How is psychosis usually diagnosed in Singapore?

Psychosis usually means that a person has lost touch with reality. That is, he/she cannot tell what is real and what is not real (imagined). It is a syndrome associated with abnormal functioning of the frontal and temporal lobes of the brain and the dopaminergic and serotoninergic projections to these areas.

The following are features of psychosis:

1. Perceiving things that are not there (hallucinations). For example, hearing voices, seeing ghosts or spirits, feeling someone touching him when there is no one there
2. Having abnormal beliefs (delusions). For example, that people are out to get him, that the government is following him, that he has special powers to save the world
3. Having disturbances in thinking and speech, manifested as disorganised thoughts and actions

A person with psychosis may not always find these experience distressing, although some people do. He may still be able to stay in work and function at a high level in his life, even if he has these experiences.

Cognitive experiences are ones that relate to mental action, such as learning, remembering and functioning. Some cognitive experiences associated with psychosis are:

• Being unable to concentrate
• Memory problems
• Unable to take in information
• Poor decision-making

Anyone can develop psychosis, men and women are equally affected. You’re most likely to first experience a psychotic episode in your early 20s, however, men are often in their teens.

There is no single cause of psychosis. It is likely that the following factors play a part:

1. Genetics – If you have a relative with psychosis, you are more likely to develop it yourself.
2. Chemicals – Natural increases in the chemical dopamine can cause hallucinations, delusions and disorganised thinking
3. Childhood trauma – There is some evidence that abuse or trauma in childhood can lead to experiencing psychosis at some point in a person’s life.
4. Drugs – Using cannabis, amphetamines, crystal meth or cocaine can increase the chance of developing psychosis
5. Stress – When a person is stressed, the brain releases a chemical called cortisol. This can increase the chances of psychosis.

Psychosis can be due to primary psychiatric disorders or can be secondary to substance use or specific medical causes. Primary psychotic disorders include:

• schizophrenia,
• delusional disorder,
• schizoaffective disorder,
• schizophreniform disorder, and
• brief psychotic disorder.

A psychotic syndrome may also accompany other psychiatric conditions such as major depressive disorder and bipolar disorder. Patients with psychosis associated with psychiatric disorders present with a combination of hallucinations (mostly auditory), delusions, and disorganized thought process, but are usually oriented and have minimal overt cognitive deficits.

With the exception of acute agitation, patients with psychosis (who are otherwise healthy) tend to have normal vital signs (blood pressure, pulse rate, temperature and respiration rate). Patients with psychosis secondary to drug use or medical causes often present with altered vital signs, visual hallucinations, and severe cognitive impairment, including confusion or disorientation.

A diagnosis of psychosis is made by a medical doctor. The following are parts of the assessment and evaluation:

1. History from patient
2. Assessment of the mental state
3. Accounts from family members or from someone who lives with the patient or knows the person well
4. Inpatient observation records
5. Results of blood tests or brain imaging

The evaluation of psychosis includes a physical exam, a complete psychiatric and medical history, and a laboratory work-up. The physical exam includes a detailed neurologic exam and a complete mental status exam, with the following areas of focus: mood and affect, thought process and content (including an evaluation of delusions, abnormal perceptions, suicidal and homicidal ideation, judgment, insight), and a cognitive exam.

The medical history should include a review of head injury, seizures, cerebrovascular disease, sexually transmitted infections, and new or worsening headaches. Collateral history from relatives is recommended to chart the onset and course of psychosis.

Hi,

Most people present to their family doctor, school counselor/teachers, or are noted by their family/friends to be suffering from psychosis, a condition which tends to start in adolescence or early adulthood.

Their symptoms may be seeing or hearing things that others do not (hallucinations), believing in unusual things such as being irrationally suspicious of others (paranoia), talking irrationally, acting in bizarre, non-characteristic ways, having an unusual change in personality, or unexplained changes in their mood.

Many are first seen by a family doctor who subsequently refers them to a psychiatrist for further evaluation. We then take a clear holistic history, do a thorough physical examination, and order appropriate investigations to exclude medical illnesses that may cause similar symptoms. Once that is done, a diagnosis of psychosis can be made and management discussed.