Psychotic Disorders

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This is an umbrella term for a group of conditions where the person loses touch with reality through experiencing perceptual disturbances, having abnormal beliefs, and lacking insight.

 

SCHIZOPHRENIA

Clinical Description

To diagnose schizophrenia there must be at least a six month history of impairment and disability and within the six months period, at least a month (or less if the symptoms have been successfully treated).

Clinical Features

SIGNS AND SYMPTOMS

  • history of the symptoms listed below.
  • Hallucinations (often auditory) and delusions(fixed false belief)
  • Speech can be irrelevant and incoherent
  • Disorganized thought / behavior
  • Lack of insight is prominent

INVESTIGATIONS

  • In a first episode of psychotic symptoms, physical causes for the symptoms must be excluded e.g delirium, thyroid dysfunction, syphilis, HIV)
  • Full physical examination
  • FBC
  • VDRL
  • Urine drug screen if available

Treatment

PITC Treatment

  • Treatment is both pharmacological and psychological {supportive counselling about the illness, compliance with medication, education to the guardians
  • The aim of treatment is to remove all symptoms if possible and to help the person to return to their previous level of functioning

 Primary treatment

  • First line commences an anti-psychotic medication which will need to be continued for at least two years if this is a first episode or for a minimum of five years if the person has had two episodes. If the person has had three or more episodes without clear precipitants (e.g., substance use, psychosocial stressors) antipsychotics should be continued for life 
  • Give Chlorpromazine 100 mg nocte or Haloperidol 2.5mg nocte. Increase dose weekly/ two weekly depending on patient response and side effects to a maximum of Chlorpromazine 300mg nocte or Haloperidol 5mg nocte.
  • Always start the antipsychotic at the lowest effective dose and prescribe as a single daily dose
  • All anti-psychotic medication ha a delayed onset of action - advice the patient/ guardian it will take 1-2 weeks before improvement is noted
  • Antipsychotics should be prescribed as monotherapy (only one antipsychotic should be used at one time)
  • Advise about the side effects:
  • Chlorpromazine: sedation, postural hypotension, constipation, photosensitivity, sexual side effects
  • Haloperidol: Extra-pyramidal side effects (parkinsonism symptoms), stiffness of limbs/jaw, eyes rolling upwards, restlessness, drowsiness, salivation, sexual side effects
  • Patients should be advised to report to the hospital immediately if they develop stiffness of limbs/jaw and abnormal eye movements
  • If EPSEs persist consider reducing the dose of anti- psychotic or adding Benzhexol 5mg daily until side effects resolve.
  • Use lower doses of antipsychotics in patients with HIV, epilepsy and intellectual disability
  • Secondary /alternative treatment
    • If symptoms have not improved on chlorpromazine/haloperidol or if the person has lots of side effects use a second-generation anti-psychotic Risperidone 1mg nocte 2 days then increase to 2mg nocte. Increase weekly/two weekly by 1mg to a maximum dose of 6mg nocte depending on patient response or side effects.

Advice about side effects:

Risperidone: weight gain, sedation, impaired glucose tolerance, sexual side effects 

  • If compliance with medication is poor despite trying to reduce side effects and counselling on the importance of compliance with medication, consider a long-acting depot anti- psychotic Fluphenazine 12.5mg IM into a large muscle e.g. gluteal/ deltoid) as a test dose
  • Caution: risk of Acute Dystonic reaction {painful spasm of head and neck muscles)
  • If occurs give Benzhexol po if able to swallow
  • Otherwise, IV/IM Procyclidine or Benzhexol 5mg OR slow IV push Diazepam 5-10mg
  • Advice about side effects: EPSE
  • Maintenance dose Fluphenazine 25mg every 4 weeks which can be increased to 50mg every 4 weeks IM after a 3-month interval

Red Flags For referral

  • If EPSE persist, consider reducing the dose or stop the Fluphenazine
  • If symptoms persist/ worsen despite 6-8 weeks of anti-psychotic medication at an effective dose
  • If side effects are not manageable
  • If the person has Catatonic symptoms
  • If the patient has been treated with two different antipsychotics (one first generation and one second generation) at adequate doses for longer than three months on each but psychotic symptoms or functional impairment persists
  • If the patient develops tardive dyskinesia (abnormal facial movements – chewing, grimacing or chorea-like trunk movements) on antipsychotics

For admission

  • Marked agitation / aggression should be managed as an inpatient following the Violence and Aggression treatment guidelines
  • Evidence of dehydration and malnutrition due to prolonged poor self-care
  • Evidence that the patient is a risk to themselves {self-harm/ neglect/ vulnerable to exploitation) or a risk to others {agitation/ aggression)
  • If insight is lacking and there is no guardian to ensure compliance with medication at home

Treatment duration

  • When considering stopping medication, discuss carefully with the patient and guardian and start to reduce slowly over 4-8 weeks
  • Advise about symptoms that would indicate relapse {difficulty sleeping, auditory hallucinations, suspicious thoughts) and inform to return to the clinic promptly. Continue to monitor until medication free for 2-3 months before discharging
  • Advise them to return to the clinic for review if have any concerns in the future

FOLLOW UP

Note:  Neuroleptic Malignant Syndrome is a severe but rare complication of anti-psychotics, presenting with fever, rigidity, fluctuating pulse and BP and reduced conscious level. It is a medical emergency. All anti-psychotics should be stopped, and the person referred for medical admission.

  • Screen for ongoing symptoms and monitor for side effects at each review
  • Adjust the dose of medication accordingly
  • Ask about any drug or alcohol use and give advice about use
  • Screen for low mood and suicidal ideation at each review and follow Depression Treatment Guideline if present
  • Once symptoms are improving advice the patient to return to their usual daily activities, including work if employed

 

SUBSTANCE INDUCED PSYCHOSIS

Clinical Description

Development of psychotic symptoms related to prolonged use of psycho- active drugs {eg cannabis) within the last month.

