Psychosis in Adults

Red Flags

• Imminent harm to self or others

• First episode of psychosis
• Suspected organic cause, e.g. brain tumour, delirium

Background

About psychosis

About psychosis

Psychoses are severe mental disorders that cause abnormal thinking and perceptions. Psychosis can occur
either in a serious mental illness or in an organic condition. For those at greater risk, psychosis can be
triggered by personal vulnerabilities or risk factors which interact with environmental stressors.

Common causes are:

• Schizophrenia
o Affects 1% of the population
o Variable course
o Usually starts in young adulthood
o Characterised by the presence of positive and negative symptoms

Positive and negative symptoms

Positive (psychotic) symptoms reflect the presence of an abnormal mental process:

▪ Delusions – false, fixed, or irrational beliefs which are firmly held and are not shared
by other people of similar cultural backgrounds.
▪ Hallucinations – sensory perceptions which occur without external stimulus. Voices
are most common, but can occur in any sensory modality.
▪ Disorganised thoughts – bizarre, difficult or illogical cognitive processing.

Negative symptoms reflect the reduction or absence of a normal mental function and include:

▪ lack of energy and motivation.

▪ social withdrawal.
▪ poor personal care or self-neglect.
▪ blunted affect.
▪ reduced speech output.
▪ impaired planning.
▪ reduced flexibility.
o Typically, there is a prodromal period before the psychotic event, lasting from a few days to
about 18 months and often characterised by some deterioration in personal functioning.
o For diagnosis of schizophrenia, the episode should have lasted for 6 months or longer and
include 1 month or more of active psychotic symptoms.
• Bipolar disorder
o Patient may develop psychotic symptoms in any mood episode.
o The delusions will likely be mood congruent.
• Depression – Severe depression may result in psychotic events, which tend to have a negative
affective component, with the possibility of somatic hallucinations or delusions.
 • One-off event (occurs in about 20% of psychotic episodes) – Brief reactive psychosis: psychotic
symptoms lasting less than 1 month, due to a stressful event.
• Drug-induced or drug withdrawal psychosis – Can recur with repeat use of the drug.
• Schizoaffective disorder
o Mood symptoms (mania or depression) are prominent in addition to the core symptoms of
schizophrenia.
o If psychotic symptoms occur only in abnormal mood states, this might indicate bipolar
disorder or depression.
• Delusional disorder
o Usually presents in mid-to-late adulthood.
o Characterised by non-bizarre delusions, e.g. grandiose, persecutory, erotomanic, or somatic.
o Any hallucinations are not prominent.
• Borderline personality disorder – May present with psychotic features in dissociative states.

Assessment

Practice point

Ask patients about command hallucinations and whether any of their voices suggest or tell them to do
something. Treat command hallucinations suggesting violence or self-harm seriously.

1. Obtain a full history:

o Risk factors

Risk factors

▪ Other mental health diagnoses which may predispose the patient to psychosis
(depression, bipolar disorder)
▪ Aged 15 to 25 years (most likely age for first episode of psychosis)
▪ Family history of schizophrenia
▪ History of a significant head injury or intellectual disability
▪ Heavy and prolonged substance abuse during adolescence (cannabis, synthetic
cannabis, methamphetamines)
▪ Within one year of a psychotic event (high-risk time for relapse)
o History of the presenting complaint

History of presenting complaint

▪ Ask about the nature of the problem, to assess whether unusual cognitions,
behaviours, or perceptions exist. It is best to "naively enquire" about unusual
experiences (e.g., hearing people disparaging or threatening, smelling poisonous gas)
rather than asking about "voices" or "hallucinations".
▪ Onset – and whether it was slow or sudden
▪ Presentation – why and how the person presented, what triggered the problem
▪ Symptoms – severity and duration
▪ Impact – on work, relationships, physical (appetite, sleep, sexual drive),
degree of distress
▪ Previous episodes – dates, treatments, outcomes
▪ General well-being – anxiety, mood, any associated physical symptoms
▪ Use the patient's description of the problem to help assess their insight.
▪ Consider taking a history from a family member or close friend even if the patient
describes their problem well.
▪ Consent is not required if there are concerns about risk. Otherwise seek patient
permission.
 ▪ Collateral histories provide important information, as the patient may voice no
concerns about their mental status or provide incomplete information.
o Personal history

