Psychosis-Symptom Contextualization: 5 rule outs

Farah is a 49-year-old female, who complains of difficulty sleeping (insomnia), feeling sad (depressed mood), and has held the belief that her daughter, Mia, was stealing her money and was trying to poison her food (paranoia).  Ron, the psychiatrist seeing Farah for the first time, examined her and noticed a lump (nodule) in her neck, some hand tremors, and weight loss.  Ron quickly assessed for acute risk, referred Farah to an endocrinologist, who confirmed a diagnosis of hyperthyroidism, treated Farah, and the psychiatric symptoms, including paranoia, subsided.

In the previous article, entitled “Symptom Contextualization-Introducing a New and Key Concept,” I introduced the concept of symptom contextualization, narrated the story of Arianna, who had been diagnosed with Schizoaffective Disorder, but whose subsequent work up confirmed a diagnosis of Anti-NMDA receptor encephalitis, which explained her presenting psychosis.  Just like Farah, Arianna presented with symptoms of psychosis, but in a context different from Schizoaffective Disorder.  What different contexts can explain psychotic symptoms; how do you tease them out; and how do we then proceed? This article is going to walk you through the steps for answering these questions and many more.  Below, I will (1) Define and provide an overview of psychosis; (2) Briefly note the major manifestations of psychosis, and (3) Proceed with symptom contextualization of psychosis.

Psychosis

From an etymological standpoint, the term “Psychosis” can be broken down into: the Greek words “psyche” which means, “mind” and “osis” which means, “state” or “condition.”  The etymological and literal definition of psychosis is therefore simply a state or condition of the mind. From a medical terminology standpoint, the term psychosis denotes a state of the mind that involves loss of contact with reality.  It was introduced in the medical literature in 1841 by Karl Friedrich Canstatt to describe the psychological manifestations of brain disease.

Major manifestations of Psychosis

After an etymological definition and a medical operationalization of the concept of psychosis, it is now worth portraying it.  Psychosis is commonly described as hallucinations; delusions; disorganized behavior; and disorganized thoughts (content and process).  While this all sounds basic, information is in the difference, and the challenge is to tease out when is it psychosis; how do we contextualize it; and is everyone who hallucinates, experiencing psychosis? This then takes us to the need to contextualize the manifestation of psychosis and arm ourselves with the tools we need to continue to do the best for the patients and clients we serve.

I. Symptom contextualization

In our previous article, I went over the why of symptom contextualization.  I also illustrated how I often ask clinicians to contextualize the behavior of laughing to self.  They often say: “Schizophrenia” and after challenging them, and with the use of the Socratic method, they almost always end up outlining 8 additional contexts that might equally explain the behavior of laughing to self.  In this section, we are going to delve directly into contextualizing the symptoms of psychosis.  So, how do we contextualize psychosis and the presenting symptoms; what is the framework?

Therefore, each time you are in presence of any of these four (4) manifestations of psychosis: hallucinations, delusions, disorganized thinking, and disorganized behavior, follow the following 5 steps:

I started this article with Farah’s history.  She presented with several symptoms, one was paranoia, a form of delusion. Farah was fully convinced of that belief, despite her son and husband’s efforts to prove otherwise.  Farah could be thought of as being “psychotic” – rightly so, but did she have Schizophrenia, and did she even require antipsychotics?  She certainly did not.  Farah’s psychosis was due to hyperthyroidism, a general medical condition that can account for psychosis.  Below is a non-exhaustive list of general medical conditions that we all have to think about in presence of psychosis, before turning to Schizophrenia, as a diagnosis.  I will simply mention them and will elaborate and describe some in subsequent articles:

 * Delirium       * Hypothyroidism (Myxedema madness)

 * Hashimoto’s thyroiditis       * Cerebral malari      * HIV psychosis

* Steroid producing tumors       * Insulinoma     * Pheochromocytoma

* Acute Intermittent Porphyria          * Systemic Lupus Erythematous

* Toxoplasmosis            * Vitamin B12 deficiency

II. Rule out Substance/toxin induced psychosis (toxic psychosis) 

Harry, a 45 year-old man, was brought to the CPEP by ambulance.  He was very belligerent, accusing the nurse, who was trying to take his vitals, of “sexually harassing” him; and he thought the social worker, interviewing him was his wife ant the psychiatrist to be from the FBI.  Harry was also experiencing both auditory and visual hallucinations, in addition to his several grandiose, paranoid and persecutory delusions.  K2 use was suspected; he was admitted to the dual diagnosis unit, and a diagnosis of K2 induced psychosis was made.  He was then referred to outpatient treatment and received Motivational Interviewing and Harm Reduction based services. Harry achieved recovery, and he is now a peer counselor, helping other people struggling with substance use.  K2 is one of the many substances that can account for psychosis.  This example illustrates that ruling out substances, as a cause of psychosis is not only a good thing but also the right thing to do.  In Harry’s case, his brother confirmed the absence of any history of psychiatric symptoms, until he started to meet with new friends, with whom he started using illicit substances.  Here is a non-exhaustive list of substances that can account for psychosis:

* K2      *Marijuana (Cannabis)      * PCP (Angel dust)

* Alcohol      * Cocaine      * Amphetamines and other stimulants

* Ecstasy      * LSD      * Ketamine    * Mushrooms

III. Rule out Neurological Conditions

Do you remember Arianna, the 16-year-old girl I introduced in the previous article?  She had been admitted to a psychiatric unit, diagnosed with Schizoaffective Disorder, prescribed Haldol and Lithium and discharged with follow up to a mental health outpatient clinic.  A premature diagnosis, without going through a more rigorous exercise of symptom contextualization, can do more damage than good to the patients and clients we serve.  It does take more time and it may take more resources, but it is the right thing to do, and it saves us from applying the incorrect diagnosis to a very serious condition.  More importantly, would you and I not want exactly the right thing to do for our 16-year-old child?  Below are some of the several neurological conditions that can account for psychosis.  They need to be ruled out before a diagnosis of Schizophrenia or Schizoaffective Disorder is given to anyone, much less to a 16-year-old:

