Guidance for General Practice

How might a person present?

Conducting the interview

Arranging treatment

Once the diagnosis has been made

  Guidance for General Practice

Introduction:

Primary care policy for identification of psychosis has to tackle the dilemma of separating a relatively unusual event for any one GP (typically twice per year) from much more common ‘alarm-bell’ symptoms. But this situation is comparable to other rare but serious illnesses where early detection is crucial (breast cancer, meningitis).

How primary care will respond depends on the local configuration of specialist services. Standard two of the National Service Framework encourages primary care to agree with specialist services guidelines for referral and treatment to define local roles and responsibilities. The principle requirement is to provide accessible and youth sensitive assessment. Again, models now exist to assist early detection of serious physical causes for symptoms e.g. breast lump, rectal bleeding, chest pain.

Primary care is not just GPs. There ore other agencies working in the community such as teachers, social workers, youth services, police and probation services each with training needs and policies for referral whether that should be via the GP or direct to the specialist assessment.

The rest of this section is split into five sections:

A. How might a person present?

B. Conducting the Interview.

C. Arranging Treatment

Classically:

• Distortion or loss of contact with reality, without clouding or consciousness
  
  
• Delusions, hallucinations and/or thought disorder
  
  
• Increased risk if there is a positive Family history
  
  
  

But more typically:

• Psychosis rarely presents in such neat parcels
  
  
• Its symptoms are rarely volunteered spontaneously and may need searching out
  
  
• The nature and intensity of symptoms vary with the particular phase of illness
  
  
  

The prodromal phase:

• Psychoses rarely present ‘out of the blue’
  
  
• Typically, several months or varying psychological and social disturbance
  
  
• Absence of clear-cut psychotic symptoms

Diane was on academically bright teenager who had a good relationship with her family. At the age of 15 she appeared to lose interest in school and became defiant. She dropped out of college, and started taking cannabis. Diane left home to live in a series of hostels and flatlets run by housing associations. After two years, aged 18, she consulted her GP with anxiety, thoughts of people following her and insomnia. She was referred to Clinical Psychology but after three attendances declined further input. The records describe treatment for anxiety with over-valued ideas.

Her mother noted Diane ‘s increasing oddness, paranoid thinking and preoccupation with food and body, during the same period of help seeking and disengagement. Friends suggested to Diane that she might have schizophrenia and asked her to watch a TV programme on the subject. She was able to see some similarities between herself and the behaviour discussed in this programme.

Presence of positive psychotic symptoms

• Thought disorder: vogue or disorganised thinking accompanied by disjointed speech which is hard to follow.
  
  
• Delusions: unshakable,’ false beliefs; often idiosyncratic and very significant to the; patient; often gradually build up in intensity and con v/ct/on before becoming entrenched. They can take many forms- e.g. persecutory, religious, grandiose, delusions of reference, somatic, thought insertion/broadcasting/withdrawal.
  
  
• Hallucinations: sensory perceptions in the absence of on external stimulus; most commonly auditory, but can also include visual, tactile, gustatory and olfactory forms.
  
  
• Somatisation: as with many mental illnesses, vogue or odd physical complaints unexplained by physical pathology can reflect an underlying psychological or psychiatric disorder
  
  
  

Kenneth was described by his parents as always being a “strange lad who drinks a lot“. His isolation and low activity rates were put down to shyness. At around the age of 23, he became convinced that a trapped nerve in his head created muzziness and caused his eyes to bulge making him look like a frog. His GP simply reassured him and eventually Kenneth complained to the Authorities about his GP ‘s lack of interest in his problem. He changed GP and was sent for a scan and EEG. Kenneth was told these tests were normal, and refusing to believe the results, he changed to another GP

There was significant psychiatric history on his mother’s side, two of his uncles having chronic schizophrenia. Kenneth never perceived himself as having a mental illness.

As well as ‘positive’ symptoms, negative symptoms often occur:

• Affective blunting
  
  
• Loss of motivation
  
  
  

In addition, there are usually a number of other ‘secondary’ features:

• Sleep disturbance
  
  
• Panic attacks
  
  
• Agitation
  
  
• Behaviour changes, social withdrawal and impaired role functioning
  
  
  
  

The commonly described scenario of the disturbed psychotic person is only one possible mode of (usually late) presentation. Just as common is the more ‘quietly’ psychotic person who is gradually slipping backwards, losing their place in society and who people dismiss as just being “odd”.

CONDUCTING THE INTERVIEW

Adolescents and young adults (particularly males) are often reluctant to consult their GP. However, complex psychological and social problems can arise and in a number of instances, those difficulties themselves may be the prime ‘diagnosis’.

One example of an approach to check out the young person’s current psychosocial functioning is the HEADSS checklist — Home, Employment (and study), Activities, Drugs, Sexuality and Suicide.

Young people experiencing a psychotic illness are likely to be distressed and frightened. Acknowledge that the person may be nervous or wary and try to find some common ground for discussion, gradually building up towards more specific questions about their psychotic experiences.

