Chronic psychotic disorders Chapter

Presenting complaints

Patients may present with:

  • difficulties with thinking or concentration
  • reports of hearing voices
  • strange beliefs, eg having supernatural powers or being persecuted
  • extraordinary physical complaints, eg having animals or unusual objects inside one’s body
  • poor hygiene
  • problems in managing life in prison, work, education or relationships
  • self-harm
  • food refusal (may have delusions that food is being poisoned) or
  • problems or questions related to antipsychotic medication.

Staff or a solicitor may seek help because of apathy, withdrawal, poor hygiene or strange behaviour.

Diagnostic features

  • Chronic problems with the following features:
    – social withdrawal
    – low motivation, interest or self-neglect or
    – disordered thinking (exhibited by strange or disjointed speech).
  • Periodic episodes of:
    – agitation or restlessness
    – bizarre behaviour
    – hallucinations (false or imagined perceptions, eg hearing voices) or
    – delusions (firm beliefs that are often false, eg the patient is related to royalty, receiving messages from the television, being followed or persecuted).

Differential diagnosis

  • Depression if a low or sad mood, pessimism and/or feelings of guilt.
  • Bipolar disorder if symptoms of mania excitement, elevated mood or exaggerated self-worth are prominent.
  • Alcohol misuse or Drug-use disorders. Chronic intoxication or withdrawal from alcohol or other substances (stimulants, hallucinogens) can cause psychotic symptoms.

Patients with chronic psychosis may also abuse drugs and/or alcohol.

Essential information

Essential information for the patient and primary support group

  • Agitation and strange behaviour can be symptoms of a mental illness.
  • Symptoms may come and go over time.
  • Medication is a central component of treatment. It will both reduce current difficulties and prevent relapse.
  • Safe, stable living conditions (eg freedom from bullying, occupation) are a prerequisite for effective rehabilitation.
  • Voluntary organisations can provide valuable support to the patient and support group.

Advice and support to the patient and primary support group

  • Seek the patient’s permission to discuss a treatment plan with staff involved in the care of the patient and obtain their support for it. A multidisciplinary care plan might consider options for location, occupation, ways of minimising unnecessary stress, an early response to signs of relapse and the monitoring of medication. Combination locations may be appropriate, eg sheltered work during the day, healthcare or Vulnerable Prisoners Unit (VPU) at night. Jointly establish appropriate expectations for the individual, to avoid inappropriate relegation to ‘basic’ status. The information leaflet on the disk for staff about psychotic disorder may be helpful .
  • Explain that medication will help prevent relapse, and inform the patient of the side-effects. Be vigilant to ensure that the patient is not persuaded/bullied into giving the medication to someone else. (They have currency, as antipsychotics may have a sedative and anti-Parkinsonian drugs a mood-elevating effect)
  • Encourage the patient to function at the highest reasonable level in work and other daily activities.
  • Minimise stress and stimulation:
    – Do not argue with psychotic thinking.
    – Avoid confrontation or criticism. Staff should respond gently and with reassurance to slow responses to orders (eg slowness in going into a cell). Use of control and restraint should be a last resort.
    – During periods when the symptoms are more severe, rest and withdrawal from stress may be helpful.
  • Keep the patient’s physical health, including health promotion, obesity and smoking, under review. (ref 1) Weight gain related to medication can be extreme. Heavy smokers may use tobacco to counteract the sedative effects of their antipsychotic medication. If this happens, consider a less sedating antipsychotic. If you suspect co-occurring substance misuse, check for possible physical problems (eg anaemia, chest problems) and nutritional deficiencies.
  • If the illness has a relapsing course, work with the patient and staff to try to identify early warning signs of relapse.
  • Encourage the patient to build relationships with key members of the healthcare team, eg by seeing the same doctor or nurse at each appointment. Use the relationship to discuss the advantages of medication and to review the effectiveness of the care plan.
  • For advice on the management of agitated or excited states, see Acute psychotic disorders.
  • If care is shared with the in-house or NHS mental-health services, agree with them who is to do what.
  • Especially if the patient becomes depressed, consider options for support, education and reassurance about their psychotic illness, including possible relapse and their future life chances. Mental-health staff may be able to provide individual counselling, goal planning and monitoring of early warning signs of relapse.

If the patient is also using substances:

  • Express concern for the patient’s well-being and avoid moral disapproval (eg ‘I’m really not happy about you taking drugs as it makes your schizophrenia worse’). Focus on building a relationship with the patient, not on pushing an unmotivated patient towards abstinence.
  • Discuss the benefits and costs of drug use (including the implications of continuing any form of illicit drug use while in prison) from the patient’s perspective. Assess the patient’s commitment to change. Thought disorder, suspiciousness and depression may make it difficult for the patient to make such a commitment.
  • Educate the patient about the effect of alcohol and other drugs on the body and on schizophrenia (eg ‘Drugs such as cannabis, LSD, stimulants and ecstasy all exacerbate the mood you are in when you take it, and so can make you more paranoid, anxious or depressed’). Feedback the results of tests, eg urine tests, changes in weight or other physical examinations.
  • Consider options for dealing with prison-related problems that may be increasing the substance use (eg boredom, bullying, low-level depression). Consider:
    – encouraging the patient to spend more time out of the cell and in enjoyable activities, eg attend education, gym, work
    – liaising, with patient permission, with wing officers about reducing stress on the unit (eg noise, bullying, teasing) or increasing activities
    – encouraging the patient to talk to any trusted friend or staff member (eg personal officer, teacher, listener, chaplain) if day-to-day problems arise rather than turning to drugs.

