Key Clinical Questions
Introduction
New-onset psychosis and recurring psychosis identified during the course of assessment and treatment of medical disorders, require immediate intervention. 0.5–2.5% of all (nonpsychiatric) hospitalized patients have a preexisting chronic psychosis and 5–25% of all referrals for psychiatric consultation are for a psychotic disorder. New-onset psychoses may be secondary to a general medical condition, iatrogenic or functional in nature (Table 226-1). Initiation of treatment for new cases and continuation (or resumption) of treatment for preexisting psychosis is of paramount importance. Neglecting or under treating the psychosis will likely lead to behavioral and medical complications. Psychosis can quickly erupt into a crisis, affecting the management of the medical disorder(s) and altering their outcome. The presence of comorbid psychiatric conditions, especially if unrecognized or under treated often increases the length of stay and cost of care.
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Definitions and Terminology
The term psychosis was first used in the mid-19th century to denote an abnormal state of mind, and typically refers to a loss of touch with reality. In 1896, Emil Kraeplin dichotomized the functional psychoses into dementia precox and manic-depressive illness to denote a chronic deteriorating cognitive disorder and an intermittent mood disorder, respectively. In 1911, Eugen Bleuler renamed the former condition as schizophrenia. This dichotomization does not cover all psychotic disorders, and various other psychotic disorders have been described. These include stress-induced reactive psychosis, conditions with mixed psychotic and mood symptoms called schizoaffective psychosis, and cyclical disorders called cycloid psychoses. In the Diagnostic and Statistical Manual of Mental Disorders (4th edition, text revision [DSM-IV-TR]), functional psychoses are described under two broad categories, namely schizophrenia and related psychoses, and mood disorders with psychosis. Psychosis secondary to a general medical condition or substance abuse is simply described as such (eg, psychosis secondary to hypothyroidism, alcohol-induced psychosis). All other psychoses are diagnosed as psychosis, not otherwise specified.
Psychosis refers to a sustained mental state of loss or impaired touch with reality. It is manifested by one or more of the following: hallucinatory experiences, delusional beliefs, disordered communication, and disorganized, unusual, strange and/or regressed behaviors. These are also referred to as positive symptoms. Transient states of perceptual alterations such as those occurring after sleep deprivation or as part of a desired religious experience are typically not considered psychosis. Psychosis is often a manifestation of substance abuse. Many general medical conditions, especially central nervous system (CNS) disorders, may lead to the manifestation of psychosis. Finally, psychosis is frequently associated with delirium and dementia.
Positive Symptoms
Hallucination refers to perceptual experience(s) in the absence of an external stimulus. The source of the perception is typically placed in objective space (ie, not from inner self, ego, subconscious, mind, soul, etc). The perception may be in any sensory modality. For example, hearing voices of people who are not around or seeing images such as those of god, the devil large and small animals, dead people, or fire. Hallucinations may also occur in the olfactory, tactile, gustatory, or proprioceptive modalities. Auditory hallucinations are more typical in functional psychosis, and visual and tactile hallucinations are more common in psychoses secondary to use of substances or from a general medical condition. However, this is not a hard and fast rule, nor is it diagnostic in and of itself.
Delusion refers to a fixed false and irrational belief. The contents are not congruent with those of the subculture to which the patient belongs and the conclusion has been arrived in an irrational manner. Delusions are categorized based on their content into persecutory, grandiose, somatic, etc Here are a few examples: (1) A man with schizophrenia believes that the FBI has stationed 360° cameras around his house, office, and car and beams these pictures around the globe to publicize his life. (2) A woman believes that surgeons enter her room in the night and replace her organs with diseased ones to spread a new type of disease. (3) A middle-aged construction worker attempts to make a million dollar bid online as a down payment for the purchase of a Caribbean island because “the next big wave was to happen as soon as I patent my new permanent roof tiles.”
Thought disorder refers to impairments in the process of thinking, and is also referred to as formal thought disorder (FTD). A commonly seen type of this is “loose associations,” although there are more than 18 varieties of disordered thinking. The impairment may be in the thinking process, language, speech, or communication. For example, a 25-year-old male with schizophrenia when asked during initial evaluation, “what seems to be the problem?” responded as follows: “I was driving along the expressway when the spiders appeared, looking ugly, uhh they made all the difference to god’s creativity. I had to know who this was. Had seen him before. His voice had that distinct sound—you know the one’s animals make when they are doing their perfunctory thing. No wonder you doctors can tell all the difference.”
