Psychosis is the term used to describe a state of mind in which the individual experiences a distortion or loss of contact with reality, without clouding of consciousness. This mental state is characterised by the presence of delusions, hallucinations and/or thought disorder. As well as these symptoms (which are sometimes referred to as positive symptoms), negative symptoms such as affective blunting and loss of motivation can also occur. In addition, there are a number of other secondary features that can present during a psychotic episode such as depression, anxiety, sleep disturbance, social withdrawal and impaired role functioning. It is these features which often provide the clue to the presence of psychosis.
Psychosis can be caused by a complex interaction of biological, psychological, social, and environmental factors. While sometimes organic factors appear to play a significant role (drug intoxication, metabolic conditions and infection), sole precipitants are less likely for functional disorders such as: brief reactive psychosis, schizophrenia, biploar disorder, schizophreniform psychosis, delusional disorder and schizoaffective disorder.
Psychotic disorders are of major social and public health importance. These conditions affect a significant number of individuals in our community. If we consider all psychotic disorders together, around 2% of people will experience a psychotic episode at some stage in their life. And, when the impact on the individual’s family is also considered, it is apparent that the indirect effects of these conditions are just as great. The cost of these disorders is considerable.
Increasing attention is being paid to strategies which might reduce the impact of these conditions on affected individuals, their families and the community. A preventive framework has been advocated. Whilst research into primary preventive strategies is on-going, there are as yet no proven strategies for primary prevention. Through the PACE clinic at OYH, the research into the identification of the earliest signs of psychosis has been able to identify several presentations that indicate someone is at increased risk of developing a psychosis. PACE has also been able to delay the onset of psychosis, thereby reducing the risk of a psychosis emerging.
EPPIC focuses on aspects of secondary and tertiary prevention; that is, strategies which focus on minimising the impact of these disorders by maximising treatment and rehabilitation efforts. Early intervention in first-episode psychosis is one such strategy for secondary prevention.
What is Early Intervention?
Early intervention is providing information, assessment and treatment at the earliest possible juncture of someone experiencing psychotic symptoms. This can happen at the 'at-risk' stage as well as once a psychotic episode has developed. Early Intervention is aimed at shortening the course and decreasing the severity of the initial psychotic episode, thereby minimising the many complications that can arise from untreated psychosis. Early Intervention can be provided through secondary consultation to GPs and other mental health services as well as through education to youth specific services to aid in the identification of people with psychotic symptoms.
Who is affected?
The onset and course of psychosis is determined by an underlying vulnerability to psychosis coupled with the impact of environmental stressors which may then trigger active psychotic symptoms. This is the so-called stress vulnerability model for psychosis. This is decribed in more detail below in What causes psychosis?
While the precise identification of individual vulnerability is not possible, it is clear that certain people are at more risk of developing a psychotic illness than others. Risk factors include:
• Family history of psychosis, particularly in first degree relatives
• Schizotypal, schizoid and paranoid personality disorders
• Adolescence and young adulthood
An estimated 80% of patients affected by a psychotic disorder experience their first episode between the ages of 15-30.
Psychosis does not discriminate and effects people of all nationalities, all social standings, all intelligence levels as well as both young males and females. There does tend to be an earlier onset of psychosis in young males than females; youth mental health services do tend to see more young males than females.
Psychosis and young people
Psychosis is most likely to occur in young adults and is quite common. Around 2 out of every 100 young people will experience a psychotic episode - making psychosis more common than diabetes in young people. Most make a full recovery from the experience.
What are the symptoms?
Psychosis can lead to changes in mood and thinking and to abnormal ideas.
In order to try to understand the experience of psychosis it is useful to group together some of the more characteristic symptoms.
Everyday thoughts become confused or don't join up properly. Sentences are unclear or don't make sense. A person may have difficulty concentrating, following a conversation or remembering things. Thoughts seem to speed up or slow down.
