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Non-Communicable Diseases, Emergency Care and Mental Health Module: 13. Psychoses
Study Session 13 Psychoses
Introduction
Global research and studies in Ethiopia show that psychoses affect between 1 and 2% of the population.
Psychosis is pronounced 'sye-koh-sis' and is the singular of psychoses ('sye-koh-seez').
Psychoses are among the most serious mental health problems that you will have to deal with in your community. They are serious for patients because they can result in serious functional and social impairments and may leave them coping with severe long-term disabilities. They are serious for the families of patients because of the negative impact on family stability and finances, often resulting in conflict and poverty for other family members. They are serious for Ethiopia because the negative impact of psychotic illnesses goes far beyond the patient and their family, causing reductions in productivity that damage the economy.
Of all the mental health problems discussed in this Module, psychotic illnesses pose the most difficulty for risk management, i.e. the identification, assessment and prioritisation of risks, and interventions to minimise, monitor and control the probability and/or impact of these risks. This usually involves efforts to reduce the ‘risk factors’ and support the ‘protective factors’ associated with a patient and their condition. In this study session you will learn about how best to manage the risks posed by psychotic illnesses, including the risks to patients and their families from traditional ideas about mental illness which can lead to cruelty and abuse. We discuss how best to challenge these negative beliefs and how to reduce the risk that people with psychotic illnesses may pose to others.
Your skills as a trained health worker are very important in achieving prompt detection and response to the early signs of psychotic illness in your community. Following referral, your role in monitoring the patient’s recovery when they return home, and in educating them, their family and their community about psychotic illnesses, is central to the task of managing the risks posed by these serious conditions. In this study session, alongside your practical training, you will learn how to identify the symptoms of psychotic illness, handle urgent problems, and help clients and their families further.
Learning Outcomes for Study Session 13
When you have studied this session, you will be able to:
13.1 Define and use correctly all of the key words printed in bold. (SAQ 13.1)
13.2 Describe the general symptoms and signs of psychosis. (SAQ 13.2)
13.3 Identify the major different forms of psychosis and their specific signs and symptoms. (SAQ 13.2)
13.4 Outline the criteria for referring people with psychosis. (SAQ 13.3)
13.5 Explain how to manage people with different types of psychosis. (SAQs 13.1 and 13.4)
13.1 What are psychoses?
We begin by examining what psychosis involves, what the general symptoms and signs are, and how you reflect on these to distinguish between different types of psychosis. In most cases of psychosis, it is not possible to identify a single cause. It is most likely that several factors interact to result in the illness (see also Study Session 9 in this Module). In some people, psychosis occurs following various bodily illnesses or damage to the brain, but this is not the case in the majority of affected people.
13.1.1 The effects of psychosis
Psychoses are a group of severe mental illnesses characterised by loss of reality contact (where the patient cannot differentiate between reality and their imagination), delusions and/or hallucinations. This leaves affected people vulnerable to strange and potentially very distressing experiences, such as hearing voices or seeing things which others around them cannot. They may also express these delusions in a way that may disturb others. For instance, they may insist that they are God, or complain that there is someone else inside them giving them orders.
Often, as a consequence of their illness, people with a psychosis struggle to meet the ordinary demands of daily life, such as routine household responsibilities, work and social interaction with others. For example, they may lose the ability to look after themselves and their personal needs properly, appearing unconcerned about their appearance and neglecting personal grooming (Figure 13.1). They may also have an inadequate or mistaken understanding of their condition, blaming malevolent spirits or other community members for placing a curse on them. Challenging such views may prove difficult, as their impaired thinking often leads them to reject evidence that contradicts such traditional beliefs.
Psychotic illnesses make sufferers personally distressed and also cause distress to others in their family and neighbourhood. The level of distress (and the risk of permanent disability) is increased by the duration and severity of the symptoms.