Personal history

▪ Family psychiatric history

▪ Developmental history
▪ Education and work history
▪ Present social situation and supports
▪ Recent major life events or stressful events
▪ Premorbid personality – temper, spirituality, relationships, violence, and impulsivity
o Positive and negative psychotic symptoms
o With patient consent, consider "break privacy seal" in HealthOne for information about the
patient's specialist mental health history and access to specialist assessment notes, progress
notes and discharge letters.
2. Assess risk of suicide, harm to others, and exploitation or neglect.

Exploitation or neglect

o Consider:
▪ any evidence the patient is gradually losing capacity to make safe decisions about
their personal care, hygiene, and nutrition.
▪ whether the patient is likely to put themselves at risk by their interactions with others.
o Be aware of possible:
▪ intellectual disability.
▪ major social problems e.g., lack of money, accommodation, employment.

Harm to others

Delusions and hallucinations, especially involving those in close contact with the patient, increase
the risk of harm to those people. Look for:

o command hallucinations with threatening content.

o acting on persecutory ideas.
o persecutory delusions focused on specific known people.
o voices with threatening or disparaging content that the patient identifies as being from
someone, or people, that they know.
o preparations to defend self (weapons, barricading).
o pathological jealousy and stalking.
o threats to kill.
o other paranoid or persecutory features.

Suicide

o Patients are at increased risk of suicide attempts:

▪ during active psychosis (due to their psychotic experiences).
▪ during remission, as they come to terms with their losses.
o Hallucinations which command the patient to kill themselves, especially those with
threatening content, are a specific risk factor for suicide in psychosis.
o See the Suicide Prevention in Adults pathway.
o Patients who are agitated and distressed may become unpredictable.
o Consider the needs of any dependent children of the patient.
o Identify if the patient holds a current firearms licence and has access to firearms, as
notification may be necessary.
3. Closely assess any unusual statements made by the patient by asking key questions to help determine
whether they may be psychotic.
4. Consider whether the symptoms may be due to a first episode of psychosis.

First episode of psychosis

o Typically occurs between the ages of 15 and 25 years.

o The earliest symptoms of psychosis may be non-specific and it may be difficult to reach a
firm diagnosis.
o A teenager or young adult may present during the prodromal period, when symptoms of an
early psychotic disorder can overlap normal-range behaviour.

Prodromal period

Changes in the prodromal period include:

▪ Emergence of transient (short duration) and/or attenuated (lower intensity) psychotic

symptoms
▪ Memory and concentration problems
▪ Unusual behaviour and ideas
▪ Disturbed communication and affect
▪ Social withdrawal
▪ Apathy
▪ Reduced interest in daily activities
o Refer any young adult who may be having a first episode of psychosis.
o A long duration of untreated psychosis and a younger age at onset are associated with poorer
long-term outcomes.
5. Ask about current and recent medications, as some prescription drugs can trigger psychosis, e.g.
steroids and stimulants. Consider substance misuse, abuse, or withdrawal.

Substance misuse, abuse, or withdrawal

o Methamphetamine
o Illicit substances, e.g. speed, LSD, cannabis, ecstasy, and magic mushrooms can cause
psychosis. Symptoms may last hours or days.
o Psychosis with cannabis abuse generally follows prolonged use rather than acute intoxication.
This is more likely to occur the younger the initiation of use.
o Concurrent alcohol and drug use is very common in patients with psychosis, and it can be
difficult to determine whether alcohol or drug withdrawal was the cause of the episode. See
Alcohol Withdrawal.
o A urine drug screen may be helpful but balance potential benefit against the risk of damage to
the doctor-patient relationship. Collateral history from family member or close friend may be
adequate.
o Treat the psychosis acutely as below.
6. Examination:
o Physical and neurological examination.
o If cognitive impairment is suspected, consider delirium and dementia.
7. Arrange baseline investigations without delaying start of treatment.

