Inpatient Management of Psychosis

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Introduction   

Psychosis is an illness or symptom of illnesses that is often misunderstood. This amalgamation of symptoms will most likely result in the patient’s loss of touch with reality. Care must be taken to properly diagnose and treat both the psychosis and the underlying issue(s) which caused it. The patient may be scared of what others will be thinking as there is a stigma associated with psychosis. The treatment plan must be individualized for the patient, taking into account any other medical problems they may have.   

Definition 

Psychosis is the result of multiple psychological symptoms that leaves the patient out of touch with reality. These symptoms or mental disorders include hallucinations, delusions, and disorganized thinking and behaviors. Psychosis is particularly common in patients with neurocognitive disorders (NCD) such as dementia, Alzheimer’s disease and Parkinson’s disease (1, 4).   

Epidemiology 

First-time psychosis has an incidence of approximately 50 in 100000 people. For males, the peak age of onset is from their teenage years to the mid-twenties. Whereas for females, the peak age of onset is from their teenage years to the late twenties. It is rare for children to present with psychosis. It is known that the earlier the onset of psychosis, the poorer the outcome. It should also be noted that the earlier the treatment is initiated, the better the outcome will be (1). 

It is more common for males to develop psychosis. Studies have shown that the prevalence of psychosis is fairly stable globally. There are some new studies that are questioning whether this remains true; they are focusing on ethnicity, sex, age, and geographical location when it comes to incidence of psychosis. Still other studies are showing that the incidence of psychosis/schizophrenia is on the rise around the world (8). 

Pathophysiology 

The neurotransmitter dopamine is most strongly linked to the onset of psychosis. The Dopamine Hypothesis came from the discovery that drugs that increase dopamine activity in the brain can lead to psychosis. On the other hand, drugs that impede dopamine receptors lessen the symptoms of psychosis. The Dopamine Hypothesis states that, in a person without psychosis, when the limbic dopamine system is suppressed, the prefrontal dopamine system takes control. In a person with psychosis, there is a reduction in the dopaminergic neurons in the prefrontal dopamine system, resulting in an overactive limbic dopamine system. When the activity in the prefrontal dopamine system is lessened, this can bring on the negative symptoms of psychosis. When the limbic dopamine system becomes overactive, it can lead to the positive symptoms of psychosis.   

Another neurotransmitter, glutamate, has also been shown to contribute to psychosis. Sensory, cognitive, motor, and affective symptoms of psychosis are linked to abnormal glutamate transmission in the brain (5, 8).   

Stages  

The clinical staging of psychosis was developed to assist providers in diagnosing and treating with greater precision. There are three stages of psychosis: (1) prodrome phase, (2) acute phase, and (3) recovery phase.  

Prodrome Phase  

The prodromal stage is the first stage of psychosis. This is where behaviors and perceptions may change, indicating that a psychotic event is about to start. As psychosis begins, the patient may show symptoms such as sleep disturbances, difficulty focusing, or feelings of wanting to be alone.   

Acute Phase  

In the acute phase of psychosis, behaviors such as hallucinations and delusions begin. As these behaviors progress, they can become debilitating and interfere with the patient’s normal life.  The length of the acute phase is undetermined and may depend on the cause of the psychosis.   

Recovery Phase  

The recovery phase is the last stage of psychosis. In this phase, the symptoms of psychosis will decrease, and the patient should be able to return to their normal life routines. This stage is brought on after treatment has started or if the patient stops the substance that may have brought on the psychosis (7). 

Clinical Signs and Symptoms 

Through every stage of psychosis, patients can present with symptoms. There are two classifications or dimensions of symptoms of primary psychosis: positive and negative. 

Positive Dimension of Psychosis 

The positive dimension of psychosis has been evolving for decades and is known as the core of primary psychosis. Symptoms include delusions, hallucinations, self-disturbances, and disorganized thinking. 

• Delusions: Delusions are continuous false beliefs which are based on flawed reasoning about reality. These beliefs are sustained even though there is evidence they are incorrect and other people do not share them. There are different types of delusions which can manifest. Persecutory delusions are when the patient believes that something/someone is out to get them; these are the most common type of delusions.  

Another type of delusion is when the patient has false beliefs about their or another person’s body. This type of delusion is called somatic. When the patient feels that a catastrophe is going to happen, they are experiencing a nihilistic delusion. An erotomanic delusion is when the patient believes that someone is in love with them. A grandiose delusion has the patient believing that they are more important than they really are.  

• Hallucinations: Hallucinations are perceived experiences that are untrue though they have the clarity and impact of true perceptions. These experiences happen without the stimulation of the organ needed for the real experience. When speaking about hallucinations, the default thought is auditory. It should be noted that hallucinations can also affect the visual, olfactory, and tactile senses. 

• Self-disturbances: These are changes in the sense of self through the patient’s experiences and actions. 

• Disorganized thinking: The patient’s speech pattern and overall communication pattern is what gives away disorganized thought. During a psychotic episode, the patient may have sequences of unrelated or very loosely associated ideas. They may be unable to properly answer questions or give long answers with excessive details. The patient may drift from the original topic of conversation, never returning to the initial point. At times, the patient may use a string of incoherent jumble of words. They may also repeat words, phrases, or other statements. 

Negative Dimension of Psychosis 

Negative symptoms of psychosis have been consistently linked with poor outcomes. As per the National Institute of Mental Health (NIMH), the negative symptoms of psychosis include the domains of alogia, anhedonia, asociality, avolition, and affective blunting. These domains are commonly known as the 5 A’s. 

