PSYCHOSIS
1. Psychosis is a serious mental disorder characterized by abnormalities of thinking and emotions, due to which the patient appears to have lost contact with reality.
2. It is characterized by hallucination and delusion.
Why do we need to know about psychosis
1. Curable
2. Impact on life, family and country
3. Stigma
Symptoms
1. Delusion
2. Hallucination
3. Disorganised Thought and Speech
4. Disorganised Behaviour
5. Negative Symptoms
Delusion
Delusion is a firm, fixed belief that is maintained despite being contradicted by reality or rational argument.
1. Types:
1. Paranoid
2. Grandiose
3. Delusion of infidelity
Hallucination
A hallucination is a perception in the absence of external stimulus that has qualities of real perception
Types:
1. Auditory
2. Visual
3. Tactile
4. Olfactory
5. Gustatory
Other features
1. Thought broadcasting,
2. Thought insertion,
3. disorganized thinking,
4. poor reasoning,
5. poor impulse control,
6. social inappropriateness
Natural history of psychosis
1. First onset typically between age 15 and 25 years.
2. There are 3 possible clinical courses
a. the person recovers completely or partially with some symptoms
b. the person recovers but has a future episode (relapse)
c. symptoms continue for 3 months or more (chronic psychosis)
Facts about psychosis
1. Psychosis occurs frequently- one person among 100 to 200
a. Has a dramatic impact on individuals, families and society.
b. Loss of relationships and income opportunities
c. Human rights violations (discrimination, abuse, confinement)
d. Burden on carers (time, money, stigma)
2. Psychosis can be managed outside hospitals
a. e.g., at primary health care clinics
b. Care can be offered in non-specialized health care
c. Medical treatment is simple and effective
d. More accessible than specialist care
e. Less stigmatized than care in mental hospitals
Classify according to HMIS
1. Schizophrenia:
a. Symptoms lasting at least one month
b. Hallucination and delusions must be present.
2. Psychosis:
a. Other forms which doesn’t meet the criteria for schizophrenia
b. Eg: Delirium, Substance Induced Psychotic Disorder, ATPD
3. Organic causes:
a. Delirium
4. Substance Induced:
a. Cannabis
b. Alcohol
5. Psychosis
a. Depression
b. Mania
Treatment
1. First Generation :
a. Chlorpromazine
b. Haloperidol
c. Fluphenazine
2. Second Generation:
a. Olanzapine
b. Risperidone
Chlorpromazine
1. MOA: D2 blocker
2. Available in 50mg and 100mg
3. Dosing range 200mg to 400mg/ day
4. S/E: Dizziness, Sedation, Urinary retention, Orthostatic Hypotension, EPS, Weight gain, Pigmentation-photosensitivity
Haloperidol
1. MOA: D2 blocker
2. Dosing : 2 to 10 mg
3. S/E:  EPS
Sedation, Dizziness, Sedation, Urinary retention , wt gain
Risperidone
1. Mechanism of action
2. T1/2 : 20 hrs
3. Metabolism
4. Excretion
5. Dosing:
6. Start with 2mg PO HS
7. Increase to 4mg in day 5
8. If symptoms improve continue same treatment if not further increase dose to 6mg

• Side effects:
1. Common side effects :Drowsiness, Weight gain
2. Less common side effects: Dry mouth, peripheral oedema, postural hypertension
3. Increase Prolactin
Olanzapine
1. MOA
2. T1/2 : 21 to 54hrs
3. Metabolism
4. Elimination
5. Start with 5 mg
6. Increase 5mg every 5 days until symptoms improve
7. Minimum effective dose : 10mg
8. Maximum dose : 20mg
9. Side effects
1. Common side effects of Olanzapine : drowsiness, weight gain
2. Less common side effects of Olanzapine :constipation, dry mouth , peripheral oedema, postural hypertension
Extrapyramidal Syndrome (EPS)
EPS are the most characteristic side effects of antipsychotics
1. Dystonia
2. Akathasia
3. Tardive dyskinesia
4. They are abnormal involuntary, repetitive, aimless movements.
5. They can create contractions, contorted positions and pain
Management
1. If extrapyramidal side-effects (EPS) occur, reduce the dose of antipsychotic medication
2. If dose reduction is ineffective, consider anticholinergics( trihexiphenydyl)to counteract side effects
3. Anticholinergics are for short-term use if extrapyramidal side-effects are acute, severe or disabling.
4. Try to taper after 6 wks
5. Trihexyphenidyl 2mg bd can increase upto12mg
Sleep
1. Monitor sleep
2. For insomnia:
a. 5mg Diazepam HS for 14 days
b. May repeat the dose upto 20 mg every 30 mins
Non Pharmacological
1. Psychoeducation to patient and family
2. Relapse prevention
3. Substance use councelling
4. Daily activities: sleep , food
5. Our aim of treatment
CAUTIONS
1. Pregnancy
2. Serious medical comorbidity
3. Children
Follow ups
1. If possible every 2 to 3 days
2. If not every week
3. When stable every 3 mths
4. Assessment in follow up:
a. Symptoms
b. Adherence
c. Side effects
5. Continue treatment for 12 mths for acute psychosis