13.1.2 Classification of psychoses
There are four different forms of psychosis, classified in terms of their onset, duration and possible outcomes. Being able to identify, and distinguish between, these four types is the starting point for effective treatment. They are:
- Acute psychoses
- Chronic psychoses
- Recurrent psychoses
- Organic psychoses.
We will discuss each of them in turn.
13.2 Acute psychoses
Acute psychoses are ‘acute’ because they begin suddenly (either with or without an obvious cause or reason) and don’t usually last longer than 1 month.
13.2.1 Signs and symptoms of acute psychoses
People with acute psychoses may hear voices when no one is present, and they may behave in an odd or aggressive way. They may for instance loudly express rather odd beliefs, or exhibit socially unacceptable behaviour. While this can be very disturbing for family and neighbours, it is important to remember that it is also extremely distressing for the person. A psychotic person is likely to be confused and frightened by the distorted situation they find themselves in, further disorientated by the inability to understand that what they are experiencing is not real.
Keep this in mind as you read the case study of Mr Goitom, whose experience is typical of people suffering from acute psychosis (Case Study 13.1).
Case Study 13.1 Mr Goitom’s story
Mr Goitom is a 27-year-old man who was happily married and a respected member of the community until he suddenly started to behave strangely. He began to say and do the oddest things, neglected his responsibilities and his wife (who tells you that ‘he just isn’t the same man any more’) and stopped eating and sleeping.
After 10 days without food or sleep, during which his behaviour to others became increasingly aggressive, his wife took him to the holy water, hoping this would cure him. However, this failed to work, with Mr Goitom shouting and screaming at his wife and others. Unable to cope with this behaviour and fearful for his wife’s safety, relatives carried him home and tied him with rope to a stake to keep him under control.
Neither Mr Goitom nor his family have any understanding of psychotic illness. Mr Goitom himself thinks he may have been bewitched by one of his neighbours. This seems believable to his wife, as she remembers he had a bitter disagreement about land ownership with this neighbour shortly before he became ill. Since then he has been obsessed by this neighbour, shouting loudly that he aims to get revenge by attacking his assumed persecutor.
From your life or work experience, have you ever come across a case like that of Mr Goitom? What kind of behaviour was involved? How did the family respond to this?
If you have experienced such a situation before, it may be that, just like Mr Goitom’s case, the family did not realise that the patient had a mental illness. It could also be that, because of the strength of traditional beliefs, the family, neighbours and others in the community accepted a supernatural — rather than a medical — explanation.
Clearly, Mr Goitom’s behaviour posed some risk to himself, to his neighbour, and possibly to others – including his wife. However, the best way to manage these risks would be for the family to acknowledge that Mr Goitom is ill and needs to see a doctor for assessment and appropriate treatment. This would be far more effective than tying him to a stake — a practice likely to increase the risk by further distressing him. Later in this study session, you will reflect on what you can do to tackle the negative aspects of traditional beliefs and increase community understanding of psychotic illnesses in situations like that of Mr Goitom.
13.3 Chronic psychoses
Chronic psychoses are ‘chronic’ because they begin gradually, but continue for a long time (over six months), with an increasing deterioration (getting worse) as time passes. They tend to affect younger age groups than other psychoses (15–30 years), and without treatment they can have terrible consequences for the sufferer. Many of the mentally ill people who are avoided by others because they are perceived as ‘mad’ are likely to be suffering from a chronic form of untreated psychosis.
13.3.1 Signs and symptoms of chronic psychoses
People with chronic psychoses may have difficulties with thinking rationally or with concentrating over a long period of time. They are likely to show disturbed speech, may hear voices, and have persistent unfounded beliefs, for instance that they are being persecuted or controlled. These symptoms can cause problems in managing work, studies or relationships, and lead to social isolation and/or hostility from other members of the community. During relapse, people with chronic psychoses may have symptoms similar to acute psychoses. A common form of chronic psychosis is called schizophrenia.
