Psychosis

Psychosis

Feb 8, 2016 0
General medicine,onthepods,psychiatry

James talks to Dr Joanne Ferguson about psychosis and how early recognition, assessment and management of such patients ensures the safety of both patient and those around them.

Summary Writer:  Linda Wu

Editor:  Bruce way

Interviewee: Joanne Ferguson

About Dr Joanne Ferguson

Joanne Ferguson is a Clinical Associate Lecturer in Psychiatry and Addictions at Croydon Community Health Centre, Concord Clinical School. She is a Specialist Psychiatrist for Drug Health Services at Rozelle and Concord Hospitals.

Psychosis 

With Dr Joanne Ferguson, Staff Specialist in Psychiatry and Addiction Medicine, Concord Clinical School and Croydon Community Health Centre, New South Wales, Australia

Introduction

Patients with psychotic symptoms can present in many ways with a variety of possible underlying aetiologies to consider. Early recognition, assessment and appropriate management of such patients is important to ensure the safety of both the patient and those around them.

What is the definition of psychosis?

Psychosis is difficult to define but is considered to be a constellation of symptoms involving a radical change in functioning and distorted sense of reality. For example, this can include beliefs that are not objectively sustainable in the cultural context, including those of a persecutory or extreme nature, hearing/seeing/smelling things that other people can’t. This can be associated with disordered thinking, poverty of thought and disordered and impulsive behavior. Delusions are culturally abnormal beliefs that are held with an unshakeable conviction and are objectively unsustainable.

Case

You are the evening junior doctor and have been asked by nurses to see Mrs Wells, a 56-year-old lady who they state is growing increasingly agitated.  Mrs Wells initially presented with pneumonia 2 days ago and is receiving intravenous antibiotics, on a background of schizophrenia. This evening she is tearful, combative and states the nursing staff are trying to poison her.

  • Recognise that this is a situation distressing for both the patient and staff
  • Recognise that this patient may be overwhelmed for a number of reasons
    • She is medically unwell
    • Her background of schizophrenia may give her a more persecuted world view
    • She may have cognitive impairment which can occur in schizophrenia
    • Patients with schizophrenia may have constrained social interactions and be accustomed to isolation
  • Ascertain that the patient is safe and that she is not about to leave
  • Approach the patient in a calm measured way
  • Allocate an appropriate amount of time so you are not rushed
  • Consider the setting in which you would like to see her e.g. in a separate quiet room, with someone else present
  • Offer a cup of tea/water
  • Familiarise yourself with her background including what she takes for schizophrenia, who she sees and her current medical issues
  • Consider safety and engagement of the patient
  • Need to be able to reassure and contain her as she is likely to need to stay in hospital longer for medical reasons
  • Patients with schizophrenia often have comorbidities and risk factors for medical illness such as smoking, and poorer self-care, making them at high risk for illness
  • Make sure she is receiving all the medications she should be on, in particular for psychosis
  • Differentiating psychosis due to organic (e.g. delirium) and non acute reasons (e.g. schizophrenia):
    • Being medically unwell makes organic pathology more likely
    • Attention – being confused, disorientated, inattentive is more consistent with delirium
    • Substance use – delirium can occur during drug withdrawal
    • Hallucinations – visual hallucinations are more likely with organic cause but can also occur in schizophrenia
  • Common precipitants for a psychosis in a patient with an underlying psychiatric illness
    • Stress e.g. medical illness, unfamiliar environment, isolation, coping with change
    • Akin to a reaction to stress that makes symptoms more prominent
  • Anybody with a diagnosed major mental illness should be referred to the Consultant Liaison service because a hospital stay can be a major stress
  • Patients with mental illness have vulnerabilities and are more likely to seek early discharge and have inadequate care
  • Can be helpful for nursing staff who may also be worried about managing the patient
  • At this point may consider a sedating medication
  • Choice of medication
    • Can offer something the patient has tried so she is familiar with it
    • Rapid effect
    • E.g. olanzapine orally disintegrating tablets – commonly used and rapidly absorbed
  • Have other staff present to support you, including security staff if necessary
  • Speak to the Consultant Liaison team or afterhours psychiatry registrar
  • Strategies in managing difficult patients:
    • Reassurance and containment
    • Can coercively treat people if required for medical reasons via Mental Health Act, Guardianship Act, general duty of care
    • May need physical or pharmacological restraint (intramuscular sedation) – always seek senior assistance if this is necessary
  • Psychosis is a general term with many subcategories including bipolar, personality disorders, schizophrenia
  • Psychosis is common
  • Patients with mental health issues are more likely to have medical conditions that are poorly managed e.g. cardiac, respiratory, diabetes
  • Have a low threshold for seeking help

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Tags: #delusions,#disordered thinking,#distorted sense of reality,#impulsive behaviour,#mental health,#psychiatric problems,#psychiatrist,#psychiatry,#psychosis,#psychotic symptoms,#wellbeing

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