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What is Psychosis?
Historical Origin of the Term:-’itis’ signifies inflammation-’osis’ signifies disorder without knowledge of cause
Neuritis: nervous system disease with inflammationNeurosis: nervous system illness with no obvious signs of inflammation or other cause
Psychosis: illness affecting awareness (psyche) without evidence of inflammation; referred to severe change in mental status or function
19th century concepts
What is Psychosis?
Modern definition of Psychosis:
The presence of one or more of:- Delusions (fixed false beliefs)- Hallucinations (auditory is most common, but can occur with any of the senses- Disorganized speech (sometimes to the point of incoherence)- Greatly disorganized behavior- Catatonia
Psychosis is relatively common
Approximately 15% of the population will experience hallucinations
5% to 8% of the population will have some form of psychotic disorder
3% of the population will have some form of recurring or chronic psychosis
What is Psychosis?It is a symptom, not by itself a specific disease
Examples of nonspecific symptoms:- Fever- Cough- Vomiting- Low Energy- Depressed mood
Nonspecific Symptoms:Causes and Treatments of Fever
Aspirin Antibiotic Quinine Steroid Physostigmine
Bacteria Effective Effective No No No
Virus Effective No No No No
Parasite (e.g. malaria)
Effective No Effective No No
Autoimmune disease(e.g. lupus)
Partly Effective
No No Yes No
Drug effect (atropine)
No No No No Effective
For a particular cause: some drugs are effective, some are notFor a particular drug: some causes respond, others don’t
Three Broad Categories of Cause:• Psychiatric Illness• ‘Medical’ Illnesses• Medications/Drugs
Causes of Psychosis
• Schizophrenia• Bipolar Disorder• Major Depression• Post-partum syndrome• Severe stress or anxiety• Personality disorders
Causes of Psychosis: Psychiatric Illnesses
• Autoimmune diseases (e.g. Lupus)• Endocrine diseases (thyroid, insulin, steroid hormones)• Infections (incl. HIV, Syphilis, CNS infections)• Narcolepsy• Seizure disorder• Tumors (in brain, or eleswhere)• CNS degenerative diseases• Nutritional deficiencies• Celiac disease• Delirium
Causes of Psychosis: Medical Illnesses
• Stimulants (including ADHD meds)• Steroids (therapeutic and anabolic)• Parkinson’s disease treatments• Opiate pain medications• Cardiovascular medications• Nonsteroidal anti-inflammatory
medications (e.g, aspirin, ibuprofen)• Antibiotics (ciprofloxacin)
Causes of Psychosis: Medications & Drugs
• Medications for ADHD are very much overprescribed.
• They are increasingly used as ‘performance-enhancing drugs.’
• Rate of psychosis from therapeutic doses is difficult to estimate. Estimates range from 0.25% to 5%.
Causes of Psychosis: Stimulants and Marijuana
• Short-term paranoia/psychosis is a widely-known cannabis side effect.
• Some users will develop long-lasting psychosis after years of regular (and otherwise unremarkable) cannabis use.
• Numerous well-designed epidemiological studies point to 200 – 500% increased risk of psychosis with long-term cannabis use.
• Not ‘medicinal’ for vulnerable brains.• “Spice” (synthetic cannabis) is a mental health disaster.
Causes of Psychosis: Stimulants and Marijuana
• Clinicians have to rely on history (of the individual patient as well as family medical and psychiatric history) – with attention to timing, nature of symptoms, co-occurrence with other symptoms, course of symptoms, age/time of onset, and many other factors.
• All patients with new-onset psychosis need a medical workup that excludes medical-toxic causes of psychosis
• A primary psychotic disorder, such as schizophrenia, is usually a diagnosis of exclusion.
Psychosis: How to know the cause
- Celiac disease involves antibodies formed against wheat protein.- Two case reports of schizophrenia-like psychosis in otherwise normal individuals who –
years later – developed clinical signs of celiac disease.- Grain+Milk-free diet accelerated rate of recovery from acute psychosis
Dohan, F.C., et al. (1969). Relapsed schizophrenics: more rapid improvement on a milk- and cereal-free diet. Br J Psychiatry 115, 595–596.
Psychosis: side note - gluten
Gluten antibodies are over-represented in schizophrenia
Psychosis: side note - gluten
Schizophrenian = 1,401
Control groupn = 900
Tissue transglutaminase antibodies
5.4% 0.8%
Anti-gliadin antibodies 23.1% 3.1%
Cascella, N. G. et al. Prevalence of celiac disease and gluten sensitivity in the United States clinical antipsychotic trials of intervention effectiveness study population. Schizophr Bull 37, 94–100 (2011).
• Detailed clinical history• Physical and Neurological exams• Blood count• Comprehensive chemistry panel• Urinalysis• Screening tests for inflammation• Thyroid studies• HIV and syphilis screens• Brain imaging
Psychosis: Exams and Tests
• Dopamine receptor blockers (‘antipsychotic’ medications)
• Clozapine• Lithium• Anti-epileptic• Antidepressant
Psychosis: Medications