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Psychosis
 Today’s Objectives
• What is Psychosis?
• Recognize psychotic symptoms

• Who gets Psychosis?

• Conditions and diagnoses associated with Psychosis

• What can be done about Psychosis?

• Medical and non-medical treatment issues
 What is psychosis?
• “a severe mental disorder in which thought and emotions are so
impaired that contact is lost with external reality”

• “a mental disorder characterized by symptoms, such as

delusions or hallucinations, that indicate impaired contact with
reality”

• “fundamental derangement of the mind characterized by

defective or lost contact with reality especially as evidenced by
delusions, hallucinations, and disorganized speech and
behavior”
 What is psychosis? NO 2 ppl will
look alike
• Someone who develops psychosis will have their own unique
set of symptoms and experiences, according to their particular
circumstances.

• Four main symptoms are associated with a psychotic episode.

They are:

I
• delusions
• hallucinations
• confused and disturbed thoughts
• lack of insight and self-awareness

i
 interface
btw
pointy Menten
What is a Delusion?
• “a persistent false belief regarding the self or persons or objects
outside the self that is maintained despite indisputable evidence
to the contrary; also : the abnormal state marked by such
beliefs (delusional)”

• “an idiosyncratic belief or impression that is firmly maintained

despite being contradicted by what is generally accepted as
reality or rational argument”
Types of Delusions:
•Persecutory (Paranoid) Delusion –the affected person fears they are being
stalked, spied upon, obstructed, poisoned, conspired against or harassed by
other individuals or an organization. characteristic of schizophrenia

•Delusion of Grandeur - the person believes they are much greater or more
influential than they really are. For example, they may be convinced they have
an exceptional talent, extravagant riches or a special relationship with a
prominent person (perhaps God).
 Types of Delusions:
• Delusion of Reference - A neutral event is believed to have a special and
personal meaning. A person might believe a billboard or a celebrity is
sending a message meant specifically for them

• Delusion of Control - False belief that people, or external force controls

one's general thoughts, feelings, impulses, or behavior.
• Thought broadcasting
I believe I hate a
• Thought insertion
• Belief that your actions are being controlled
transmitter in my
teeth
• Somatic Delusion –a person is convinced something is physically wrong
with them despite evidence to the contrary.
Delusionalparasitoids
believingthey'reinfested
w bugs
 Types of Delusions:
• Delusional Jealousy –This usually develops due to a fear that a spouse or
partner is being unfaithful. These doubts are unfounded.

• Erotomania-The patient is firmly convinced that a person he or she is fixated

upon is in love with them. Erotomania often concern a famous person and
usually there is no contact between the patient and the victim, who has
never encouraged the patient.
 Types of Delusions:
• Bizarre Delusion – Implausible
• Example: Aliens have removed my brain
• Non-Bizarre Delusion – False, but possible
• The CIA is following me
• Mood congruent - delusion that is consistent with the depressed
or manic state of the sufferer.
• Mood Neutral – Delusions not related to or influenced by
mood.
 Types of Delusions:
• Capgras Delusion–Delusion that others (usually relatives) have
been replaced by imposters that looks like mydaughter
but that aint
• Cotard Delusion – Delusion that one doesn’t exist or has died.

• Folie a deux – Shared Psychosis, Delusion transmitted from

one to another (usually two close people).
 What is NOT a Delusion?
• A religious or spiritual belief that is shared by a community of
believers.
• Examples:
• Virgin birth of Jesus catholism Scientology
• Galactic overlord Xenu sent disembodied alien beings to infest the Earth
• Speaking in tongues

• A cultural belief shared by a cultural group.

 What is a Hallucination?
• “an experience involving the apparent perception of something
not present”

•
Time
“perception of objects with no reality usually arising from
disorder of the nervous system or in response to drugs”

• A sensory experience of something that does not exist outside

the mind. A person can experience a hallucination in any of the
five senses.
 What is a Hallucination?
• Perceived “objects” may include:
• Sounds (most common)
• Visions
• Smells
C Needa neuro workup Assoc w
• Touch temporal lobe
epilepsy
• Hallucinations can be associated with psychosis, drug use, neurological
disorders and delirium.
cus
piggingatop

• Hypnagogic and Hypnopompic Hallucinations – Considered normal

phenomena
 What is a Hallucination?
• Hallucinations can be caused by disorders of
the:
• Mind
• Brain
• Nerves
• End organ (e.g. eye, ear, skin, etc.) phantom
limb
disorder
Hallucinations
 Auditory Hallucinations:
• Auditory hallucinations are false perceptions
of sound. They have been described as the
experience of internal words or noises that have
no real origin in the outside world and are
0
perceived to be separate from the person's
mental processes.
 Auditory Hallucinations:
• Common Auditory Hallucinations:
• Name being called
• Rolling commentary
• Commands to act
• thanxCommands or suggestions to kill oneself
 CommandHallucinations:
• Most concerning form of Auditory
Hallucinations:
• Command hallucinations are hallucinations in the form of commands.
They may range from innocuous to commands to harm others or self.
People experiencing command hallucinations may or may not comply
with the hallucinated commands, depending on circumstances.

