Understanding psychosis
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Understanding psychosis
- 3. Objectives • Identify what we mean by psychosis • Identify what it is ‘isn’t’ • Discuss the difference between symptoms and illness • Identify other medical conditions • Describe the main presenting symptoms • Identify what causes psychosis • Have a brief look at first episode psychosis • Discuss and Identify ‘First Aid’ for psychosis • Briefly identify treatment options
- 4. What is Psychosis... ?
- 5. What it is…. • A psychiatric term • Greek: Psyche: Abnormal Mind / Condition • Experiences: Hallucinations, Delusions, Unusual Beliefs • Loss of contact with reality • A marked change in behaviour
- 7. R.D. Laing ‘Madness need not be all breakdown. It may also be break- through. It is potential liberation and renewal as well as enslavement and existential death’
- 9. Diagnosis • Severe Depression • Schizophrenia • Bi Polar (Affective) Disorder • Schizoaffective Disorder
- 10. What other mental health issues witness psychosis as a symptom? • Some Personality Disorders • PTSD • OCD • Brief Hallucinatory experiences
- 11. Medical Conditions Plants • Secondary Psychosis Dementia Animal Toxins Flu Parkinson’s Therapeutic Drugs Brain Psychosis Tumour Recreational Drugs** Lupus Cancer Treatment Liver and Kidney problems B12 Childbirth Thyroid problems
- 12. Is it common? • UK Health Authorities suggest 1 in every ? People in Britain has had psychosis. • 100 • 200 • 500
- 13. Other Facts • 80% of all cases of Psychosis are experienced by people aged 16 – 30 • There are more incidences in urban than rural communities • In the UK there is a slightly higher prevalence in people from black and ethnic minority groups • Men and women are affected with equal frequency
- 14. Main presenting symptoms • Hallucinations • Delusions • Thought disturbances • Lack of insight
- 15. 4 Main Symptoms • Hallucinations – Sight, Sounds, Touch, Smell • Delusions – Paranoid, Grandeur • Thought Disturbances – Speech, content, train of thought • Lack of insight – Unaware, lack self awareness
- 16. What causes it? • Physical (Organic) • Substance Induced (e.g.: Drugs and Alcohol) • Medication • Brain Chemistry** • Inherited Vulnerability • Traumatic experiences
- 17. Brain Chemistry • What Happens Normally? • Information is moved around the brain, from nerve cell to nerve cell, by means of chemical substances, called??? • A message travels along the nerve and when it approaches the nerve ending a neurotransmitter is released (1) • The neurotransmitter is received by the next cell (2) • some of the neurotransmitter gets reabsorbed (3) • When enough neurotransmitter is received by the next nerve cell the message moves forward (4) NEUROTRANSMITTERS.......
- 18. However..... • Dopamine and Serotonin are two neurotransmitters that are important in psychosis • In people with psychosis, the balance between these chemicals is disturbed • One theory, is that in psychosis there may be too much Dopamine • Symptoms of psychosis, like Hallucinations and odd beliefs ( Delusions ) are thought to be related to this overstimulation • Nerve cells shut down • Symptoms • Medication • Treatment
- 19. First Episode Psychosis • 3 phases • Prodrome • Acute • Recovery
- 20. First Aid – For Psychosis • Not a sticking plaster for the mind, some real practical guidance.
- 21. How should you approach someone who may be experiencing psychotic symptoms • Caring and non judgmental, share your concerns • Privately, away from distractions • Tailor your approach • Be specific about your concerns • Allow the person to articulate themselves • Offer reassurance
- 22. How can you be supportive? • Treat the person with respect • Avoid any confrontation • Bee honest
- 23. How would deal with ‘delusions’ and ‘hallucinations’? • Validate their ‘realness’ • Don’t argue, dismiss, or minimise • Don’t act alarmed, horrified or embarrassed
- 24. How would you deal with communication difficulties? • Uncomplicated responses, succinct • Be patient, allow time • Don’t assume someone doesn’t understand
- 25. How should you encourage someone to get professional help? • What did the person do previously? • Support the person emotionally and practically
- 26. What if the person refuses help? • Encourage to talk to someone the person trusts • A person can’t be forced to accept help • Above all, remain friendly, and open to the possibility of future help
- 27. What about a crisis? • Remain calm, assess risks • Is there an advance directive? • Who can help? • Can the person be left alone? • Use appropriate communication • What if things escalate?