For more information, see Comorbidity.

References

1 Brown S. Excess mortality of schizophrenia: a meta-analysis. Br J Psychiatry 1997; 171: 502-508. (AI) Reports on life expectancy and excess mortality rate, including from physical illnesses, in patients with schizophrenia.

Medication

  • Antipsychotic medication may reduce psychotic symptoms (see BNF, Section 4.2.1). Examples include haloperidol (1.5-4 mg up to three times day-1), or an atypical antipsychotic (ref 1) (eg olanzapine, 5-10 mg day-1, or risperidone, 4-6 mg day-1).
  • The dose should be the lowest possible for relief of symptoms. The drugs have different side-effect profiles. Indications for atypical drugs include uncontrolled acute extrapyramidal effects, uncontrolled hyperprolactinaemia and predominant, unresponsive, negative symptoms (eg withdrawal and low motivation). For more information on the different types of antipsychotic drugs and their side-effect profiles, see Maudsley Prescribing Guidelines. (ref 2)
  • Inform the patient that continued medication will reduce the risk of relapse. In general, antipsychotic medication should be continued for at least 6 months following a first episode of illness, and longer after a subsequent episode. (ref 3)
  • Monitor compliance and the call up for review if more than two doses are missed.
  • If, after team support, the patient is reluctant or erratic in taking medication, injectable long-acting antipsychotic medication may ensure the continuity of treatment and reduce the risk of relapse. (ref 4) It should be reviewed at 4-6-monthly intervals. Doctors and nurses who give depot injections in primary care need training to do so. (ref 5) If available, specific counselling about medication also is helpful. (ref 6) Advise the nurse administering the medication to seek out the patient should he/she fail to attend an appointment.
  • Discuss the potential side-effects with the patient. Common motor side-effects include:
    – Acute dystonias or spasms that can be managed with anti-Parkinsonian drugs (see BNF, Section 4.9) (eg procyclidine, 5 mg three times per day, or orphenadrine, 50 mg three times per day).
    – Parkinsonian symptoms (eg tremor and akinesia), which can be managed with oral anti-Parkinsonian drugs (see BNF, Section 4.9) (eg procyclidine, 5 mg up to three times per day, or orphenadrine, 50 mg three times per day). Withdrawal of anti-Parkinsonian drugs should be attempted after 2-3 months without symptoms as these drugs are liable to misuse and may impair memory.
    – Akathisia (severe motor restlessness) may be managed with dosage reduction, or beta-blockers (eg propranolol, 30-80 mg day-1) (see BNF, Section 2.4). Switching to a low-potency antipsychotic (eg olanzapine or quetiapine) may help.
    – Other possible side-effects include weight gain, galactorrhoea and photosensitivity. Patients suffering from drug-induced photosensitivity are eligible for sunscreen on prescription.

References

1 Atypical antipsychotics appear to be better tolerated, with fewer extrapyramidal side-effects, than typical drugs at therapeutic doses. Even at low doses, extrapyramidal side-effects are commonly experienced with typical drugs. Whether atypicals improve the long-term outcome has yet to be established. Risperidone, amisulpride and possibly olanzapine have a dose-related effect. Selected references (BII):
a American Psychiatric Association. Practice guidelines: schizophrenia. Am J Psychiatry 1997; 154(Suppl 4): 1-49. Reports that 60% of patients receiving acute treatment with typical antipsychotic medication develop significant extrapyramidal side-effects.
b Zimbroff D, Kane J, Tamminga CA. Controlled, dose-response study of sertindole and haloperidol in the treatment of schizophrenia. Am J Psychiatry 1997; 154: 782-791. Haloperidol produced extrapyramidal symptoms at 4 mg day-1.
c Mir S, Taylor D. Issues in schizophrenia. Pharmaceut J 1998; 261: 55-58. Reviews evidence on the efficacy, safety and patient tolerability of atypical antipsychotics.
d Duggan L, Fenton M, Dardennes RM, El-Dosoky A, Indran S. Olanzapine for schizophrenia. Cochrane Library, Oxford 1999. Update software. e Kennedy E, Song F, Hunter R, Gilbody S. Risperidone versus conventional antipsychotic medication for schizophrenia. Cochrane Library, Oxford 1998, issue 2.

2 Taylor D, McConnell D, Abel K, Kerwin R. The Bethlem and Maudsley NHS Trust Prescribing Guidelines. London: Martin Dunitz, 1999. Available from: Martin Dunitz, 7-9 Pratt Street, London NW1 0AE. Tel: 020 7482 2202. £14.99 + £2.00 postage and packaging.

