What is Psychosis?

Psychosis is a severe psychiatric condition, which affects the way in which an individual not only experiences the world around them, but also causes distortions in their thinking. So psychosis is relatively rare. It affects around 1% of the global population. And despite being relatively rare, it is considered by the World Health Organisation to again be one of the most debilitating conditions that we tend to see. It’s in the top ten leading causes of disability. What we also tend to find, as with OCD, is that the media portrayal of psychosis can be somewhat inaccurate.

So people with psychosis are generally portrayed as being dangerous in nature and violent, whereas in most cases they tend to be the victims of abuse or bullying or have experienced some kind of trauma in their lives. So as opposed to being the perpetrators of a violent act, they tend to be most likely on the receiving end of a violent act. And there are specific kinds of psychotic disorders that we look at so the one that is probably most famous, one that we have probably most mostly heard about is schizophrenia. We also have schizoaffective disorder, which involves aspects of psychosis and aspects of mood as well. Affective, referring to a mood disorder.

We have delusional disorder, a brief psychotic disorder, so a brief psychotic episode as well as schizophrenia form disorder. And our diagnostic manuals once again are really handy in terms of helping us identify what type of psychosis we may be looking at. So earlier on, when an individual first presents with psychosis and we’ll touch on the key symptoms and signs to look out for here we tend to diagnose them with having first episode psychosis. If they present after being treated with those symptoms again, then we look to narrow it down to specific type of psychosis, whether it be schizophrenia, schizoaffective disorder and so forth.

But what’s key to remember is that the first time and many times it can be the only time that a patient presents with these symptoms. We consider it to be a first episode. But there are also three stages when we’re looking at psychosis. More broadly speaking, we have the first stage, which is the prodromal, and this is where we have certain early signs that can be really, really difficult to pick up on or notice. And these are difficult to notice because they don’t necessarily look out of the ordinary or scream you know psychosis. It could be things such as feeling more stressed, more anxious, low in mood. There could be changes in their ability to concentrate.

They also become potentially more withdrawn from social situations, and there could be disturbances in sleep problems. Now, something that may be a little bit more easier to notice would be odd beliefs if an individual start to hold odd beliefs. And this goes beyond just conspiracy theories. Sort of believing those conspiracy theories and very fixed beliefs in that regard that are unshakable. And again, that doesn’t necessarily suggest pathology in itself. Then we move on to the acute phase or the acute stage, rather. And this is where we’re looking at when those initial symptoms of psychosis first appear and individuals tend to become increasingly distressed and they may also appear to be quite frustrated and agitated.

So if we’ve correctly identified those key signs and symptoms, then we move on to managing the symptoms associated with psychosis and the specific type of psychosis we may be looking for, looking at. And then we move into a phase of recovery So this is where treatment has been provided. Many people can go onto to recover. It’s not necessarily a life sentence in itself. So whilst relapse can happen and it may happen it’s important to consider that we just keep going and try to help the patients to move into that phase of recovery once again. Now, the key types of symptoms that we’re looking for in psychosis, we tend to divide into three categories.

Firstly, we have what I refer to as the positive symptoms. And the positive symptoms are the hallucinations and the delusions. So this is where we’re looking at distorted experiences of reality. So hallucinations refer to seeing or hearing or experiencing things in our immediate environment that aren’t there or rather that aren’t experienced by others. So there are a number of different types of hallucinations. And these all relate to our five senses. So the most common are auditory hallucinations, hearing things that aren’t there. So hearing people talking or talking about them or giving commands, telling people what to do. There are also visual hallucinations. So seeing things and these are different to delusions.

Delusions are different to hallucinations in that hallucinations tend to to be an experience of reality itself. We also have tactile, for instance, or gustatory taste, which are relatively rare. So there are an array of types of hallucinations, but the most common would be auditory. And we also have delusions, which are those false beliefs that are really, really fixed and resistant to change. You can’t reason them away. And the nature of the delusion also again depends on the individual. It could be a persecutory delusion in nature.

A person could believe, for instance, that MI5 and MI6 are after them because for whatever reason, they do believe that, and they may even believe that their family and their loved ones are in on this plot to capture them. That also relates to a paranoid delusion. We have somatic delusions. So it’s very, very difficult to at times help patients with psychosis or to get them to agree to to get treatment because their reality has significantly changed from the reality that we experience. They lack insight into the condition because psychosis has that impact on the brain itself. There also negative symptoms that are important to consider. And these relate more to the emotional side of things.

So the negative symptoms that we look at relate more to mood and emotion. So this is where we’re looking at things such as flat emotion. So tone is quite flat. There is perhaps less eye contact. They derive less pleasure in activities that they once found pleasurable. And there’s also a decrease in motivation to do things. There’s also monotone speech, so monotonous in nature. And these all kind of resemble those key signs and symptoms of depression as well, which is why earlier on we may suspect that a patient has depression until those positive symptoms, those hallucinations and delusions become more prominent.

And there are also cognitive symptoms and this is where we’re looking at distorted thinking, difficulty sustaining focus and attention and concentration, and also a slowing in processing speed. So they’re a bit slower in their thinking as well. So positive and negative symptoms are key to consider alongside cognitive symptoms. Now, the causes of psychosis and this is again, an area of lots of current research, specifically when we’re looking at genetic and biological causes, we see a lot of this research currently taking place at Cardiff University, looking at identifying specific genes that may predispose individuals to psychosis. And we know that there is a genetic component to this.

