Download Recognising signs of paranoid schizophrenia

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Recognising signs of
paranoid schizophrenia
In the second of a three-part series on psychosis, Elizabeth Owens focuses
on the diagnosis and management of paranoid schizophrenia
More than 35,000 people have schizophrenia in Ireland
and each year over 800 people will be diagnosed with the
illness for the first time. Schizophrenia is just one type
of psychosis; other types of psychosis include delusional
disorder, drug-induced psychosis and bipolar disorder. Collectively, more than 1,200 people develop some form of
psychosis in Ireland every year.
This article forms the central part in a series of three
articles focusing on the differing presentations of psychotic
illness in general practice. The first article focused on the
‘at risk mental state’ or prodromal stage of psychotic illness.
This article elaborates on the critical period post-onset of
psychotic symptoms. The questions posed and answered
include: why intervene early; what are the available treatment approaches; and how best to engage the newly unwell
psychotic patient. The third article in the series will discuss
an established case of psychosis.
Duration of untreated psychosis
Duration of untreated psychosis or DUP is the time from
manifestation of the first psychotic symptom to initiation of
adequate treatment. The international average DUP is 27
months. 1 The delay in getting treatment is crucial because
the longer individuals with psychosis remain untreated,
the greater the opportunity for serious physical, social or
legal harm. In the period before they present to psychiatric services, one-in-four people have thought of harming
themselves and one-in-eight have actually attempted selfharm.2
International research has found the following associated
with longer DUP:
• Increased suicidality
• Worse quality of life at presentation
• Worse negative symptoms
• Less likely to achieve remission
• Longer time to remission.
Clinical vignette
Jane is a 22-year-old science student (third year, recently
failed summer exams and needs to repeat next month) and
her mother has arranged for the GP to see her because she
is worried that her daughter is ‘stressed out’. Jane has been
sleeping poorly for the past two months since finishing her
summer exams. She sleeps during the day and is awake all
night, and her concentration has been poor for the past six
months.
While she is not happy, Jane is not feeling sad, tearful
or hopeless. She is not particularly interested in personal
hygiene anymore, and her mum has to really push her to
have a shower.
Eliciting psychosis
The following questions are phrased in a way most likely
to help you elicit psychosis if present
• Sometimes people have experiences that other people
can’t really understand. For example, that the radio or
TV are referring to you, that there are hidden messages
in things around you or that things around are strange
in some way. Is this happening for you?
• Sometimes people hear noises or voices when no-one is
speaking and there is nothing to explain what they are
hearing. Do you ever have something like that happening? If yes, what do they say? How many are there? Do
they seem to be having a conversation among themselves about you? Do they comment on what you are
doing?
• Do you believe someone is trying to hurt you or plot
against you? Or that there any conspiracies that involve
you? Are you frightened?
• Is anything interfering with your thinking? Some people
feel as if thoughts are being put into their heads that
are not their own. Do you ever feel that your thoughts
are broadcast out loud so that other people can hear
what you are thinking or feel that thoughts are being
taken out of your head against your will?
Socially, Jane hasn’t seen her friends for the past six
months and isn’t keen to see them despite them ringing to
speak to her. She believes one of her friends has been secretly
filming her with a hidden camera every time she visits for the
past three months, and that she has convinced the others to
play along. Jane believes her friend is part of a global cult of
Satanists and that she is surreptitiously trying to make her
join. She regularly hears her voice and those of others speaking outside her ear when no-one is around. This friend can
also control her thoughts – putting some strange ones in and
taking normal ones out. Jane is reluctant to leave the house
alone because of the hidden ‘signs’ (such as cars passing and
dogs barking) all around her which indicate she is watching.
Jane doesn’t use illicit substances or alcohol. Her maternal grandmother had a chronic mental illness and required
injections regularly and a long stay in a psychiatric facility.
Diagnosis
Paranoid schizophrenia is the most common type of psychosis (50% of all psychotic illnesses). There is a greater
than one-month history of delusions and hallucinations,
and a six-month history of social/academic decline.
Discussion points
Paranoid patient – gaining her trust
It’s important that her situation is approached in a nonjudgemental/non-confrontational manner, especially when
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initially trying to ascertain her symptoms. It is not recommended to either indulge the delusion or challenge it, but
rather approach it from the ‘personal effects’ angle – how
distressing this is for her, how it’s affecting her life, that
things can’t be easy at the moment.
Poor insight – engaging her
Trying to encourage the patient to attend psychiatric
services is frequently a challenge. One way around this is
to emphasise that you would like a specialist opinion to
ensure that there are no other explanations for all this or
for management of the distressing anxiety/stress/insomnia
associated with the problem.
