Psychosis: Schizophrenia

Overview

The term 'psychosis' covers a set of related conditions, including:

• schizophrenia – most common
• schizoaffective disorder
• schizophreniform disorder
• delusional disorder
• non-affective psychoses

Psychosis and the specific diagnosis of schizophrenia represent a psychiatric disorder that alters the patient's perceptions, thoughts, mood, and behaviour.

Each patient will have a unique combination of symptoms and experiences.

Psychotic disorders are relatively common, with schizophrenia being the most common.

The rate of schizophrenia is higher in Black Caribbean and Black African migrants and their descendants.

Assessment

A patient should be suspected of being at risk of developing a psychotic disorder if they are distressed, have deterioration in social functioning, and have: 

• transient (short duration – less than 1 week) or attenuated (lower intensity) psychotic symptoms
• other experiences or behaviour suggestive of possible psychosis, e.g. suspicion, mistrust, or perceptual changes
• a first-degree relative with a psychotic disorder including schizophrenia

Symptoms that indicate deterioration in social function include:

• memory and attention problems
• social withdrawal, e.g. loss of contact with friends, job loss, poor education attendance
• unusual or uncharacteristic behaviour
• disturbed communication and affect
• unusual perceptual experiences – accompanied by bizarre ideas
• reduced interest in day-to-day activities, e.g. poor personal hygiene
• poor sleep 

The acute phase of positive symptoms is characterised by:

• hallucinations:
  • auditory hallucinations − most common
  • visual, smell, taste, or tactile hallucinations − less common
• delusions:
  • delusions of reference – the patient believes that ordinary events, objects, or behaviour have an unusual meaning specifically for them
  • delusions of control – the patient believes that their thoughts, feelings, or behaviour are being controlled
  • delusions of persecution − the patient believes that other people are plotting against them
• thought disorder − impairment of the ability to form thoughts from logically connected ideas
• behavioural disturbances, e.g. agitation and distress

Negative Symptoms

After resolution of the acute phase, negative symptoms often predominate (not in all patients) and may include:

• loss of motivation
• difficulties expressing emotions
• self-neglect
• disrupted social interactions, work, and studies
• poor memory and attention

Assessment

It is not always possible to define if the patient has schizophrenia or a functional psychosis in the primary care setting, as more extensive investigation is often necessary.  However, attempts should be made to differentiate the cause of psychosis and identify underlying conditions

Conduct a medical assessment to assess for underlying causes, such as:

• prescribed drugs that can cause psychosis, e.g anticonvulsants, high-dose corticosteroids, levodopa, dopamine agonists or opioids
• alcohol and illicit or street drug use:
  • if they have been used, ask about:
    • the particular substance
    • quantity, frequency, and pattern of use
    • the route of administration
    • the duration of current level of use
  • substances may include:
    • amphetamines
    • cocaine
    • cannabis
    • 'legal highs', e.g. cannabinoids – can be undetectable in standard urine drug screen tests
  • If the patient has used substances, conduct an assessment of dependency
• temporal lobe epilepsy
• cerebrovascular disease 
• dementia

Carry out a physical examination and consider investigations, such as:

• HbA1c
• full blood count
• thyroid test
• urea and electrolytes
• liver function test
• B12 and folate
• ECG

Perform a mental health assessment to assess for:

• positive psychotic symptoms such as hallucinations and delusions
• abnormalities of mood such as anxiety, depression or elevated mood
• deterioration in personal functioning
• memory and concentration problems
• family history of schizophrenia
• risk factors for violence, e.g. criminal history, hostile behaviour or recent substance / alcohol misuse 
• psychosocial family issues, e.g. disrupted childhood experiences and family circumstances
• the patient's capacity to make decisions about their own care – including whom they want involved in this decision-making

The diagnosis of a psychotic disorder is made following a specialist assessment by a specialist mental health service, e.g. an early intervention in psychosis service.

Differential diagnoses of schizophrenia and psychosis include:

• affective disorders associated with psychotic symptoms:
  • severe depression
  • bipolar disorder 
• post-traumatic stress disorder:
  • distinguished from psychotic disorders by the existence of a traumatic event and characteristic features, such as re-living or re-enacting the event
  • can co-exist alongside psychosis
• obsessive compulsive disorder:
  • when strong irrational beliefs are held, but related to specific fears, and for which the patient has developed rituals
  • can be particularly difficult to distinguish from psychosis when the patient has obsessive and intrusive thoughts commanding actions which can be perceived as voices in their head
• autism spectrum disorder or communication disorders:
  • may be distinguished from psychotic disorders by their deficits in social interaction with repetitive and restricted behaviours
• borderline personality disorder:
  • patients often present with voices in their head, usually in the second person rather than first person
  • is associated paranoid ideas tend to be non-bizarre and can be more easily linked to traumatic experiences
• learning disabilities, e.g. autistic spectrum disorders
• organic causes –mostly rare causes of psychosis requiring investigation in secondary care:
  • drug-induced psychosis caused by cannabis, corticosteroids, opioids, cocaine oramphetamines
  • cerebrovascular disease
  • cerebral tumour
  • temporal lobe epilepsy
  • hypo- or hyperthyroidism 
  • sepsis
  • porphyria
  • multiple sclerosis
  • Cushing's syndrome
  • systemic lupus erythematosus – SLE;
  • Wilson's disease 
  • Huntington's disease

When communicating with the patient, parent, and carer:

• avoid confrontation
• speak in a quiet voice, but clearly
• ensure another healthcare professional is on standby
• determine if the patient is comfortable with the involvement of a relative, friend, or carer
• try to accommodate their wishes wherever possible

Risk assessment of harm to self and others

For all patients at risk of or experiencing their first episode of psychotic symptoms, undertake a risk assessment of harm to themselves and others, in order to determine if the patient:

• requires compulsory admission under the Mental Health Act; or 
• requires immediate referral to an on-call psychiatrist or early intervention service; or
• does not require a same-day response

Consider other risks including:

• child safeguarding issues
• adult safeguarding issues
• assault
• exploitation
• vulnerability to traumatic injuries
• unintentional harm to self − disorganised behaviour or poor judgement of risk

Red Flags

Patients at immediate risk of harm are usually in the acute phase of psychosis.

For patients judged to be at high risk of harm to themselves or others, arrange a same-day specialist mental health assessment by the early intervention in psychosis service.

Do not start antipsychotic treatment drug while awaiting specialist assessment, unless it is done under advice from a consultant psychiatrist.

If the patient has an existing care plan, refer to the crisis section, and consider referral to the key clinician or care co-ordinator identified in the plan.

Services

• Primary Care Liaison Service

• Bristol - Psychosis Early Intervention

• North Somerset - Psychosis Early Intervention

• South Glos - Psychosis Early Intervention

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.