Baseline investigations

o FBC, CRP, HbA1c, creatinine, electrolytes, calcium, phosphate, LFTs, TSH, lipids, prolactin
o BMI – height and weight
o Urine microscopy
o ECG – most anti-psychotic medications prolong QT interval
 8. Determine the most likely cause of the psychosis:
o a mental disorder e.g., schizophrenia, depression, bipolar disorder, one-off episode,
schizoaffective disorder, delusional disorder, borderline personality disorder.
o an organic condition with psychological symptoms.

Organic conditions

Consider:

▪ brain tumours or cysts.

▪ dementia, including Alzheimer disease.
▪ degenerative brain diseases (e.g., Parkinson disease, Huntington disease) and certain
chromosomal disorders.
▪ HIV and other infections that affect the brain.
▪ some types of epilepsy.
▪ stroke.
▪ delirium – Symptoms due to an organic disorder, e.g. infection, metabolic upset,
alcohol and drug withdrawal.

Management

1. If violent or threat of harm to self or others, call the police.

2. If high concern about imminent harm, contact police or request urgent specialist mental health
services assessment.
3. If there are lesser but still significant concerns about risk to self or others, or uncertainty about the
significance of the presenting symptoms, request non-urgent specialist mental health services
assessment promptly or consider urgent specialist mental health advice.
4. If any suspicion of first episode of psychosis (especially if aged 15 to 25 years), request non-urgent
specialist mental health services assessment. This will usually involve Early Intervention in
Psychosis Service (Totara House). This is a critical time for neurological and social development,
and early referral will improve the long-term outcome.
5. If substance misuse, abuse or withdrawal is suspected, treat the psychosis acutely and recommend
alcohol and drug reduction or withdrawal.
6. Manage any suspected organic cause.
7. Further management depends on the stage of the psychotic illness:

Acute psychosis

0. Decide whether the patient can be managed safely in the community while awaiting further
treatment. Consider requesting urgent specialist mental health advice.
1. Provide patient information.
2. Involve family/whānau or carers.
▪ Patient consent to involve family/whānau or carers is not required if there are
concerns about risk.
▪ Give the number for Crisis Resolution (CR - formerly PES), 0800-920-092. In
Ashburton, 0800-222-955. Write the number on the back of a HealthInfo card, and
encourage them to keep it in their wallet.
3. Begin a low-dose atypical antipsychotic (see Antipsychotic Medication pathway).
4. For anxiety, agitation, and insomnia, consider using a benzodiazepine short term:
▪ diazepam – 5 mg to 10 mg as required up to 15 mg per day, or
▪ clonazepam – 0.5 mg to 1 mg up to 3 mg per day.
5. Recommend healthy eating, and exercise.
6. Consider community service providers and rehabilitative therapies for practical support,
psycho-education, and activity-based recovery to improve social and occupational function.
Chronic psychosis

7. Patients with stable disease may be under the care of Mental Health Services. Ensure good
communication with the patient's psychiatrist or case workers, especially when changing
medications.
8. Consider the core issues:
▪ Prevention and early detection of relapses.
▪ Improvement of physical health and quality of life.
9. Review patients regularly once antipsychotic medications and symptoms are stable. Every 3
to 6 months, review:
▪ compliance.
▪ side-effects, including extrapyramidal side effects, sexual side-effects, weight gain
(see Antipsychotic Medication).
▪ response to treatment.
▪ any deterioration in symptoms.
10. Review alcohol and drug use.
11. Engage patient in regular physical health and mental illness review. PHO funding options are
available to support patients with chronic psychosis.
12. Discuss self-help strategies for maintaining mental stability.
13. Consider dietitian referral for weight reduction in chronic stable patients who meet the
criteria.
14. Provide education and supports:
▪ Involve family/whānau or carers:
▪ Consent is not required if there are concerns about risk.
▪ Give the number for Crisis Resolution (CR - formerly PES) – 0800-920-092.
In Ashburton, 0800-222-955. Write the number on the back of a HealthInfo
card, and encourage them to keep it in their wallet.
▪ Involve community service providers and rehabilitative therapies for peer support,
activity-based support, and education to improve social and occupational function.
▪ Consider the needs of dependent children of patients with chronic psychosis.
▪ Consider respite admission:
▪ Planned respite in times of worsening stress or mental health symptoms
▪ Up to 3 days urgent respite to prevent deterioration in symptoms
15. For further chronic disease management, see Complex Long-term Disorders.

