Psychoses

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 Session outline

• Introduction to psychoses.
• Assessment of psychoses.
• Management of psychoses.
• Follow-up.
• Review.

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 Activity 1: Person’s story

• Present the person’s story of what

it feels like to live with psychoses.

• First thoughts.

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What do local people believe?

• What are the local names for people with

psychoses?

• How are individuals with psychoses treated

in the local community? How are their family
treated?

• Where can the individual and their family

seek help?

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Symptoms

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 Symptoms of psychosis

Disturbed perceptions: Disturbed behaviours and

Hallucinations emotions:
• Altered perception, i.e. hearing • Disturbances of behaviour:
voices, seeing or feeling things social withdrawal, agitation,
that are not there. disorganized behaviour,
Disturbed thinking: inactivity or hyperactivity, self-
neglect, loss of interest and
Delusions: motivation.
• False belief that the person is • Disturbances of emotions:
sure is true, i.e. person believes marked apathy, poor speech,
family are poisoning her. Or one word answers, slowed
person believes he is royalty. Or speech, thoughts may be
person may believe his family disorganized and hard to follow,
are aliens in disguise. disconnect between reported
emotion and facial expressions
or body language.
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Symptoms of bipolar disorder

Disturbed mood: Manic episode:

• Person has episodes where Increased activity levels, elevation
they are manic and other of mood (potentially very happy and
episodes where they are very agitated).
depressed They may talk very rapidly, have lots
• Characteristically recovery of different ideas and increased
between the episodes is levels of self-worth and self-
complete. importance.
They may have hallucinations and
delusions, i.e. hear voices and/or
believe that they are powerful, that
their ideas can change the world.
Engage in risk taking behaviours
(gambling, spending money,
promiscuity etc.).
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 Natural history of psychosis

• First onset typically between age 15 and

29 years.
• There are three possible clinical courses:
o The person recovers completely or partially
with some symptoms.
o The person recovers but has a future episode
(relapse).
o Symptoms continue for a longer period.
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Natural history of bipolar disorder

• First onset typically between the ages of

15–29 years.
• The pattern of mood swings can vary
widely between people:
o Some will have a couple of bipolar episodes in
their life time and stay stable in between.
o Others will have many episodes.
o Some will only experience manic episodes.
o Some will experience more depressed episodes
than manic episodes.

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 Impact of psychoses

Impact on the individual:

• Break up of relationships
• Negative and at times scary experience of symptoms.
• Loss of employment, studies, opportunities.
• Financial consequences.
• Stigma and rejection by community.

Impact on the family:

• Medical costs.
• Time and energy looking after the person (carer burden).
• Emotional distress.
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 Impact of psychoses

Impact on society:
• Loss of workforce.
• Costly medical interventions and (unnecessarily)
lengthy hospitalizations.
Human rights violations:
• People with psychoses maybe chained and
confined.
• They may be beaten as punishment or treatment.
• They may receive treatments that are ineffective
and dangerous due to misunderstanding the causes
of psychoses.
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 Human rights violations

Asdila is a young woman who hears voices. As she was

wandering on the street and talking out loud, the
police arrested her. She had not committed any
offence but while in custody she was told that she
would be transferred to a psychiatric hospital.
In the hospital she was forced to take high doses of
psychotropic drugs which made her extremely unwell.
She was bullied and attacked by staff and other male
patients. She has no way to challenge her detention.

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 Discussion

• What stigma and discrimination do

people with psychoses face in your
community?

• What can you do to reduce the stigma?

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 What you can do to decrease stigma,
discrimination and human rights violations

• Treat people with respect and dignity.

• Avoid making assumptions, e.g. The person is dangerous or the
person lacks capacity.
• Do not assume that the person is unable to make choices or
decisions concerning treatment. Involve the person in the
development of their treatment plan.
• Avoid involuntary admission and treatment, seclusions and
restraints and other coercive practices.
• Treat psychoses at the non-specialist level which is less
stigmatizing, more acceptable and accessible for people.
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 What you can do to decrease stigma,
discrimination and human rights violations

• Provide accurate and supportive information to the person

concerned and their family:
o About psychoses as well as treatment and recovery options.
o Dispel myths about psychoses.
o Raise awareness on the rights of people with mental disorders
including psychoses.
• Raise awareness among other health professionals and
colleagues, family members and the wider community in
order to dispel the stigma, myths and misconceptions about
psychoses.
• Involve people with mental disabilities and their carers in any
awareness raising activities. Empower them to speak for
themselves.