3 Al Dixon LB, Lehman AF, Levine J. Conventional antipsychotic medications for schizophrenia. Schizophrenia Bull 1995; 21: 567-577. Presents overwhelming evidence that continuing maintenance therapy reduces the risk of relapse. It concludes that it is appropriate to taper or discontinue medication within 6 months to 1 year for first-episode patients who experience a full remission of symptoms.

4 Adams CE, Eisenbruch M. Depot versus oral fluphenazine for those with schizophrenia. Cochrane Library, Oxford 1998, issue 2. (AI)

5  Kendrick T, Millar E, Burns T, Ross F. Practice nurse involvement in giving depot neuroleptic injections: development of a patient assessment and monitoring checklist. Prim Care Psychiatry 1998; 4: 149-154 (AIV) Of the 25% of people with schizophrenia who have no specialist contact, many have a practice nurse as their only regular professional contact. The levels of knowledge of schizophrenia and its treatment of those nurses was often no better than that of lay people.

6 Kemp R, Kirov G, Everitt B, David A. A randomised controlled trial of compliance therapy: 18 month follow up. Br J Psychiatry 1998; 172: 413-419. (AII) Patients who received specific counselling about their attitudes towards their illness and drug treatment were five times more likely to take medication without prompting than controls.

Referral

Referral to the secondary mental-health services is advised:

  • urgently, if there are signs of relapse, unless there is an established previous response to treatment
  • non-urgently:
    – to clarify diagnosis and ensure the most appropriate treatment
    – if there is non-compliance with treatment, problematic side-effects or breakdown of the living arrangements, eg problems on ordinary location or with occupation
    – for all new patients with a diagnosis of psychosis to obtain information about and review any existing care plan
    – for all patients who also abuse substances to review their medication to ensure that unwanted side-effects (eg sedation) are not increasing drug use.

Patients with a range of mental-health, occupational, social and financial needs are normally managed by specialist services. Referral for a key-worker under the Care Programme approach should always be considered.

The community mental-health services may be able to provide compliance therapy, (ref 1) family interventions, (ref 2) cognitive-behaviour therapy (ref 3) and rehabilitative facilities.

Refer patients who are misusing substances and express some motivation to reduce for substance abuse counselling. (ref 4) Liaise with the substance-misuse service to ensure the continued prescription of antipsychotic medication. Stress to the patient that relapses are to be expected, are not signs of failure and will not mean a loss of your support and respect (see Comorbidity).

If release is planned, work cooperatively with both probation or throughcare-planning officers to ensure that appointments with a general practitioner and specialist mental healthcare are arranged and that housing, money for food, clothes and heating are arranged.

If release is not planned, inform the local mental-health services that the patient may present to A&E in the area and advise them to look out for him/her.

For more detail on throughcare, see Managing the interface with the NHS and other agencies.

References

1 Kemp R, Kirov G, Everitt B, David A. A randomised controlled trial of compliance therapy: 18 month follow up. Br J Psychiatry 1998; 172: 413-419. (AII) Patients who received specific counselling about their attitudes towards their illness and drug treatment were five times more likely to take medication without prompting than controls.

2  Mari JJ, Streiner D. Family intervention for people with schizophrenia. Cochrane Library, Oxford 1991, issue 1. (AI) Families receiving this intervention, which promotes a more supportive family environment, may expect the family member with schizophrenia to relapse less and to be in hospital less.

3 Jones C, Cormac I, Mota J, Campbell C. Cognitive behaviour therapy for schizophrenia. Cochrane Library, Oxford, issue 4, 2001. (AI) Four small trials show that cognitive-behaviour therapy is associated with substantially reduced risk of relapse.

4 Ideally a modified form of motivational interviewing that takes account of the additional problems of a patient with a severe mental illness will be used. Drake RE, McFadden C, Mueser K, McHugo GJ, Bond R. Review of integrated mental health and substance abuse treatments for patients with dual disorders. Schiz Bull 1998; 24: 589-608; Bellack AS, Diclemente CC. Treating substance abuse among patients with schizophrenia. Psychiat Serv 1999; 50: (1), 75-80.

Resources

Resources for patients and primary support groups

Hearing Voices Network: 0161 834 5768 (Self-help groups to allow people to explore their voice hearing experiences)

MIND Infoline: 08457 660 163 (outside London); 020 8522 1728 (Greater London)

National Schizophrenia Fellowship: 020 8974 6814 (adviceline: Monday-Friday, 10:30 am-3 pm); 020 7330 9106 (office)

National Schizophrenia Fellowship (Northern Ireland): 02890 402 323

National Schizophrenia Fellowship (Scotland): 0131 557 8969

SANELine: 08457 678000 (12 pm-2 am, 7 nights)

Education and workshops may provide opportunities for creative expression

Education or Psychology Departments may provide basic social skills training

Resource leaflets:

Coping with the side-effects of medication (pdf)

Working with a prisoner with severe mental illness (pdf)

Early warning signs form (pdf)

Healthy Living with Schizophrenia. London: Health Education Authority 1998. Available from: Marsdon Book Services. Tel: 01235 465565

R Coleman, M Smith. Working With Voices. Handsell, 1997 Newton le Willows. Workbook to help voice hearers manage their voices.