Relapse in chronic psychosis

16. Check compliance to medication.

17. For patients who previously responded to clozapine, seek mental health advice to arrange
referral for re-initiation and monitoring under specialist supervision.
18. Otherwise, restart the last effective dose of antipsychotic that the patient responded to. The
dose does not need to be gradually increased. See Antipsychotic Medication.
19. If under mental health services, provide an update about the patient’s condition.
20. If psychotic symptoms are not settling rapidly, request non-urgent specialist mental health
services assessment.
21. Discuss self-help strategies for maintaining mental stability. Recommend healthy eating,
exercise, and reducing or eliminating caffeine.
22. Provide education and supports:
▪ Involve family/whānau or carers:
▪ Consent is not required if there are concerns about risk.
▪ Give the number for Crisis Resolution (CR - formerly PES) – 0800-920-092.
In Ashburton, 0800-222-955. Write the number on the back of a HealthInfo
card, and encourage them to keep it in their wallet.
▪ Involve community service providers and rehabilitative therapies for peer support,
activity-based support, and education to improve social and occupational function.
 ▪ Consider the needs of dependent children of patients with chronic psychosis.
▪ Consider respite admission:
▪ Planned respite in times of worsening stress or mental health symptoms
▪ Up to 3 days urgent respite to prevent deterioration in symptoms

Request

• Request urgent specialist mental health services assessment if:

o high concern about imminent harm.
o severe neglect.
o acute psychotic features disrupting normal function.
• Request non-urgent specialist mental health services assessment if:
o significant but not immediate risk to self or others.
o treatment resistance.
o diagnostic uncertainty.
o first-time use of antipsychotic medication.
o suspected new-onset psychosis.
• Request specialist mental health advice:
o to discuss any concerns, including uncertainty about significance of presenting symptoms or
whether the patient can be managed safely in the community while awaiting further
treatment.
o if significant symptoms and wanting to start medication before the patient is seen.
• Consider requesting a mental health community support worker:
o for more stable but chronically unwell patients.
o some chronic relapsing patients may also benefit from community support.
• Consider respite admission for chronic relapsing patients.
• Consider dietitian assessment in chronic stable patients, where the criteria are met.

Patients may also wish to consider referral to a private clinical psychologist or psychiatrist.
Acutely Disturbed Young Adult
Red Flags

• Risk to self or others

Background

About acutely disturbed young adults

About acutely disturbed young adults

A young adult presenting with an acutely disturbed mental state will likely be experiencing either
intoxication, psychosis, or delirium.

Assessment

Practice point

Consider the patient’s social and cultural background in their assessment and management as this can
significantly affect the outcome. Culturally appropriate resources may be required.

1. If patient requires interpreter services, request assistance from the TIS. See also Transcultural Mental
Health Centre – Working Cross Culturally – Acute Mental Health Presentations.
2. Take a history. Ask about:
o Duration of symptoms

Duration of symptoms

If acute onset, more likely related to intoxication or delirium.

▪
If preceded by prolonged period of less severe changes and social decline, more likely
▪
to be psychosis.
o Hallucinations
o Delusions
o Changes in mood
o Past psychiatric history
o Family history
o Medications
o Medical illnesses
3. Complete a HEEADSS assessment.

HEEADSSS assessment
Domains Screening questions
Home o Where do you live?
o Who lives at home with you?
o Is this stable accommodation for you?
o Do you feel okay and safe at home?
o How is your relationship with family and friends?

Education and o How is school/work/looking for work going?

employment o Do you go every day?
o How do you feel you are coping with school/work?
o Many young people experience bullying at school or at home via the internet.
Have you experienced this?

Eating o Do you worry about your body or your weight?

o Do you try things to manage your weight?
o Are any of your family or friends worried about your weight or your attitude
towards your body or food?

Activities o What do you like doing?

o Do you have friends that you hang out with?
o What kind of things do you do together?
o Do you mainly spend time on your own?
o Is this okay with you?