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 Global impact of psychoses

• Affects 21 million people globally (more

common among men – 12 million than
women – 9 million).
• Has an early onset in many (15–29 years old).
• People with psychoses are two and a half
times more likely to die early than the
general population, due to physical illness
such as cardiovascular, metabolic and
infectious diseases.
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 Why it is important to treat in
non-specialized health settings
• Psychoses is treatable.
• Medicines and psychosocial interventions are
effective at treating psychoses.
• People with psychoses can be cared for outside
of hospitals – in non-specialized health settings
and the community.
• Engaging the family and community in the care
of people with psychoses is important.

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Activity 2: Exploring the symptoms
of psychoses

1. Identify whether the person is experiencing a

hallucination or delusions? Explain your
decisions.

2. Identify how the hallucination or delusion

impact on the person’s life? Explain your
decisions.

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Factors influencing communication

• The person’s thoughts might be disorganized and unclear.

• The person might be sharing unusual beliefs.
• The person might refuse to speak.
• The person might avoid any eye contact.
• The person may not feel that they need medical care.
• Often the family will report the issue, not the person.

Now we will discuss how these issues affect your

interaction with the person.

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Establish communication and build trust

• Treat the person with respect and dignity.

• Try to understand the person’s perspective.

• Introduce your questions in a respectful way.

• Do not rush; it may take several sessions to build trust.

• Do not challenge false beliefs or mock the person.

• Ask how the person’s life has been affected.

• Advocate on the person's behalf.

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 Activity 3:
Video demonstration: Assessment

Show the mhGAP-IG psychoses

assessment video.

https://www.youtube.com/watch?v=
tPy5NBFmIJY&index=4&list=PLU4ies
kOli8GicaEnDweSQ6-yaGxhes5v
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 Delirium

An organic brain syndrome characterized by acute onset of:

• Confusion (person appears confused, struggles to
understand surroundings).
• Difficulty in focusing, shifting or maintaining attention.
• Changes in feeling (sensations and perceptions).
• Changes in level of consciousness or awareness.
• Disturbance in orientation to time, place and
sometimes person.
• Disorganized thinking – speech does not make sense.
• Changes in mood – anger, agitation, anxiety,
irritability, anxiety to apathy and depression.
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 Management of delirium

If you think that a person has delirium:

• Try to identify and manage underlying cause.

• Assess for dehydration and give fluid.

• Ensure that the person is safe and comfortable .

• Continue to reassess and monitor the person after initiating

management.

• Refer the person to a specialist (e.g. neurologist, psychiatrist, or

internal medicine specialist).
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 Managing concurrent
MNS conditions and psychoses
Psychoses can occur with:
• Depressive episodes – people can experience hallucinations and
delusions when depressed.
• Post-partum psychosis – in the days and weeks after giving birth
women can experience changes in mood (including mania and
depression). They can experience hallucinations and delusions and
significant confusion in their thinking and behaviour.
• Substance use disorders – intoxication due to substance use can
produce significant disturbances in mood and changes in levels of
consciousness, confusions and erratic behaviour. Withdrawal from
substances can also cause confusion, erratic behaviour, changes in
consciousness and perception.
• Dementia – people living with dementia can report experiencing
changes in perceptions (hallucinations and delusions).

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 Case scenario

• A 22-year-old woman is brought to the clinic

by her parents. They are concerned about
her bizarre behaviour and strange speech.
They explain the young woman keeps
getting very agitated and angry and states
that she wishes to “escape from a terrible
monster taking the shape of her father”.
Today she violently attacked her father.

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 Case scenario continued

• Her father has multiple cuts and bruises on his

face and body from where he was attacked.
• The young woman is obviously still agitated and
restless. She cannot stay still and keeps trying
to get away from her father. She is shouting at
him to “go away” “get out” “leave me”.
• What can you do to manage the situation?

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How to ask about hallucinations and delusions?

Symptoms Person Family

Hallucinations e.g. Do you hear voices e.g. Do you see the
or see things that no person talking to
one else can? someone else when
alone? As if the person
is talking to someone?
Delusions e.g. Do you believe that e.g. Did the person
someone is planning to share any ideas that you
hurt you? found strange and
Do you feel that you are unlikely to be true?
under surveillance?

