Chapter 36Assessment of Psychosis

• Medportal eLearning Course Modules (requires Medportal Login): Assessment of Psychosis
• ADMSEP eModules (requires Medportal Login): Psychotic Disorders

• Hallucinations – outside of range of normal (i.e. not hypnagogic or hypnopompic). Affected senses sometimes are diagnostic.
• Delusions – fixed, false beliefs outside of sociocultural norms (including family). These can change over time within a person.
• Disorganization– observers have difficulty understanding

• Affect flattening; Poverty of speech; Anhedonia; Slow withdrawal; ↓ Self Care; ↓ motivation

• Often paucity of movement to point of immobility

• Deficits in goal-directed behaviour; Deficits in Attention & Concentration; Difficulty Prioritizing; Difficulty Problem Solving; Memory deficits
• Anosognosia (Lack of insight) –important determinant of adherence to treatment

• “Craziness”; Antisocial Behaviour; Split Personality; Anger (avoid term “he went psycho”)

• Medications as Etiologies of Psychosis: Analgesics, anesthetics, anticholinergics, anticonvulsants, antihistamines, antihypertensives and CV medications, ABx, Antiparkinsonians, CTx, Corticosteroids, GI medications, muscle relaxants, NSAIDS, OCs (Phenylephrine, Pseudoephedrine), Antidepressants, Disulfiram.
• Substances of Abuse as Etiologies of Psychosis: Alcohol; Cannabis; PCP; Other Hallucinogen; Inhalant; Sedative, hypnotic or anxiolytic; Amphetamine (or other stimulant); Cocaine; Other (or unknown) substance.
  • Note on Cannabis: THC (tetrahydrocannabinol), is implicated as a risk factor for Schizophrenia particularly exposure to developing brain (around age 25). CBD (Cannabidiol) is an active area of research in the treatment of Schizophrenia.

Questions to Ask Patient:

• Have you had any strange or odd experiences lately that can’t be explained?
• Do you ever hear or see things that other people can’t hear or see?
• Do you ever feel that people are bothering you or trying to harm you?
• Does it seem that strangers look at you a lot or make comments about you?

Questions to Ask Yourself in Course of Interview:

• Are you (interviewer) having any trouble following the patient’s answers, understanding what they are trying to say?
• Is the patient pressured in speech?
• Does the patient seem unable to answer questions because of being perplexed or thought blocked?
• Does the patient go of the subject and get lost in their words?

• Have you felt under the control or influence of an outside force?

• Thought Insertion: Have you felt thoughts are being put into your mind? Do you experience telepathy?
• Thought Withdrawal: Have you experienced thoughts being taken out of your mind?
• Thought Broadcasting: Have you felt that other people are aware of your thoughts?
• Thought Echo: Have you experienced voices or people echoing your thoughts?

• Do you feel you are being singled out for special treatment? Is there a conspiracy against you?

• Do programs on the television or radio hold special meaning for you?

• Do you feel that a familiar person has been replaced by an imposter?

• Do you feel special, with unusual abilities or power?
• Do you have a special purpose to fulfill during your life?

• Are you a very religious person?
• Are you especially close with God in comparison to others in your faith group?

• Do you believe that you have sinned or have done something deserving punishment?

• Do you feel that something terrible has happened or will happen to you?
• Do you feel that a part of your body has stopped functioning? Been removed?
• Do you feel that you have died?

• Are you concerned that you might have a serious illness?
• Are you worried about your body?
• Do you worry that you might be being poisoned?

• How are you getting on with your partner? Do they feel the same way?

• I gather you have been under a lot of stress lately. Sometimes when people are under a lot of stress, they find that their imagination/mind plays tricks on them.
• Have you had any unusual experiences lately?
• Have you heard anything unusual, or have you heard anything that other people can’t hear?
• Have you seen anything unusual, or seen things that other people don’t notice, or see?

• ID: How many voices are there? Who are they?
• Content: What are they saying? Are they in the second person (talking to you), third person (two talking about you), or running commentary?
• OPQRST: What is frequency and duration of these voices? Is there any onset or precipitating factors?
• Command Hallucinations: Are they telling you to do things (command hallucinations)?

