PSYCHOSIS

Submitted to: Dr. Ayesha Sana

Group Members:

 Ateeb Mazhar
 Syed Ehtisham
 Kaleem Talib
 Bilal Bin Shoukat
Content Layout

 Introduction
 Etiology
 Epidemiology
 Pathophysiology
 Types of Psychotic Disorders
 Signs And Symptoms
 Diagnosis/Evaluation
 Treatment For Psychosis
 Case Study
 References
Introduction

 Definition: “Psychosis refers to an abnormal condition of the mind described as involving a

‘loss of contact with reality’.
 Psychosis is a common and functionally disruptive symptom of many psychiatric,
neurodevelopmental, neurologic, and medical conditions.
 According to modern research significantly larger, a variable number will experience
at least one psychotic symptom in their lifetime.
 It is the hallmark feature of schizophrenia and other psychotic disorders.
Etiology

 Psychosis may result from a primary psychiatric illness, substance use, or another
neurologic or medical condition.
 Primary psychotic disorders are considered to develop due to environmental factors
such as substance abuse, stress, immigration, infection, postpartum period, or other
medical causes.
 There is significant evidence for genetic risk factors in the pathogenesis of psychotic
disorders.
Epidemiology

 The incidence of a first-time episode of psychosis is approximately 50 in 100000

people.
 The incidence of schizophrenia is about 15 in 100000 people.
 The peak age of onset for males is teens to mid-20s.
 For females, the onset tends to be teens to late-20’s.
 Psychosis is extremely uncommon in children.
Pathophysiology

 Most strongly linked to the pathophysiology of psychotic disorders is the

neurotransmitter dopamine. The positive symptoms of psychotic disorders are
believed to be caused by excess dopamine in the mesolimbic tract.

 Glutamate, an excitatory neurotransmitter, is also implicated. Multiple studies have

found a decreased function of the N-methyl-D-aspartate (NMDA) glutamate receptor.

 Imbalance in GABA & acetylcholine balance also play an important role in psychosis.
Types of Psychotic Disorders

 Schizophrenia
 Generalized Anxiety Disorder
 Post Traumatic Stress Disorder
 Obsessive Compulsive Disorder
 Bipolar Disorder
 Psychotic Depression
 Drug-Induced Psychosis
 Phobias
 Amnesia
 Identity/Personality Disorder.
Abnormalities associated with Psycosis

 Psycotic disorders are to be defined by abnormalities in one of the following five

domains:
1. Delusions (fixed false beliefs, are evidence of impaired reality testing).
2. Hallucinations (perceptions occurring in the absence of corresponding external or
somatic stimuli).
3. Disorganized thoughts (non-linear thought pattern).
4. Disorganized behavior (unpredictable and/or inappropriate emotional response).
5. Negative symptoms (inexpressive or emotionally blunted i.e flat affect.)
Evaluation

Interview is of the utmost importance for guiding the treatment plan. As usual, one starts by
obtaining a thorough history.
 Timeline and severity of symptoms
 Prior psychiatric conditions
 Hospitalizations
 Previous medical history.
 Medications taken (psychiatric and non-psychiatric)
 History of substance use.
 Detailed social history
 History of trauma (emotional, physical, sexual).
 Suicidal ideation with prior attempts
 Auditory/visual hallucinations.
Diagnosis

 One must make a careful observation regarding the patient’s appearance, behavior,
speech, mood, affect, thought process, and thought content.
 A standard medical workup can help to rule out non-psychiatric causes of psychosis.
• CBC Urinalysis
• Thyroid-stimulating hormone (TSH), T3, T4
• Liver function tests
• CT, MRI
• EEG
• Lumbar puncture
• Rheumatologic or immunologic workup.
TREATMENT

 The management of a psychotic patient varies greatly depending on the origins of

the psychosis.
 A psychiatric medication is a licensed psychoactive drug taken to exert an effect on the
chemical makeup of the brain and nervous system.
 Antipsychotic medications are the gold-standard treatment for psychotic episodes
and disorders, and the choice, dosing, and administration of the medication will
largely depend on the scenario.
 Initial dosing of anti-psycotics should be at a low dose and titrated up as needed.
 Anti-psycotics are very useful In treating the psychotic symptoms of drug-induced
psychosis, mania, delirium & the psychotic features of depression.
Mechanism of Action of Stimulant Drugs

 Majority of stimulants manipulate monoamine transmission. The monoamines

consist of dopamine, norepinephrine and serotonin. 
 They are relevant to the reward, motivation, temperature regulation and pain
pathways. 
 Stimulants commonly either block the reuptake or stimulate the efflux of dopamine
and norepinephrine, increasing the activity within their circuitry.
 When these pathways are altered by stimulants, they are associated with “negative”
symptoms and movement disorders.
Cont..

