. It affects 1%–2% of the population.
++
++
DSM-5 criteria for a manic episode5
++
Bipolar I disorder has one fully fledged manic or mixed episode and usually depressive episodes.
++
Bipolar II disorder is defined as a major depressive episode with at least one hypomanic episode lasting a minimum of 4 days but no classic manic episodes.
++
The symptoms of mania may appear abruptly, usually in the teens or young adulthood.
++
Typical inherent features, in addition to the above, include:
++
reckless behaviour, overspending
hasty decisions (e.g. job resignation, hasty marriages)
impaired judgment
increased sexual drive, energy and activity
poor insight into the problem
variable psychotic symptoms—paranoia, delusions, auditory hallucinations
++
Note: The peak onset is in early adult life. The exact cause is unknown, but there is a strong hereditary basis. Episodes may be precipitated by stress.
++
‘Hypomania’ is the term used to describe the symptoms of mania that are similar to but less severe (without criterion C) and of shorter duration.
++
The subsequent major depressive phase is associated with a high risk of suicide.
++
Good questions to ask the patient with suspected ‘bipolar’ disorder:
++
How have you been feeling in yourself?
Have you felt especially good about yourself?
Do you feel that you are special or have special powers?
Have you been spending more than usual?
Have you been needing less sleep than usual?
+++
Management of acute mania1,15
++
This is a medical emergency requiring hospitalisation for protection of both family and patient. Involuntary admission is usually necessary. It may be a first episode or a relapse due to poor treatment compliance or substance abuse. A recent meta-analysis indicates that antipsychotics are the most efficacious drugs.
++
++
++
++
haloperidol or a second-generation antipsychotic e.g. aripiprazole16
or
lithium carbonate 750–1000 mg (o) daily in 2 or 3 divided doses increasing according to serum levels
or (a mood stabilising agent)
sodium valproate 200–400 mg (o) bd initially
or
carbamazepine 100–200 mg (o) bd initially
++
If a parenteral antipsychotic drug is required:
++
haloperidol 5–10 mg IM or IV
Repeat in 15–30 minutes if necessary (risk of tardive dyskinesia)
Change to oral medication as soon as possible
++
Failure to respond to treatment:17,18,19
++
ensure maximum concentration of first drug
switch to a different drug e.g. olanzapine to lithium
combine drugs, e.g. second-degree antipsychotic + lithium
ECT is of proven benefit for recalcitrant problems
++
Remember to provide supportive psychotherapy with appropriate psychosocial interventions.
+++
Prophylaxis for recurrent bipolar disorder
++
(Over 90% will have a recurrence at some time: consider medication if two or more episodes of either mania or depression in the previous 4 years.)
+++
Recommended prophylactic agents5
++
lithium carbonate125–500 mg (o) bd then adjusted
or
second-generation antipsychotic agent
or (if depression prominent)
lamotrigine or carbamazine or sodium valproate
++
Use long-term lithium (e.g. 3–5 years). Target plasma level for maintenance is usually 0.6–0.8 mmol/L. A US study recommended lithium as the prime mood stabiliser.16
++
If poor response, use another agent.
Unwanted side effects of lithium include:
With anti-epileptics, adjust dosage according to clinical response and toxicity.
+++
Management of bipolar depression10,17
++
This is a difficult component to treat and antidepressants should not be used alone.11 Many mood-stabilising agents appear to have a bimodal (antidepressant and antimania) effect and can be useful in the absence of classical antidepressants.15
++
A recommended regimen is:
++
an antidepressant (e.g. SSRI, SNRI or MAOI)
plus
lithium, valproate, carbamazepine, quetiapine, lamotrigine or olanzapine (one of these used for prophylaxis)
++
Antidepressants are usually withdrawn within 1–2 months because of a propensity to precipitate mania.
++
ECT is an effective treatment for bipolar depression while psychological therapies such as CBT and psychoeducation have proven efficacy.
++
Bipolar I patients usually recover but proceed to have further episodes of depression or mania.11
+++
Liaison with family and carers
++
Promote a caring support and pyschoeducation program for patient and family. Educate about the patient’s ‘relapse signature’ for a manic or depressive episode.
+++
Body dysmorphic disorder5
++
Body dysmorphic disorder is characterised by a preoccupation with the belief that some aspect of physical appearance is abnormal, unattractive or diseased. The person’s concern and distress is out of proportion to any imagined or actual defect and usually not amenable to reassurance. This preoccupation causes significant functional impairment. The condition rarely presents directly and may be over-represented in the area of dermatology or plastic surgery. It begins in late childhood or early adolescence. The person’s focus is on the face, head or secondary sexual characteristics.
++
Patients may be helped by counselling and psychotherapy including CBT. There is clinical evidence that SSRIs help if the symptoms suggest an obsessive–compulsive disorder. An antipsychotic agent may help where beliefs are delusional or in the context of a psychotic disorder.
++
Depression is very common and presents in a great range of severity. In the context of ‘the disturbed patient’ depression can be confused with dementia or a psychosis, particularly if the following are present:
++
psychomotor agitation
psychomotor retardation
delusions
hallucinations
++
The following questions need to be addressed:
++
Is the depression primary (i.e. not secondary to another psychiatric condition such as schizophrenia or anxiety disorder)?
Is it part of a bipolar disorder? Has there been a previous manic or hypomanic episode? If so, a different approach to treatment is required.
Is the depression caused by another illness or physical factor (e.g. hypothyroidism, cerebrovascular disease or medication)?
Is the patient psychotic?
Is the patient a suicide risk?
++
The treatment of depression is presented in CHAPTER 19.