Referral to mental health services
Some patients will have enough insight to expect you to
talk to them about psychiatry referral. Usually the patient
will bring it up, but some may wait to see your reaction to
their story. In reading the individual, you should be able to
gauge if you can be more direct in your advice, telling them
that you are concerned they are suffering from a mental illness and need specialist assessment.
If the patient is highly resistant to this idea, working on
the issues and problems that exist for the patient around
the delusion (anxiety, unable to work, etc.) can open up
another route toward psychiatric referral. Sometimes, playing down the individual’s need and emphasising the need
of their loved ones (eg. stressed parents) for that individual
to have an assessment can help motivate the individual to
accept referral.
GP survey
A nationwide, cross-sectional questionnaire survey was
undertaken to assess aspects of the detection and management of suspected psychosis in general practice. Some 261
GPs participated and their response suggested that they
wanted more information about early psychosis, access to
rapid assessment, a more multidisciplinary approach and a
closer liaison with psychiatric services. The most commonly
encountered symptom was bizarre behaviour, implying that
patients either don’t present early in the course of their illness or that the early symptoms of psychosis are difficult
to elicit.
Treatment of psychosis and schizophrenia
Increasingly, multidisciplinary teams are becoming
involved in delivering care to people with psychosis and
schizophrenia. Secondary care services are moving toward
assessing and treating people with psychosis as outpatients.
The ideal treatment programme will involve pharmacological and psychosocial interventions.
Psychotic symptoms require urgent referral to psychiatric
services. If the person does not accept referral immediately,
you may wish to contact the appropriate mental health service to seek advice on how best to proceed to maximise the
likelihood that the person will engage. You may have to
initiate pharmacological treatment during this time. Inpatient admission under the Mental Health Act 2001 may be
required.
Pharmacological treatment
Antipsychotics are traditionally divided into first generation (typical) or second generation (atypical) agents.
Side-effects include extrapyramidal side-effects such as
akathisia, dystonia, pseudo-Parkinson’s and tardive dyskinesia. These are less common with SGAs. Anticholinergic
(eg. dry mouth, blurred vision, urinary retention and constipation); Cardiovascular (eg. orthostatic hypotension and
QTc prolongation). Histaminergic (eg. weight gain and
sedation). Important considerations related to prescribing
include side-effect profile, the presence of any comorbid
illness, concomitant medications and past adherence and
past response to medication (for patient who has had previous episode of treated illness).
In cases where there is a delay in accessing specialist
care and/or the patient is experiencing significant distress,
it may be necessary to prescribe an antipsychotic. Advise
the patient about a possible three to six week delay between
initiation and anti-psychotic effect.
• A dvise of potential side-effects and that most are
transitory
• Generally prescribe a second generation anti-psychotic
• Titrate from minimum effective dose adjust according to
response and tolerability, assess over six to eight weeks
• For most people with a first episode psychosis, the recommended duration of antipsychotic treatment is one year
• For most people with a second or further episode the recommended duration of antipsychotic treatment is at least
five years.
Psychosocial treatment
The recommended interventions below are not available
in all mental health services.
Cognitive behavioural therapy (CBT)
CBT is an effective psychological treatment for some
people with psychosis/schizophrenia. CBT for psychosis and
schizophrenia is ideally offered as an adjunct to medication
and carer education about psychosis. It helps to link the
person’s feelings and patterns of thinking which underpin
distress. The goal of CBT in psychosis and schizophrenia
is not to eradicate symptoms but to relieve distress and
reduce unhelpful behaviours.
Patients presenting with psychosis or schizophrenia who
wish to engage in psychological intervention are most appropriately referred to secondary or tertiary care services.
Family support and psycho-education
Having a family member with psychosis or schizophrenia
is stressful as families experience confusion, guilt, stigma
and pessimism about long-term prospects. Informing families about the diagnosis, nature of symptoms and treatment
is likely to be helpful not only to the family but also to
the affected individual. Interventions aimed at increasing a
family’s knowledge about the illness may not only empower
the family and reduce the burden on relatives but also significantly reduce the risk of relapse in the affected family
member.
Vocational rehabilitation
Participating in education or the workforce is a key part of
recovery. Specialised early intervention services are in their
infancy in Ireland. A pilot project has been established in
east Dublin and Wicklow called Detect. Elsewhere, intervention early in the course of psychotic illness continues to be
undertaken by the local community adult mental health team.
For more information, see www.detect.ie.
Elizabeth Owens is a clinical research fellow with Detect in
Co Dublin (psychosis and mental health services organisation)
References on request
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