It is common for a person experiencing a psychotic episode to hold false beliefs, known as delusions. They may be so convinced of their delusion that the most logical argument cannot make them change their mind. Common delusions may include: paranoia, where the young person may believe that they are being watched or followed, or others want to harm them; grandiosity, where a person believes they have speical abilities or powers.
In a state of psychosis, the person sees, hears, feels, smells or tastes experiences that are not actually occurring, but the sensation that these experiences are real can be quite overwhelming.
How someone feels may change for no apparent reason. They may feel strange and cut off from the world with everything moving in slow motion. Mood swings are common and they may feel unusually excited or depressed. People's emotions seem dampened, they feel less than they used to, or show less emotion to those around them.
People experiencing psychosis behave differently from the way they usually do. They may be extremely active or lethargic. They may laugh inappropriately or become angry or upset without apparent cause. Often, changes in behaviour are associated with the symptoms already described above.
Symptoms vary from person to person and may change over time.
What are the types of psychosis?
Everyone's experience of psychosis is different and attaching a specific name or label to the psychotic illness is not always useful in the early stages.
However, when someone is experiencing an episode of psychosis, a diagnosis of a particular type of psychotic illness is usually given; a diagnosis shold not be 'set in stone' - treating clinicians should always be open to reviewing, and if necessary, changing the diagnosis as the episode of illness progresses. The particular type of illness is identified by the symptoms experienced. Formulating a diagnosis will also depend on what brought on the illness and how long the symptoms last.
- schizophrenaform disorder
- schizoaffective disorder
- drug intoxication
- delusional disorder
- bipolar disorder
- major depression with psychotic features
- brief reactive psychosis
- medical illnesses that resemble a psychiatric disorder
What causes psychosis?
A number of theories have been suggested as to what causes psychosis, but there is still much research to be done.
There is some indication that psychosis is caused by a poorly understood combination of biological factors that create a vulnerability to experiencing psychotic symptoms during adolescence or early adult life. These symptoms often emerge in response to stress, drug abuse or social changes in such vulnerable individuals. Some factors may be more or less important in one person than in another.
In first-episode psychosis, the cause is particularly unclear. It is therefore necessary for the young person to have a thorough examination to rule out potential medical causes and to help make the diagnosis as clear as possible. This usually involves medical tests, as well as a detailed interview with a mental health specialist.
Course and outcome vary from person to person. Recovery is likely, with most people experiencing a cessation of positive symptoms within a 12 week period from acute onset once adequately treated.
What can be done?
Effective treatments are readily available for psychotic illnesses. The earlier treatment is started, the quicker and better the recovery. With appropriate treatment the majority of young people who experience a psychotic illness will recover. However, for some young people, psychosis can become an episodic problem through their lives.
A person experiencing a psychotic illness will require specialist assistance. Treatment for psychosis involves the use of antipsychotic medication, individual counselling, family support and counselling, practical support, and involvement in a recovery program which focuses on helping a young person attain social recovery in particular.
The focus of treatment is to control and minimise symptoms, to assist the young person to make sense of and overcome any associated trauma, and to prevent relapse through decreasing risk factors such as stress, substance abuse, family conflict and stigma.
A targeted program of recovery also focusses on protective factors such as: secure accommodation and income; engagement in work or study; developing coping strategies to deal with stress; strong social networks and family supports; and adherence to medication.
What can you do?
Young people experiencing a psychotic disorder are not always able to understand, or willing to explain what is happening to them. Most fear they will be labelled as "mad". Many do not seek help on their own. Professionals working with young people may be in a position to identify a young person experiencing a psychotic disorder and assist the young person to get the help they need.
General Practitioners can provide an initial assessment and possibly even commence treatment (see GP Manual) while also assisting referral to a tertiary mental health service.
All services working with families should support the family of a young person who has been diagnosed with a first episode of psychosis, as the emergence of psychosis is often a time of crisis for the whole family, as with any major illness.