Overview of Psychosis

Overview of psychosis
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Overview of psychosis Author Michael D Jibson, MD, PhD Disclosures Last literature review version 19.3: Fri Sep 30 00:00:00 GMT 2011 | This topic last updated: Thu Feb 25 00:00:00 GMT 2010 (More) INTRODUCTION The syndrome of psychosis is relatively common, affecting 3 to 5 percent of the population at some point in life [1,2]. The primary care clinician may have contact with untreated patients with emerging symptoms of psychosis, or provide routine and sick care for diagnosed patients already under treatment with antipsychotic medications. Any clinician who treats a broad cross-section of patients will encounter psychosis and related symptoms and will benefit from an understanding of features of psychotic syndromes and proficiency in the use of antipsychotic drugs. The presentation and evaluation of different psychotic disorders will be reviewed here. Issues related to antipsychotic medications, the treatment of specific psychotic disorders and of psychosis in special populations, and the nonpharmacologic treatment of psychosis are discussed separately. (See "Schizophrenia: Clinical manifestations, course, assessment, and diagnosis" and "Bipolar disorder in adults: Epidemiology and diagnosis" and "Psychosis and pregnancy" and "Postpartum psychosis: Epidemiology, clinical manifestations, and assessment" and "Postpartum psychosis: Treatment" and "Overview of the neuropsychiatric aspects of HIV infection and AIDS" and "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Second-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Overview of psychotherapy".) PSYCHOSIS Psychosis a disturbance in the perception Help improve UpToDate. Did is UpToDate answer your question? Section Editor Stephen Marder, MD Deputy Editor Richard Hermann, MD
INTRODUCTION PSYCHOSIS Hallucinations Delusions Thought disorganization Agitation Aggression PSYCHOTIC DISORDERS Schizophrenia Bipolar mania Major depression with psychotic features Schizoaffective disorder Alzheimer disease Delirium Brief psychotic disorder Substance induced psychotic disorder Delusional disorder Psychosis secondary to a medical condition DIAGNOSTIC EVALUATION TREATMENT Voluntary versus involuntary treatment INFORMATION FOR PATIENTS SUMMARY AND RECOMMENDATIONS REFERENCES
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Assessment and management of the acutely agitated or violent adult Benzodiazepine poisoning and withdrawal Bipolar disorder in adults: Epidemiology and diagnosis
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been established or a diagnostic evaluation is in progress. Hallucinations Hallucinations are false sensory perceptions occurring in any of the five sensory modalities. Auditory hallucinations are the most common, followed by visual, tactile, olfactory, and gustatory. The common rule that auditory hallucinations signify a primary psychiatric disorder, such as schizophrenia, while nonauditory hallucinations suggest psychosis in the context of a medical problem such as alcohol withdrawal, is only partially true. The relative frequency of nonauditory hallucinations increases with medical illness, but auditory hallucinations occur commonly with medical diagnoses as well. The type of hallucination experienced by the patient may be suggestive of a particular diagnosis, but is not pathognomonic and should not preclude further investigation. Delusions False beliefs that are firmly held despite obvious evidence to the contrary, and not typical of the patient's culture, faith, or family, are classified as delusions. Persecutory, grandiose, religious, somatic, and other delusions are all common and cross diagnostic boundaries. Paranoid schizophrenia, for example, is not uniquely associated with persecutory delusions, nor do grandiose delusions occur exclusively with manic episodes. Delusions are further characterized as bizarre or nonbizarre, based on their plausibility. A bizarre delusion is one that is immediately recognized by an objective observer as aberrant, such as alien abduction, family members being replaced by doubles, or thoughts being controlled by projected energy beams. Nonbizarre delusions are those that could happen in the real world, such as having one's telephone tapped, a spouse having an affair, or one's business partner plotting to take over the company. Ideas of reference are a common subtype of delusion in which the patient believes that neutral information in the environment refers specifically to him or her. This often takes the form of "special messages" to or about the patient from the television, radio, newspaper, or recorded music. Similarly, patients may experience outside forces as