Schizophrenia is a severe, chronic mental illness that affects about one in a hundred people at some point in their lives. As with other psychoses, they experience episodes in which they perceive reality differently. They may have hallucinations or delusions (see Box 10.3 in Study Session 10). The first acute episode, when the symptoms are experienced for the first time, can be very stressful, because the people experiencing the illness and their family and friends are unprepared and have no idea what is happening to them (see Case Study 13.2).
Case Study 13.2 Mr Abebe’s story
Mr Abebe is a 25-year-old farmer and a married father of two children. He lives near his parents. Both his parents and wife were always proud because Mr Abebe was a well-liked and respected member of the community and known as a ‘good family man’. However, about a year ago, he started to behave in an increasingly strange manner. His wife reported to his father that Mr Abebe was ‘not himself any more’, becoming withdrawn, moody, inactive and unsupportive. Gradually, his condition became worse. He neglected his work and family and was often seen whispering to himself, smiling and laughing for no apparent reason when alone. When he talked to people, what he said no longer made any sense, so people began to avoid contact, leaving him even more socially isolated. His parents and wife were terribly worried and took him to a traditional healer to cure his strange ‘curse’. The healer gave him some herbs to drink and a ritual healing ceremony was performed, but there was no improvement.
Mr Abebe’s case illustrates the key features of someone who is suffering from a chronic psychosis: his illness started gradually without any clear cause and he progressively deteriorated over a prolonged time. Without treatment, people like Mr Abebe are likely to face a miserable future as their worsening condition leads to the loss of family and friends, and they become increasingly unable to support themselves. However, with treatment, about 60% of patients recover to lead full and useful lives. Ensuring access to such life-changing treatment is a key part of your work.
13.4 Recurrent psychoses
Recurrent psychoses occur episodically (that means they come and go), usually with complete recovery between attacks. A common form of recurrent psychosis is bipolar disorder (previously known as manic depression). This is a condition in which a person’s mood can swing from one extreme to another. It is characterised either by manic episodes (periods of mania), or by mania alternating with depression (which you learned about in Study Session 12). Mania is a state of abnormally elevated or irritable mood, arousal and/or energy levels, which in some respects represents the opposite of depression.
13.4.1 Signs and symptoms of recurrent psychoses
People with recurrent psychoses such as bipolar disorder may suffer from unrealistic or ‘grandiose’ thinking, in which they see themselves as very important people – more important than anyone around them – often with important tasks or ‘missions’ they must complete. During the manic episode, they will tend to have increased energy levels, high moods and difficulty in controlling their impulsive behaviour. They often speak very quickly and tend to jump from one topic to the other (also called ‘flight of ideas’). They also often find themselves unable to sleep and are easily distracted. Because they think they are very important and successful, they may engage in bizarre behaviour like giving away their personal property for no apparent reason. When you see people with mania, they may appear unusually cheerful and make jokes all the time.
Manic episodes can vary in intensity, from mild to extreme forms. Some people will retain sufficient control to function normally, while others will be severely affected and requiring treatment. People with sever bipolar disorder are often unaware of their condition. When considering referral, you should also be wary: during an episode of mania, affected individuals can often be mistaken for having taken drugs or other mind-altering substances.
13.5 Organic psychoses
Organic psychoses occur as a direct result of physical illness or brain damage. In addition to the general features of psychoses already described, there are likely to be alterations in the person’s conscious state. For example, they may appear disorientated or confused, and show symptoms of underlying physical illness. There are two types of organic psychosis: acute and chronic.
13.5.1 Signs and symptoms of acute organic psychoses
Acute organic psychoses are characterised by sudden onset, usually over hours or days, where the person appears disoriented and struggles to make sense of their surroundings, and may exhibit ‘clouded’ thinking and distorted awareness, a fluctuating level of consciousness and poor memory recall. These symptoms can impact on the person’s relationships with others, increasing their social isolation and reducing the support they might receive from their community. People with acute organic psychosis may be alert and responsive to your questions, but may rapidly become drowsy and inattentive. Alternatively, they may fail to comprehend the questions put to them and appear disoriented and confused.
