Psychosis

Positive Symptoms (excess of)

Classic psychotic symptoms occur with a patient's confusion of the boundaries between themselves and the world.

hallucinations - auditory (voices, music, noise) most common, but can also be visual, tactile, gustatory, or olfactory.

delusions - fixed, false beliefs that a person cannot be talked out of

• contrary to person's educational and cultural background
• grandiose
• nihilistic
• persucatory
• somatic
• sexual
• religious

aimless, inappropriate, or bizarre behaviour

• strange clothing
• social, sexual behaviour
• repetitive-stereotyped

disorganized thought form and thought content

• derailment
• tangentiality
• incoherence
• illogicality
• circumstantiality
• pressure of speech
• clanging

hostility

Negative Symptoms

Thought to involve mesolimbic system

• affect flattening: unchanging facial expression, poor eye contact, lack of vocal inflection
• alogia: delay or failure in responding to questions or comments
• avolition: inactivity or early loss of interest in ongoing activity, poor grooming, physical anergia
• anhedonia
• attention: social inattentiveness
• apathy
• emotional or passive withdrawal
• amotivation

Mood Disturbance

• anxiety
• depression
• feeling strange
• irritability
• anger
• excitement
• mood swings
• inappropriate affect

Cognitive Deficits

Can be some of the earliest symptoms and have the most impact on functioning. Lack of insight is common, and is one of the most difficult symptoms to treat.

• frontal cortex functions: problem solving, planning, judgment, lack of insight
• attention, concentration, and information processing
• memory

History

Diagnoses are made based on comprehensive assessment

• phase of disorder
• review medical history
• get collateral information from family if consent is given
• assess substance use
• mental status examination

A full history should be carried out, with particular attention paid to:

• prodromal symptoms (consider SIPS - Structured interview for Prodromal Symptoms)
• psychotic features (consider PANSS - Positive and Negative Symptom Scale)
• changes in behaviour and functioning
• suicidal and homicidal ideation/behaviour
• substance use, particulary in relation to psychotic symptoms

A full mental status exam should also be completed, including evaluation of capacity to consent.

Collateral history is extremely valuable, and seek it from many sources. Interview with family members if possible and consent is given.

Signs and Symptoms of first-episode psychosis include:

• withdrawal from usual activities with friends and family
• persistent decline in functioning in everyday activities, at school or at work
• persistent dysphoria, anxiety, or irritability, especially in the absence of stressors
• rapid fluctuations in mood (emotional lability) or with little emotion or affect
• unreasonable suspiciousness
• insomnia or restless pacing at night
• unusual or bizarre behaviour
• unusual perceptions: hypersensitivity, illusions, or hallucinations
• difficulties thinking or expressing thoughts
• problems with attention and concentration

Substance use, especially marijuana, is very common in people with psychosis. It is important to avoid diagnosing substance-induced psychosis when a primary condition is present. Look for:

• symptoms preceding subtance use or persisting after use and withdrawal
• bizarre symptoms or marked thought disorder

There is evidence that marijuana can trigger psychotic disorders - see under schizophrenia - causes and risk factors.

Physical Exam

A physical and neurological exam should be carried out

Lab Investigations

lab work includes

Diagnostic Imaging

A head CT is usually done, primarily for patients and families to know you've ruled everything else out.