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directly about each of these symptoms. Family members should also be queried for evidence of delusional or referential thinking in the patient. Thought disorganization Disruption of the logical process of thought may be represented by loose associations, nonsensical speech, or bizarre behavior. These symptoms are typically accompanied by a high level of functional impairment and high risk for agitated and aggressive behavior. Disorganized thinking may prevent the patient from giving a coherent history or meaningful consent to treatment. The clinician should seek corroborative sources of information, such as the family, and may consider involuntary administration of medication or hospitalization. Agitation Agitation is an acute state of anxiety, heightened emotional arousal, and increased motor activity. Agitation is common in a variety of psychiatric and medical conditions, and frequently accompanies psychosis. When agitation presents in the context of a psychosis, it must be treated concurrently. (See "Assessment and management of the acutely agitated or violent adult".) Agitation may be worsened by the psychotic patient's awareness of deteriorating thought organization, disturbing delusional thoughts, or tormenting voices. External factors may include the unwelcome intrusion of medical or law enforcement personnel attempting to aid the patient. Aggression Acts or threats of violence are common in acute psychotic states, especially in patients with persecutory delusions, thought disorganization, and poor impulse control [3]. Antipsychotic medications do not reduce the likelihood of violence in the general population. However, medications that reduce active psychotic symptoms are effective in reducing the risk of violence occurring in the context of psychosis [4]. (See "Assessment and management of the acutely agitated or violent adult".) PSYCHOTIC DISORDERS Psychosis occurs in a variety of diagnostic contexts. Identification of different psychotic disorders are based on diagnostic criteria, as described in the American Psychiatric Association's Diagnostic and Statistical Manaual of Mental Disorders (DSM) or the World
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there is a continuous spectrum of psychosis, with patients exhibiting overlapping features of currently defined illness, In support of the latter concept, a large population study has identified a common genetic basis for schizophrenia and bipolar disorder [5]. The following disorders represent currently defined conditions. For each patient and type of disorder, it is important to recognize the appropriate target symptoms and expected benefits of antipsychotic treatment. Schizophrenia Schizophrenia is a severe, chronic disorder characterized by periods of active psychosis and persistent deterioration in social, occupational, scholastic, and personal functioning. The broad-ranging effects of schizophrenia are typically categorized as positive, negative, cognitive, and affective symptoms. Positive symptoms are those aspects of the illness that are added onto normal experience, such as hallucinations, delusions, and thought disorganization. Positive symptoms are synonymous with active psychosis. These symptoms are highly correlated with hospital admission, but not with other aspects of the patient's functioning, such as independent living, employment, or maintenance of personal relations [6]. Negative symptoms are those things that are taken away from normal experience, including blunted affect (lack of facial expression, voice modulation, or expressive gestures), loss of motivation, anhedonia (inability to experience pleasure), asociality (loss of social interest), and alogia (decreased verbal communication). Negative symptoms are moderately correlated with functional impairment [6]. Cognitive symptoms include deficits in each of the basic domains of intellectual function (memory, attention, verbal processing, and executive function). Cognitive symptoms are highly correlated with loss of function in work, housing, and relationships [7]. Affective symptoms most commonly include bizarre
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Antipsychotic medication is effective primarily for positive symptoms. Optimal long-term treatment includes continuous antipsychotic usage. Negative symptoms show a modest response to antipsychotic medications, affective symptoms respond in about 50 percent of patients, and cognitive symptoms respond minimally. Thus, antipsychotic treatment is effective in reducing the risk of hospital admission, but otherwise does little to aid the patient in maintenance of employment, independent living, or personal relationships. Patients with schizophrenia require specialized psychosocial interventions and medication monitoring most often available through community mental health agencies or other specialty clinics. (See "Schizophrenia: Clinical manifestations, course, assessment, and diagnosis".)
