Psychosis

  • About

    Schizophrenia spectrum and other psychotic disorders are made up of disorders that include schizophrenia, other psychotic disorders, and schizotypal personality disorder. Schizophrenia spectrum diagnoses make up about two-thirds of all psychotic disorders.

    People with psychotic disorders experience changes in the way they interpret reality. Every individual is different and symptoms of psychosis can vary from person to person, and can also change over time. Some common symptoms of psychotic disorders are:

    Emotional changes:

    • Feeling distanced or detached from one's body or thoughts
    • Feeling that the surrounding world is strange or not real
    • Feeling unusually excited or feeling down and depressed, experiencing mood swings
    • Finding it hard to show emotions or feeling less emotions than before

    Perceptual or sensory changes:

    • Hallucinations: having the sense of experiencing something that really isn't there (e.g., seeing, hearing, smelling, tasting or feeling things that do not exist in reality but is experienced by the person as extremely real)

    Cognitive changes:

    • Delusional thinking or false beliefs, having fixed thoughts about something that probably isn't true and not accepting any logical arguments that it isn't the case (e.g., believing that your thoughts are being controlled by an external force)
    • Difficulty concentrating, paying attention and remembering things
    • Everyday thoughts can seem confusing or jumbled, and thoughts might seem faster or slower than usual

    Behavioral changes:

    • Social isolation or becoming withdrawn
    • Problems with work, social or family life
    • Problems with motivation or problems with increased activity
    • Laughing at inappropriate times or becoming upset without an identifiable cause

    Physical changes:

    • Problems with sleep (e.g. not sleeping due to preoccupation with thoughts)

     

    Onset, prevalence, and burden of psychotic disorders in young people

    Around 3 in every 100 people in the general population will experience a psychotic disorder at some stage in their lives (1). The lifetime prevalence of schizophrenia disorder is just under 1 in every 100 people (1). At 21%, schizophrenia is the leading principal diagnosis of young people in contact with community mental health services in Australia (2). It is also the third leading contributor to the burden of disease and injury in Australian males aged 15-24, and the fifth leading contributor for females of the same age (3).

    Psychotic disorders are rare before the age of 14 years, but there is a sharp increase in its prevalence between the ages of 15-17 years (4). Overall, about 50% of people who develop a psychotic disorder will do so by the time they are in their early 20s. The mean age of onset tends to be a little younger in males (18-25 years) than females (25-35 years) (4,5).

    Risk factors

    A number of factors are known to increase the likelihood that a person will have a psychotic disorder (6-8) They include:

    Early life factors:

    • Genetic vulnerability - family history of psychotic disorder
    • Complications during pregnancy or birth (e.g. fetal hypoxia)
    • Season of birth (late winter/early spring)
    • Developmental delay
    • Traumatic experiences (e.g. abuse or neglect)

    Late childhood/adolescent factors:

    • Substance use, particularly cannabis
    • Psychosocial stress
    • Urbanicity
    • Migration
    • Cognitive impairments
    • 'Attenuated' or mild psychotic symptoms

    It is important to note that psychotic symptoms seem to be part of the continuum of normal experiences. In the general population, there is a median prevalence rate of approximately 5% and a median incidence rate of approximately 3%, and 75-90% of psychotic experiences are transitory and disappear with time (9). Therefore, the presence of psychotic symptoms does not automatically indicate a diagnosis of a psychotic disorder, and a comprehensive assessment over time is necessary.

     

    References

    1. Perälä, J., Suvisaari, J., Saarni, S. I., Kuoppasalmi, K., Isometsä, E., Pirkola, S., ... & Lönnqvist, J. (2007). Lifetime prevalence of psychotic and bipolar I disorders in a general population. Archives of General Psychiatry, 64(1), 19-28.
    2. Australian Institute of Health and Welfare 2011. Young Australians: their health and wellbeing 2011. Cat. no. PHE 140 Canberra: AIHW.
    3. Australian Institute of Health and Welfare 2007. Young Australians: their health and wellbeing 2007. Cat. no. PHE 87 Canberra: AIHW.
    4. Kessler, R. C., Amminger, G. P., Aguilar‐Gaxiola, S., Alonso, J., Lee, S., & Ustun, T. B. (2007). Age of onset of mental disorders: a review of recent literature. Current Opinion in Psychiatry, 20(4), 359.
    5. Ochoa, S., Usall, J., Cobo, J., Labad, X., & Kulkarni, J. (2012). Gender differences in schizophrenia and first-episode psychosis: a comprehensive literature review. Schizophrenia Research and Treatment, 2012.
    6. Yung, A. R., Phillips, L. J., Yuen, H. P., & McGorry, P. D. (2004). Risk factors for psychosis in an ultra high-risk group: psychopathology and clinical features. Schizophrenia Research, 67(2), 131-142.
    7. Pantelis, C., Yücel, M., Bora, E., Fornito, A., Testa, R., Brewer, W. J., ... & Wood, S. J. (2009). Neurobiological markers of illness onset in psychosis and schizophrenia: the search for a moving target. Neuropsychology Review, 19(3), 385-398.
    8. Phillips, L. J., Francey, S. M., Edwards, J., & McMurray, N. (2007). Stress and psychosis: towards the development of new models of investigation. Clinical Psychology Review, 27(3), 307-317.
    9. Van Os, J., Linscott, R. J., Myin-Germeys, I., Delespaul, P., & Krabbendam, L. (2009). A systematic review and meta-analysis of the psychosis continuum: evidence for a psychosis proneness-persistence-impairment model of psychotic disorder. Psychological Medicine, 39(02), 179-195.
  • Assessment

