Assessing and managing psychosis, drug misuse and violence and aggression

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Chapter 16 Assessing and managing psychosis, drug misuse and violence and aggression

Rosie Doy, Elizabeth Jane Blowers, Emma Sutton

Primary survey 269
Psychotic illness 270
Features of psychosis and differentiation from organic confusion 270
Specific types of illness 273
Responding to a person in crisis 275
Services available 276
Substance misuse 278
The nature of substance misuse 279
Assessing substance misuse 280
Brief interventions 280
Violence and aggression 282
Personal and scene safety 282
Post-incident support 286

Primary survey

The objectives of this chapter are listed in Box 16.1. Assess the risk of self harm or the potential of harm to others, including you. Call for urgent back up if this is the case. You may need to call the police if you think there are real and immediate risks of violence. If you judge management of the patient will require the use of the Mental Health Act, you will need to mobilise an Approved Social Worker (ASW), the patient’s GP or a doctor approved under Section 12 of the Mental Health Act (1983).

Box 16.1 Chapter objectives

Psychotic illness

image To discuss the recognition of psychosis in primary survey positive patients and those with non-life-threatening psychotic presentations
image To describe mental health assessment, differential diagnoses and therapeutic approaches to the person with psychotic symptoms
image To clarify referral and care pathways

Substance misuse

image To identify the tiers and responsibilities related to substance misuse service delivery
image To discuss first-line assessment and recognition of problems related to substance misuse and appropriate care pathways
image To explore psychosocial issues, co-morbidity and care strategies for primary survey negative patients who have misused drugs

Violence and aggression

image To clarify the challenge of violence and aggression in health care
image To explore reasons why violence and aggression occur
image To discuss personal and scene safety, the use of the assault cycle, de-escalation skills and post-incident staff support

Psychotic illness

This section will discuss:

image the differentiation between psychotic illness and an organic acute confusional state
image schizophrenia
image bipolar disorders (manic depression)
image post-natal psychosis.

Around 1% of the population experience at least one acute episode of schizophrenia1 and a similar number will be affected by bipolar disorder (manic depression) at some time during their lives. Post-natal depression and psychosis is now the leading cause of all maternal deaths by suicide.

Features of psychosis and differentiation from organic confusion

In psychosis, the person typically loses the ability to distinguish between reality and thoughts due to hallucinations or delusions. These symptoms usually first appear in the late teens or early twenties (slightly later for women).

The symptoms of psychosis can be difficult to categorise. Disturbance of thought is key to the diagnosis. This thought disturbance can take -many forms. Delusions (false beliefs) and hallucinations are common. Auditory hallucinations are common – these may take the form of voices commenting on the patient’s actions or voices discussing the patient. The patient may believe that thoughts are being either inserted into or removed from their mind. Overwhelming negative feelings such as apathy, neglect and severe blunting of mood are common in severe depressive syndromes (Box 16.2).

Box 16.2 Signs and symptoms of psychosis

image Delusions – false, fixed beliefs that are not amenable to change despite objective and contradictory evidence to the contrary
image Hallucinations – disordered perception of senses including hearing voices (auditory), visual, taste (gustatory), smell (olfactory), feeling strange sensations (tactile) – these may cause the person to act on their perceptions
image Mood (affect) disturbances
image Social isolation, withdrawal and apathy – poor social and living skills, self-neglect
image Thought (cognitive) disturbances – the person may believe that thoughts are being inserted into or taken out of their mind; or that their thoughts are being broadcast; they may have disordered thinking and communicate bizarrely or incoherently
image Unpredictable or bizarre behaviour

Patients who have had a previous episode of psychotic illness are likely to be known to the specialist mental health services, though many are managed completely within primary care. It is likely that most pre-hospital and emergency care practitioners will encounter patients in crisis who have an undetected illness (the incidence of new cases of schizophrenia is 1–2 per 10 000 population per year) or those experiencing a relapse.

