Assessment of Acute Psychosis

Learning Objectives

• To understand the meaning of key terms• To appreciate range of signs and symptoms

encountered in psychotic patients• To appreciate the importance of a

comprehensive multidisciplinary approach in acute psychosis

• To be aware of challenges, difficulties and dangers inherent in the assessment process.

Core curriculum

• A competency based curriculum for specialist core training in Psychiatry

• February 2009

Intended learning outcomes• 1 history and examination• 2 differential diagnosis and formulation• 3 clinical management plan• 4 risk assessment• 5 therapeutic interviews• 6 record keeping• 7 management of severe and enduring illness• 8 communication• 9 team working

• 10 – 18

Intended learning outcome 1• Knowledge • Define signs and symptoms found in patients presenting with psychiatric and

common medical disorders • Recognise the importance of historical data from multiple sources

• Skills • Elicit a complete clinical history, including psychiatric history, that identifies the

main or chief complaint, the history of the present illness, the past psychiatric history, medications, general medical history, review of systems, substance abuse history, forensic history, family history, personal, social and developmental history

• Overcome difficulties of language, physical and sensory impairment • Gather this factual information whilst understanding the meaning these facts

hold for the patient and eliciting the patient’s narrative of their life experience

• Attitudes demonstrated through behaviours • Show empathy with patients. Appreciate the interaction and importance of

psychological, social and spiritual factors in patients and their support

Core Curriculum• Demonstrate interviewing skills: The appropriate initiation of the

interview, the establishment of rapport, the appropriate use of open ended and closed questions, techniques for asking difficult questions, the appropriate use of facilitation, empathy, clarification, confrontation, reassurance, silence and summary statements. Solicit and acknowledge expression of the patients’ ideas, concerns, questions and feelings.

• Understand the ways in which patients may communicate that are not directly verbal and have symbolic or unconscious elements.

• Communicate information to patients in a clear fashion

• Appropriately close interviews

Generic Assessment in Psychiatry

• History• Mental State Examination• Risk assessment• Investigations• Management to facilitate assessment

Psychosis (and neurosis)• ‘Psychoses are major mental illnesses. They are exceedingly

difficult to define although they are usually said to be characterised by severe symptoms, such as delusions and hallucinations, and by lack of insight’ Gelder 1983

• Neurosis is a psychological reaction to acute of continuous perceived stress, expressed in emotion or behaviour ultimately inappropriate in dealing with that stress’ Sims 1983

Psychosis A mental illness which markedly interferes with a person’s

capacity to meet everyday demands. Any mental disorder which involves loss of contacts with

reality and deterioration of social functioning. A mental disorder in which a serious inability to think, perceive

and judge clearly affect ability to function normally.

Hierarchy of psychiatric classification

• Organic syndromes• Functional psychoses• Neuroses• Adjustment reactions

• Pyramid or hierarchy?

ICD Classification

F00 DementiaF10 Disorders due to psychoactive

substance useF20 Schizophrenia, schizotypal and delusional disordersF30 Affective disorders

Organic Schizophreniform Psychosis Affective Differential Other Malingering Not psychosis Personality disorder Neurosis

Neurodevelopmental disorder

Setting the Scene for Assessment

1 Background information +++ (RIO and other sources)

2 Get help

3 Create a safe environment

Taking CarePredictors for Immediate Violence/Aggression• Previous history of violence• Young male patient• Forensic history• Substance misuse• Antisocial explosive impulsive traits• Associated with subculture prone to violence• Social restlessness, rootlessness• Specific threats to named victims

History

• Full history and mental state examination (other informants, interpreter)

• Presenting complaints Symptom cluster and pattern – and a sense of order in

which symptoms emerge if you can

Onset and duration Precipitants Exacerbating factors Interventions and effect

History• Any psychiatric history

• Eg previous depressive episodes whether or not sought treatment relevant in presentation of mania with psychosis

• Previous BLIPS or subthreshold psychotic symptoms• DSH

• Drug history; prescribed, illicit, alcohol

• Family history - ask questions if positive history

History

• Personal History• Early life. Neurodevelopmental history• Best level of education and employment – and

change since• Current circumstances (including housing and

financial issues)• Current/previous interface with criminal justice

system• Social support

Key Symptoms and Signs• Level of consciousness• Level of orientation• Motor symptoms• Disordered form of thought• Perceptual symptoms• Disordered content of thought• Passivity phenomena• Disordered mood• Insight

APEARANCE AND BEHAVIOUR: OBSERVATION

Mental State Examination

• Appearance

• Behaviour (including abnormal movements)

• Speech Form Content

Mental State Examination• Mood

• Thought Form (assessed in speech) Content (delusions, obsessions,

overvalued ideas) Possession (who’s thoughts are they?) Remember suicidal ideation homicidal ideation

Mental State Examination

• Perception Hallucinations Illusions All modalities• Insight (and capacity)• Bedside cognitive function tests