    Formal systems for the diagnosis of mental illness (1,2) describe a number of different types of psychotic disorder, including:

    • Schizophrenia (psychotic illness has been continuing for at least 6 months, with at least 1 month where symptoms were active)
    • Schizophreniform disorder (psychotic illness has been continuing for less than 6 months)
    • Schizoaffective disorder (co-occurring symptoms of psychosis and a mood disorder, such as depression or bipolar disorder, and were preceded or are followed by at least 2 weeks of delusions or hallucinations without prominent mood symptoms)
    • Delusional disorder (having at least one month of delusions but no other psychotic symptoms)
    • Brief (or acute or transient) psychotic disorder (psychotic symptoms develop suddenly in response to major stress - lasts more than 1 day and remits by 1 month)
    • Schizotypal personality disorder

    Assessment Tools

    To decide whether a young person may be experiencing a psychotic disorder, a comprehensive, longitudinal assessment by a mental health professional is required. It is important to note that assessment must be an ongoing process and aside from gaining information about symptoms, the purpose of assessment also includes engaging the young person in order to develop a therapeutic alliance and seeking to understand the personal context of their symptoms (3).

    Providing a thorough assessment should be balanced with the need to develop a therapeutic alliance with the young person, and techniques to promote engagement should be incorporated into the assessment (3). This could include interviewing techniques such as careful listening, taking the young person and their concerns seriously, providing an optimistic, calm, and supportive environment, ensuring there is sufficient time for the interview, and using open-ended questions as far as possible (4).

    As a first step, the assessment should cover the following domains (3,4):

    • Clinical and personal history, including the context for their current symptoms
    • Mental state examination (in particular, the young person's insight)
    • Biological assessment (e.g. comorbid medical conditions)
    • Cognitive assessment, including social cognition
    • Comorbid psychiatric disorders, including substance misuse
    • Risk assessment (risk of harm to self or others, risk of neglect or victimisation, and risk of non-adherence to treatment or disengagement from services)

    It may also be beneficial to use a standardized assessment interview such as the Comprehensive Assessment of At-Risk Mental States (CAARMS) (5) to assist in assessing symptoms that may indicate imminent development of a psychotic disorder and to determine if a young person meets criteria for being at ultra high risk for onset of a psychotic disorder.

     

    References

    1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. Washington, D.C: American Psychiatric Association.
    2. World Health Organization. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.
    3. Early Psychosis Guidelines Writing Group, Australian Clinical Guidelines for Early Psychosis, 2nd edition. 2010. Orygen Youth Health, Melbourne.
    4. Jackson, H. J., & McGorry, P. D. (Eds.). (2009). The recognition and management of early psychosis: a preventive approach. Cambridge University Press.
    5. Yung, A. R., Yuen, H. P., McGorry, P. D., Phillips, L. J., Kelly, D., Dell'Olio, M., ... & Buckby, J. (2005). Mapping the onset of psychosis: the Comprehensive Assessment of At‐Risk Mental States. Australian and New Zealand Journal of Psychiatry, 39(11‐12), 964-971.
  • Treatment

    Early detection and treatment of psychotic disorders is important for reducing the distress associated with psychotic symptoms and helping the affected person to retain their day-to-day functioning (eg. at school or work, and their relationships with family and friends). There is considerable interest in the potential to prevent the onset of psychosis and to use early, intensive treatment to reduce its short-term damaging effects (such as loss of work or social functioning) and improve long-term recovery.

    Different stages of illness (e.g. ultra high risk, first-episode psychosis) and different phases of acuity (e.g. acute, recovery, or relapse) might indicate different treatment approaches. The current Australian clinical guidelines for the treatment of psychosis provide recommendations according to stages of illness and acuity (1).

    Integrated early intervention services for a first episode of psychosis (FEP) have been developed in Australia and elsewhere, and have been found to have clinically significant benefits over standard care (2). Common components of an integrated early intervention FEP service include:

    • Case management to ensure continuity of care
    • Psychological therapy (e.g. cognitive behavioural therapy)
    • Medication and monitoring of metabolic indices and side effects (3)
    • Family and group programs
    • Vocational and educational services (e.g. Individual Placement Support program) (4)

    A longer duration of untreated psychosis before diagnosis and treatment can worsen the medium- and long-term outcomes (5). Effective intervention in the early stages of illness can help reduce long-term disability in work and family, education, and social relationships.