• Ask Open Ended Questions: As reviewed in MSE, open-ended questions can help reveal thought process, and can also allow psychosis to reveal itself.
• Take the patient’s perspective: try to understand the way they see the world – without affirming you believe it. “I believe that you’ve been experiencing it; and if we understand it better, we can come up with a plan to help you.” Psychosis can dictate patient perception; it is their truth the way they see it.
• Connect with the patient’s feelings and goals: Build rapport and trust; Show how your goals for treatment serve their interests, and base your treatment plans on their goals

• Summarize what you understand and feed it back: Did I get that right? → Bringing the patient along with you. Then ask their opinion about what they think is going on
• Use short statements and questions: Tell me more; what do you mean? I didn’t quite understand

• Explore: Focus patient’s attention on resistance: can you help me understand what that’s about?
• Consequences: Show advantages of giving up resistance – in Psych Emerg, let them know that you need to know what’s going on for you to assess safety to go home, or potential admission to hospital.
• Shifting: Can begin by focusing on area with less resistance e.g. things patient is comfortable talking about like work – then shift. May not necessarily start interview with Chief Complaint in this instance
• Induction to Bragging: Works more for Antisocial personality disorder but can also work in psychosis (or low self-esteem) – encourage the patient before talking about difficult topics.

• Focus on Suffering: Focus on suffering and how you can help. Accept patient’s misperceptions without challenging or explicitly labelling as hallucinations or delusions to the patient. They may recognize their delusions as disturbing, but not as a symptom. Choose non-clinical words; base your phrasing on the patient’s words. Appeal to the part of the individual that is scared, suffering and concerned.
• Negotiate plan without alienating: Hospitalization is security; medications protect against stress.
• Avoid Common Tropes: Avoid asking “What does this mean?” or “How did this make you feel?”
• Lack of Insight can improve with treatment: When on treatment for 6 months-1 year, insight may appear. There is risk patient stops their medication before insight comes, where management becomes difficult.

• Notice emotional signs; Try to express patient’s state of mind when appropriate.
• Patients may talk in metaphors to hide affect
• If you ignore affect, the patient may become distant – i.e. sense that you can’t feel what I’m feeling

H/D Rx 1DF

• H/D: Either Delusions or Hallucinations
• Rx: H/D developed soon after or during intoxication or withdrawal, and substance capable of producing these symptoms
• 1: 1-month window where psychosis could be substance-induced after the drug not taken
• D – Delirium: outside of delirium course
• F – Function: Markedly impaired

DSM-5 Correlation Highlights:

• DSM Criteria: 5 of 5 listed in H/D Rx 1DF
• Requires lack of insight into their hallucinations – if the patient realizes the hallucinations are substance induced, these would instead be classified as substance intoxication or withdrawal WITH PERCEPTUAL DISTURBANCE
• Specifiers → Onset with respect to Substance: During intoxication, or during withdrawal; Substance; Severity: HDSMN, each assigned a score from 0 to 4 (present and severe)

HDSM-11:

• H – Hallucinations
• D - Delusions
• S – Disorganized Speech: Derailment, incoherence
• M – Motor Behaviour: Grossly disorganized or catatonic
• 11 – 1 Day – 1 Month: Sudden onset (<2 wks), short duration (<1 month of acute phase symptoms), eventual full return of f(x)

DSM-5 Correlation Highlights:

• DSM Criteria: 1 of 4 of HDSM required to make the diagnosis, duration of active phase 1 day – 1 month
• Specifiers → Stressors: With marked stressors (stressful to almost anyone in similar circumstances); without marked stressors; and Postpartum onset (During pregnancy, or <4 weeks Post-Partum); Catatonia; Severity: HDSMN, each assigned a score from 0 to 4 (present and severe)

HDSMNF-6:

• H – Hallucinations
• D – Delusions
• S – Disorganized Speech: Derailment, incoherence
• M – Motor Behaviour: Grossly disorganized or catatonic
• N – Negative Symptoms: ↓ Emotional expression or avolition
• F – Function: Markedly impaired vs. prior to onset, failure to achieve expected functioning.
• 6 – 6 Months: Must have continuous signs of disturbance for 6 months, with 1 month of HDSMN symptom criteria.

DSM-5 Correlation Highlights:

• DSM Criteria: 2 of 5 of HDSMN, 1 of which must be H, D or S, duration >6mo; Note Schizophrenia DOES include the ↓ social f(x) criteria
• In situations where active phase symptoms remit within a month due to treatment, Criterion still met if clinician estimates they would not have remitted in absence of treatment
• Negative Symptoms: Common in Prodromal and Residual phase, can be severe. Social withdrawal → often first sign of disorder.
• Lack of Insight into illness: Most common predictor of non-adherence to treatment
• Neurological Soft Signs: ↓ Motor coordination, sensory integration, motor sequencing of complex movements, left-right confusion, and disinhibition of associated movements. Can be minor physical anomalies of face and limbs as well.
• Rule Out: Schizoaffective disorder and Depressive disorder or Bipolar disorder with psychotic features → no major concurrent mood/manic symptoms, or very brief duration vs total course (<50%)
• ASD or Childhood Communication D/O: Can only give Schizophrenia diagnosis if H/D present 1 month+ with Schizophrenia base criteria