• Alogia: Alogia is when the patient speaks less often than normal and uses less words when they do speak. They also tend to take a long time to talk and are unlikely to initiate conversation. When asking questions, the patient will reply with short responses saying only what is necessary to answer the question. 

• Anhedonia: Anhedonia can be thought of as both consummatory and anticipatory. The patient with anhedonia does not feel pleasure when performing acts that should feel pleasurable. They may also not feel the associated pleasure in the anticipation of performing pleasurable acts. 

• Asociality: This is a decrease in normal social interactions and in the drive to initiate them. This is due to a disinterest and lack of any desire to interact.   

• Avolition: Apathy is another name for avolition. This refers to a lack of involvement in any type of activity. Avolition is due to both a disinterest in activities and a loss in the motivation to perform them. 

• Affective blunting: Affective blunting is usually referred to as blunted affect. It is both a decrease in the patient’s expression of emotions and reaction to circumstances (4, 6). 

Assessment 

As with most disease processes, the first line of treatment is a thorough assessment. The patient interview is perhaps the most important tool in developing an individualized plan of care. The clinician should start by obtaining an accurate history (it should be noted that a patient having a psychotic episode may not be the best historian). The history needs to include certain items: 

• Timeline and severity of symptoms. An accurate timeline is important to assess the onset of psychosis. The type and severity of symptoms will also give the provider insight to help formulate the plan of care. 

• Previous psychiatric history. Assessing any prior psychiatric history will guide the plan of care. It may also facilitate the diagnosis process. 

• Previous medical history. There are medical conditions that are linked to psychosis.  Obtaining a proper medical history will give valuable insights and guide the plan of care. 

• Medications. An accurate medication reconciliation is important. There are medications that can contribute to psychotic episodes. It is also important to rule out any medication interactions that may present with the treatment of psychosis. 

• Substance use. The use of drugs and alcohol can contribute to the onset of psychosis. 

• Trauma. Trauma of all types (social, physical, sexual, emotional) can be a major cause of psychosis. Knowledge of the trauma will also guide the plan of care. 

• Mental Status Exam. When suspecting any type of psychiatric disorder, the Mental Status Exam (MSE) should be performed. The MSE has the provider take into account the appearance, mood, behavior, speech, and affect of the patient. It should be used with every encounter with the patient. This will help the provider paint a picture of any changes in the mental status of the patient. Looking back, the provider can compare prior assessments and map the course of the psychosis. 

A regular work-up should be performed, including a urinary drug screen.  This will help rule out any non-psychiatric causes of the psychotic episode. One thing to take note of is that not all substances can be found in routine labs. Once the non-psychiatric causes are ruled out, a psychiatric consultation can be ordered to find the diagnosis and begin treatment tailored to the patient’s case (1). 

Etiology 

The cause of psychosis remains unknown. The mechanism by which it develops is also unknown. Though the prevailing thought is that psychosis (and particularly schizophrenia) is mainly a disease of the brain, recent studies point to early development, social and psychological processes, and genetics as playing a role in its onset and development. Issues such as childhood trauma, sexual abuse, drug use/abuse, infectious disease, and pregnancy have all been known to contribute to the onset of psychosis. It is important to take a comprehensive history when assessing a patient with psychosis (1).  

Treatment 

Currently, the most common approach in the treatment of psychosis is antipsychotic medications. Typically, second-generation antipsychotics are preferred to first generation.   

First Generation Antipsychotics 

Chlorpromazine and other first generation antipsychotics are all dopamine D2 receptor antagonists. They also share many of the same adverse effects such as parkinsonism, motor restlessness (akathisia), involuntary repetitive movements (tardive dyskinesia), and hyperprolactinemia. In 1990, the drug clozapine was approved by the U.S. Food and Drug Administration (FDA). It is practically free of the adverse effects of increased prolactin and neurologic issues. 

Second Generation Antipsychotics 

Researchers built on the success of clozapine and developed more drugs with the same or less efficacy. Though all the second-generation medications do not have neurologic adverse effects, they do present with other adverse effects such as weight gain and insulin resistance (3). 

Treatment of psychosis should be personalized and based on the clinical presentation of the patient. Cognitive behavioral therapy has proven to be effective yet rarely used worldwide.  Other psychosocial interventions are often implemented for patients with psychosis, though the interventions used are rarely validated by any up-to-date research (4). 

Quality of Life 

Patients suffering from psychosis often have issues with normal life functioning. One of the biggest issues is the stigma associated with mental illness. Both the stigma from others who look down on the patient with psychosis and, perhaps more detrimental, the internal stigma the patient places on themselves. With prolonged psychosis, there is a strong connection with internalized stigma and poor social functioning, and an increase in psychotic symptoms. These affect the patient’s overall functioning and quality of life. It should be noted that when a patient has psychosis, this also puts a strain on their family. Often, it is up to the family members to manage the patient’s treatment and adherence to the plan. They can be greatly affected by the patient’s issue and may, themselves, need counseling. They can also be stigmatized because of their family member’s diagnosis (2). 

Conclusion

Psychosis is a complex disorder which can affect the patient in many different ways. Patients with psychosis have been known to completely detach themselves from reality. As such, the problem can also greatly affect the family of the patient. The most important aspect, from the nursing point of view, is early detection through an extensive assessment with a comprehensive history. The treatment should be designed with the individual patient in mind.   

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