Psychoses

Definition

Psychoses are conditions characterized by loss of contact with reality and disordered thinking processes, such as delusions—a firm belief in the false or impossible—and hallucinations—seeing or hearing things that others cannot see or hear.

Description

People with psychoses are referred to as being psychotic. In addition to delusions and/or hallucinations they may be paranoid—unreasonably suspicious or fearful. Psychoses can develop gradually or appear suddenly. In older adults psychoses are usually associated with other disorders, especially dementia, delirium , or mood disorders such as depression .

Psychosis is a symptom of schizophrenia. Some older adults may have first developed symptoms of schizophrenia as adolescents or young adults or in middle age; however, most seniors with psychoses have their first symptoms in old age. Many psychotic seniors have paraphrenia, characterized by paranoid delusions and hallucinations.

Delirium, which is also called toxic psychosis, is characterized as an acute confused state, a common complications of an illness or recovery from surgery in older adults. The term ICU psychosis (also called ICU syndrome) refers to the sudden onset of severe psychiatric symptoms in patients being treated in intensive care units following surgery. Hallucinations and paranoia are common with delirium.

Seniors may be reluctant to seek help for psychoses because they may not understand mental disorders or are ashamed of their symptoms and because Medicare offers few benefits for psychiatric care.

Demographics

Psychoses may affect as many as one out of every 50 seniors, and it is expected that as the elderly population increases there will be a large increase in the number of people with psychoses. (Prevalence differs from community dwelling elders and elders in nursing homes.) The initial onset of schizophrenia in older men is very rare, since males usually develop schizophrenia in adolescence or early adulthood. Women can develop schizophrenia at a somewhat older age—about 2% of cases are after age 45 and 10 to 15% after age 59. In addition about 4.5 million Americans suffer from the progressive dementia of Alzheimer's disease , and at some point most patients with advanced Alzheimer's experience delusions and possibly hallucinations.

Causes and symptoms

Causes

Psychoses almost always have a biological basis. They may be a temporary symptom of another mental or physical disorder or the primary symptom of a chronic psychotic disorder. The exact cause of psychoses is unknown although some researchers believe that they result from an overreaction in the brain to neurotransmitters, the chemicals that carry messages between neurons.

Common causes of psychoses in elders include:

• neurologic disorders such as stroke or Parkinson's disease
• mood disorders such as severe depression or bipolar disorder
• schizophrenia, which often runs in families
• other emotional or mental disorders such as delirium or dementia.

Lewy body dementia is more likely to cause psychoses with paranoia, delusions, and hallucinations than are other types of dementia such as Alzheimer's disease. Hallucinations with Lewy body dementia usually develop earlier in the disease progression than in cases of Alzheimer's. The hallucinations are usually visual and often detailed, complex, and even pleasant.

Other causes of psychoses in seniors include:

• brain injury from a tumor or stroke
• recovery from anoxia or hypoxia, in which the supply of oxygen to the brain is diminished due to events such as a heart attack or heart surgery
• Huntington's disease, an inherited disorder that develops in middle age
• a manganese deficiency that results in schizophrenic symptoms
• temporary psychoses from a physical illness such as a severe infection or from extreme stress
• repeated use of cocaine at increasingly high doses
• temporary psychosis from excessive alcohol or chronic psychosis from long-term alcohol abuse.

Drugs used to treat mental or neurologic conditions that may cause temporary psychoses include:

• opioid analgesics
• benzodiazepines
• digoxin
• drugs with anticholinergic side effects
• corticosteroids for pain management
• levodopa and dopamine agonists used to treat Parkinson's disease.

ICU psychosis is a common but temporary event among older adults hospitalized in an intensive care unit (ICU). These patients are seriously ill and are subjected to numerous medical tests and medications. ICUs can be very confusing, with beeping electronic monitors, bright lights, and frequent sleep interruptions. Also the rooms or cubicles may be without clocks or windows.

Symptoms

Delusions and hallucinations are the primary symptoms of psychoses. However, even with chronic psychoses, symptoms may come and go. Some people have delusions that they are famous. People with paranoid delusions may fear that others are controlling their lives, persecuting them, or have concocted elaborate plots against them. They may believe that family or friends have deserted them or are trying to take their money or property. These types of paranoid delusions are among the most common symptoms of schizophrenia in older adults. Hallucinations are also common among older schizophrenics and may involve several senses.