Specifiers → Course: Same as Delusional Disorder; Catatonia; Severity: HDSMN, each assigned score from 0 to 4 (present and severe)

HDSMN + M

• H – Hallucinations:
• D – Delusions:
• S – Symptoms
• M – Motor Behaviour
• N – Negative Symptoms
• +
• M – Mood: Major episode concurrent with active schizophrenia (must include depressed mood i.e. can’t make diagnosis only with anhedonia + SIGECAPS), present for majority of duration of active + residual portions (>50%)

DSM-5 Correlation Highlights

• DSM Criteria: Meeting criteria for Schizophrenia, with uninterrupted period of illness with a concurrent major mood episode. In addition, must have Hallucinations or Delusions 2+ weeks in absence of major mood episode. Major mood episode criteria must be met in majority (>50%) of lifetime duration of illness.
• Specifiers → Mood Type: Bipolar or Depressive Type; Catatonia; Course: Same as Delusional Disorder; Severity: HDSMN, each assigned a score from 0 (not present) to 4 (present and severe)
• Note: No ↓ Social f(x) criterion to make the diagnosis (can be present, though)
• Schizoaffective Disorder’s time can begin with a manic/depression S(x), not necessarily needs to be related to the FEP.
• Negative Symptoms: May be less severe and persistent than in schizophrenia.
• Anosognosia (Poor Insight): Common in Schizoaffective disorder –less severe and pervasive than in Schizophrenia
• Mood Disorders: Individuals with Schizoaffective Disorder at ↑ risk for developing episodes of MDD or Bipolar disorder if mood symptoms persist after Schizophrenia symptoms dissipate

Major Change between DSM-IV and DSM-5: Mood symptoms measured over entire course of psychotic illness, vs. assessment of current period of illness. If mood symptoms remit but schizophrenia symptoms persist, diagnosis can then switch back to Schizophrenia.

CAMP NEWS GEMS

• C – Catalepsy: Passive induction of posture held against gravity
• A – Agitation: Not influenced by external stimuli
• M – Mannerism: Odd, circumstantial caricature of normal actions
• P – Posturing: Spontaneous, active maintenance against gravity
• N – Negativism: Opposition/no response to instructions/external stimuli
• E – Echopraxia: Mimicking another’s movements
• W – Waxy Flexibility: Slight & even resistance to positioning by examiner
• S – Stupor: No psychomotor activity; not actively relating to environment
• G – Grimacing
• E – Echolalia: Mimicking another’s speech
• M – Mutism: Minimal to no verbal response (exclude if known aphasia)
• S – Stereotypy: Repetitive, abnormally frequent, non-goal-directed movements

DSM-5 Correlation Highlights:

• DSM Criteria: 3 of 12 listed in CAMP NEWS GEMS
• Catatonia - in general: Patient sits or lies expressionless, motionless and mute, sometimes in very uncomfortable or contorted postures. There are 12 psychomotor features, and Catatonia is its own diagnosis (see below)

HDSMN-16:

• H – Hallucinations
• D - Delusions
• S – Disorganized Speech: Derailment, incoherence
• M – Motor Behaviour: Grossly disorganized or catatonic
• N – Negative Symptoms: ↓ Emotional expression or avolition
• 16 – 1 Month – 6 Months: Either duration 1-6 months (active phase), or examination after 1 month, before 6 months.

DSM-5 Correlation Highlights:

• DSM Criteria: 2 of 5 of HDSMN required to make the diagnosis, duration of active phase 1 month – 6 months.
• Note: No ↓ Social f(x) criterion to make diagnosis
• Specifiers → Prognostic Features: 2 of 4 - Good (Onset of prominent psychotic symptoms < 4wks before first change; confusion/perplexity; good premorbid f(x); absence of blunted/flat affect); Catatonia; Severity: HDSMN, each given score from 0 to 4 (present, severe)
• Key Idea: 1/3rd will recover – Schizophreniform is final diagnosis; 2/3rd will not recover – either Schizophrenia or Schizoaffective Disorder is final diagnosis