The initial consultation may not provide definitive diagnosis but only allow you to establish a feel for the problem. The person may need time to build up trust and repeat visits over a couple of weeks can often make things a lot clearer. Be alert to the person whom you are concerned about if they fail to turn up to their appointment — be prepared to assertively make contact.

The changes in behaviour or personality characteristic of psychosis are often noticed by the family but not realised or volunteered by the person. In this situation, it may be the family who present on their own, with concerns about their son or daughter, or their spouse. Indeed, the family may be very distressed by the situation and unsure how to proceed.

Brenda was a 33-year-old married mother of a 5-year-old child. Her husband described the onset of her ill health to the birth of the child, when she was diagnosed as suffering from postnatal depression. With no ongoing intervention, the husband managed her increasingly suspicious behaviour by forsaking all his interests, believing it was his role to care for her and that the GP and Heath Visitor could not be expected to help. Brenda escorted by her husband eventually presented at the accident and emergency department in a florid psychotic state, physically aggressive and expressing delusions of being controlled.

In early psychosis, be assertive in assessing the person, rather than letting things go to crisis because the person doesn’t want to see you. If the family present without the person try to get a sense of the urgency of the situation.

Encourage the young person to come in and see you or if the situation seems sufficiently serious or perhaps visit them at home. If a home assessment is contemplated, a preliminary assessment of the person’s potential for aggression needs to occur (although violence is not common and is nearly always a defensive or reactive phenomenon). This requires discussion with the person’s family. If there are clear indications of risk, you should enlist the support of experienced community psychiatric workers and a joint assessment may be preferable.

ARRANGING TREATMENT

The young person experiencing a first-episode of psychosis will require specialist psychiatric assistance.

Treatment approaches for a young person with a newly diagnosed psychosis are quite different to those given to a person with more long-standing illness (1). There is strong evidence for the benefits attained by psychosocial treatments, and the importance of working with the young person’s family.

One clear example of this difference can be seen in the area of psychopharmacological treatment.

• People experiencing a first episode of psychosis are typically very sensitive to pharmacological effects of these drugs and therefore more susceptible to side effects.
  
  
• Low-dose regimes are just as effective in controlling positive symptoms and far more acceptable by causing fewer side effects.
  
  
• Newer atypical antipsychotic drugs such as Risperidone and Clozapine are again more acceptable by causing fewer side effects and may also prove pharmacologically more effective.
  
  
• Full remission takes time but occurs in the majority of people. About 60% of clients will respond by 12 weeks, another 25% more slowly, and 15% will not respond to traditional neuroleptics. However, this treatment resistant group may respond to the newer atypical neuroleptics (4).

When discussing your concerns or your diagnosis with the person and their family, it is best to be fairly general in your comments. People will feel very threatened if abruptly told they have Schizophrenia. They are far more likely to be receptive to obtaining assistance for their ‘stress’, ‘confusion’ or ‘sleep difficulties’, whilst you ‘check things out further’. By using this approach, clients can often be encouraged to accept help, particularly in the early stages of psychosis.

In general, we should be sensitive to the potential trauma and shame of enforced hospitalisation both to the person and their family. Perhaps outpatient or home-based treatments are options with close monitoring via the family. Where these are not suitable options, it is important to ensure that transport to hospital and the admission itself, is also handled with care.

ONCE THE DIAGNOSIS HAS BEEN MADE

Client and family may be bewildered and distressed by the impact of the illness. Working with clients and families in remission is critical to the recovery process and primary care has a crucial role in support and adjustment following diagnosis.

Sensitivity is required to the traumatic nature of discovery of major mental illness and the need for information and empowerment of clients and families.

There are several important non-medical inputs providing social, educational and vocational aspects of care which require co-ordination in a community setting.

Relapse is predictable by a characteristic pattern of early signs in any individual and permits early recognition and appropriate action. Such management has been shown to drastically reduce the severity and length of relapse and minimise the risk of resort to hospitalisation.

Integration of the primary and secondary responses should promote assertive and pro­active management and is best achieved by a systematic and organised approach to care agreed between the relevant agencies.

References

Birchwood, M., McGorry, P., Jackson,H. (1997) Early Intervention in Schizophrenia British J of Psychiatry; 170: 2-5

Johnstone, E.C., Crow, T.J., Johnstone, A.L. and Macmillan, J.F. (1986) The Northwick Park Study of first episode, schizophrenia: 1. Presentation of the illness and problems relating to admission. British J of Psychiatry 148:115 - 120.

McGorry. P.D., Edwards, J., Mihalopoulos, C., Harrigan, S.M., Jackson, H.J. EPPIC: (1996) An evolving system of early detection and optimal management. Schizophrenia Bulletin, 22(2): 305-326,

Wyatt, R.J., Henter, I.D. (July 1997) Schizophrenia: the Need for Early Treatment. The Harvard Mental Health Letter