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Bipolar mania A manic episode is a discrete, sustained period of elevated or irritable mood, decreased need for sleep, increased activity, rapid thought and speech, grandiosity, and poor judgment that might place the patient at risk for injury to self or others, loss of reputation, financial impropriety, or sexual indiscretion. About 80 percent of untreated manic patients develop psychotic symptoms. Although many psychotic symptoms in the context of mania are congruent with mood, such as grandiose delusions, many are not. It is not possible to distinguish a manic episode from an acute exacerbation of schizophrenia on the basis of a mental status examination alone, and a review of the patient's behavior leading up to the acute episode, and subsequent clinical course, is necessary. A common strategy is to treat the patient who has acute bipolar mania with a combination of an antipsychotic drug and a mood stabilizer, and then withdraw the antipsychotic several weeks or months after the patient has returned to a symptom-free baseline. The rate of relapse is high in untreated patients, and continuity of prophylactic mood-stabilizing medication is essential [9,10]. (See "Bipolar disorder in adults: Epidemiology and diagnosis".) Major depression with psychotic features Psychotic features may be found in patients with major depression,
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therapy with antidepressant and antipsychotic medications, but the outcome of medication treatment tends to be less satisfactory than for nonpsychotic depression [12-14]. Electroconvulsive therapy (ECT) has consistently been found to be highly effective for both psychotic and depressive symptoms and is recommended for patients who have failed to respond to antidepressant-antipsychotic combination therapy [15]. (See "Initial treatment of depression in adults" and "Treatment of resistant depression in adults" and "Medical consultation for electroconvulsive therapy".) Schizoaffective disorder Schizoaffective disorder is a condition in which the patient meets the diagnostic criteria for both schizophrenia and a major mood disorder, and both sets of symptoms are prominent in the patient's course of illness. Most studies of antipsychotics group schizophrenia and schizoaffective disorder together in their measures of antipsychotic efficacy. Psychotic symptoms in schizoaffective disorder respond to these medications precisely as they do in schizophrenia. Alzheimer disease As many as 40 percent of patients with Alzheimer disease experience psychotic symptoms, primarily delusions, and visual hallucinations [16]. In addition, behavioral dyscontrol and agitation are common and may be associated with psychosis [17]. Antipsychotics have been shown to ameliorate psychotic symptoms and to improve behavioral problems, but also carry significant risk for increased mortality. (See "Treatment of behavioral symptoms related to dementia" and "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Second-generation antipsychotic medications: Pharmacology, administration, and comparative side effects".) Delirium Delirium is an acute disturbance of consciousness and cognition characterized by inability to focus or maintain attention, disorientation, memory impairment, and language disturbance. Psychotic symptoms and behavioral dyscontrol are common [18]. Delirium is most often the consequence of a medical condition, substance intoxication, or medication side effect.
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states".) Brief psychotic disorder Symptoms of psychosis may arise in response to stressful events and resolve quickly with treatment or removal of the stressor. In theory, these symptoms could arise in anyone subjected to sufficiently stressful circumstances. In practice, they are most often associated with predisposing character pathology, such as schizoid, schizotypal, paranoid, borderline, or histrionic personality disorders [20]. Psychotic symptoms in this context are indistinguishable from those in other disorders, but respond readily and dramatically to antipsychotic medications, hospital admission, and social support. Substance induced psychotic disorder Psychosis may result from ingestion of prescribed medications, alcohol, or illicit drugs, or from withdrawal of alcohol or sedative/hypnotic drugs such as barbiturates or benzodiazepines. In most instances the presence of offending substances is detectable, however, cases of persistent psychosis for days or weeks after a drug is cleared from the body have been described, especially with hallucinogens and amphetamines [11]. Drug-induced psychosis is best addressed by withdrawal of the offending agent, followed by antipsychotics for severe or persistent symptoms. Psychosis associated with withdrawal of alcohol or sedative/hypnotics is a medical emergency requiring immediate intervention to avoid progression to potentially fatal delirium tremens. Although antipsychotic medications are occasional useful in these cases, detoxification with benzodiazepines is the definitive and preferred treatment. (See "Management of moderate and severe alcohol withdrawal syndromes" and "Benzodiazepine poisoning and withdrawal".) Delusional disorder Isolated, nonbizarre delusions in an otherwise high-functioning person may constitute delusional disorder, a relatively uncommon condition compared with other forms of psychosis [2]. The presence of hallucinations, clearly implausible beliefs, or functional deterioration is not consistent with this diagnosis and would point to one of the more common psychotic disorders.