- 28. What if the person becomes aggressive? • De-escalation • Don’t be hostile, disciplinary or challenging • Don’t threaten or prompt aggression • Avoid raising your voice or talking too fast • Stay calm, avoid abrupt movements • Don’t restrict the person’s movement • Be aware of increasing fear and possible aggression
- 29. Dolly’s experiences, CBT • F:VideosDolly's experience with psychosis and CBT.flv
- 30. Treatment Options • Talking Treatments • Medication • Community Care and CPA • Hospital admission • Crisis Teams / Support lines • Early Intervention in Psychosis • Advocacy • Advance Decisions
Notas do Editor
- Imagine that I have just landed on earth. You strange earth creatures speak of this thing called ‘psychosis’ What is this phenomena. In pairs discuss what we mean by psychosis.
- Psychiatric term – It is borne from the medical and in psychiatry. That said, RD Laing, in the 60s suggested psychosis was almost a spiritual expereince, unwelcome perhaps, but symbolic all the same.Greek: Psyche: Abnormal Mind / Condition, first introduced by a psychiatrist called Kanstatt as early as 1841.Experiences– Hallucinations, delusions, unusual beliefsLoss of contact with reality – When people are psychotic it stops people thinking clearly. People may not be able to tell the difference between reality and their imagination, this often stops people from acting in a normal way. There is a marked change in behaviour
- Experiences are not always symptoms of a psychotic illness. A number of people have heard voices or hold beliefs which might be considered to be unusual, certainly through western eyes, but the person is not distressed. Other cultures often respect voice hearing for example as great wisdom and truth, spiritual significance and thus these experiences are culturally rich and not seen as wrong or in need of fixing. In the western world, psychosis is something that people wouldn't want or desire.
- RD Laing was a Scottish Psychiatrist, interested in particular, in the experience of psychosis. Laing's views on the causes and treatment of serious mental dysfunction, greatly influenced by existentialphilosophy, ran counter to the psychiatric orthodoxy of the day by taking the expressed feelingsof the individual patient or client as valid descriptions of lived experience rather than simply as symptoms of some separate or underlying disorder. The Divided Self, The Politics of Experience.
- Video Clip???Unfortunately, films, especially, tend to show people with psychosis in very unflattering ways. That's how misunderstandings start. Often people think, psychotic, oh yes, of course, someone with multiple personalities! Have you ever heard someone say that people with psychosis have a multiple personality disorder? They're just like in the movie Me, Myself and Irene.Multiple personality disorder is a very rare condition and has nothing to do with psychosis at all.Films like these suggest another myth: that people experiencing psychosis are psychopaths. The facts are quite the opposite. A psychopath is someone who has no compassion or empathyfor other people, they are socially manipulative, and sometimes they dangerous to themselves and others. A psychopath doesn't care about anyone but him/herself, they may seem charming, but this is surface, dig deeper and the only thing a psychopath wants is something for themselves. This does not describe someone with psychosis.
- It is a very broad term, and is even considered to be so wide that it does not even represent itself as a proper diagnosis. Despite this, the signs and symptoms lead psychiatrists to assume that it is a mental illness. But many factors are interplaying, often people refer to their problems as a psychotic illness or having a psychotic episode. However, it could be part of a more serious mental health condition, such as?? Most common?
- Personality Disorders – Paranoid Personality Disorder, Borderline Personality Disorder.Post Traumatic Stress DisorderOCDBrief Hallucinatory experiences – Not uncommon, you do not need to be suffering from a psychiatric illness. Hallucinations when falling alseep or waking are perfectly normal. Stress(brief reactive psychosis) bereavement, severe sleep deprivation, sensory deprivation, sensory impairment, caffeine intoxication. B12 – A deficiency of B12 (some meats, fish, poultry, eggs, milk products ) Defiecny often not check for in mental health hospitals.
