Chapter 16 Assessing and managing psychosis, drug misuse and violence and aggression
Primary survey
The objectives of this chapter are listed in Box 16.1. Assess the risk of self harm or the potential of harm to others, including you. Call for urgent back up if this is the case. You may need to call the police if you think there are real and immediate risks of violence. If you judge management of the patient will require the use of the Mental Health Act, you will need to mobilise an Approved Social Worker (ASW), the patient’s GP or a doctor approved under Section 12 of the Mental Health Act (1983).
Box 16.1 Chapter objectives
Psychotic illness
Substance misuse
Psychotic illness
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
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).
Box 16.2 Signs and symptoms of psychosis
Exclusion of an acute organic confusion
It is not always easy to distinguish between medical/physiological disorders and mental illness presentations. Medical problems are potentially treatable and may indicate a life-threatening emergency that may be amenable to treatment (Box 16.3). History of fits, diabetes, head injury, –recent febrile illness or acute confusion should be excluded (a full list is given in Chapter 15). Check the temperature, level of consciousness, orientation and speed of onset as these can help distinguish between and physical or psychiatric cause (Table 16.1).
Organic | Functional | |
---|---|---|
Age | >40 years | <40 years |
Onset | Sudden | Gradual |
Physical abnormalities on examination | Yes | No |
Activity | Hypo-/hyper-active, tremor, ataxia | Rocking, repetitive action, posturing |
Consciousness | Impaired | Awake and alert |
Orientation | No | Yes |
Lucid thoughts | Some | Infrequent |
Hallucinations | Visual | Auditory |
Memory impairment | Recent memory | Remote memory |
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.
Analysis
The categorisation of severe mental illness is not easy. You do not have to make a definite diagnosis – indeed it may be inadvisable to ‘label’ a patient in the first contact emergency situation. However it is important to have some appreciation of the main categories. These are summarised in Box 16.5.
Box 16.5 Differential diagnoses of psychotic disorder – specific mental disorders
Specific types of illness
Schizophrenia
Develop rapport and therapeutic relationship taking account of language and culture of the patient. Involve patients and carers/advocates in care decisions. Look for a previously documented crisis care plan and check concordance with and previous response to any treatment/medication package. Assess alcohol and substance use or misuse.
In an acute episode of psychosis, especially the first experience, the person may be absolutely terrified and confused. There may be suicidal ideas (about 10% of patients with schizophrenia will commit suicide within 5 years of the onset of their illness; about 30% of people with schizophrenia attempt suicide at least once). They may ‘hear’ voices demanding that they harm themselves.3 Those most at risk are male patients, the unemployed, socially isolated or recently discharged from hospital.
TIPPhysical examination may also be necessary; schizophrenia is associated with a high mortality, with death on average 10 years earlier than the general population. Cardiovascular disease and/or diabetes are responsible for many of these excess deaths1,4
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.’
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.
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.
Box 16.8 Summary of findings related to women who commit suicide