Diseases causing fever (such as chest infection or infection of the brain), head injury, fits, the excessive use of alcohol or other drugs, diabetes and high blood pressure can all be causes of acute organic psychosis. These conditions are usually reversible and short-lived, and can be cured by appropriate treatment.
13.5.2 Signs and symptoms of chronic organic psychoses
Chronic organic psychoses are forms of psychosis arising from permanent physical and/or brain damage. A common feature of chronic organic psychosis is progressive loss of memory, usually combined with other, more general, psychotic symptoms. Loss of memory without psychotic features is called dementia (see Study Session 15 of this Module).
13.6 Early recognition and identification of psychoses
In your work, you should consider the possibility of a psychosis if you see a person whose behaviour has any of the features listed in Box 13.1.
Box 13.1 Recognition of psychoses
Suspect possible psychosis if someone is:
- talking and acting strangely or in a manner that you and others consider to be abnormal
- becoming very quiet and avoiding talking to, or mixing with, other people
- claiming to hear voices or see things that other people don’t
- being very suspicious, perhaps claiming that other people are trying to harm them
- being unusually cheerful, exhibiting high levels of confidence in their own abilities and expressing an exaggerated sense of their own importance in relation to others.
When you suspect someone is suffering from a form of psychosis, you need to ask the patient (and others) questions to find out the type and severity of the condition (Figure 13.2).
For details of the most effective questions to assist your assessment, refer back to Study Sessions 10 and 11 of this Module.
13.7 Referral
People with acute psychoses, or acute organic psychoses, or suffering a psychotic relapse, should be referred urgently.
If, following assessment, you think that a person may be suffering from one of the psychotic illnesses detailed above, you should consider referral to a health centre or the nearest institution with mental health specialists. Using the criteria outlined in Table 13.1, decide whether the person needs referring and whether this is an urgent or non-urgent referral. People with acute psychoses or acute organic psychoses, or suffering a psychotic relapse, should be referred urgently. For such emergency cases, you should arrange immediate transport to a higher health facility, either taking them yourself or arranging for others to do so. For less urgent cases, you can use the regular referral route.
| Urgent referral | Non-urgent referral |
|---|---|
| If you think a person may be suffering from acute psychosis | If a person has chronic psychosis (organic or non-organic) or recurrent psychosis |
| For a person with acute organic psychosis | If there is non-compliance with treatment |
| If there are signs of relapse or if there are complications from treatment (see also Study Session 11) | Failure of treatment |
13.8 The management of psychoses
Early identification is crucial in the management of psychoses. This is because (as you discovered earlier) treatment can be highly effective if it is provided before the condition has time to deteriorate further. For example, the early identification and treatment of patients with acute psychosis often results in complete recovery. Medication is one central component of treatment for a range of psychoses, and is often highly effective in reducing the patient’s difficulties and providing emotional stability. Here, you should seek to gain the support of the family (or others close to the patient) to ensure their adherence to treatment and to guard against relapse. Adherence means agreeing to and following the advice and treatment prescribed by the health professionals.
Each type of psychosis requires specific management. This will be the topic of discussion for the remainder of this study session.
13.8.1 Management of acute psychoses
When you suspect that someone in your community is suffering from an acute psychosis, your first responsibility should be the management of risk. This involves concern for the risk posed to the patient by the illness, by the patient’s own actions or inaction, and by the actions of others, and also the risks posed by the patient to property, family and friends, and to others in the community (see also Section 10.4 of Study Session 10).
Remember, people suffering with acute psychoses can often respond very well and very quickly to interventions, if these are undertaken in a supportive and confident manner. There is a great deal you can do to calm and reassure such people, just by talking to them. You should also try to involve family and friends to create a supportive environment that will be there to assist the patient when you are not present.
