Psychosis assessment

Assess the patient s symptoms, review patient and family history, and obtain initial medical evaluation to rule out other causes of psychosis. 

Efficacy in short-term treatment. From studies in adult schizophrenia, it is evident that clozapine treatment has at least the same or superior antipsychotic effect, compared to typical antipsychotics. In some studies, clozapine was superior with regard to symptom reduction in severe and acute schizophrenic patients. As the guidelines do not allow the use of clozapine as a first-choice drug, most patients have been treated before with at least two atypical or typical antipsychotics. Only one controlled trial has assessed the efficacy of clozapine in child and adolescent psychiatry. In this study (Kumra et ah, 1996), clozapine was found to be superior to haloperidol in all measures of psychosis, and showed a striking superiority for both positive and negative symptoms. 

The Krawiecka Goldberg Scale (or Manchester Scale) is a brief ten-item scale for assessment of changes in the clinical status of patients suffering from psychosis. The items include depression, anxiety, delusions and hallucinations, incoherence, flattened affect, poverty of speech and psychomotor retardation. The absence of items typical of schizoaffective and manic psychoses limits the use of this instrument. It is, however, useful for follow-up of inpatients and outpatients for longer periods of time (Krawiecka et al.y 1977). 

Investigators have attempted to assess the impact of antipsychotics on the cognitive and the behavioral disturbances characteristic of schizophrenia. The antipsychotics decrease typical, but nonspecific, positive symptoms such as hallucinations and delusions ( Table 5-4). Thus, labeling them as antischizophrenic agents is too restrictive inasmuch as they also benefit such disparate disorders as psychotic depression or mania, iate-onset paraphrenia, and organic-induced psychosis. As the symptoms reduced by neuroleptics are typical of psychosis in general, these agents are best conceptualized as a type of antipsychotic. 

Complicating the proper assessment and, by implication, the most appropriate therapy for many patients, is the very real possibility of neuropsychiatric syndromes that may mimic classic psychiatric disorders, exacerbate them, or coexist with such disorders as major depression, panic attacks, and brief reactive psychosis. Thus, the CNS may be affected by various primary malignancies or secondary metastases cardiovascular disorders, leading to ischemic episodes or hemorrhagic events and several HIV-related complications. 

Nonpsychotic persons also experience impaired performance as judged by a number of psychomotor and psychometric tests. Psychotic individuals, however, may actually show improvement in their performance as the psychosis is alleviated. The ability of the atypical antipsychotic drugs to improve some domains of cognition in patients with schizophrenia and bipolar disorder is controversial. Some individuals experience marked improvement and for that reason, cognition should be assessed in all patients with schizophrenia and a trial of an atypical agent considered, even if positive symptoms are well controlled by typical agents. 

The classification of NMDA antagonists as nonaddictive drugs was based on early assessments, which, in the case of PCP, have recently been questioned. In fact, animal research shows that PCP can increase mesolimbic dopamine concentrations and has some reinforcing properties in rodents. Concurrent effects on both thalamocortical and mesolimbic systems also exist for other addictive drugs. Psychosis-like symptoms can be observed with cannabinoids, amphetamines, and cocaine, which may reflect their effects on thalamocortical structures. For example, cannabinoids, in addition to their documented effects on the mesolimbic dopamine system, also enhance excitation in cortical circuits through presynaptic inhibition of GABA release. 

Boeijinga PH, Soufflet L, Santoro F, Luthringer R. 2007. Ketamine effects on CNS responses assessed with MEG/ EEG in a passive auditory sensory-gating paradigm An attempt for modelling some symptoms of psychosis in man. J Psychopharmacol 21 321-337. 

In a cross-sectional survey of Yemeni adults the self-reported frequency of khat use and psychological symptoms was assessed using face-to-face interviews with members from a random sample of urban and rural households (10). Of 800 adults surveyed, 82% of men and 43% of women had used khat at least once. There was no association between khat and negative adverse psychological symptoms, and khat users had less phobic anxiety (56%) than non-users (38%). The authors were surprised by these results and offered several explanations that the form of khat used in Yemen is less potent than in other locations that prior reports of khat-related psychosis occurred in users in unfamiliar environments that the sampling procedure may have under-represented heavier khat users and that their measurement tool was not sensitive enough to detect psychological symptoms. 

She reported daily oral consumption of street amfeta-mine 1.6 g. At the time of assessment, she had given up her work. Initially, she felt good while taking the drug, but more recently she had been using it to get going there were no symptoms of psychosis or affective disorder. 

The patient s airway, breathing, and circulation should be assessed and supportive care instituted as necessary. Many patients are anxious and respond to reassurance and a quiet, nonthreatening, nonstimulating environment. Benzodiazepines may be necessary for agitation or anxiety. Hyperthermia and seizures should be managed using standard therapy, a cool mist spray and fans for hyperthermia, and a benzodiazepine for seizures. Psychosis may require treatment with haloperidol. 

Clients who suffer from psychosis vary greatly in their responses to medication and other forms of intervention. Therefore, most primary-care practitioners steer away from prescribing medicine for these individuals, although primary care and general medicine physicians often treat conditions such as depression. One major aspect of treatment expectations is that the client with a psychotic disorder is rarely given a prescription and sent home. After assessing the client, extensive monitoring and support... 

A. Assessment. Agitation, delirium, or psychosis may be caused by a variety of drugs and toxins (Table 1-14). In addition, such symptoms may result from a functional thought disorder or metabolic encephalopathy caused by medical... 

Chapter 23 First episode psychosis fFEPf Preparation Assessment Management What if... ... 

Chapter 24 Psychosis—longer term Preparation Assessment Management Take-home message Further reading... 

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