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psychotic symptoms [22]. These include: Neurologic problems: CNS infections, neoplasms, vascular events, cognitive disorders, and seizures Endocrine dysfunctions: thyroid, parathyroid, or adrenal abnormalities Metabolic problems: hypoxia, hypercarbia, hypoglycemia, fluid or electrolyte abnormalities, aberrant copper clearance. Hepatic and renal disorders Autoimmune disorders: systemic lupus erythematosus Treatment should focus on the primary medical condition, but antipsychotic medications are appropriate and frequently helpful. DIAGNOSTIC EVALUATION Psychotic symptoms are systematically evaluated by a mental status examination, including a detailed investigation of the presenting symptoms, as well as observation of the patient's grooming, hygiene, level of psychomotor activation, mood, affect, degree of thought organization, level of alertness, short- and long-term memory, attention, insight, and judgment. Patients should be specifically asked about hearing voices, seeing things others do not see, sensations of things touching or crawling on the skin, and smelling or tasting things without explanation. Common paranoid symptoms to pursue include whether the patient believes people are following, spying on, or wanting to harm him or her. Patients should be asked directly about thought reading, special messages from television or radio, unusual religious experiences, and special powers or abilities. Medical evaluation should include a comprehensive history, physical examination, and screening laboratories, including basic chemistries, complete blood count, hepatic and renal functions, thyroid functions, urinalysis, and drug screen. Brain imaging is not routinely indicated, but should be Help improve UpToDate. Did UpToDate answer your question?
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determined by both the nature of the symptoms and the diagnostic context in which they occur. In cases involving identifiable medical pathology, correction of the underlying disorder is essential, but may not be sufficient to restore normal thought processes [22]. Symptomatic treatment with antipsychotic medications is appropriate in these cases. Antipsychotic medications, often in conjunction with other psychotropic drugs, are the mainstay of treatment for psychotic disorders. (See "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Second-generation antipsychotic medications: Pharmacology, administration, and comparative side effects".) Efforts to identify individuals at high risk for psychosis and to develop early interventions are underway, with some promising results. (See "Pharmacotherapy for schizophrenia: Acute and maintenance phase treatment".) Voluntary versus involuntary treatment Treatment for psychosis should be voluntary whenever possible, but the nature of the illness may lead patients to fear or avoid treatment. In most venues, dangerousness to self or others, or the inability to provide for one's basic needs of food, clothing, and shelter, is sufficient cause for involuntary treatment. The legal mechanism for undertaking this differs significantly by legal jurisdiction. Clinicians, especially those in emergency settings, should become familiar with involuntary treatment procedures within their legal jurisdictions. The local community mental health agency or the nearest psychiatric emergency service should be able to assist with information, legal forms, and other aid in arranging involuntary care. INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general
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comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Beyond the Basics topics (see "Patient information: Bipolar disorder (manic depression)" and "Patient information: Dementia (including Alzheimer disease)") SUMMARY AND RECOMMENDATIONS Psychosis is a disturbance in reality perception, involving hallucinations, delusions, and thought disorganization. Patients are at risk for agitation, aggression, and impulsivity. We recommend treatment for psychotic symptoms, whether or not a diagnosis has been established. (See 'Psychosis' above.) Schizophrenia is a chronic disorder with periods of active psychosis and deterioration in social and occupational functioning. "Positive symptoms" (hallucinations, delusions, and though disorganization) respond to antipsychotic medication. We suggest maintaining antipsychotic medication for schizophrenia as discontinuation of medication leads to relapse within one year in about 75 percent of patients. (See 'Schizophrenia' above.) "Negative symptoms" of schizophrenia (withdrawal, anhedonia, loss of motivation) and cognitive impairment respond less well to antipsychotic medication and adversely impact functional status of the patient. We suggest psychosocial interventions that are generally best provided in specialty clinics. Affective symptoms of schizophrenia may respond to antipsychotic medications. We suggest initial treatment with antipsychotic medication, with addition of antidepressant medication after resolution
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antipsychotic and mood stabilizing medications are used concomitantly, and mood stabilizers are preferred for maintenance treatment. (See 'Bipolar mania' above.) We recommend that all depressed patients be asked about psychotic symptoms. Patients with major depression with psychotic features require combination therapy with antidepressant and antipsychotic medication, or electroconvulsive therapy. (See 'Major depression with psychotic features' above.) Up to 40 percent of patients with Alzheimer disease have psychotic symptoms (delusions and visual hallucinations). Antipsychotic medications can improve behavioral problems and hallucinatory activity, though are associated with increased mortality in this population. (See 'Alzheimer disease' above.) Psychosis may be related to substance withdrawal, and may be the consequence of a variety of medical conditions. (See 'Substance induced psychotic disorder' above and 'Psychosis secondary to a medical condition' above.) A thorough mental status examination and medical evaluation should be undertaken in patients suspected of having psychotic symptoms. (See 'Diagnostic evaluation' above.) Treatment of psychosis should focus both on the psychotic symptoms and the underlying disorder. Antipsychotic medication is appropriate for psychotic symptoms in the context of primary psychiatric disorders, and may be useful for control of symptoms in cases of medical illness. (See 'Treatment' above and "First-generation antipsychotic medications: Pharmacology, administration, and comparative side effects" and "Second-generation antipsychotic medications: Pharmacology, administration, and comparative side effects".)