If the patient or their family have traditional views about mental health, you will need to be very careful in challenging these, as such challenges are unlikely to improve the relationship with the patient or gain you the community support you will need to manage the various risks (see Study Session 9).
After you have provided emergency care, if appropriate, you should arrange an urgent referral to a health centre or a hospital where the patient can continue their treatment. When the person returns, it will be your responsibility to follow up this treatment by arranging continuing care within the community.
13.8.2 Management of chronic psychoses
The main objectives in the management of chronic psychoses are:
- to maintain good mental health
- to support the person’s rehabilitation and resettlement in the community, including their return to work and/or normal domestic activities
- to minimise the risk of permanent disability arising from the illness.
Anyone identified with a chronic psychosis should be referred to the local health centre or hospital, where they may receive a course of antipsychotic medication (drugs used to treat psychosis). Once the patient has completed their in-house treatment at the health centre or hospital, they will return to the community, where you should draw on their support networks to ensure their continued adherence to treatment as prescribed by the doctor (see also Section 11.2.4 in Study Session 11).
If you decide that there is a need for an adjustment in the medication, or you believe that a relapse has occurred, the patient should be referred back to the treating doctor. In most cases, the use of antipsychotic medication continues for at least six months after the symptoms disappear. Clear information should be given to the patient and their family about their illness and the importance of adhering to the instructions for their medication. You should also stress to the patient (and their family) the serous risks of taking this medication while also using other substances. Inform them that cigarettes, khat, cannabis and alcohol are all likely to reduce the effectiveness of medication and — particularly in the case of cannabis and alcohol — may make the symptoms worse or result in relapse. Table 13.2 lists the two most commonly prescribed antipsychotic drugs in Ethiopia, with their usual dosages.
| Drug | Usual adult dose |
|---|---|
| Chlorpromazine | 50–300 mg orally/day (one or divided dose) |
| Haloperidol | 2–6 mg orally/day (one or divided dose) |
13.8.3 Management of recurrent psychoses
The objective of treating people with recurrent psychoses is to control the acute symptoms when they occur. For example, an agitated patient suffering a manic (or depressive) episode may require emergency treatment to stabilise their condition and keep them safe. When the episode resolves, regular antipsychotic medication should prevent a recurrence with little need for further intervention, other than monitoring the patient’s state.
Patients can also be encouraged to take an active role in their own care by helping them recognise and identify early warning symptoms like sleep disturbance, excessive or elevated moods, abnormal levels of energy, etc. When a patient notices such symptoms, advise them to return to the treatment centre and request a review and/or an adjustment in their medication.
13.8.4 Management of organic psychoses
The main objective in the management of organic psychoses is to address the immediate risks to the patient and to others. The aim should be to identify people with acute organic psychoses quickly and make an urgent referral for medical treatment. In the case of chronic organic psychoses, refer the patient via the usual route for further management and identification of any community care needs.
13.8.5 Management algorithm
In all cases of psychosis, you not only identify and refer patients to specialist or other health facilities, it will also be your responsibility to respond to feedback from the higher level by arranging follow-up and continuing care at the community level. Figure 13.3 summarises this process.
13.9 Advice and support for patients and their families
The advice and support that you give to patients and families can be a tremendous help. It can comfort the patient and can reduce the anxiety felt by family members and carers. It also gives carers an insight into your professional knowledge about how best to handle disturbed patients in a humane and caring manner. Such knowledge is perhaps the most effective way of counteracting negative traditional approaches to mental illness.
When assessing someone with a psychotic illness and deciding on a treatment plan, it is important to include the patient and their family, and to emphasise the importance of adhering to the medication. If the illness is one where the possibility of relapse is high, work with the patient and family members so they know how to identify early warning signs.
In terms of rehabilitation, patients should be encouraged – as much as possible – to return to their normal work and other daily activities. Family and carers should reduce sources of stress for the patient by being supportive, and by avoiding verbal criticism or confrontation, which may aggravate the psychosis.