 Antipsychotics are D2 dopaminergic receptors antagonists e.g ZIPRASIDONE, are

effective in case of Schizophrenia.
 They inhibit dopamine reuptake into neurons by binding to dopamine transporters
(DAT), resulting in an increase of the concentration of dopamine in the synaptic
cleft.
 This prevention of dopamine reuptake with the additional release of dopamine
results in an increase in concentration of dopamine in the mesolimbic and
mesocortical pathways in the brain, thus causing more pleasure.
 Medications Used to Treat Anxiety Disorders

 1. Antidepressants
 2. Benzodiazepines
 3. Barbiturates
 4. Beta-Blockers (usually used to
treat heart conditions associated
with psycosis).
Classification of Anti-depressant Drugs
Medications Used to Treat Depression Disorder :

 Generic name: SERTRALINE

 Brand Name: Zoloft
 Dosage: initiated with a dose of 25 mg once daily. After one week, the dose should be
increased to 50 mg once daily.
 Side Effects: Diarrhea, dyspepsia, nausea, insomnia, loose stools, dizziness, drowsiness,
paresthesia, headache
 Indications: Treating depression or OCD Nursing interventions 
Medications Used to Treat Bipolar Disorder/Mania

 Generic name: LITHIUM

 Brand Name: Lithobid
 Dosage: Morning 3 tabs (900 mg) Night time 3 tabs (900 mg)
 Side Effects: Irregular pulse , increased frequency of urination, weight gain, and mildly
shaking hands.
 Indications: to treat manic- depressive disorder ( bipolar disorder).
 Nursing interventions: monitor pulse to obtain baseline data. monitor weight on a
weekly basis. report any changes in urinary frequency.

 Of note, clozapine and olanzapine specifically have been shown to reduce the risk of
suicide in psychotic patients as well as used in the treatment of bipolar disorder.
Medications Used to Treat Anxiety Disorders

 Generic name: ALPRAZOLAM

 Brand Name: Xanax/Alp
 Dosage: initiated with a dose of 0.25 to 0.5 mg given three times daily.
 Side Effects: Drowsiness, dizziness, increased saliva production, sluggishness.
 Indications: to treat anxiety and panic disorders.
 Nursing interventions: council patient to avoid driving or operating hazardous equipment.
Drug Induced Psychosis

 The most common cause of stimulant-induced psychosis is amphetamine and

methamphetamine use as well as other CNS stimulants i.e Cocaine, Nicotine &
caffeine etc.
 These drugs can also demonstrate significant side effects, including extrapyramidal
symptoms and dangerous QT prolongation.
 Circumstantiality, motor dysfunctions, chronic low self esteem, aggression etc are
all symptoms of Drug induced Psychosis.
Cont..

BENZODIAZEPINE ANTAGONISTS:
 Flumazenil is a GABA receptor antagonist that can rapidly reverse the effect of
benzodiazepines.
 The drug is available in I/V only.
 Onset of its action is short with a half life of about 1 hour.
 Antipsychotics

 Antipsychotics, also known as neuroleptics,[1] are a class of medication primarily used to manage psychosis

 (including delusions, hallucinations or disordered thought), principally in schizophrenia but also in a range
of other psychotic disorders.

 The use of antipsychotics may result in many unwanted side effects such as involuntary movement disorders, 
gynecomastia, impotence, weight gain and metabolic syndrome.

First-generation antipsychotics, known as typical  Second-generation drugs, known as 

antipsychotics atypical antipsychotics  
These medications are generally preferred because they
first-generation antipsychotics have frequent and potentially
significant neurological side effects  First-generation pose a lower risk of serious side effects than do first-
antipsychotics include: generation antipsychotics. Second-generation
•Chlorpromazine antipsychotics include:
•Fluphenazine • Aripiprazole (Abilify)
•Haloperidol • Clozapine (Clozaril, Versacloz)
•Perphenazine • Risperidone (Risperdal)
MOA: • Olanzapine (Zyprexa)
•Block dopamine D2 receptors in the dopaminergic pathways of
the brain.
•Atypical neuroleptics also antagonize effects of Serotonin.
 Pharmaco-therapeutic algorithm for the treatment of schizophrenia

  second-generation (atypical) antipsychotics (SGAs)—with the exception of clozapine—are the agents of choice for
first-line treatment of schizophrenia. Clozapine is not recommended because of its risk of agranulocytosis.