9 10 it's psychosis schizo

bipolar
etc
 Visual Hallucination
• “a perception of a visual image with no external cause
usually arising from a disorder of the nervous system or
psychosis (without known neurological disease) or in
response to drugs”

oftenthere's a concurrent
Substance abuse
 Visual Hallucination
• Simple (non-formed) Visual Hallucinations – Lights, colors,
shapes and indiscreet objects.
LSD O
• Complex (formed) – Clear lifelike images of people,
animals, objects etc.
 Visual Hallucination
• The most frequent causes of visual hallucinations are drug
intoxication or withdrawal

• The second most frequent reason is neurologic (arising from

the brain)

• Despite common beliefs and representations in the media,

visual hallucinations are uncommon in pure psychiatric
conditions
Olfactory Hallucination
(Phantom odors)
•Phantosmia is the phenomenon of smelling odors that are not really present.
The most common odors are unpleasant smells such as rotting flesh, vomit,
urine, feces, smoke, or others

•Phantosmia often results from damage to the nerves in the olfactory system

•Phantosmia can also be induced by epilepsy neurological

disorder
•Phantosmia is also thought to possibly have psychiatric origins move
possibly
Olfactory Hallucination
•Any patient with true olfactory hallucinations deserves a medical
/ neurological assessment.
What is NOT a Pathalogic
Hallucination
(normal states)
•Internal ruminations…even if the client refers to these
ruminations as “voices.”
internal vs Auditory
•Bereavement ruminations
tucination
•Hypnagogic or hypnopompic phenomena

not uncommon Not pathologic

Thought Disorder
• “a disorder of cognitive (thought) organization,
characteristic of psychotic mental illness, in which
thoughts and conversation appear illogical and lacking in
sequence and may be delusional or bizarre in content.
Thought Disorder
Poverty of Speech Noanswer 1 minimal answer
Thought Blocking
Circumstantial
Loose Association
Flight of Ideas
Word Salad
Thought Disorder
Thought Disorder
Poverty of Speech

Absence of normal speech or content. May be a “negative” symptom of

schizophrenia. May also occur in severe depression.

Not to be confused with resistance or poor engagement.

Q: “What are your plans for lunch?”

A: “Eat”
Thought Disorder
Thought Blocking

An abrupt stop in the middle of a train of thought; the individual may or may
not be able to continue the idea

Q: “What are your plans for lunch?”

A: “I’m meeting my sister and we are going to…” (block…)
Thought Disorder
Circumstantialiality
An inability to answer a question without giving excessive, unnecessary
detail. This differs from tangential thinking, in that the person does
eventually return to the original point.
I
Q: “What are your plans for lunch?”
but they don't derail
A: “I am going to meet my sister. You know, my sister she eats so much. She
is thinking about going on I diet but she really doesn’t like vegetables. I try to
tell her that she should eat salad but she really doesn't like it. You know her
doctor tells her she should eat salad. I guess she is more of a meat eater. So
I’m going to meet my sister at McDonald’s.”
Thought Disorder
Loose Association (tangentiality)
Wandering from the topic and never returning to it or providing the
information requested.
Never answer
DERAIL Question
Q: What are your plans for lunch?
A: "My dog is from England. They have good fish and chips there. Do you
know that fish breathe through gills?
Thought Disorder
Flight of Ideas the guy in the video word Salad
Excessive speech at a rapid rate that involves fragmented or unrelated ideas.

Q: “What are your plans for lunch?”

A: "My dog is from England. They have good fish and chips there. Do you
know that fish breathe through gills? Breathing feels good. I like breathing
but I don’t have gills. Gills, bills, wills*. I put bleach in my hair when I was
in Jamaica.

*Clang association
Thought Disorder
Word Salad

Complete incoherence of thought and speech

Disorders Associated with
at teast 6 Mos huffefilloss
Psychosis sis lookslikeschizo

Schizophrenia (Schizophreniform) difference

of time
Bipolar Disorder length
Schizoaffective Disorder
Delusional Disorder
Major Depression with Psychotic Features
Post Traumatic Stress Disorder
Substance use
Substance Withdrawal

Medical Causes
 cluster of conditions w
Schizophrenia a
diff manifesting factors
A mental disorder often characterized by abnormal social genetic
disposition
behavior and failure to recognize what is real. Common
use
symptoms include delusional beliefs, unclear or confused drug
thinking, auditory hallucinations, reduced social engagement,
emotional expression, and physical inactivity.