Summary of Study Session 13
In Study Session 13, you have learned that:
- Psychoses are characterised by disturbances of thought such as delusion, hallucination and/or loss of reality contact. People with psychosis often do not realise they are ill.
- There are four different forms of psychoses: acute psychoses, chronic psychoses, recurrent psychoses, and organic psychoses.
- Early identification of psychoses involves considering the symptoms listed in Box 13.1.
- Once it is recognised that a person is suffering from an acute episode of psychosis or from a psychotic relapse, it is essential that they are referred urgently to a higher-level health facility with appropriate mental health services.
- People suffering from psychoses should not be subjected to criticism or abuse. Respect, honest advice, and support from you, their family and the community are the most effective means of ensuring adherence to treatment and successful recovery.
Self-Assessment Questions (SAQs) for Study Session 13
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
SAQ 13.1 (tests Learning Outcomes 13.1 and 13.5)
Which of the following statements is false? In each case say why it is incorrect.
A Acute psychosis always has an obvious cause.
B A patient suffering from acute organic psychosis should be kept at home tied up because there is no risk of medical complication.
C A patient who has recovered from psychosis should be encouraged to fulfil their responsibilities, like working or preparing food.
D Criticising or embarrassing a person who is suffering from psychosis will help them stop thinking in strange ways.
Answer
A is false. Acute psychosis is an illness which may or may not have obvious cause. Commonly, it is associated with exposure to stressful situations.
B is false. Acute organic psychosis is usually caused by physical illness or brain damage. Immediately upon identification, the patient needs to be referred to a health centre or hospital.
C is true. People with psychosis should be encouraged to return to their work and responsibilities because this can help their recovery.
D is false. Treatment of psychosis involves treatment and support. Criticising or embarrassing a person is unlikely to help them and may well increase the distress they are already suffering.
SAQ 13.2 (tests Learning Outcomes 13.2 and 13.3)
Read Case Studies 13.1 and 13.2 again. Is there a difference between these two cases? Explain in what ways they are different.
Answer
The case studies of Mr Goitom and Mr Abebe are different from each other in a number of ways. The onset of Mr Goitom’s illness was very sudden and there was a rapid development of his symptoms: increasing aggression, sleeplessness and loud shouting, which are consistent with acute psychosis. In Mr Abebe’s case, the symptoms (being withdrawn, moody and inactive) developed gradually over a longer period and progressed slowly. This is consistent with chronic psychosis.
SAQ 13.3 (test Learning Outcome 13.4)
While doing your routine healthcare activities at a place where malaria is common, a man from the kebele told you that a woman in the neighbourhood appeared very confused following her fever. What do you think is the client’s problem, and how would you handle such a case?
Answer
The symptoms in this case are consistent with acute organic psychosis, but it is possible that malaria is the reason for her confusion. She should therefore be referred immediately to the nearest health centre for proper evaluation and treatment.
SAQ 13.4 (tests Learning Outcome 13.5)
A young man, who is an active member of the youth association in your area, comes to you and asks you to help one of his friends who has been behaving strangely, talking senselessly to himself. He has already been prescribed antipsychotic medication but this does not seem to be working. He also chews khat all day, drinks alcohol and smokes many cigarettes. How would you manage this case?
Answer
The young man described in this case has already been identified with chronic psychosis and his treatment has been initiated. However, a likely reason for treatment failure and the persistence of his symptoms may be his continued use of substances. There is strong evidence that cigarettes can affect the body’s ability to heal itself, while the heavy use of khat and alcohol are likely to reduce the effectiveness of his antipsychotic medication and aggravate his symptoms. In this situation you should warn the patient (and his family and friends) about the negative effects of khat and alcohol on a person with a psychotic illness. You should also enquire about the details of his treatment: is he taking his medication regularly (adherence to treatment), and has he experienced any adverse effects (suggesting a review of treatment)?