Disorganized behavior refers to a host of behaviors reflective of a lack of organization, cohesiveness, and purpose in one’s external behavior, often reflecting the internal chaos of the mind. States of excitement, stereotypical movements, severe withdrawal and isolation, catatonic stupor, regressed behaviors including poor self-care and hygiene, etc are all subsumed under this term.
Negative Symptoms
Negative symptoms refer to a set of emotional and behavioral manifestations that indicate loss of normal mental functions.
Blunted affect refers to a diminution in the tone, experience, range, and depth of emotion and is used interchangeably with the term flat affect. A person exhibiting a blunted affect may not show appropriate sadness, happiness, anger, etc as warranted by an event or situation.
Alogia refers to a state of reduced speech. The patient may respond minimally to questions and/or appear to have difficulty being productive with verbal expressions.
Apathy, avolition, and anhedonia describe a state of reduced interest and emotion and inability to experience pleasure.
Related Terminology
In the context of psychosis, terms such as reality testing, impaired capacity, poor judgment, poor insight, poor ego boundaries, etc are often used by psychiatric clinicians.
Reality testing: This is the capacity to correctly interpret internal stimuli such as thoughts, feelings, and somatic sensations, etc, and/or the external environment, such as people and events in relation to oneself. Example: A patient may believe that gurgling sounds out of one’s belly are messages from his deceased mother that he is being controlled by the devil.
Poor ego boundaries: This is a disturbance in volition, ownership, and boundaries of one’s thoughts, feelings, and perceptions. Thus, a patient may believe his thoughts are being heard/known by others. Patient may attribute control of actions such as eating, talking, walking, etc or emotions to others. For example, a 25-year-old woman believed that the dentist had inserted a powerful microchip into her teeth and was able to make her experience sexual feelings toward older men.
Poor insight: This is a lack of awareness of one’s own behavior, especially in relation to the need for change. For example, a 35-year-old man was angry at his wife for having called the mental health crisis line for help after he had been neglecting to eat or shower and was sitting at home for several days gazing out of the window and sighing frequently. He claimed he was “just resting.”
Poor judgment: This is the inability to assess the totality of one’s situation, consequences, and necessary actions. For example, a 65-year-old person with suspected dementia refused to move out of the home after it had been condemned by the social service agency because “it is my mother’s home and I will fix it by the weekend.”
Impaired capacity: This is the inability to assess a specific condition or situation, its consequences, and actions to be undertaken. Example: A 45-year-old man with a history of traumatic brain injury, seizures, and severe cognitive impairment had developed aplastic anemia and was in isolation on the step-down medical unit with a fever. He consistently refused to have any blood transfusion, saying “had the flu many times, clears up in a couple of days.”
Disorders
| Disorder | Course and Duration | Features and Diagnosis | Outcome/Comments |
|---|---|---|---|
| Brief psychotic disorder | Acute, days to < 4 weeks | Often precipitated by stress. Dramatic and fluctuating psychosis. Other causes ruled out. | Full remission of symptoms and return of function. |
| Schizophreniform disorder | Acute, > 4 weeks and less than 6 months | Schizophrenia-like symptoms. Mood disorder. Substances and medical conditions ruled out as cause. | May progress to schizophrenia. |
| Schizophrenia | Chronic, years | > 1 month of psychotic symptoms, > 6 months of behavior change. Mood disorder, substance abuse and general medical conditions ruled out. Functional decline. | Persistence of symptoms in 30–60% of patients. Some recovery is possible in most. |
| Schizoaffective disorder | Chronic, years | Symptoms of psychosis and mood disorder are equally prominent. > 2 weeks of psychosis without mood symptoms. | Outcome is better than schizophrenia. |
| Delusion disorder | Chronic, > 1 month to years | Prominent nonbizarre delusion(s). No hallucinations or minimal. | Personality is preserved. Function often preserved. |
| Depression with psychosis | Intermittent > 2 weeks | Depression is primary. Content of psychosis often congruent with mood. | Outcome better than schizophrenia. Responds well to electroconvulsive therapy. |
| Mania with psychosis | Intermittent > 1 week | Mania is primary. Content of psychosis often congruent with mood. | Outcome better than schizophrenia. |