Diagnosis is based on observed behavior and the person's

reported experiences

0
Not Multiple personality Disorder
Schizophrenia Fit'mbeidterm
Approximately 1% of the US Population N TK
Age of onset earlier for males (28yo) than females (32yo)

35 you're safe
Onset rare after age of 35yo once

25 – 50% will attempt suicide

5-10% will die by suicide

Marked impairment reflected by decreased rates in employment, marriage,

parenthood and “disability”
Schizophrenia
Shocking statistics:

Schizophrenia has great human and economic costs.

It results in a decreased life expectancy by 25 years.

This is primarily because of its association with obesity, poor

diet, sedentary lifestyles, and smoking, with an increased rate of
suicide playing a lesser role (10%)
Schizophrenia Types
Paranoid
Disorganized DSM II still hear
Undifferentiated ppl use
these tours
*Subtypes not recognized in DSM-V. They are still commonly
discussed
Schizophrenia
medicine become good at this
M
•Positive symptoms are those that most individuals do not normally
experience. They can include delusions, disordered thoughts and speech, and
hallucinations
Sx's that are ADDED

•Negative symptoms are deficits of normal emotional responses or of other

thought processes. They commonly include flat expressions, poverty of
speech, lack of motivation and/or lack of desire to form relationships

•Cognitive symptoms are impairments in information processing, attention

and executive functioning

abnitingstoindoapamaear order
 Marked impairment

A to D have to do B C
Need to get from
first
Schizophrenia
Onset
Late adolescence and early adulthood are peak periods for the onset of
schizophrenia

Cause
Likely a combination of genetic and environmental factors (including drug
use). Probably no one gene or cause (family of disorders)

Prodrome – Pre first psychotic “break”

Deterioration from normal function and behavior in daily life including work,
social engagement and personal care. Difficult to distinguish from normal
adolescent angst
Bipolar (affective)Disorder
*also known as Manic Depression

A mental disorder characterized by periods of elevated mood and

periods of depression. The elevated mood is significant and is
known as mania or hypomania depending on the severity or
whether there is psychosis. (hypomania does not include
psychosis)
Bipolar (affective)Disorder
Mania
During mania an individual feels or acts abnormally happy,
energetic, or irritable (irritable mania). They often make poorly
thought out decisions with little regard to the consequences (e.g.
sexual, gambling).The need for sleep is usually reduced.
Depression
During periods of depression there may be crying, poor eye
contact with others, and a negative outlook on life.
Schizoaffective Disorder
overlap Btw bipolar er schiropmenia
A mental disorder characterized by abnormal thought processes
and deregulated emotions. The diagnosis is made when the
patient has features of both schizophrenia and a mood disorder,
but does not strictly meet diagnostic criteria for either alone

Genetic overlap between Bipolar Disorder and Schizophrenia

believe to exist.
Bipolar vs. Schizoaffective
Disorder and psychosis
Schizoaffective
Moodswing

Depression
Mania

ptsychosis
presents
at any state alongthis
DelusionalDisorder
Delusional disorder is a mental illness in which the patient
presents with delusions, but with no accompanying
hallucinations, thought disorder, mood disorder, or flattening of
affect. Delusions tend toward plausible (non-bizarre)
Major Depressive Disorder with
Psychosis
A mental disorder characterized by a pervasive and persistent low
mood that is accompanied by low self esteem and by a loss in
interest or pleasure in normally enjoyable activities. In severe
cases, depressed people may have symptoms of psychosis. These
symptoms include delusions or, less commonly, unpleasant
hallucinations.

*This is in reality a relatively rare condition however it is

frequently over diagnosed I
Post Traumatic Stress Disorder
May develop after a person is exposed to one or more traumatic
events, such as warfare, a sexual assault, serious injury, or threats
of imminent death. The diagnosis may be given when a group of
symptoms, such as disturbing recurring flashbacks, avoidance or
numbing of memories of the event, and hyperarousal, continue
for more than a month after the occurrence of a traumatic event.

Vivid flashbacks may represent psychotic phenomena. *an area of

some controversy

tactile hallucinations thosewho

suffered
rape
Substance related
Most substances of misuse can cause psychotic symptoms and
experiences. This is especially true with:
Hallucinogens (LSD, PCP)
Stimulants (Cocaine, Methamphetamine)
Marijuana (paranoia) in youth can cause psychosis
Chronic use of Alcohol (alcoholic hallucinosis)

Psychosis is less common with opiates (heroin, codeine,

oxycontin, etc.)
Substance related
Withdrawal from many substances of misuse can cause
psychosis.