- List any medical conditions you may have heard of, where psychosis maybe a feature, discuss in pairs. Animal Toxins– Snakes, spiders, scorpions, Lyme Disease – Deer TickPlants – The oil in Poison IvyLupus – auto immune, between 12 and 50%. Arise from an overactive immune response of the body against substances and tissues normally present in the body. In other words, the body actually attacks its own cells. Childbirth – immediately after birth, possibly for people suffering from severe postnataldepression.
- In some cases this is just one episode, while for others there maybe psychotic episodes throughout a persons life, or it may be part of a bigger problem, e.g. Schizophrenia
- 4 groupsHallucinations – What are they? What types?Delusions – What are they? What types?Thought Disturbances – What are the signs?Lack of insight – How might we know someone is lacking insight?
- HallucinationsSight – Visual - Colours, shapes, imagine people or objects that to others would not be there.Sounds – Auditory - Usually voices, maybe unpleasant, angry, sarcasticTouch – Tactile - May have a crawling or creeping on or in the skinSmell – Olfactory - Strange or unpleasant Others can include: Taste, vivid or dreamlike, the sensing of body movements, animals and people appearing closer or further away than they actually are. DelusionsParanoid – The most common. A person may believe someone is out to hurt them, or being watched, being talked about. Normally, this leads the person to display unusual behaviour as the paranoia takes over. For example, a person may decide to throw away or hide their mobile phone if they believed it was a device to control their mind.Grandeur – This is when someone believes they have a certain power or authority. It might be that someone believes they are an important person, god, the prime minister, someone with huge influence. It might also involve the belief that the person has a special power such as being able to bring someone back from the dead.Thought DisturbancesA person might have disturbed, confused and disrupted patterns of thought. Speech might be rapid, the person may flit from one subject to another rapidly, a person’s train of thought might stop mid sentence or subject.Lack of Insight – It is likely that whatever the person is thinking or doing, they are unaware of that they are becoming unwell. There maybe small levels of insight but as the symptoms intensify then self awareness depletes. A person who is admitted to hospital may be of the opinion that they are well and all round are not.
- It is possible for anyone to experience a psychotic episode, though there are now suggestions that psychosis is linked to specific vulnerabilities, stress, trauma etc.That said, it is commonly associated with these factors:Physical (Organic) - Sleep, usually lack of, severe jet lag. Viral infections, illness, high fevers, malaria, pneumonia have been implicated. It could be through a head trauma / injury. It might be, as we have stated, related to dementia, where the brain cells die and connections that once existed have now depleted. There have been incidences of psychotic episodes related to lead and mercury poisoning and changes in blood sugar levels. Substance Induced – Use of, or withdrawal from, alcohol and drugs, can be associated with psychosis.Alcohol – 3% of alcoholics suffer from psychosis. The long term effects distort neurons in the brain and cause genetic dysfunction. Psychosis has also been related to vitamin deficiency, (B1 – Thiamine). There is also an increased risk of depression and suicidal ideation and suicide.Drugs – Cannabis, Cocaine, Amphetamine, LSD, Ketamine, Crystal Meth, have all been associated with psychotic symptoms. These substances are known as ‘psychoactive’. They affect certain areas of the brain, which could affect the condition of the mind.Medication - Some prescription medications may also trigger psychotic episodes, examples include some tranquilizers, anti-epilectic drugs, antidepressantsdrugs used to open up the airways (anticholinergics), and levodopa (for Parkinson's disease). Brain Chemistry – There is much evidence now to suggest that psyhotic experiences are brought about by biological changes in the brain structure or brain chemistry. Inherited vulnerability – This is inconclusive. Although studies now show if you have a relative who has suffered from Schizophrenia or Bi Polar Disorder then you have a higher risk of developing it yourself. No single gene has been found to be responsible, so brain imaging and testing and prediction is difficult. Also, many people who suffer from psychotic episodes have no known family history.Traumatic experiences – Physical, emotional and sexual abuse. It maybe the stress of such expereinces or repressed emotions hwihc later come to the fore that might increase psychotic thinking.