Psychoses in severely depressed people usually involve delusions. People with psychotic depression may have delusions of being worthless, sinful, or impoverished. Psychotic depression may also cause hallucinations. People may be frightened by their hallucinations or simply accept them.

People with a type of psychosis called delusory parasitosis itch all over their bodies and believe they are covered with parasites. They sometimes give detailed descriptions of the insects crawling over their skin.

About 10% of people with severe vision loss have visual hallucinations but no other symptoms of psychoses, and they are usually aware that what they are seeing is not real.

People with psychoses may spend a great deal of time by themselves or in bed. They may sleep all day and stay awake all night. They may be unable to care for their personal hygiene and may seem withdrawn and apathetic. They may get angry or excited for no apparent reason. Delusions and hallucinations can lead to bizarre behavior. Older adults who become overly suspicious may isolate themselves from family and friends. People who believe that their food is being poisoned may develop unusual eating habits or avoid food altogether, leading to malnutrition . Psychoses are a common cause of behavioral problems in people over 65, including wandering, disruptive verbal outbursts, and physical aggressiveness. However, seniors with paraphrenia are often able to communicate and function well despite their delusions and/or hallucinations.

Diagnosis

Psychoses are diagnosed by their symptoms. The cause of the psychosis is then determined based on the following:

• a review of the patient's prescription and nonprescription medications
• blood tests for the presence of drugs that can cause psychoses
• a physical exam and blood tests to determine whether a medical problem is causing or contributing to the psychosis
• computed tomography (CT) or magnetic resonance imaging (MRI) of the brain if there are neurological symptoms such as weakness on one side of the body.

Treatment

If the psychosis is caused by another disorder, such as severe depression, treating that disorder may alleviate the symptoms. If the psychosis is caused by a drug, changing the medication usually relieves the psychotic symptoms. ICU psychosis can be alleviated by moving the patient to a calmer environment. Support and reassurance from family, friends, and healthcare providers is an important aspect of treating psychoses.

Since most psychoses appear to be biological in origin, they are treated with antipsychotic medications rather than psychotherapy. Psychotic depression may be treated with antipsychotics in combination with an antidepressant. The antipsychotic is usually discontinued once the antidepressant takes effect. Antipsychotics are also occasionally used to treat delusions and hallucinations in people with Parkinson's disease, stroke , or other brain disorders. If people with visual hallucinations due to vision loss become unable to distinguish the hallucinations from reality or become very distressed, they may be treated with antipsychotic medication.

Treatment usually begins with a low dosage of an antipsychotic, and the dosage is increased gradually every few days while the healthcare provider checks for potentially serious side effects. Some antipsychotics are taken just once a day and may be taken at bedtime to reduce side effects such as sleepiness. In general older adults who respond to an antipsychotic are kept on the lowest effective dosage for at least six months. If there is a relapse after the initial treatment the antipsychotic may be continued indefinitely.

Typical antipsychotics

Antipsychotics, also called neuroleptics, affect dopamine, a neurotransmitter that is thought to be involved in schizophrenia. Antipsychotics were first introduced in the 1950s and they differ primarily in their potency and side effects. These typical antipsychotics include:

• chlorpromazine
• fluphenazine
• haloperidol
• loxapine
• mesoridazine
• molindone
• perphenazine
• pimozide
• thioridazine
• thiothixene
• trifluoperazine.

All of these antipsychotics have numerous possible side effects:

• dry mouth
• constipation
• weight gain
• fever
• drowsiness, sedation
• restlessness
• dizziness
• blurred vision
• increased heart rate
• decreased blood pressure
• tremors
• seizures
• muscle stiffness progressing to rigidity
• muscle damage, known as neuroleptic malignant syndrome.

QUESTIONS TO ASK YOUR DOCTOR

• What is meant by psychosis?
• What do you think is causing my psychosis?
• Could I have schizophrenia?
• How does schizophrenia differ in older adults as compared with younger people?
• Could my psychosis be associated with another disorder such as dementia?
• Might talk therapy or psychotherapy help me?
• What medication should I take?
• What are the possible side effects or dangers of this medication?
• What do I need to do to remain in my home?