    In areas where such integrated early intervention specialised services do not exist, general practitioners may need to initiate early treatment and provide ongoing clinical management (see (6) for a summary of key issues for acute management).

    The evidence map provides reference details for studies of prevention and treatment interventions for psychosis disorders in young people

     

    References

    1. Early Psychosis Guidelines Writing Group, Australian Clinical Guidelines for Early Psychosis, 2nd edition. 2010. Orygen Youth Health, Melbourne.
    2. Bird, V., Premkumar, P., Kendall, T., Whittington, C., Mitchell, J., & Kuipers, E. (2010). Early intervention services, cognitive-behavioural therapy and family intervention in early psychosis: systematic review. The British Journal of Psychiatry, 197(5), 350-356.
    3. Curtis, J., Newall, H. D., & Samaras, K. (2012). The heart of the matter: cardiometabolic care in youth with psychosis. Early Intervention in Psychiatry, 6, 347-353.
    4. Killackey, E., Jackson, H. J., & McGorry, P. D. (2008). Vocational intervention in first-episode psychosis: individual placement and support v. treatment as usual. The British Journal of Psychiatry, 193(2), 114-120.
    5. Marshall, M., Lewis, S., Lockwood, A., Drake, R., Jones, P., & Croudace, T. (2005). Association between duration of untreated psychosis and outcome in cohorts of first-episode patients: a systematic review. Archives of General Psychiatry, 62(9), 975-983.
    6. Fraser, R., Berger, G., & McGorry, P. (2006). Emerging psychosis in young people-part 2: key issues for acute managementAustralian Family Physician, 35(5), 323.
  • guidelines

    The following authoritative guidelines provide evidence-based information about the practical treatment of schizophrenia and related psychotic disorders:

    Psychosis and schizophrenia in children and young people: Recognition and management. (2013) National Institute for Health and Clinical Excellence (NICE) CG 155, United Kingdom.

    Early Psychosis Guidelines Writing Group, Australian Clinical Guidelines for Early Psychosis, 2nd edition: a brief summary for practitioners. 2011. Orygen Youth Health, Melbourne.

    Early Psychosis Guidelines Writing Group, Australian Clinical Guidelines for Early Psychosis, 2nd edition. 2010. Orygen Youth Health, Melbourne.

    McGorry, P., Killackey, E., Lambert, T., Lambert, M., Jackson, H., & Codyre, D. (2005). Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders. Australian and New Zealand Journal of Psychiatry, 39(1-2), 1-30.

    Schizophrenia. Australian Treatment Guide for Consumers and Carers. (2009). Royal Australian and New Zealand College of Psychiatrists.

    Mental Health First Aid Australia. Psychosis: first aid guidelines. Melbourne: Mental Health First Aid Australia; 2008.

    International Early Psychosis Association Writing Group. (2005). International clinical practice guidelines for early psychosis. British Journal of Psychiatry, 187(48), s120-s124.

  • More info

    The following selected articles provide more information about psychosis:

    Stafford, M. R., Jackson, H., Mayo-Wilson, E., Morrison, A. P., & Kendall, T. (2013). Early interventions to prevent psychosis: systematic review and meta-analysis. BMJ, 346, f185.

    Crossley, N. A., Constante, M., McGuire, P., & Power, P. (2010). Efficacy of atypical v. typical antipsychotics in the treatment of early psychosis: meta-analysisBritish Journal of Psychiatry, 196(6), 434-439.

    McGorry, P. D., Nelson, B., Amminger, G. P., Bechdolf, A., Francey, S. M., Berger, G., ... & Yung, A. R. (2009). Intervention in individuals at ultra-high risk for psychosis: a review and future directionsJournal of Clinical Psychiatry, 70(9), 1206.

    McGorry, P. D., Killackey, E., & Yung, A. (2008). Early intervention in psychosis: concepts, evidence and future directions. World Psychiatry, 7(3), 148-156.

     

    Cochrane reviews:

    Naeem F, Farooq S, Kingdon D. Cognitive behavioural therapy (brief versus standard duration) for schizophrenia. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD010646. DOI: 10.1002/14651858.CD010646.pub2.

    Kumar A, Datta SS, Wright SD, Furtado VA, Russell PS. Atypical antipsychotics for psychosis in adolescents. Cochrane Database of Systematic Reviews 2013, Issue 10. Art. No.: CD009582. DOI: 10.1002/14651858.CD009582.pub2.

    Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD004718. DOI: 10.1002/14651858.CD004718.pub3.

    Hamann J, Kissling W, Leucht S, Rummel-Kluge C. New generation antipsychotics for first episode schizophrenia. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD004410. DOI: 10.1002/14651858.CD004410.