Description
“Psychosis” is a broad term, however for the purpose of this document can be taken to refer primarily to schizophrenia and associated disorders namely, schizoaffective disorder and other Schizophreniform disorders.
Schizophrenia and associated psychotic disorders are typically characterised and often initially diagnosed through the recognition of psychotic phenomena. These include “first rank” symptoms such as delusional ideas, hallucinatory experiences and formal thought disorder. Individuals will also often present with negative symptoms, these tend to manifest as diminished motivation, social blunting, poverty of speech, self neglect and social withdrawal.
ICD 10- Schizophrenia:
- Thought broadcast, insertion, withdrawal or blocking
- Delusions of control influence or passivity
- Hallucinatory voices providing a running commentary, discussing the patient, emanating from a body part or thought echo
- Persistent delusions of other kinds that are culturally inappropriate and completely impossible
- Persistent hallucinations in any other modality accompanied by half formed delusional ideas
- Formal thought disorder, blocking, irrelevant speech, neologisms
- Catatonic behaviour – excitement, posturing or waxy flexibility
- Negative symptoms – apathy, paucity of speech, blunting, incongruous affect
- Decline in functioning, interpersonal, occupational
ICD 10 – Schizoaffective disorder
A disorder characterised by the simultaneous presence of affective symptoms and symptoms of schizophrenia (as listed above) during the same episode of illness.
Who to refer [based on www.nice.org.uk guidance cg178]
First Episode Psychosis
If a person is distressed, has a decline in social functioning and has:
- transient or attenuated psychotic symptoms or
- other experiences or behaviour suggestive of possible psychosis or
- a first-degree relative with psychosis or schizophrenia
Refer them urgently for assessment without delay to a specialist mental health service. Please accompany your urgent referral with a phone call in line with urgent referral protocols-but especially important her to help work out if this might be first episode psychosis, or to get advice on interim management.
For acutely ill patients at risk of rapid deterioration, or harm to themselves or others please see mental health emergencies here.
Relapse and re-referral to secondary care in individuals with established illness
When a person with an established diagnosis of psychosis or schizophrenia presents with a suspected relapse (for example, with increased psychotic symptoms or a significant increase in the use of alcohol or other substances), primary healthcare professionals should refer to the crisis section of the care plan. Consider referral to the key clinician or care coordinator identified in the crisis plan.
For a person with psychosis or schizophrenia being cared for in primary care, consider referral to secondary care again if there is:
- poor response to treatment
- non-adherence to medication
- intolerable side effects from medication
- co morbid substance misuse
- risk to self or others
When re-referring people with psychosis or schizophrenia to mental health services, take account of service user and carer requests, especially for:
- review of the side effects of existing treatments
- psychological treatments or other interventions
Who not to refer
- Medication advice for stable patients can be requested without need for full referral. This can be done by marking clearly on the referral ‘Advice Only’
- Patients in whom substance misuse is the primary problem [and not being used to mask psychotic symptoms] – these patients should be directed towards Substance Misuse services – please see here.
- Patients with stable ‘voice hearing’ who are known not to have schizophrenia. Support is available from the Hearing Voices Network if wished (http://www.hearing-voices.org/).
- Patients requesting referral for diagnosis where the presentation does not fit with ICD-10 diagnostic criteria for schizophrenia and there is no suspicion of other underlying mental health problems requiring specialist diagnosis and input.
How to Refer
Please refer via SCI Gateway. An outline of patient’s current presentation and specifically any risks posed in the situation is helpful including risk of self-harm, vulnerability to exploitation, risk of financial or employability harm, risk to any dependents of neglect or other harm. If the patient is new to the area, please include old letters if you have them.
Summary of primary care management [based on NICE CG 178]
First Episode Psychosis
Do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist. This referral should be marked ‘urgent’ as the standard is to see the patient within one week and should certainly not wait as long as a routine referral. Where there is a risk to the patient or others, please see here for details of emergency mental health services.
For guidance on assessment and management see NICE Clinical guideline – 178:
https://www.nice.org.uk/guidance/cg178/chapter/1-Recommendations
Patient Information:
Royal College of Psychiatrists: https://www.rcpsych.ac.uk/mental-health/problems-disorders/schizophrenia
Mind : https://www.mind.org.uk/information-support/types-of-mental-health-problems/schizophrenia
Rethink Mental Illness [formerly the National Schizophrenia Fellowship]: https://www.rethink.org/advice-and-information/about-mental-illness/learn-more-about-conditions/schizophrenia/
Hearing Voices Network: http://www.hearing-voices.org/
