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Psychosis

Psychosis

What is psychosis?

Psychosis is a pathological mental condition that is often accompanied by delusions, hallucinations and disorganised speech and behaviours. The thoughts and perceptions of people suffering from psychosis are usually out of touch with reality. Core psychotic symptoms are usually presented in such mental disorders as schizophrenia and delusional disorder.

Early treatment is important

Early identification and proper treatment of psychosis can minimise the disabilities and prevent serious complications from developing.

 

How common is psychosis?
Prevalence rate

Lifetime prevalence of psychotic disorders varies across studies. According to the Hong Kong Mental Morbidity Survey, approximately 2.5% of the Hong Kong Chinese adult population have a lifetime diagnosis of psychotic disorder.

Gender ratio

An almost equal sex ratio.

Age of onset

The onset is mostly from 20 to 30 years old.

 

What causes psychosis?

What causes psychosis?

There is no single explanation for the disorder. Nevertheless, medical findings have revealed that the aetiology of the condition is related to such factors as genetics, environmental stressor, brain pathology and misuse of substances.

Family inheritance

Family inheritance is a major risk factor for psychosis. Taking schizophrenia (a common diagnosis related to psychosis) as an example, statistics show that the general population has about 1% risk of developing the disorder in their lifetime, but if a person has a biological parent with schizophrenia, the risk increases to 17%, and if both biological parents have developed schizophrenia, the risk further increases to 46%.

On the other hand, when looking at identical twins who have almost the same genes, the risk of one sibling developing schizophrenia is only at 48% when the other sibling has developed the disorder. This shows hereditary factor does not single-handedly determine whether or not a person would develop psychotic disorders like schizophrenia.

Environmental stressors

Various kinds of life demands, such as study, work and personal pursuits, produce different degrees of mental stress. Failing to manage such accumulated stress effectively may induce psychosis. There is risk of developing psychosis, despite the absence of related family history.

Other risk factors

Traumatic brain injury, brain related diseases and drug abuse (e.g. using cannabis, “ice” i.e. methamphetamine hydrochloride) that cause neurological damage to the brain sometimes also lead to symptoms of psychosis.

 

What are the symptoms of psychosis?

What are the symptoms of psychosis?

Symptoms of psychosis can be put into three groups, namely “positive symptoms”, “negative symptoms” and “other symptoms”. If you find these symptoms in your family or friend, they may suffer from the condition and should be assessed by doctors.

Positive symptoms

The “positive symptoms” are pathological conditions generated by psychosis. These symptoms are believed to involve the dysfunction of neurotransmitters, for example, dopamine, in the brain.

Delusion
  • Disturbance in thinking
  • False but firm belief which is not reasonably explained by the patient’s social and cultural background
  • Common contents of delusion include thoughts of being persecuted, the mind being invalided and controlled by mysterious external forces
Hallucination
  • Disturbance in perceptions
  • Hearing (the most common), smelling, feeling or seeing something which does not exist in reality
Disorganised thinking and speech
  • Confused thoughts and conversion which are incoherent, empty, hard to understand by others, or even completely nonsense
Negative symptoms

The “negative symptoms” refer to the decline of normal psychological functioning.

Lack of volition
  • Prefer to stay at home all day instead of going to school or work
  • May neglect personal hygiene etc.
  • Lack of interest on most of the activities
Blunting of emotion and poverty in thought
  • Seldom talk, difficult to communicate with others and express themselves
  • Blunting of emotion and lack of facial expressions, do not show emotion response towards happy or sad events
Other symptoms
Impairments in functioning
  • Impairments in cognitive function, e.g. attention, judgement and memory
  • A decline in social and vocational functioning

 

What are the treatments of psychosis?

Treatments include medication, psychotherapy, rehabilitation training and family intervention.

Medication
Types First generation antipsychotics Second generation antipsychotics
Common drugs
  • Chlorpromazine (Largactil)
  • Flupenthixol (Fluanxol)
  • Fluphenazine (Modecate)
  • Haloperidol (Haldol)
  • Pericyazine (Neulactil)
  • Sulpiride (Dogmatil)
  • Trifluoperazine (Stelazine)
  • Zuclopenthixol (Clopixol)
  • Amisulpride (Solian)
  • Aripiprazole (Abilify)
  • Clozapine (Clozaril)
  • Olanzapine (Zyprexa)
  • Paliperidone (Invega)
  • Quetiapine (Seroquel)
  • Risperidone (Risperdal)
Indications
  • Very effective to relieve the positive symptoms of psychosis, and leading to a gradual recovery
  • When the acute illness is under control, the continuation of medication can effectively reduce the risk of relapse
  • Also indicated for bipolar disorders
  • Clozapine is particularly effective to a group of patients who are resistant to other antipsychotics
Mechanism of action Work by regulating the neurotransmitters activities, such as dopamine in the brain
Side effects/ Points to note
  • Parkinsonian features:
    • Hand tremor, rigid limbs, slowness in movement
    • Some long-term users may experience change in muscle tonicity leading to rhythmic, involuntary movements of face, jaw or limbs
  • Endocrine effects:
    • Periods to stop, abnormal production and secretion of breast milk
  • Other side effects:
    • Fatigue, somnolence, weight gain, dizziness, purplish pigmentation of the skin, abnormal liver function tests, hypotension, ECG changes, arrhythmias
  • Patients should consult their doctor if they become pregnant or intend to become pregnant during therapy
  • Much less Parkinsonian and endocrine side effects
  • Relatively more risks of developing metabolic syndrome:
    • High blood sugar, high blood lipid, high blood pressure, weight gain
  • Other side effects
    • Fatigue, somnolence, dizziness, constipation, dry mouth, hypotension, ECG changes
  • Side effects of Clozapine (Clozaril):
    • Agranulocytosis (Although there is less than 1% chance of having this serious side effect, patients are required to have regular blood test for white blood cell count)
    • Fatigue, somnolence, weight gain, dizziness, constipation, hypersalivation, urinary incontinence, rapid heartbeat, chest infection (myocarditis)
  • Patients should consult their doctor if they become pregnant or intend to become pregnant during therapy