Exclusion of an acute organic confusion

It is not always easy to distinguish between medical/physiological disorders and mental illness presentations. Medical problems are potentially treatable and may indicate a life-threatening emergency that may be amenable to treatment (Box 16.3). History of fits, diabetes, head injury, –recent febrile illness or acute confusion should be excluded (a full list is given in Chapter 15). Check the temperature, level of consciousness, orientation and speed of onset as these can help distinguish between and physical or psychiatric cause (Table 16.1).

Box 16.3 Screening for physical causation

Medical assessment/emergency indicated if:

image fever
image history of recent fit
image impaired or depressed level of consciousness
image known diabetic
image loss of awareness of surroundings
image recent onset of confusion, disorientation and memory impairment
image signs of head injury or recent history of head injury (2 weeks)
image suspected chest or urinary tract infection (esp. in the elderly)

Table 16.1 Features distinguishing organic from functional causes of psychosis

  Organic Functional
Age >40 years <40 years
Onset Sudden Gradual
Physical abnormalities on examination Yes No
Activity Hypo-/hyper-active, tremor, ataxia Rocking, repetitive action, posturing
Consciousness Impaired Awake and alert
Orientation No Yes
Lucid thoughts Some Infrequent
Hallucinations Visual Auditory
Memory impairment Recent memory Remote memory

Psychiatric assessment

The objectives are to obtain an accurate history of the presenting problem, assess the patient’s mental state and personality, and to identify possible causes/triggers to the current situation. In addition to the usual approach to history taking and past medical/psychiatric history of the patient, it is useful to assess the patient’s expectations/wishes and their appropriateness. The patient’s mental state should then be assessed; this may involve the use of the Mental State or Mini Mental State Examinations (see, for example, the Oxford Handbook of Psychiatry2). Another approach to mental state examination is given in Box 16.4.

Box 16.4 The ABCDE model – initial psychiatric assessment

image A Appearance – neglected, dishevelled, inappropriate dress for weather/environment?
image B Behaviour – disinhibited, impulsive, bizarre, aggressive, unpredictable, withdrawn?
image C Communication – incoherent, rapid and disconnected, confused, limited/uncommunicative?
image D Ideation – beliefs, delusions, preoccupied, perception, hallucinations, thought processes?
image E Emotion – excitable, euphoric, suspicious, sad, flat, depressed, inappropriate to situation, rapidly changing (labile)?

The patient’s presentation may be complicated by emotional arousal (e.g. anger), the misuse of alcohol and co-morbidity. An example of the latter is ‘self-medication’ with cannabis by patients experiencing the symptoms of schizophrenia. In the UK 9–35% of people with schizophrenia misuse alcohol or drugs.

Analysis

The categorisation of severe mental illness is not easy. You do not have to make a definite diagnosis – indeed it may be inadvisable to ‘label’ a patient in the first contact emergency situation. However it is important to have some appreciation of the main categories. These are summarised in Box 16.5.

Box 16.5 Differential diagnoses of psychotic disorder – specific mental disorders

image Acute or transient psychotic disorder – usually associated with acute stress and resolves in 2–3 weeks
image Bipolar disorder (also called manic depression) – cyclic disorder characterised by repeated episodes of elevated mood (mania) and depression
image Persistent delusional disorder – characterised by a single delusion or set of related delusions; there are no hallucinations nor disturbances in mood, speech or behaviour
image Post-natal depression and psychosis
image Psychoactive substance abuse
image Schizophrenia
image Severe clinical depression with psychotic features

Specific types of illness

Schizophrenia

The main symptoms are of thought disorder. Belief that thoughts are being inserted or removed or transferred to the patient are common. Auditory hallucinations such as a commentary of patient’s actions or a voice anticipating or repeating the patient’s thoughts are often described. Delusions are common. The patient is often isolated and may exhibit apathy and blunting of mood.

Develop rapport and therapeutic relationship taking account of language and culture of the patient. Involve patients and carers/advocates in care decisions. Look for a previously documented crisis care plan and check concordance with and previous response to any treatment/medication package. Assess alcohol and substance use or misuse.