Clinical Features

SIGNS AND SYMPTOMS

  • Hallucinations {often auditory but can be visual etc) and delusions {fixed false belief) often paranoid/ suspicious in nature
  • Speech can be irrelevant and incoherent
  • Abnormal behaviour and at times agitation and aggression
  • Lack of insight is prominent

INVESTIGATIONS

  • Physical causes for the symptoms must be excluded (as described in schizophrenia)
  • FBC
  • VDRL
  • Urine drug screen if available
  • PITC

Treatment

Aim of treatment is to reduce/ remove symptoms and to encourage abstinence from the psycho-active drug

Primary treatment

  • Advise to stop using the drug
  • A short course of oral Diazepam may help with agitation, insomnia while symptoms resolve Prescribe Chlorpromazine 100mg nocte or Haloperidol 2.5mg nocte and increase weekly/two weekly depending on response and side effects. Continue treatment for up to six months after resolution of symptoms.
  • In Substance induced psychosis, psychotic symptoms should resolve in a month after cessation of substance. If symptoms persist beyond a month, a diagnosis of Schizophrenia should be considered and the patient managed as per the Schizophrenia guidelines.

Treatment duration:

  • Medication should be continued for 6 months after complete symptom resolution
  • When considering stopping medication, discuss carefully with the patient and guardian and start to reduce slowly over 2-4 weeks
  • Advise about symptoms that would indicate relapse e.g difficulty sleeping, auditory hallucination, suspicious thoughts and inform to return to the clinic promptly
  • Continue to monitor until medication free for 4- 6 weeks before discharging
  • Advise them to return to the clinic for review if have any concerns in the future

FOLLOW UP

  • Psychosocial interventions for cessation of substance use should be used as described in Alcohol Related Disorders

 

PUERPERAL PSYCHOSIS

Clinical Description

  • A disorder affecting the mother, which can develop within 6 weeks of childbirth
  • It can be particularly florid with vivid hallucinations, delusions, marked agitation and aggression
  • Care must be taken, as there can be significant risk to both mother and baby

Clinical Features

SIGNS AND SYMPTOMS

  • Confusion
  • Insomnia Anxiety
  • Agitation
  • Possible aggression
  • Mood changes
  • Hallucinations (in any modality) and delusions (particularly paranoid persecutory)

INVESTIGATIONS

  • The puerperium is a time of increased risk of many physical conditions such as sepsis, post- partum hemorrhage, metabolic imbalance, eclampsia etc.
  • These conditions can present with delirium and so care must be taken to exclude underlying physical causes
  • Full physical examination including vital signs
  • FBC U&E LFT
  • Blood/ urine glucose
  • MRDT
  • PITC

Treatment

General Management

  • The aim of treatment is to reduce/ alleviate symptoms to allow a return to usual functioning and to promote good bonding between mother and baby
  • Medication treatment duration is for at least 1 year
  • First assess the risk of the mother to herself and her baby (some may have thoughts of harming their baby due to the psychotic symptoms) and the risk of aggressive behaviour
  • If present follow Violence and Aggression Treatment Guideline. Ensure that the baby is in the care of a guardian and that all mother baby interactions are supervised until more stable
  • Care should be taken in breastfeeding mothers as medication can be found in the breastmilk. Use low doses and increase slowly. Monitor the baby for evidence of sedation

Primary treatment

  • Give Risperidone 1mg 24 hourly. The medication should preferably be taken after breast feeding or after breast milk has been expressed to minimize amount ingested by baby. Increase by 1mg weekly/two weekly depending on side effects and response to a maximum of 6mg once daily.
  • If Olanzapine is available, use as primary treatment. Take baseline fasting blood sugar, weight and triglycerides before start. Prescribe 5mg once daily, increase to maximum of 10mg once daily. Monitor weight, random blood sugar, triglycerides monthly while on use.
  • If Risperidone or Olanzapine not available, Chlorpromazine 100-200mg or Haloperidol 2.5-5mg may be used.  
  • Avoid use of diazepam. If necessary, use promethazine 25-50 mg or lorazepam 1-2 mg if agitated 

Red Flags

For referral

  • If symptoms persist or worsen, despite adequate doses of anti-psychotic for 6- 8 weeks
  • If there is evidence that the baby is failing to thrive {dehydration, weight loss, inadequate care etc.)

For admission

  • Marked agitation / aggression should be managed as an inpatient following the Violence and Aggression treatment guidelines
  • Evidence that the patient is a risk to themselves (self-harm/ neglect/ vulnerable to exploitation) or risk to the infant, other children or others {agitation/ aggression)
  • Screen for suicidal ideas and harmful thoughts toward infant at each follow-up as risk of suicide and infanticide remains high in first year after recovery.
  • Ask about any drug or alcohol use and give appropriate advice.
  • Once symptoms are improving advise the patient to return to their usual daily activities, including work if employed

Treatment duration

  • If first episode: Medication is continued for 1 year from complete resolution of symptoms
  • If previous episodes of psychotic illness (e.g., schizophrenia/ Bipolar affective disorder) continue medication for 2-5 years from complete resolution of symptoms
  • When considering stopping medication, discuss carefully with the patient and guardian and start to reduce slowly over 4-8 weeks
  • Advise about symptoms that would indicate relapse (difficulty sleeping, auditory hallucination, suspicious thoughts) and inform to return to the clinic promptly
  • Continue to monitor until medication free for 2-3 months before discharging
  • Advise them to return to the clinic for review if have any concerns in the future or when pregnant again (high risk of recurrence in future pregnancies)