If patients experience any undesirable side effects during drug treatment, please consult the doctor as soon as possible to clarify the worries and make appropriate adjustments.

Tips on medications:

  • Control of side effects:

    The risks of developing metabolic syndrome can be modified by a healthy lifestyle, e.g. physical exercise and diet control. Besides, side effects differ very widely among individuals. Patients should report the problems to their doctor who can adjust the medications to minimise the side effects.

  • Prevent a relapse:

    In most cases, doctors recommend the patient to continue the medication after recovering from an episode to consolidate the recovery and minimise the risk of a relapse.

Psychotherapy

Psychotherapy is usually used in conjunction with medication; it helps patients learn coping strategies and reduce mental distress caused by their symptoms.

Rehabilitation training

Negative symptoms are mainly managed by psychiatric rehabilitation training, e.g. social skill training and supported employment. Receiving rehabilitation training at the early stage of psychosis is crucial in preserving the motivation to activities and work ability.

Benefits
  • Allow the patient to regain the skills essential for interacting with people in daily living and workplace
  • Maintain motivation to job and to master the skills
  • Employment is effective in boosting the self-esteem of patients
  • Help the patient reintegrate into the society
Family intervention

Family intervention is also an important treatment for psychosis. Therapists will help the family to explore the current problems and coping strategies, and provide the family with information about the illness.

Benefits
  • Encourage respect and communication within the family
  • Reduce blame on the patients and family guilt

Know more – Family support is important

Psychological stress is an important factor in the onset and subsequent relapses of psychosis. There are strong evidences showing that inappropriate family relationships, such as family members being hostile, critical or emotionally over-involved towards the patient, will increase the patient’s stress and risk of relapse.

 

How to support and help patients with psychosis?
Early detection of psychosis enhances the chance of getting better treatment results

Treatment is more effective if psychosis is detected at its initial stage. However, when detection and treatment are delayed, the patient's condition may deteriorate and will require a longer period of treatment. They will also be more likely to suffer from strain and damage to the brain, which will further reduce the effectiveness of treatment.

People suffering from early psychosis may be unwilling to receive treatment. They may believe that their symptoms will spontaneously disappear or deny the seriousness of the symptoms. They therefore feel skeptical or worried about undergoing therapy. Other common concerns include how people will perceive them, and a fear that others will discover they are undergoing psychiatric treatment. Therefore, family members’ care and encouragements for their help seeking become particularly important.

Know more – What are the early signs of psychosis?

During early psychosis, positive symptoms such as delusion or hallucination may be less severe and patients have more control over their acts; these make those symptoms more difficult to detect.

Early signs of psychosis:

  • A sudden drop in grades or job performance
  • Trouble thinking clearly or concentrating
  • Suspiciousness or uneasiness with others
  • Decline in self-care or personal hygiene
  • Spending a lot more time alone than usual
  • Having strong but inappropriate emotions or no feelings at all
Fully support sufferers to get through the hardship

The recovery process varies between different patients. Some may recover within a short time, while others may take longer. Generally speaking, the duration from the onset of illness to recovery may last for a few months. However, if the psychotic symptoms persist, the recovery process will be prolonged.

Patients may feel depressed if their symptoms are not under control. During the recovery process, patients may worry that their condition is incurable and feel anxious for their future. We need to understand they are struggling with their illness and may be vulnerable, and persistent supports to them are critical during this time.

 

Tips for caregivers:
Encourage proactive treatment:

Encourage the patient to take medication and attend therapies regularly to enhance recovery and reduce risk of relapse.

Watch out for early signs of relapse:

such as anxiety, insomnia, appetite change, loss of interest, social withdrawal, depressed mood, feelings of being teased or referred, being excessively insistent.

Accept their behaviours:

Stay calm. Do not be argumentative or critical towards patient’s symptoms and behaviours. Do not argue with patient about the genuineness of their hallucinations or delusions. May help them to focus on something else from their symptoms, such as encouraging them to talk or do things that they are interested.

Communicate and encourage:

Listen patiently to them first, pay attention to their positive changes, improvements or merits. Talk in simple and direct ways and be encouraging.

Provide regular life:

Set a structured timetable for sleep, work and interest. Engage them in normal daily life as far as possible.

Encourage social interactions:

Encourage patient to attend social rehabilitative service to enhance their social life.

Take care of yourself:

Supporting patients suffering from psychosis is a long-term challenge. So carers need to look after their own physical and mental health, to rest and regenerate, and then to accompany patients to get through the troubled time. Ask for help when necessary.

 

 

 

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Reference source(s): Websites of the Institute of Mental Health Castle Peak Hospital and E.A.S.Y