Assessing and managing psychosis, drug misuse and violence and aggression

Chapter 16 Assessing and managing psychosis, drug misuse and violence and aggression






Psychotic illness


This section will discuss:






Around 1% of the population experience at least one acute episode of schizophrenia1 and a similar number will be affected by bipolar disorder (manic depression) at some time during their lives. Post-natal depression and psychosis is now the leading cause of all maternal deaths by suicide.



Features of psychosis and differentiation from organic confusion


In psychosis, the person typically loses the ability to distinguish between reality and thoughts due to hallucinations or delusions. These symptoms usually first appear in the late teens or early twenties (slightly later for women).


The symptoms of psychosis can be difficult to categorise. Disturbance of thought is key to the diagnosis. This thought disturbance can take -many forms. Delusions (false beliefs) and hallucinations are common. Auditory hallucinations are common – these may take the form of voices commenting on the patient’s actions or voices discussing the patient. The patient may believe that thoughts are being either inserted into or removed from their mind. Overwhelming negative feelings such as apathy, neglect and severe blunting of mood are common in severe depressive syndromes (Box 16.2).



Patients who have had a previous episode of psychotic illness are likely to be known to the specialist mental health services, though many are managed completely within primary care. It is likely that most pre-hospital and emergency care practitioners will encounter patients in crisis who have an undetected illness (the incidence of new cases of schizophrenia is 1–2 per 10 000 population per year) or those experiencing a relapse.




Psychiatric assessment


The objectives are to obtain an accurate history of the presenting problem, assess the patient’s mental state and personality, and to identify possible causes/triggers to the current situation. In addition to the usual approach to history taking and past medical/psychiatric history of the patient, it is useful to assess the patient’s expectations/wishes and their appropriateness. The patient’s mental state should then be assessed; this may involve the use of the Mental State or Mini Mental State Examinations (see, for example, the Oxford Handbook of Psychiatry2). Another approach to mental state examination is given in Box 16.4.



The patient’s presentation may be complicated by emotional arousal (e.g. anger), the misuse of alcohol and co-morbidity. An example of the latter is ‘self-medication’ with cannabis by patients experiencing the symptoms of schizophrenia. In the UK 9–35% of people with schizophrenia misuse alcohol or drugs.




Specific types of illness




Bipolar disorder


Bipolar disorder is defined by NICE5 as: ‘an episodic, potentially life-long, disabling disorder (with) diagnostic features including periods of mania and depression characterised by periods of abnormally elevated mood or irritability, which may alternate with periods of depressed mood. These episodes are distressing and often interfere with occupational or educational functioning, social activities and relationships.’


The evidence shows that there is often a considerable delay between the onset of the disorder and first contact with services.


Most people experience some changes in mood, but a patient with mania (Box 16.6) has a persistently high and euphoric mood, which is out of keeping with their circumstances and the environment. A key feature of management is to provide a calm, structured environment with avoidance of over-stimulation balanced with space for walking to use up excess –energy. Hospital admission is therefore often necessary. In contrast, hypomania (i.e. when the symptoms are not extreme enough to significantly impair work/relationships) can be managed within primary care.



Be aware that many medications may induce the symptoms of mania including antidepressants, other psychotropic medication, anti-parkinsonian medication, cardiovascular and respiratory drugs, anti-TB medications, steroids and drugs of misuse.



Post-natal depression and psychosis


Following childbirth, around 70% of women experience ‘baby blues’; this usually occurs 3–5 days after the birth and resolves quickly. However, about 10% experience post-natal depression which exhibits the same symptoms as a severe (major) depression.6 Secondary survey would be supported by use of the Edinburgh Post-natal Depression Scale.7


A small percentage of new mothers (0.1%) develop puerperal psychosis (Box 16.7) – this normally develops within 3 weeks of the birth.



This is a serious illness and may require prompt specialist intervention and the admission of the mother and baby. ‘Why Mothers Die’ – The Confidential Enquiry into Maternal Deaths8 indicates clearly that 50% of the women who commit suicide (Box 16.8) have a previous history of serious mental illness, 25% related to their last childbirth. This is in fact the leading cause of maternal death. Four times as many suicides occurred following delivery than in pregnancy itself and many women with puerperal psychosis who kill themselves do so later than 6 weeks following delivery.


Jun 14, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Assessing and managing psychosis, drug misuse and violence and aggression

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