BDNF: 4 of 4

• B – Brief Mood: Depressive/manic episodes minor in comparison to duration of delusions
• D – Delusions: 1 month or longer
• N – Not Schizophrenia: Criterion A (HDSMN) never met
• F – Function: Not markedly impaired

DSM-5 Correlation Highlights:

• Specifiers → Delusion Type: Erotomanic; Grandiose; Jealous; Persecutory; Somatic; Mixed; or Unspecified (doesn’t fit the described specific types); Bizarre Content; Course:
  • 1st episode, current acute episode (full criteria met)
  • 1st episode, current partial remission (partial criteria)
  • 1st episode, currently in full remission (no criteria met)
  • Multiple Episodes, currently in acute episode
  • Multiple Episodes, currently in partial remission
  • Multiple Episodes, currently in full remission
  • Continuous: Periods of subthreshold symptoms are very brief vs course

• A positive CAM tool requires the presence of both features 1 & 2 and either feature 3 or 4

• 1) Acute Onset, Fluctuating Course

  • Is there evidence of an acute change in mental status from patient’s baseline?
  • Did the (abnormal) behaviour fluctuate during the day, that is, tend to come and go, or increase and decrease in severity?

• 2) Inattention

  • Did the patient have difficulty focusing attention, for example, being easily distractible, or having difficulty keeping track of what was being said?

• 3) Dis-organized Thinking

  • Was the patient’s thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject?

• 4) Altered Level of Consciousness

  • Overall, how would you rate this patient’s level of consciousness? (alert [normal]), vigilant [hyperalert], lethargic [difficult to maintain aroused state], obtunded [responds to stimulation other than pain], stupor [only to pain], or coma [unresponsive to pain]) - Negative screen if “alert”, otherwise positive

Why Check: Delirium is a disturbance of attention or awareness accompanied by a change in baseline condition that cannot be better explained by a pre-existing or evolving Neurocognitive Deficit. It is relatively common, with a community prevalence of 1-2%, a prevalence of 14-24% on hospital admission, and a prevalence of 83% at end of life. Delirium is frequently missed by healthcare provider assessment, and is associated with increased mortality, with a risk of persistent cognitive dysfunction particularly in patients with underlying dementia. Delirium is a clinical diagnosis that can present as hyperactive (agitated behaviour, ↑ psychomotor activity), hypoactive (↓ psychomotor activity – can be mistaken as depression) or mixed (most common). A positive CAM greatly increases the likelihood of delirium (LR+ 10.3, LR- 0.2).

• A – Acute: Onset hours-days
• A – Attention & Awareness: ↓ ability to direct, focus, sustain, shift & ↓ orientation to environment
• C – Cognition Disturbance: Memory, disorientation, language, visuospatial ability, perceptions
• A – Arousal: not severely reduced (not a coma)
• E – Etiology: Physiological consequence of underlying medical condition, substance intoxication or withdrawal, medication, toxin, or combination.

• 3 Delirium Types: Hyperactive (Agitated); Hypoactive (↓ LoC, worse at night); and Mixed (mixture of Hyperactive & Hypoactive)
• Specify Etiology: Substance intoxication delirium; Substance withdrawal delirium; Medication-induced delirium; Delirium from other medical condition; Delirium from multiple etiologies

• Prescription medications: Any new or recent changes to medications? Are there any neurogenic or psychogenic medications? Are there medications that may lead to electrolyte abnormalities? Has the patient experienced any medication-related adverse effects?
• Illicit substances: Any signs of acute drug intoxication? Of overdose? Of withdrawal? Any history of substance use disorders?
• Consider toxicology panel (urine/plasma, ethanol, etc.).
• Common Causes: Benzodiazepine Use/Withdrawal; Anticholinergics; Corticosteroids; Alcohol Use/Withdrawal; Opioid Use; Anti-Parkinsonian Drugs; Stimulants; Cardiac glycosides

• Is the patient febrile? qSOFA: sBP ≤100, RR >20, or GCS ≤14? Tachycardia?
• Consider urinalysis, chest x-ray, blood cultures.
• Common Causes: Pneumonia, UTI, Sepsis, CNS infections (meningoencephalitis, brain or epidural abscess), Neurosyphillis, etc.

• Any conditions that may cause electrolyte derangements? Any past history of endocrine disorders? Any past episodes of hypoglycemia?
• Consider CBC, electrolytes, extended electrolytes, glucose, creatinine, liver function tests, TSH.
• Common Causes: ↑/↓ Na, Hypercalcemia, Hyper/hypo-glycemia, Acute Kidney Injury, Uremia, Hypercarbia, Hypoxia, Acidosis, Hepatic Encephalopathy, Wernicke’s Encephalopathy/Korsakov’s Psychosis (re. Thiamine deficiency), Hyper/hypothyroidism, etc.