- Dopamine and Serotonin – The two most important neurotransmitters in psychosis. In reality, it is much more complicated than this, as there are more than 100 different neurotransmitters.Dopamine – Increased dopamine can cause cognitive and emotional difficulties. It can impair social and self awareness and how we behave. In people with psychosis, the balance between these chemicals is disturbedOne theory, is that in psychosis there may be too much Dopamine.Excess dopamine causes an overstimulation of the nerves. This means that too many messages are being sent at the same time.Nerve cells slow down - When the brain is over stimulated for a prolonged period, it causes the nerve cells to shut downSymptoms of poor concentration and reduced motivation, may be related to this shut downThe treatment of psychosis involves medications that work to restore the chemical balance in the brain. They work by "mopping up" the excess Dopamine. Treatment also involves managing stress and restoring the balance in the person's environment http://www.cdhb.govt.nz/totara/early.htm
- A very frightening experience, highly disturbing, confusing and distressing.Prodrome– This is the early stages, signs will be hardly noticeable. There maybe some changes in behaviour and perception but this might not be viewed by others as worrying (From the Greek, meaning precursor, what comes before). Although, this is difficult to spot, it might be, if recognised then early intervention is accessible through mental services.Acute – More chronic phase. This is where the symptoms are more pronounced and noticeable. E.g. Hallucinations, delusions and thought disorder.Recovery – The pattern of recovery is so variable, but with support and access to the right treatment then recovery can be quick and timely.
- Caring and non judgmental – Share your concerns. Note: The person you may be trying to help may not trust you, they may fear that you see them as different and therefore may not open up to you. Privately , away from distractionsTailor your approach – Often difficult. Be mindful that the person may be suspcious of your intentions, they may avoid eye contact etc, give someone the space that they need. Be specific about your concerns – State the specific concerns that worry you. It is maybe unhelpful to act as you know what they might be suffering from, in other words stating the possible diagnosis. Allow the person to articulate themselves – Allow the person to tell you what they believe, what they are experiencing. Allow the person to set that pace during the interaction. Note: The person may well be frightened and exposing their thoughts and feelings may cause great fear. Offer reassurance – Ask the person what will help them retain control and keep safe. Reassure that you are there to help and support them. Convey a message of hope, offer the possibility of support and help to access that support. If the person simply won’t converse, them allow the person the choice not to talk about their experiences, offer time to talk in the future.
- Treat the person with respect – Show empathy, not sympathy. Try and express to the person how difficult it must be for them experiencing and believing things that are clearly causing stress. Again don’t judge what they say, even though the level of their experience may not be something which is happening in reality. People who are suffering from psychotic symptoms often find it difficult to tell what is real and what is not real. Avoid any confrontation – Criticism or blame can be destructive. The person is suffering from a set of symptoms, they may behave and say things that ordinarily they wouldn't be expressing, it is best not to take anything personal to heart. Don’t be sarcastic or patronising. Be honest – It is important to plain with people, be honest. Don’t promise something you can’t keep to.
- Validate their realness – It is ok to say you can’t see, how or believe the things the person can perceive. Delusions and hallucinations can be very real to people.Don’t argue, dismiss, or minimise – Conflict will only occur and the possibility of further communication will be affected. Don’t act alarmed, horrified or embarrassed – Often people say unusual things and express ideas which are chaotic and perhaps even disturbing. Show concern if appropriate. Don’t laugh at what anyone might say, however unusual. Also, when someone is stating paranoid beliefs it is best to allow the person to express their ideas, but don’t collude or encourage, thinking may inflame.