 Stage 1 is first-line  If the patient shows little or no response, still no response,  move to stage 3, which
monotherapy with an proceed to stage 2, which consists of consists of clozapine monotherapy with
SGA monotherapy with either another SGA or an monitoring of the white blood cell (WBC)
FGA. count.

If stage-3 therapy fails. proceed to  if stage 5 treatment is unsuccessful,

stage 4, which combines clozapine
with an FGA, an SGA, or
electroconvulsive therapy (ECT).
stage 5 calls for monotherapy with
an FGA or an SGA that has not stage 6 consists of combination
therapy with an SGA, an FGA, ECT,
been tried.
and/or a mood stabilizer.
 CASE STUDY

CASE # 01
 Chris is a 20-year-old male who is in his second year of college. He is seeking treatment due to persistent fears that
campus security and the local police are tracking and surveilling him. He cites occasional lags in his internet speed as
evidence that surveillance devices are interfering with his electronics. His intense over-thinking about this has begun getting
in the way of his ability to complete schoolwork, and his friends are concerned – he says they have told him, “you’re not
making sense.”

 Chris occasionally laughs abruptly and inappropriately and sometimes stops speaking mid-sentence, looking off in the
distance as though he sees or hears something. He expresses concern about electronics in the room (phone, computer)
potentially being monitored and asks repeatedly about patient confidentiality, stating that he wants to be sure the police won’t
be informed about his treatment. His beliefs are fixed, and if they are challenged, his tone becomes hostile.

Disturbed thought processes perceptions

False reality & beliefs Disorganized speech
& Suspiciousness

Aggression & aggitation

 Non Pharmacologic treatment:
SYMPTOMS •Talking therapy
•Cognitive Behavioral Therapy (CBT)
 Anxiety •Assertive Community Treatment (ACT)
•Family Psycho-education for Schizophrenia
 Delusions
•Social Skills Training (SST) for Schizophrenia
 Hallucinations
Pharmacological Treatment:
 Psychosis
Starting SGAs (Atypical Antipsychotic)
Diagnosis • Aripiprazole 15mg/day initially
• Mood stabilizer augmentation (Valproate 500mg/day)
Schizophrenia • If the patient shows little or no response, he should
proceed monotherapy with either another SGA or an FGA
(olanzapine)
 CASE STUDY
Case # 02
Victor is a 27-year-old man who comes to you for help at the urging of his fiancée. He was an infantryman discharged in 2014
after serving two tours of duty in Iraq. His fiancé has told him he has “not been the same” since his second tour of duty and
it is impacting their relationship. He “sleeps with one eye open” and, on the occasions when he falls into a deeper sleep, he
has nightmares. He endorses experiencing several traumatic events during his second tour, but is unwilling to provide
specific details. He reports to you that he finds it difficult to perform his duties as a security guard because it is boring and
gives him too much time to think.

He spends much of his time alone because he feels irritable and doesn’t want to snap at people. At the same time, he is easily
startled by noise and motion and spends excessive time searching for threats that are never confirmed both when on duty
and at home. He also avoids seeing friends from his Reserve unit because seeing them reminds him of experiences that he
does not want to remember.
SYMPTOMS
•Hypervigilance  Psychotherapy:
•Intrusive Thoughts
 Some types of psychotherapy to be used in PTSD treatment
•Irritability
include:
•Loss of Interest
•Sleep Difficulties  Cognitive therapy. helps to recognize the ways of thinking
•Trauma (cognitive patterns) that are keeping him stuck — for
example, negative beliefs about himselff and the risk of
traumatic things happening again.
DIAGNOSIS:
 Exposure therapy. Exposure therapy can be particularly
Post Traumatic Stress Disoreder helpful for flashbacks and nightmares.It helps to safely face
both situations and memories that he finds frightening so
that He can learn to cope with them effectively.
Medications
Several types of medications can help improve  Eye movement desensitization and reprocessing
symptoms of PTSD: (EMDR). EMDR combines exposure therapy with a series of
Antidepressants. (SSRI) medications sertraline 50 guided eye movements that help to process traumatic
to 200 mg/day and 20mg OD memories and change how He reacts to them.
Prazosin.  10-16 mg at night
THANK YOU
References

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4455840/

 Henning A, Kurtom M, Espiridion

E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis.
Cureus 11(2): e4126. doi:10.7759/cureus.4126

 https://en.wikipedia.org/wiki/Psychosis

 http://www.nimh.nih.gov/health/publications/mental-health- medications/complet
e-index.shtml

 https://go.drugbank.com/categories/DBCAT000603