• Any head injuries or trauma? Recent falls? Features of stroke or intracranial hemorrhage? Focal/Non-focal neurological findings? History of cancer, particularly those with common brain mets (lung, breast, colon, renal cell, melanoma)?
• Consider CT head or MRI head.
• Common Causes: CNS infection (meningoencephalitis, brain or epidural abscess); Epileptic seizures; Hemorrhagic or ischemic stroke, Intracranial tumor (primary or metastatic), etc.

• MMSE: More sensitive for dementia, than detecting a Mild Cognitive Impairment (MCI → 10% of MCI patients will progress to Alzheimer’s Disease each year)
• MoCA: More sensitive to detecting a Mild Cognitive Impairment (MCI) – visit https://mocacognition.com/paper, which has 3 versions available with different questions for each dimension assessed and is also available in multiple languages. Using different versions on repeat assessment helps avoid a practice effect where patient might recall the test or may have studied.
• Mini-Cog: An alternative, 3-question test useful for screening individuals in need of further evaluation (not in diagnosing MCI), i.e. in general practice where your clinical suspicion of MCI is low. Link to copies of the test and scoring guide. Emphasis on word registration & recall (Delayed Recall in MOCA & MMSE), and clock drawing (Part of MOCA).

Why Check: Note that Normal Aging may include subjective cognitive changes from baseline without evidence of objective impairment (i.e. testing normal), not affecting social or usual daily activities. The Canadian Task Force on Preventive Healthcare strongly recommends NOT routinely screening asymptomatic adults aged 65 years and older, but to remain alert to symptoms suggestive of cognitive decline or impairment and/or concerns expressed by patient supports and undertake appropriate diagnostic testing if warranted³. To screen for neurocognitive disorders, either major (e.g. dementia) or mild (e.g. mild cognitive impairment), the MMSE, MoCA or Mini-Cog are helpful tools. Importantly, these tools screen but do NOT diagnose neurocognitive disorders.

• Abnormal clock-drawing test (part of Mini-COG and MOCA) moderately increases the likelihood of dementia (LR+ 5.3, LR- 0.5)
• MOCA: Validated for Outpatient setting only (whereas Mini-Cog and MMSE are validated both in hospital and in the outpatient setting); useful for screening for Mild cognitive impairment (MCI)
• MMSE: The likelihood of suspected dementia is increased by MMSE score ≤20 (LR+ 14.5), ≤23 (LR+ 8.1, LR- 0.2), and 21-25 (LR+ 2.2), while it is greatly decreased by MMSE score ≥26 (LR+ 0.1).

(Threshold of MOCA < 26 on screening assessment)

DSM-5 Diagnostic Criteria

• Evidence of a modest cognitive decline in 1+ cognitive domains (Complex attention, Learning/ memory, Language, Executive function, Perceptual-Motor, Social Cognition) based on concern of individual, knowledgeable informant, or clinician and modest impairment in cognitive performance (e.g. by standardized neuropsychological testing or, in its absence, another quantified clinical assessment).
• Cognitive deficits do not interfere with independence in everyday activities (but may require greater effort, compensatory strategies, or accommodation to manage ADLs/IADLs).
• Cognitive deficits do not occur exclusively in context of a delirium.
• Cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder, schizophrenia)

(Threshold of MMSE < 24 on screening assessment)

DSM-5 Diagnostic Criteria

• Evidence of significant cognitive decline in 1+ cognitive domains (6 domains – see above) based on concern of individual, knowledgeable informant, or clinician and substantial impairment in cognitive performance (e.g. by standardized neuropsychological testing or, in its absence, another quantified clinical assessment)
• Cognitive deficits interfere with independence in everyday activities (e.g. at minimum requiring assistance with ADLs/IADLs).
• Cognitive deficits do not occur exclusively in context of a delirium.
• Cognitive deficits are not better explained by another mental disorder (e.g. major depressive disorder, schizophrenia)
• Note: CMA Driving Guide defines moderate-severe dementia as a Loss of 1 ADL or 2+ IADLs

• Specify Etiology (for Mild or Major Neurocognitive Disorder): Alzheimer’s disease; Frontotemporal lobar degeneration; Lewy body disease; Vascular disease; Traumatic brain injury; Substance/medication use; HIV infection; Prion disease; Parkinson’s disease; Huntington’s disease; Another medical condition; Multiple etiologies; Unspecified