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involuntary treatment' above.)

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Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES 1. van Os J, Hanssen M, Bijl RV, Vollebergh W. Prevalence of psychotic disorder and community level of psychotic symptoms: an urban-rural comparison. Arch Gen Psychiatry 2001; 58:663. 2. Perl J, Suvisaari J, Saarni SI, et al. Lifetime prevalence of psychotic and bipolar I disorders in a general population. Arch Gen Psychiatry 2007; 64:19. 3. Glazer WM, Dickson RA. Clozapine reduces violence and persistent aggression in schizophrenia. J Clin Psychiatry 1998; 59 Suppl 3:8. 4. Keck PE Jr, Strakowski SM, McElroy SL. The efficacy of atypical antipsychotics in the treatment of depressive symptoms, hostility, and suicidality in patients with schizophrenia. J Clin Psychiatry 2000; 61 Suppl 3:4. 5. Lichtenstein P, Yip BH, Bjrk C, et al. Common genetic determinants of schizophrenia and bipolar disorder in Swedish families: a population-based study. Lancet 2009; 373:234. 6. Ho BC, Nopoulos P, Flaum M, et al. Two-year outcome in first-episode schizophrenia: predictive value of symptoms for quality of life. Am J Psychiatry 1998; 155:1196. 7. Breier A, Schreiber JL, Dyer J, Pickar D. National Institute of Mental Health longitudinal study of chronic schizophrenia. Prognosis and predictors of outcome. Arch Gen Psychiatry 1991; 48:239. 8. Martin RL, Cloninger CR, Guze SB, Clayton PJ. Frequency and differential diagnosis of depressive syndromes in schizophrenia. J Clin Psychiatry 1985; 46:9. 9. Judd LL, Akiskal HS, Schettler PJ, et al. The long-term
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11. Ohayon MM, Schatzberg AF. Prevalence of depressive episodes with psychotic features in the general population. Am J Psychiatry 2002; 159:1855. 12. Wijkstra, J, Lijmer, J, Balk, F, et al. Pharmacological treatment for psychotic depression. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004044. 13. Schatzberg AF, Rothschild AJ. Psychotic (delusional) major depression: should it be included as a distinct syndrome in DSM-IV? Am J Psychiatry 1992; 149:733. 14. Schatzberg AF. New approaches to managing psychotic depression. J Clin Psychiatry 2003; 64 Suppl 1:19. 15. Khan A, Cohen S, Stowell M, et al. Treatment Options in Severe Psychotic Depression. Convuls Ther 1987; 3:93. 16. Paulsen JS, Salmon DP, Thal LJ, et al. Incidence of and risk factors for hallucinations and delusions in patients with probable AD. Neurology 2000; 54:1965. 17. Aarsland D, Cummings JL, Yenner G, Miller B. Relationship of aggressive behavior to other neuropsychiatric symptoms in patients with Alzheimer's disease. Am J Psychiatry 1996; 153:243. 18. Meagher DJ, Trzepacz PT. Delirium phenomenology illuminates pathophysiology, management, and course. J Geriatr Psychiatry Neurol 1998; 11:150. 19. Platt MM, Breitbart W, Smith M, et al. Efficacy of neuroleptics for hypoactive delirium. J Neuropsychiatry Clin Neurosci 1994; 6:66. 20. Jrgensen P, Bennedsen B, Christensen J, Hyllested A. Acute and transient psychotic disorder: comorbidity with personality disorder. Acta Psychiatr Scand 1996; 94:460. 21. Manschreck TC. Delusional disorder: the recognition and management of paranoia. J Clin Psychiatry 1996; 57 Suppl 3:32. 22. Patkar AA, Mago R, Masand PS. Psychotic symptoms in patients with medical disorders. Curr Psychiatry Rep 2004; 6:216.
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Overview of Psychosis

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involuntary treatment' above.)

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