Perhaps the most dangerous side effect of these antipsychotics is tardive dyskinesia (TD), which most often affects the muscles of the face causing people to involuntarily grimace, smack their lips, or stick out their tongues. It can also cause rocking back and forth, marching in place, wiggling fingers, rotating ankles, or writhing of the arms or legs. The drug is usually discontinued at the first sign of TD. However, TD may not go away after the drug is discontinued, and there is no effective treatment for it. The risk of TD with typical antipsychotics is 5% per year of medication. Women are at greater risk and the risk increases with age.

Long-term treatment with typical antipsychotics often leads to a syndrome called parkinsonism, with symptoms that are similar to Parkinson's disease. Symptoms of parkinsonism usually disappear after the drug is discontinued; however, sometimes the symptoms persist or even increase for a short time. Years of treatment with high doses of antipsychotics can result in irreversible parkinsonism.

These medications are generally not prescribed for patients who have problems with balance or stability, since they increase the risk of falling. Thioridazine can cause life-threatening abnormal heart rhythms and requires routine eye examinations.

Atypical antipsychotics

Newer or atypical antipsychotics, introduced beginning in 1990, are much better tolerated by older adults since they are less likely to cause fever, tremor, muscle stiffness and damage, and TD. These drugs include:

• aripiprazole
• clozapine
• olanzapine
• quetiapine
• risperidone
• ziprasidone.

Intramuscular administration of ziprasidone has been shown to be an effective treatment for older adults with schizophrenia.

Most of the side effects of these newer anti-psychotics are mild, and those such as drowsiness, rapid heartbeat, and dizziness usually disappear after the first few weeks. Clozapine is seldom prescribed because it can cause seizures and prevent bone marrow from producing white blood cells to fight infections. However, it is often effective when other antipsychotics are not, and it is the drug of choice for treatment-resistant schizophrenia. Patients on clozapine should have blood tests every one to two weeks. Clozapine and ziprasidone may cause abnormal heart rhythms, and risperidone can increase the risk of stroke in people with dementia.

The treatment of psychoses in patients with dementia has been problematic. Antipsychotic drugs are commonly administered to elderly patients in long-termcare facilities and about one-third of the estimated 2.5 million Medicare recipients in nursing homes in the United States have been given atypical antipsychotics. However, they are not approved by the U.S. Food and Drug Administration for use in Alzheimer's patients. Studies suggest that they are ineffective in treating psychoses related to Alzheimer's disease and that the side effects and risks outweigh any benefits.

Nutrition/Dietetic concerns

There is some evidence that manganese and zinc supplements may improve psychotic symptoms in schizophrenics. However, manganese can increase blood pressure in older people and possibly cause headaches .

Prognosis

If psychoses are caused by depression, sleep deprivation, or another treatable disorder, treating the disorder often cures the psychoses. However, if the primary symptom is chronic psychosis or if the psychosis is associated with dementia, long-term drug treatment and supportive care from family, friends, and healthcare providers can significantly improve the quality of life for many people.

KEY TERMS

Antipsychotics —Powerful tranquilizers used to treat psychoses by blocking dopamine receptors on nerve cells.

Delirium —A mental condition characterized by confusion, disordered speech, and hallucinations.

Delusory parasitosis —A type of psychoses in which people believe that there are insects crawling over their skin.

Dementia —A progressive brain disorder characterized by confusion, memory loss, and inability to think and reason.

Dopamine —A neurotransmitter in the brain.

ICU psychosis —A psychosis that results from being confined in a hospital intensive care unit.

Lewy body dementia —A form of dementia characterized by the formation of abnormal round bodies in regions of the brain involved in thinking and movement; often includes hallucinations.

Neuroleptics —Antipsychotics.

Neurotransmitter —A substance that helps transmit impulses between nerve cells.

Paraphrenia —A group of mental disorders characterized by paranoia; includes paranoid schizophrenia.

Parkinsonism —A group of neurological conditions that resemble Parkinson's disease; caused by the deficiency or blockage of dopamine by drugs, toxins, or disease.

