Psychosis

  • About

    People with psychotic disorders experience changes in the way they interpret reality.

    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 other people do
    • Perceptual or sensory changes:
      • Hallucinations: having the sense of experiencing something that really isn't there (eg, seeing, hearing, smelling, tasting or feeling things that do not exist in the environment and that others don't think is there)
    • 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 (eg, believing that your thoughts are being controlled by someone else)
      • Difficulty concentrating, paying attention and remembering things
      • Everyday thoughts can seem confusing, making it hard to understand sentences
    • Behavioral changes:
      • Social isolation or being withdrawn 
      • Problems with work, social or family life
      • Problems with motivation or problems with increased activity
      • Responding differently to situations, for example laughing when things don't seen funny
    • Physical changes:
      • Problems with sleep

    Onset of psychotic disorders in young people
    Around one in every 100 people will experience psychosis at some stage in their lives (1). In Australia, between 0.3-0.5% of males and 0.2-0.3% of females aged 18-24 will have been treated for psychosis within the previous month (1).

    Schizophrenia is the third leading contributor to the burden of disease and injury in Australian males aged 15-24, and the fifth leading contributor for females (2).

    Overall, about 50% of people who develop a psychotic disorder will do so by the time they are in their early 20s. The age of onset tends to be a little older in females than males (1, 3).

    Risk factors
    A number of factors are known to increase the likelihood that a person will have a psychotic disorder (4). They include:

    • Genetic vulnerability (for example, a psychotic illness in other family members) 
    • Complications during pregnancy or birth
    • Place and season of birth
    • Differences in brain structure and function
    • Substance abuse
    • Psychosocial stress

    Research has indicated that there are some additional factors that place a person at particularly high risk (4). This includes genetic vulnerability and the occurrence of:

    • 'Attenuated' or mild psychotic symptoms
    • Brief, limited or intermittent psychotic symptoms
    • An unexplained increase in problems with work or school and social or family life

     

    References
    1. Jablenskey A, McGrath J, et al. Psychotic disorders in urban areas: an overview of the Study on Low Prevalence Disorders. Aust NZ J Psychiatry. 2000 Apr;34(2): 221-236.

    2. Australian Institute of Health and Welfare. Youth Australians: their health and wellbeing. 2007 Cat. no. PHE 87. Canberra: AIHW.

    3. Kessler RC, Amminger GP, et al. Age of onset of mental disorders: a review of recent literature. Curr Opin Psychiatry. 2007 Jul;20(4): 359-364.

    4. Yung AR, Phillips LJ, et al. Risk factors for psychosis in an ultra high-risk group: psychopathology and clinical features. Schizophr Res. 2004 Apr 1; 67(2-3): 131-142.

  • 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)
    • 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) 
    • Delusional disorder (having one or more delusional beliefs)
    • Brief (or acute or transient) psychotic disorder (psychotic symptoms develop suddenly in response to major stress)
    • Psychotic disorder not otherwise specified (NOS)
    • Schizotypal disorder

    Assessment Tools
    To decide whether a young person may be experiencing a psychotic disorder, a comprehensive assessment by a mental health professional is required.  As a first step, the assessment involves asking questions about a range of aspects of a person life including their:

    • Home and Environment;
    • Education and Employment; 
    • Activities; 
    • Drugs and Alcohol; 
    • Relationships and Sexuality; 
    • Conduct Difficulties and Risk-Taking; 
    • Anxiety and Eating; 
    • Depression and Suicide; 
    • Psychosis and Mania

    To assess specifically for the presence of a psychotic disorder, a comprehensive Mental State Examination by a mental health professional trained in clinical assessment is required. It may also be beneficial to use a standardized assessment interview such as the Comprehensive Assessment of the At-Risk Mental State (CAARMS) to assist in identifying a young person who is either at ultra high-risk of developing a psychotic disorder, or is currently experiencing a psychotic disorder.

    See the Yung et al 2005 publication of the CAARMS for more information (3).

    References

    1. DSM-IV Psychotic disorders

    2. ICD-10 Schizophrenia disorders

    3. Yung AR, Yuen HP, et al. Mapping the onset of psychosis: the Comprehensive Assessment of At-Risk Mental States. Aust NZ J Psychiatry. 2005 Nov-Dec;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. Integrated early intervention services have been developed in Australia and elsewhere, aiming to provide:

    • Assertive case management
    • Medication
    • Psychological therapy
    • Family and group therapy 
    • Vocational interventions

    A longer duration of untreated psychosis before diagnosis and treatment can worsen the medium- and long-term outcomes (1). 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 (2) for 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. Marshall M, Rathbone J. Early intervention for psychosis. Cochrane Database Syst Rev. 2006 Oct 18;(4): CD004718.

    2. Fraser R, Berger G, et al. Emerging psychosis in young people - Part 2 - key issues for management. Aust Fam Physician. 2006 May;35(5): 323-327.

  • guidelines

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

    Australian Clinical Guidelines for Early Psychosis Second Edition (2010) Orygen Youth Health Research Centre

    The Australian Clinical Guidelines for Early Psychosis 2nd Edition- Evidence Map Quick Reference (2008) Orygen Youth Health Research Centre

    Clinical practice guidelines for the treatment of schizophrenia and related disorders (2005) Royal Australian and New Zealand College of Psychiatrists

    Keshavan MS, Roberts M, et al. Guidelines for Clinical Treatment of Early Course Schizophrenia. Curr Psychiatry Rep. 2006 Aug;8(4): 329-334.

    International Clinical Practice Guidelines for Early Psychosis (2005) International Early Psychosis Association Writing Group

    Schizophrenia. Core interventions in the treatment and management of schizophrenia in adults in primary and secondary care.  (2009) National Institute for Health and Clinical Excellence (NICE) CG 82, United Kingdom

  • More info

    Relevant general interest articles:

    Yung AR, Killackey E, et al. The prevention of schizophrenia. Int Rev Psychiatry. 2007 Dec;19(6): 633-646.

    Killackey E, McGorry PD. Interventions in the early stages of psychosis. Psychiatric Annals. 2008 Aug;38(8): 521-526.

    Crossley NA, Constante M, et al. Efficacy of atypical vs typical antipsychotics in the treatment of early psychosis: meta-analysis. Br J Psychiatry. 2010 Jun;196(6): 434-439.

    Rummel C, Hamann J, et al. New Generation Antipsychotics for First Episode Schizophrenia. Cochrane Database Syst Rev. 2003;(4): CD004410.

    Jones C, Comac I, et al. Cognitive Behaviour Therapy for Schizophrenia. Cochrane Database Syst Rev. 2004 Oct 18;(4): CD000524.