We have identified that certain genes do contribute to the onset of psychosis, but we also know that there are key environmental factors, such as once again, adverse early life experiences in trauma, social isolation is really important, and we know that adverse experiences, for instance, poverty and even experimenting with things like recreational drugs, we know that some people respond very badly to cannabis, whereas in most instances, experimenting with cannabis won’t lead to a psychotic episode, whereas for some individuals it can do so. But environmental factors, even for instance, when we’re looking at the context of the UK, there are certain studies that have looked at ethnic minority groups in London who are isolated from other individuals who share their culture.

That in itself can also potentially be a predisposing factor, which is interesting for certain individuals if we’re looking at the genetic risk being there as well. So as with the other conditions that we looked at. It’s not nature versus nurture, it’s again nature and nurture, it’s the gene environment interaction that is key here, which may predispose individuals to psychosis and the onset of psychosis at certain points in the life course. Now, in terms of diagnosis, again, we rely on our diagnostic manuals here, the ICD 11 and the DSM 5. But what is rather challenging in this regard, as mentioned earlier, is the lack of insight that patients have in relation to their condition.

So we know that psychosis affects the brain in such a way that individuals experience reality differently to the rest of us. And as such, because there is a clash between their reality and our reality, you can’t really convince them that their reality is not real. It is real to them. So you would most likely need to intervene, a GP in the first instance could be, is a useful starting point and the GP will then refer to a psychiatrist, most likely if they’re worried about the patients to the crisis team and the crisis team will perform further assessments. So the crisis team will assess whether this is a picture of psychosis.

They’ll also look at whether the patient is a danger to themselves or to others. Generally what we tend to find is that suicide ideation can be quite prominent in these patients. In other words, thinking of suicide sometimes having thoughts about harming themselves in a way, is a way for them to sort of stop anything, anything bad from happening to them because they again may believe that something bad is coming their way. So that’s important to assess. Again, performing a mental state examination to kind of ascertain exactly what kind of a picture it is that we’re looking at here. And it’s also important to consider things such as the Mental Health Act.

So because these patients may lack insights, and tend to lack insights, we need to consider the level of risk and also what we’re looking at specifically, do we need to help these patients by considering the Mental Health Act and sectioning? Now, that’s a term that scares a lot of people, and it’s something that mental health professionals don’t want to do. We prefer to use the least restrictive option, but in certain instances where you have to intervene to protect someone from themselves, you do rely on the Mental Health Act in order to do so.

So in terms of treatment, what we’re looking at here is initially the crisis team will assess the patient and they’ll assess whether they can be treated in the community. So at home, basically with a, within the care of the community mental health team who will visit the patient, ensure that they’re taking the medication and not only care for them from a kind of medication perspective, but also in terms of talking therapy. There will be a nurse who’s in touch with them looking at the social side of things and an array of services that they can offer.

If they’re worried about the patient’s level of risk, their home environments and any other factors that may make it more challenging to be treated from home, they will probably consider a hospital admission and the patient will be treated in the relevant ward, which again is much more pleasant than what the media would have us believe. Patients tend to have their own rooms, their own bathrooms, and they’re cared for by by the nurses who also are on hand for any support that they may need. So patients are assigned a care coordinator. It tends to be a psychiatric nurse. And the care coordinator, as the term suggests, will coordinate their care in total.

So they will have a psychiatrist that they will see and speak to, the psychiatrist will obviously manage the medication and that side of things. But they will also have, for instance, certain psychological interventions. So cognitive behavioural therapy where a patient can engage with this has proven to be quite effective, but they may also consider things such as family therapy, which is important when considering the family dynamic as a whole, and also helping the family understand the condition better. Art therapy has also proven to be quite an effective way of dealing with the negative symptoms and helping the patient also express themselves. So art therapy is also encouraged by the CMHT and also if a patient is admitted on the ward.

Now, in terms of treatment, we know that a relapse can occur. So what’s important is also educating patients about their triggers and what I refer to as their relapse indicators and ensuring that they are aware of these. And what they may also find quite, quite challenging is adherence to taking their medications are complying with that. And what we tend to find is that giving patients the responsibility of their own care seems to be quite effective. The old way of telling someone what to do proves to be less effective, especially if they’re of an older age.

So looking at having the patients take on the responsibility for their care and if they don’t want to take a particular drug for certain reasons, maybe they’re worried about the side effects, encouraging that conversation with a psychiatrist and thinking about whether there is a different type of anti-psychotic medication that can be prescribed, which helps with avoiding certain side effects such as weight gain, some of the antipsychotic medications can cause weight gain. So that’s important to consider as well and to validate the patient’s concerns. So in essence, psychosis is something that is very important to consider with regards to the level of risk patients may present with. And this is where we’re also looking at suicidal ideation and even suicide attempts.

So if you’re concerned for anyone’s well-being, if they’re presenting with any of the key signs and symptoms alluded to in this presentation, contact their GP immediately and also consider contacting NHS 24. If it’s an emergency, if it’s life threatening, as always, contact triple nine. But for more information about psychosis, Mind offer information as well as support where appropriate, as do YoungMinds so this is again more for younger individuals. And what we tend to find is that psychosis tends to present before the age of 30 in most cases, but it can also occur later on in life. Again, it depends on certain traumatic experiences that an individual may have.

And then there are a number of other support services and networks available, such as Samaritans. Once again, that can help if individuals are experiencing thoughts of self-harm and suicidal ideation. And as with the previous talks, the NHS website is always a great place to to consult for more information and further further support as well that the NHS can offer