* Alzheimer’s disease      * Lewy Body Dementia

* Neurosyphilis       * Epilepsy       * Narcolepsy

* Migraine      * Stroke      * Neurocysticercosis      * Brain Tumors

* Multiple Sclerosis        * Anti NMDA receptor encephalitis

IV. Rule out Other Contexts

Ann, a 37 y/o female was taken to the ER. “I don’t know who this is. What exactly is she doing here; we need to dispose of her” was Ann’s incessant order to her husband.  Ann was in fact referring to her 2-week-old baby, Annie.  The context was either too obvious, or this condition has been well known, or a combination of both; regardless, Ann was correctly diagnosed with Postpartum Psychosis.  She was appropriately treated and Annie is now a healthy 5-year-old in kindergarten and enjoying her weekly ballet classes.  After general medical conditions, substances or toxins, and neurological conditions have been ruled out, it is worth remembering other contexts, different from a neuropsychiatric condition that can also account for psychosis.

Besides Postpartum Psychosis, a non-exhaustive list includes and is not limited to:

1. Menstrual Psychosis

2. Hypnagogic hallucinations (normal hallucinatory experiences that occurs while someone is trying to fall asleep)

3. Hypnopompic hallucinations (normal hallucinatory experiences that occur while someone is trying to wake up)

4. Bereavement (seeing or hearing the voice of a deceased loved one)

5. Sensory impairment (possible with severe sleep deprivation)

V. Rule out Neuropsychiatric Conditions

As stated above, it is essential for us to always think of different contexts, including distinct neuropsychiatric conditions, other than Schizophrenia or Schizoaffective Disorder that may account for psychosis. Here is a non-exhaustive list:

*Personality disorder   *Delusional Disorder *Complex Trauma (PTSD)

*Brief Psychotic Disorder     *Dissociative Identity Disorder

 *Obsessive Compulsive Disorder      *Bipolar Disorder, Manic Episode

*Major Depressive Disorder, Severe

*Shared Psychosis (Delusions or hallucinations are transferred from one individual to another one)

*Tardive Psychosis (Induced by the use of antipsychotics)

Forty percent of individuals with Alzheimer Disease, and most of those affected with Lewy Body Dementia (a type of dementia), present with psychosis.  Eleven percent of those with Systemic Lupus also present with psychotic symptoms.  Schizophrenia and/or Schizoaffective Disorder should always be diagnoses of exclusion.  This means that when we evaluate for psychosis, we all need to force ourselves to use the principle of symptom contextualization, using the 5 steps I introduced in this article.  Let us be sure we rule out: general medical conditions (Hyperthyroidism, for example), substance induced or toxic psychosis (K2 induced psychosis, for example), neurological conditions (Lewy Body Disease, for example), other contexts of psychosis (Post Partum psychosis, for example), and a neuropsychiatric condition other than Schizophrenia or Schizoaffective Disorder (Complex Trauma, for example).

I hope you found this article enjoyable, informative, and translational to your practice.  If you use it as an empowering tool to continue doing your best for the patients and clients you serve, then, this article has served its purpose.  But, will you keep this as a secret or will you share it with your colleagues?  If you do share, you will be contributing to the change we all strive to see, understanding how care can be better provided to our patients and clients.

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Bibliography

• Freudenreich, Oliver (3 December 2012). “Differential Diagnosis of Psychotic Symptoms: Medical “Mimics””. Psychiatric Times. UBM Medica
• Yuhas, Daisy. “Throughout History, Defining Schizophrenia Has Remained a Challenge (Timeline)”. Scientific American Mind (March 2013)
• Honig A., Romme M.A., Ensink B.J., Escher S.D., Pennings M.H., deVries M.W.; Romme; Ensink; Escher; Pennings; Devries (October 1998). “Auditory hallucinations: a comparison between patients and nonpatients”. J Nerv Ment Dis. 186 (10): 646–51. PMID 9788642. doi:10.1097/00005053-199810000-00009
• Cardinal, R.N. & Bullmore, E.T., The Diagnosis of Psychosis, Cambridge University Press, 2011, ISBN 978-0-521-16484-9
• Ohayon, M.M.; R.G. Priest; M. Caulet; C. Guilleminault (October 1996). “Hypnagogic and hypnopompic hallucinations: pathological phenomena?”. British Journal of Psychiatry. 169 (4): 459–67. PMID 8894197. doi:10.1192/bjp.169.4.459
• Sharma, Verinder; Dwight Mazmanian (April 2003). “Sleep loss and postpartum psychosis”. Bipolar Disorders. 5 (2): 98–105. PMID 12680898. doi:10.1034/j.1399-5618.2003.00015.x
• Devillieres, P.; M. Opitz; P. Clervoy; J. Stephany (May–June 1996). “Delusion and sleep deprivation”. L’Encéphale. 22 (3): 229–31.
• Shibayama M. (2011). “Differential diagnosis between dissociative disorders and schizophrenia”. Seishin shinkeigaku zasshi=Psychiatria et neurologia Japonica. 113 (9): 906–911. PMID 22117396
• Pillmann, Frank; Marneros, Andreas (2004). Acute and transient psychoses. Cambridge, UK: Cambridge University Press. p. 188. ISBN 0-521-83518-6. OCLC 144618418
• McKeith, Ian G. (February 2002). “Dementia with Lewy bodies”. British Journal of Psychiatry. 180 (2): 144–47. PMID 11823325. doi:10.1192/bjp.180.2.144