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Activity 4: Role play: Assessment

- A man who is well known to you is

homeless and lives under the tree
opposite your practice. He has been seen
talking to himself and laughing to himself,
is unkempt and ungroomed.
- Assess him according to the psychoses
assessment algorithm on page 35 mhGAP-
IG.
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 Promoting daily activities
Reducing stress and
strengthening social Ensuring safety in the
support community
and mobility
community support

Pharmacology

Psychoeducation

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Activity 5 Video demonstration:
Managing psychoses

• How did the health-care provider explain the

treatment options?
• Were the risks and benefits of medication
explained?
• Were the benefits of psychosocial
interventions explained?

https://www.youtube.com/watch?v=Ybn401R2gl
4&list=PLU4ieskOli8GicaEnDweSQ6-
yaGxhes5v&index=5
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 Activity 6: Psychoeducation

• Group 1: Key messages in

psychoeducation for psychosis.

• Group 2: Key messages in

psychoeducation for bipolar disorder.

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Activity 7: Promoting functioning in
daily living activities

Promoting functioning in daily living activities is a

crucial step in their journey to recovery. It will:
• Help a person cope with and manage their symptoms.
• Reconnect the person with their community.
• Empower the person to take back some control of their
life.
• Give the person the opportunity to learn and/or earn an
income so they can live independently in the future.
• Give the person hope that they will recover and have a
better future.

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Initiating antipsychotic medication

Are antipsychotics better started early or late?

Early!

For prompt control of psychotic symptoms,

health-care providers should begin antipsychotic
medication immediately after assessment. The
sooner the better.

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Initiating antipsychotic medication

Is it better to start with a low dose or a high

dose?

Low!
Start with a low dose within the therapeutic
range and increase slowly to the lowest
effective dose in order to reduce the risk of
side-effects. Start low, go slow.

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Initiating antipsychotic medication

Which route is preferable?

• oral
• intramuscular.

Oral!
Consider intramuscular treatment only if oral
treatment is not feasible. Do not prescribe long-term
injections (depot) for control of acute psychotic
symptoms.

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Initiating antipsychotic medication

How many antipsychotic medications should

we prescribe at a time?
• one
• more than one.
One!
Try the first medication at an optimum dose for
at least four to six weeks before considering it
ineffective.

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 Case scenario

Yosef is 21 years old has been brought to you by his mother.

His mother says that recently Yosef "is not the same." He is no
longer studying and prefers to stay home doing nothing.
You notice that Yosef is wearing summer clothes although it is
cold and raining. He looks like he has not washed for weeks.
When you talk to him, Yosef avoids eye contact. He gazes at the
ceiling as if looking at someone. He mumbles and gestures as if
he is talking to someone.

He does not want to see his friends, he seems disconnected from

his family and has no energy.
He is refusing to eat food in the home as he believes his mother is
trying to poison him.
You assess Yosef and decide to start him on antispyshchotic
medication to see if that improves his symptoms.

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 Antipsychotic medications

• What are the starting doses for

haloperidol, chlorpromazine and
riseperdione ?
• What are the effective doses?
• What are the side-effects for each drug?

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 Case scenario

Maria is a 35-year-old woman. She is married and has two

children (10 and 8 years old). For the last five years she has held a
management level position in a local bank and has been enjoying
her career. In the last two months she has been experiencing
changes in her mood. She has been arguing with people at work
and her family at home. She is getting frustrated as she does not
feel people are listening to her or understanding her. Her speech
is very fast and confusing as she is having so many ideas at the
same time. She is spending a lot of money and that is causing
arguments with her husband. She is active all the time and is not
sleeping well.

After a thorough assessment you decide she is experiencing a

manic episode.

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 Mood stabilizers

• What are the starting doses for lithium,

sodium valproate and carbamazepine?
• When should you not use lithium?
• What are the effective doses?
• What are the side-effects of each drug?

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 Review and adherence

• What should you do if Yosef complains of muscle

rigidity and stiffness, and you notice that he has
involuntary repetitive lip smacking?
• What could you do if a person who has started
to take risperidone complains that they feel it is
not doing anything to help them?
• How would you help someone who stopped
taking sodium valproate because they were
gaining too much weight and felt
uncomfortable?

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 Case scenario

A 28-year-old woman called Fatima gave birth to

her second child two weeks ago. Her husband
explains that she is not sleeping at all and she is
struggling to feed the baby. She believes that
her baby is in danger but she does not know
how to protect it. Sometimes she thinks it would
be better if she and the baby were both dead.
On one occasion the husband has stopped her
from being violent towards the baby.

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Activity 8: Role play: Follow-up

• Follow-up with a person with psychosis.

• Focus on reassessment of the symptoms.
• Assessment of side-effects of medication.
• Assessment of psychosocial interventions
specifically strengthening social support,
reducing stress and life skills.

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 Review

• MCQs

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