Physical Examination

• All patients presenting with an acute psychosis require a full physical examination

• Including neurological examination

Differential Diagnosis• specific psychotic symptoms• severity• duration• presence of other symptoms or signs – affective, organic• Presence of FRS

• working diagnosis or diagnoses

• Formulation• vulnerability factors, triggers

‘why has this particular patient developed this particular illness at this particular time’

Investigations

Standard Physical examination FBC, U+E, LFT, TFT, Fasting Glucose Urine drug screen ECG

Also considerImaging

CT/MRI EEG

CK

If suspect encephalitisliaise with neurologyanti –nmda antibodiesMRI, EEG, CSF

Potential Dangers: Acute Brain Syndrome

• Patient over 40 with no past psychiatric history• Abnormal vital signs• Clouding of consciousness• Disorientation• Visual hallucinations

Medical Causes of Disturbed Behaviour• Intoxication• Overdose• Delirium tremens• Head injury• Prescribed medication• Meningitis/encephalitis• Vasculitis• Hypoglycaemia• Impaired cerebral oxygenation• Wernicke’s encephalopathy• TLE• Paraneoplastic syndrome• Dementia

QUESTIONS: IN PAIRS

• HOW DO WE BEGIN?

• ESTABLISHING RAPPORT WITH THE ACUTELY PSYCHOTIC PATIENT

• PHRASING DIFFICULT QUESTIONS

• ASKING ABOUT FIRST RANK SYMPTOMS

QUESTIONS

• You are there to help: ESTABLISH THERAPEUTIC ALLIANCE

• Honesty without confrontation

Examples• “It sounds as though you have been though a lot recently”

• “If I understand a bit more about what you have been through, we might be able to help”

Asking about First Rank Symptoms• Voices:

• Passivity:

• Thought interference:

• NORMALIZATION and EMPATHY

Examples• “Does your mind ever play tricks on you”

• “Do you hear voices when no-one is there?”

Examples• “When we are under a lot of stress, it is common to have

usual or frightening experiences, such as hearing a noise”

• “Tell me a bit more about that… does it ever sound like a voice?”

Suicide: Risk AssessmentSuicide: Risk Assessment

• MENTAL STATE• Hopelessness• Unexplained Improvement of Symptoms esp depression• Psychotic Symptoms• Development of insight

Suicide: Risk AssessmentSuicide: Risk Assessment

• Always ask!

• How do you feel about the future? (i.e. do you have one?)• Do you feel hopeless?• Have things got so bad you felt as if you can’t carry on?• Have you ever had thoughts of harming yourself• Have you ever thought of ending your life?• Do you think you would act on these thoughts?

Potential Dangers of Violence and Aggression

• Command hallucinations• Irritability, hostility, suspiciousness • Morbid jealousy/erotomania• Misidentification phenomena• Passivity and alienation

Violence: Risk AssessmentViolence: Risk Assessment

• Mental illness is a risk factor for violence• Small compared to total violence in society• Co-morbid substance misuse increases risk• Active symptoms are more important than underlying diagnosis

Violence : the factsViolence : the facts

• 102 out of 718 homicide offenders (14%) had past contact with mental health services

• 58(8%) had contact in the year prior to the offence• Only 15 were receiving intensive community care• 4% had schizophrenia

Violence: Risk AssessmentViolence: Risk Assessment

• HISTORY• Gender (M>F)• <35y old• Past History of Violence• Itinerant lifestyle• Current substance misuse• Lack of education/ skills• Disposition (suspiciousness, impulsivity, irritability)• History of childhood abuse/ disorganisation• Lack of education/ skills

Violence: Risk AssessmentViolence: Risk Assessment

• MENTAL STATE:• Fear, anger, frustration, humiliation, self-righteousness and jealousy• Command Hallucinations• Persecutory delusions, passivity phenomena• Clouding of consciousness/ intoxication/ confusion

TIPS:

• Get as much information as you can before the interview.

• Collaboration not collusion

• Keep it short if necessary

• Know when to finish

Detaining patientsHas patient got insight?Has patient got capacity?

Validity of consent to treatment/admission

Will consent be sustained over a sufficient period?

MHA trumps MCA

Summary

1. Keep safe, and manage risks2. Take care and time . history . examination . physical examination . investigations3. Get a collateral history4. Perform joint assessments where possible, time limited

MCQSThe following are Schneiderian 1st Rank symptoms: • Thought echo

• Ideas of reference

• Somatic hallucinations

• Delusional mood

• Flatness of affect

MCQSThe following are recognized associations with delusional jealousy:

• Depression

• Alcoholism

• Impotence

• Personality disorder

• Pervasive sense of inadequacy

MCQS

“Normal” experiences include: • A. Jamais vu• B. Delusional perception• C. Derealization• D. Visual hallucinations• E. Deja-vecu