| Substance-induced with psychosis See Table 226-4. | Variable. As long as substance is used. | Psychosis follows substance use. Visual and tactile hallucinations may often be seen. Alcohol and amphetamine psychosis may mimic delusions and hallucinations of schizophrenia. | Psychosis may persist days to weeks after abstinence. |
| Delirium with psychosis | Brief in duration | Disturbed consciousness. Psychosis often inferred from behavior. Fragmentary and fleeting delusions. Visual and tactile hallucinations may be seen. | May require frequent parenteral antipsychotics in small doses rather than bolus or single large dose. |
| Psychosis due to a general medical condition See Table 226-3. | Varies with condition | Verified by diagnosis of the underlying medical condition, and resolution with its treatment. Visual hallucinations may often be seen. May be part of delirium. | |
| Dementia with psychosis (Alzheimer, vascular, etc) | Intermittent or chronic | Often inferred from behavior. Delusions are fragmentary and not well elaborated. | May not be evident as much in late dementia. Low doses of antipsychotics may be sufficient. |
| Developmental disorder with psychosis (autism spectrum disorders, mental retardation) | Intermittent or chronic | Delusions are often poorly formed and fragmentary. Visual hallucinations may be seen. Psychosis may sometimes be understood as literal or concrete interpretation of reality, or over-learned behavior. | Higher doses of medications often not well tolerated. |
This disorder manifests acutely, is often associated with a significant external stress, runs a short course of days to weeks, and resolves without leaving significant residual pathology. One or many positive psychotic symptoms are present. Often these are dramatic and changing. Negative symptoms are typically absent. The symptoms may reflect the stress. For example, a 17-year-old girl manifested an acute psychosis with delusions that she was pregnant with evil twins and believed that she would deliver them any day now resulting in mayhem in the world. She had been raised with strong religious values and had reluctantly participated in sexual intercourse with her boyfriend during spring break. With short-term hospitalization and antipsychotic therapy, the psychosis resolved without any residual deficits.
In this condition, the onset is acute with one or more positive symptoms of psychosis that tend to be well defined. Negative symptoms are absent. There may or may not be a clearly associated stress factor. The condition lasts several weeks and may resolve or progress to schizophrenia. Often the term is used as an “on-hold” diagnosis till one can establish (or rule out) the more onerous diagnosis of schizophrenia.
This is the best-established disorder in this group. Typically, it begins between 18 and 25 years of age, although both earlier and later onset are recognized. It is a pervasive mental disorder and manifests with symptoms in multiple domains, such as thinking, perceptions, emotions, and (lack of) insight. Auditory hallucinations, persecutory delusions, disturbances in the ownership and privacy of one’s thinking (thought broadcasting, thought insertion, thought withdrawal), loose associations, and negative symptoms of blunted and inappropriate affect are classic symptoms of schizophrenia. Depending on the main symptoms, it is subtyped into paranoid, disorganized, and catatonic types.
The psychosis may manifest episodically or continuously but the disorder is continuous. Behavioral changes (prodrome) such as social withdrawal and odd thinking may precede the core psychotic symptoms. The psychotic symptoms last well over a month at a minimum, and typically for several months to even years. Milder psychotic symptoms and behavior changes may remain after the major symptoms have subsided (residual). Impairment in role function accompanies the psychosis and persists chronically, making this illness one of the most disabling medical conditions. Most of the decline is seen within the first five years of the illness. The symptomatic and functional outcome is not uniform for all and is quite variable. Approximately one-third of patients have a milder form of the illness and do well, another third have moderate severity and may remain with some symptoms and disability, while unfortunately another third have a severe form of the disorder and remain with significant symptoms and severe disability.
It is important to rule out mood disorders (depression, mania) and (physical) medical causes as well as substance use as causes of psychosis before making a definite diagnosis of schizophrenia.
This condition manifests with both prominent symptoms of psychosis and mood. It is conceived of as a chronic condition, similar to schizophrenia in its course and outcome. Some classifications recognize a schizophrenia subtype and a bipolar subtype, within schizoaffective disorder.
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