Especially true with alcohol (delirium tremens)

Medical
Many medical conditions can cause psychosis

•Disorders causing delirium

•Neurodegenerative disorders (Alzheimer's, Parkinson’s)
•Focal neurologic disease (stroke, tumor)
•Infectious disease
•Autoimmune disease
•Metabolic Disease
•Poisoning
Treatment of Psychosis
Medical treatment of psychosis
Antipsychotic medications
Medical treatment of Underlying condition
Medical Treatment of Mood
Antidepressants we're
not
ppl's
Mood Stabilizers delusions
tapping woah
Psychotherapy
Wellness focused (Wellness, Purpose, Recovery) 4 trying
Vocational rehabilitation we're Sx's
Peer Support Programs to help
as
oppressid
not be
 Treatment of Psychosis NTK
Medical treatment of psychosis
Antipsychotic medications effective
very delusions
First Generation: treating
Haldol (haloperidol) block hallucinations
Thorazine dopamine epositNESX's
r Second Generation (atypical)
is
or Risperdal (risperidone) also work
Zyprexa (olanzapine on
Seroquel (quetiapine) J.ofterfof.meof serotonin
Geodon (ziprasidone) blocking
Abilify (aripiprazole)
dopamine
wanigingbtangents
Treatment of Psychosis
Antipsychotic medications help WI mood disorders
Work by altering / stabilizing / normalizing neurotransmitters,
mostly dopamine and serotonin in the mesolimbic pathways

Produce changes in other neurotransmitter pathways that are

mostly responsible for side effects
Treatment of Psychosis
Antipsychotic medication side effects
Movement

0
Extrapyramidal (EPS) Stiffness and tremor
Dystonia
Tardive Dyskinesia
Metabolic
long term ticks
Weight Gain won't
go away
Glucose see more often
Cholesterol
30 40lb gain in 3 mos
WI zypnexa I
Treatment of Psychosis
Antipsychotic medication side effects
Prolactin when block dopamine can 9 these levels
Breast tissue development
Galactorrhea

QT Prolongation – Risk of ventricular arrhythmia

First generation – esp. Thioridazine
Ziprasidone – greatest association among second generation agents
 moue assoc M
1stgeneration
Treatment of Psychosis
Antipsychotic medication side effects: assoc
w
of
dopamineblockade
Neuroleptic malignant syndrome (NMS) is a rare however life-threatening
idiosyncratic reaction to antipsychotic drugs characterized by fever, altered
mental status, muscle rigidity, and autonomic dysfunction.
•On average, onset is 4-14 days after the start of therapy; However, NMS can
occur years into therapy.
•Severe muscular rigidity
•Hyperthermia (temperature >38°C)
•Increased creatine kinase (50-100% of cases)
•Autonomic instability
•Changes in the level of consciousness - delerium
Treatment of Psychosis
Monitoring for antipsychotic medication side effects:
Movement –AIMS test to look
Weight individual's movement
Blood Pressure
Blood Glucose shoofeldy
Blood Lipids if prescribing
Treatment of Psychosis
Why do we select a particular antipsychotic?
Patient history – Past treatment response
Side effect profile
Co-occurring medical conditions (diabetes, obesity)
Dosing
Compliance w their sx's can they take
Cost biD
something
Treatment of Psychosis
can work in ppl
Clozapine: atypical 2nd
gun because NOTHINGELSE
Reserved for treatment refractory patients (in the USA) HAS
Particularly effective in treatment refractory schizophrenia
Association with agranulocytosis requires frequent blood
monitoring
Other side effects may include weight gain, glucose elevation,
lipid elevation, myocarditis, constipation

g g of ppl who take this

prone to infection
gets granular cytosis
a
can fatal
Treatment of Psychosis
Great Esp for
F
Injectable Antipsychotic medications
Every 2 weeks – 3 months! a that
pop
is
of
unaware
Effective Strategy for poor adherence their
Haldol Decanoate condition
Prolixin Decanoate
Risperdal Consta 1
Invega Sustenna removes
Abilify Maintenna non compliance
Zyprexa Relprevv
as variable
Treatment of Psychosis
Medical treatment of Underlying condition
If underlying condition is a mood disorder, treat the mood
disorder with mood stabilizers (e.g. Lithium) or antidepressants.
Often this is in addition to an antipsychotic (temporarily).

If the underlying condition is medical, treat the medical

condition.
Psychotherapy for Psychosis
Usually recommended in addition to medication

Cognitive Behavioral therapy (CBT)

Reduces symptoms
Improve adherence
Family Interventions (FI)
make sure the
Reduces relapse
family member is
as supported
just
as patient
 Culture and Psychosis
• Culture and religious background must be taken into
account in evaluating the possible presence of psychosis.

• Important to distinguish psychosis from culturally

sanctioned response patterns and beliefs

• The content of delusions may vary across cultural contexts