Schizophrenia —A psychotic disorder characterized by delusions, hallucinations, personality disintegration, and deterioration of everyday functioning.

Tardive dyskinesia (TD) —A neurological disorder characterized by uncontrollable movements and caused by the prolonged use of antipsychotics.

Antipsychotic medications do not cure psychoses, but they can reduce or eliminate delusions and hallucinations or shorten a psychotic episode. They may need to be continued indefinitely to prevent further episodes. Antipsychotic medications generally appear to be as effective in older adults as in younger people. Patients experiencing their first psychotic episode often respond better to antipsychotics than those with chronic psychosis, but they may experience more side effects from the drugs. Finally, both typical and atypical antipsychotics may increase the risk of death in elderly patients.

If the psychosis is a component of another mental disorder such as dementia, it may not respond as well to antipsychotics, and the patient may become increasingly paranoid, distraught, angry, or even violent. Paranoia associated with dementia can be unpredictable, often changing its form.

Caregiver concerns

Patients with psychoses require reassurance and support. They should not be confronted about their delusions and hallucinations. Caregivers should acknowledge that the patient believes something or sees or hears something that the caregivers do not and that this is upsetting. Patients should be encouraged to maintain social contacts and support networks, and caregivers should remind them of who the people around them are and reassure them of their safety.

Resources

BOOKS

Hassett, Anne, et al., eds. Psychosis in the Elderly. New York: Taylor & Francis, 2005.

Henderson, Claire, ed. Women and Psychiatric Treatment:A Comprehensive Text and Practical Guide. New York: Routledge, 2006.

PERIODICALS

Broadway, Jessica, and Jacobo Mintzer. “The Many Faces of Psychosis in the Elderly.” Current Opinion in Psychiatry 20, no. 6 (November 2007): 551.

Carey, Benedict. “Drugs to Curb Agitation Are Said to Be Ineffective for Alzheimer's.” New York Times (October 12, 2006): A1.

“Psychosis: U.S. FDA Issues Public Health Advisory for Antipsychotic Drugs in Elderly.” Science Letter (May 3, 2005): 1416.

Schneeweiss, Sebastion, et al. “Risk of Death Associated with the Use of Conventional versus Atypical Anti-psychotic Drugs Among Elderly Patients.” Canadian Medical Association Journal 176, no. 5 (February 27, 2007): 627–632.

OTHER

“Elder Health at Your Fingertips: Chap. 34: Psychoses (Delusions and Hallucinations).” Aging in the Know. May 25, 2005 [cited April 1, 2008]. http://www.healthinaging.org/agingintheknow/chapters_ch_trial.asp?ch=34#top.

ORGANIZATIONS

American Geriatrics Society, Foundation for Health in Aging, Empire State Building, 350 Fifth Ave., Suite 801, New York, NY, 10118, (212) 755-6810, (800) 563-4916, (212) 832-8646, [email protected], http://www.healthinaging.org>.

American Psychiatric Association, 1000 Wilson Blvd., Suite 1825, Arlington, VA, 22209, (703) 907-7300, (888) 35-PSYCH, [email protected], http://www.healthyminds.org.

Geriatric Mental Health Foundation, 7910 Woodmont Ave., Suite 1050, Bethesda, MD, 20814, (301) 654-7850, (301) 654-4137, [email protected], http://www.gmhfonline.org.

International Psychogeriatric Association, 550 Frontage Road, Suite 3759, Northfield, IL, 60093, (847) 501-3310, (847) 501-3317, http://www.ipa-online.org.

National Alliance on Mental Illness, Colonial Place Three, 2107 Wilson Blvd., Suite 300, Arlington, VA, 22201-3042, (703) 524-7600, (888) 950-NAMI, (703) 524-9094, http://www.nami.org.

National Institute of Neurological Disorders and Stroke, NIH Neurological Institute, PO Box 5801, Bethesda, MD, 20824, (301) 496-5751, (800) 352-9424, http://www.ninds.nih.gov.

National Mental Health Information Center, PO Box 42557, Washington, DC, 20015, (800) 789-2647, (240) 221-4295, http://mentalhealth.samhsa.gov.

Margaret Alic Ph.D.