Drugs o Do you drink? Smoke?

o Have you tried or used drugs?
o What have you tried?
o Have you regularly used alcohol or drugs to help you relax, calm down or feel
better?
o Would any of your friends or family say you have a problem with drinking or
drugs?

Sexuality o Are you in a relationship? (No: Have you ever been in one? Yes: What's your
relationship like?) If so, with whom: male, female, transgender, other?
o Do you consent to this level of intimacy?
o Do you use contraception, and if so, what kind?
o Have you had an STI screen?
o Do you identify as straight/bisexual/gay/lesbian? Perhaps you are unsure?
o Have you ever had any negative experiences about being gay/lesbian/bisexual?

Suicide and o Have you ever deliberately harmed or injured yourself?

self-harm o Have you ever put yourself in unsafe situations?
o Do you often feel out of control with your behaviour?
o Do you feel sad or down more than usual?
o Have you lost interest in things that you usually like doing?
o Are you having trouble sleeping?
o Have you thought about suicide?
o Do you have a suicide plan?
o Do you have symptoms of anxiety?
o Do you experience voices or hallucinations?
o Do you have a family history of mental health problems?

4. Perform risk assessment.

Risk assessment
 o Assess risk to self:
▪ Suicidality
▪ Deliberate self-harm
▪ Misadventure
▪ Impulsivity
▪ Risk to reputation
o Assess risk to others:
▪ Aggressive behaviour
▪ Persecutory beliefs
▪ Impulsivity
▪ Command hallucinations
▪ Poor judgement
5. Examine the patient:
o Perform mental state examination.
o If concern regarding the possibility of delirium or intoxication, perform physical
examination.

Physical examination

▪ Check vital signs:

▪ Heart rate
▪ Blood pressure
▪ Temperature
▪ Respiratory rate, including Glasgow Coma Score
▪ Look for:
▪ signs of alcohol withdrawal – tremor, tachycardia, hallucinations, raised
temperature, anxiety/agitation.
▪ sources of occult infection e.g. urinalysis, listen for cardiac murmurs,
respiratory examination.
6. Arrange investigations.

Investigations

o Initial blood tests may include FBC, TFT, EUC/LFT, CMP, serology (Hep B and C, HIV,
and syphilis), B12, and folate.
o Perform urine drug screen.
o Consider brain imaging preferably with MRI, or CT if not available.
7. Try and determine if the patient is intoxicated, delirious, or psychotic.

Determine whether intoxicated, delirious, or psychotic

Delirium (acute organic brain syndrome):

o An acute reversible mental disorder characterised by confusion, disorientation, fluctuating

cognitive impairment and a disturbance of consciousness.
o It has numerous organic causes including CNS disease, systemic disease, traumatic brain
injury, medications, intoxication, and withdrawal.

Intoxication:

o An acute change in mental state caused by recent ingestion of a psycho-active agent. Similar
presentations may also occur in withdrawal states.
o Precise effects depend upon the substance involved but often involve changes in perception,
attention, thinking, judgement, emotional control, arousal and behaviour.
o Methamphetamine intoxication and withdrawal can be associated with severe agitation.
 Psychosis:

o A mental disorder characterised by changes in thinking, emotional response, perception and

behaviour to the point where the person is out of touch with reality.
o Typical symptoms are hallucinations, delusions, disorganised thinking, and impaired reality
testing.
8. Assess severity, safety, and disability:
o Severe (requiring emergency management)

Severe (requiring emergency management)

▪Clearly disturbed, highly disorganised, agitated, obvious hallucinations

▪Completely unable to fulfil usual social roles
▪Unable to maintain independent living
▪Unwilling to engage in care
▪Risk of harm to self or others
▪Likely to need acute admission
o Moderate (requiring urgent management)

Moderate (requiring urgent management)

▪ Clear symptoms but not as clearly agitated or out of touch with reality
▪ Struggling with usual activities
▪ Willing to engage in care
o Mild

Mild

▪ Limited or isolated symptoms e.g., single fixed delusion, occasional non-distressing

auditory hallucination
▪ Presentation attributed to the use of substance – patient no longer intoxicated and
indicating discontinuation of use
▪ Willing to engage in care
▪ Not a risk of harm to self or others
▪ Not clearly identifiable as mentally unwell to a casual observer