- Many people suffering from psychosis are unable to think logically.Uncomplicated responses, succinct – If someone's speech is disorganised speak clearly yourself, don’t discuss complex ideas in detail, this will only add to confusion for the person. Also, repeat yourself if necessary but not constantly. Be patient, allow time – Sometimes people need to process the information. Responses will be more delayed than usual, that is to be expected. If the person appears flat and not responding well, it doesn't mean that the person is feeling nothing. Don’t assume someone doesn’t understand – A person’s response might be limited, but they may not process all that you have said in the time it would take to process ‘normally’
- What did the person do previously? – It maybe that the episode is the first, but if not, what happened before? Ask the person. Ascertain as to whether what happened before was a success or not and why? Try and seek out who they trust and who might offer them the best support.Support the person emotionally and practically – If the person does want help, then support the person to accept the help and offer any emotional and practical support. A person maybe fearful of some support services or they may lack confidence or the ability to do anything about it, even with some insight.
- In reality, a person may refuse any help.Encourage to talk to someone the person trusts - A person may be confused, fearful, or even denial there is a problem at all. Is there someone they can trust? A friend, family member?A person can’t be forced to accept help – That is if they don’t fit the criteria to admitted to hospital under the MH Act. If a person’s symptoms are severe and they are clearly a risk to themselves or others, then immediate support should be sought. Never threaten the person with hospital admission or duties under the mental health act. Above all, remain friendly, and open to the possibility of future help – Someone is much more likely to seek you out for support if they feel you have treated them humanistically.
- Remain calm, assess risks – Evaluate how the person is coping, feeling and responding to what they are experiencing. The main risks to be mindful of, are risk to self and others. Is the person at risk of suicide? Advance directives– They used to be called relapse prevention plans, is there one in place? Try and follow this if there is. Who can help? – Apart from mental health services, friends, family members? Enlist that support if necessary. Can the person be left alone? – A judgement call. If you think they are a danger to themselves, stay with them. Use appropriate communication – Clear, concise, non threatening, answer any questions calmly. If someone is making a request and it is safe and reasonable, make yourself available to help. What if things escalate? – If they do, and in reality, they can, ask for appropriate help immediately. When specialist staff are contacted be clear about what has happened to date. If your call for help and support is not dealt with in the way you think it should be, continue and persist and document your attempts.
- It is rare, many people believe the opposite, but the risk in a crisis situation for someone with psychotic symptoms is that they likely to be more of a risk to themselves. That said, some caution might need to be heeded too.In the end you should never put yourself at risk. Remove yourself and others from a situation, call for emergency services.
- Talking Treatments – In other words, counselling. CBT is something that is used regularly. Help will involve developing coping strategies, putting experiences into context, keeping diaries of experiences. Some therapists may help someone challenge paranoid beliefs. Psychodynamic approaches may also be useful, looking more in-depth about unconscious and subconscious reasons behind someone’s experiences. Making sense of current situations in relation to the past can be useful for some. The key in all approaches is getting some control back. Medication – Most people will be offered some form of anti psychotic medication. The aim is to reduce the psychotic symptoms. Experiences may still be prevalent and people often have to find the right medication and right level to maintain themselves. If the psychosis is co-morbid with other problems, depression for example, then it is likely the person will also be offered anti depressants, or if it is Bi Polar, a mood stabilising drug. Some studies suggest that it is best to look at more social interventions of management first, before medication is used. Ultimately, what tends to occur is that medical professions become concerned about ending that medication due to relapse concerns. The problem with some medicines is the unwanted side effects, weight gain, lethargy, sexual dysfunction, involuntary movements. Community Care and CPA – People who come into contact with psychiatric services will receive an assessment under CPA. If in secondary care services, the person will receive a care co-ordinator, usually a CPN or Social Worker. Hospital admission – Some people may need time in hospital for further assessment. Crisis Teams and Support linesEarly Intervention in Psychosis – For people 14 – 35 services are available some areas for people experiencing their first episode of psychosis. This is about treating symptoms early, and trying to support the person without the problem worsening. It is also important that these services help and support the person to maintain what they have, job, school, college, and help people avoid drugs, excessive drinking, and involvement with the criminal justice system. AdvocacyAdvance Decisions – Get that crisis plan, or living will in place. It is legally binding, but needs to be written inconjunction with the key provisions of the Mental Capacity Act, 2005.