Visual summary Psychotic disorders Identification and management

The term psychosis embraces a constellation of symptoms characterized by “positive” symptoms, such as hallucinations or delusions. Less obvious “negative” symptoms include decreased enjoyment and motivation

Positive psychotic symptoms Negative psychotic symptoms

Delusions Thought disorder Decreased enjoyment Decreased motivation

Hallucinations Disorganized behavior Social withdrawal Neurocognitive impairments

Di erential diagnosis for positive symptoms Positive psychotic symptoms have a wide differential, and can manifest as a result of other disorders, deficiencies, and infections

PSYCHOTIC DISORDERS

PRODROMAL BRIEF/TRANSIENT ENDURING Emerging psychosis Less than 1 month 1 month or longer

Subthreshold experiences Acute and transient disorders Schizophrenia

Schizophreniform Schizoaffective disorder

Substance induced psychosis Persistent Delusional Disorder Unspecified non-organic psychosis

NON-PSYCHOTIC ORGANIC CAUSES

Personality disorders Temporal Personality lobe disorders epilepsy PRIMARY MOOD DISORDERS

Dissociative disorder Space Dissociative occupying disorder lesion Depressive psychosis

PTSD Limbic encephalitis PTSD Manic episode with psychotic features Anxiety disorders Anxiety B12 deficiency disorders Mixed affective state with psychosis Autism spectrum disorder Substance Autism Hyperthyroidism spectrum induced psychosisdisorder Bipolar disorder HIV infection

Acute intoxication state Non-pathological symptoms, in context of developmental/environmental change ALSO CONSIDER: Postpartum psychosis Medication-induced symptoms Steroids Mefloquine Dopamine agonists

Management of psychotic disorders Early referral to specialist services is beneficial. However, longer term cases may involve management in primary care. A General Practitioner (GP) may support four to eight patients with psychotic disorder and see one new presentation each year

Prodromal Brief / transient Enduring Prodromal illness can only be Occur abruptly within two weeks and Enduring or recurring symptoms may established retrospectively. However, are usually related to an acute indicate a longer-lasting condition it is possible to identify patients at stressful event or use of a drug high risk for developing psychosis

Subthreshold experiences Acute and transient disorders Schizophrenia Subtle changes in perception may Occur abruptly within two weeks and Enduring/recurring psychosis, or single antecede frank psychosis are related to an acute stressful event episode of illness followed by remission

KEY REFLECTION: Substance induced psychosis Schizoaffective Disorder Usually begins to resolve within days Equally prominent symptoms of Would I be surprised if this of stopping use of substance schizophrenia and a mood disorder turned out to be psychosis over the next 6 months? Cannabis Cocaine Persistent Delusional Disorder Predominantly delusional content, Amphetamines typically lasting several months

Unspecified non-organic psychosis does not satisfy criteria for the other types of psychosis as above

Offer Consider Offer

Bio-psycho-social approach Antipsychotic medication Psychological therapies Treatment is tailored around These are a cornerstone of treatment, symptoms and effects on quality 2nd generation Risperidone and can be offered adjunctively to of life and function medication. They can be used These tend to be Olanzapine preferred due to preemptively before a formal diagnosis fewer extra- Quetiapine to reduce or delay onset of psychosis Specialist early intervention teams pyramidal side Aripiprazole Cognitive behavioural therapy Community based services are the effects preferred model of care for people over 14, including: Family interventions 1st generation Haloperidol Allocated keyworker

Psychiatrist If treatment Social and occupational Clozapine A multidisciplinary approach resistant consider Suitable accommodation Options for employment

Physical health Monitor for cardio-metabolic risk

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