Psychosis Assessment

exp date isn't null, but text field is

For the purposes of this quick guide, psychotic disorders are conditions with at least two of the following symptoms:

  • hallucinations (usually hearing voices)
  • delusions (fixed, false beliefs, not shared by others in the person’s culture)
  • disorganised behaviour and/or speech (agitation, hyperactivity / inactivity, incoherent / irrelevant speech, signs of self-neglect)

Other symptoms include social withdrawal and lack of motivation. The person usually does not realise that they are mentally unwell (i.e. lacks insight).

Acute psychosis describes an episode of psychosis lasting less than a month.   Many people who have a single episode of acute psychosis will have no recurrence.

Chronic psychosis refers to those who have further episodes of psychosis. Some will go on to develop persistent disabling symptoms.  This group of disorders includes schizophrenia.

It is hard to tell the difference between acute psychosis and mania (part of Bipolar Disorder – see separate chapter). In acute mania, there are often psychotic symptoms but also:

  • Elevated or irritable mood; inflated self-esteem
  • Decreased need for sleep
  • Increased activity and energy

Impulsive or reckless behaviours such as excessive spending and sexual indiscretion

Causes and Risk

The cause of psychotic disorders is not fully understood but includes genetic factors, early childhood adversity and stressful environmental factors.

Risk

Up to 20% of people with chronic psychosis will commit suicide. If the person is aggressive or at risk of harm to self or others, see these sections.

IMPORTANT: It is crucial to consider the cause of psychotic symptoms before making a diagnosis.

Delirium, dementia, severe depression, mania and drug-induced psychosis are all common causes and the management is often quite different for these conditions. If you suspect these, see their sections for further assessment and management

 

Simplified Assessment

In addition to the general psychiatric assessment and mental state examination outlined earlier in the guide, the following information is crucial to obtain if you suspect psychosis:

Ask the patient and family whether this is the first episode of illness (acute psychosis), or whether there are previous episodes of illness (chronic psychosis). 

See Part 7 of this book for English and Chichewa translations of good questions to ask about psychosis.

  • Any infections, accidents, changes to medications etc. (this could be delirium)?
  • Assess for any of the symptoms of severe depression including nihilistic delusions (believing oneself to be dead) or hallucinations that started with or after depressed mood (this could be psychotic depression).
  • Any recent chamba (cannabis) use before symptoms (this could be drug-induced psychosis)?
  • Any recent stressful event or emotional trauma (this could be acute stress reaction)?
  • Any long-term cognitive impairment (this could be dementia or intellectual disability)?

Typical MSE

A + B

Often self-neglect, agitation, disordered, bizarre clothing, preoccupied

Speech

Loud/none, odd words

Mood

Often distressed / perplexed, elated if manic

Thought

Delusions, thought interference, difficult to follow

Perception

Hallucinations – usually voices. Visual suggests DELIRIUM

Cognition

Impaired concentration, drowsiness suggests DELIRIUM

Insight

Impaired, often none at all