In an acute episode of psychosis, especially the first experience, the person may be absolutely terrified and confused. There may be suicidal ideas (about 10% of patients with schizophrenia will commit suicide within 5 years of the onset of their illness; about 30% of people with schizophrenia attempt suicide at least once). They may ‘hear’ voices demanding that they harm themselves.3 Those most at risk are male patients, the unemployed, socially isolated or recently discharged from hospital.

TIPPhysical examination may also be necessary; schizophrenia is associated with a high mortality, with death on average 10 years earlier than the general population. Cardiovascular disease and/or diabetes are responsible for many of these excess deaths1,4

Bipolar disorder

Bipolar disorder is defined by NICE5 as: ‘an episodic, potentially life-long, disabling disorder (with) diagnostic features including periods of mania and depression characterised by periods of abnormally elevated mood or irritability, which may alternate with periods of depressed mood. These episodes are distressing and often interfere with occupational or educational functioning, social activities and relationships.’

The evidence shows that there is often a considerable delay between the onset of the disorder and first contact with services.

Most people experience some changes in mood, but a patient with mania (Box 16.6) has a persistently high and euphoric mood, which is out of keeping with their circumstances and the environment. A key feature of management is to provide a calm, structured environment with avoidance of over-stimulation balanced with space for walking to use up excess –energy. Hospital admission is therefore often necessary. In contrast, hypomania (i.e. when the symptoms are not extreme enough to significantly impair work/relationships) can be managed within primary care.

Box 16.6 Signs and symptoms of mania

image Bizarre or inappropriate behaviour
image Decreased sleep which may lead to exhaustion
image Delusions and hallucinations
image Elevated mood
image Enhanced libido, flirtatiousness, sexual disinhibition and promiscuity
image Flight of ideas – racing thoughts
image Grandiose ideas and inflated self-esteem
image Impaired concentration, distractibility
image Impaired judgement and decision making
image Impulsive behaviour and recklessness, disregard for danger; spending sprees
image Increased energy and activity levels
image Increased pain threshold
image Irritability, truculence and aggression
image Labile moods – quickly changing, e.g. from elation to anger
image Poor insight
image Pressure of speech which may be difficult to understand

Be aware that many medications may induce the symptoms of mania including antidepressants, other psychotropic medication, anti-parkinsonian medication, cardiovascular and respiratory drugs, anti-TB medications, steroids and drugs of misuse.

Post-natal depression and psychosis

Following childbirth, around 70% of women experience ‘baby blues’; this usually occurs 3–5 days after the birth and resolves quickly. However, about 10% experience post-natal depression which exhibits the same symptoms as a severe (major) depression.6 Secondary survey would be supported by use of the Edinburgh Post-natal Depression Scale.7

A small percentage of new mothers (0.1%) develop puerperal psychosis (Box 16.7) – this normally develops within 3 weeks of the birth.

Box 16.7 Signs and symptoms of post-natal psychosis

image Delusions and hallucinations (as indicated above)
image Feelings of guilt
image Low mood which may alternate with elation and euphoria
image Sleep disturbances
image Appetite problems
image Confusion
image Ambivalence towards the baby

This is a serious illness and may require prompt specialist intervention and the admission of the mother and baby. ‘Why Mothers Die’ – The Confidential Enquiry into Maternal Deaths8 indicates clearly that 50% of the women who commit suicide (Box 16.8) have a previous history of serious mental illness, 25% related to their last childbirth. This is in fact the leading cause of maternal death. Four times as many suicides occurred following delivery than in pregnancy itself and many women with puerperal psychosis who kill themselves do so later than 6 weeks following delivery.

Box 16.8 Summary of findings related to women who commit suicide

image 87% were white
image 83% were over the age of 25 years
image 46% were over the age of 30 years
image 55% had previous children
image 54% were seriously ill, either suffering from a postpartum psychosis or a very severe depressive illness
image 50% had a previous history of serious illness, of whom half had been admitted to a psychiatric unit
image 50% were in contact with psychiatric services during their index maternity, 75% of whom were receiving some form of treatment
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