The Maudsley Guidelines on Advanced Prescribing in Psychosis

Paul Morrison, David M. Taylor, Phillip McGuire

• Publisher: Wiley-Blackwell
• Year: 2019
• Print ISBN: 9781119578444
• eBook ISBN: 9781119578437
• Edition: 1
• Topic: Medicine
• Subtopic: Psychiatry & Mental Health

A guide to treating psychosis that provides information on drug options and side-effects in order to allow for weighing treatment options knowledgably

The Maudsley Guidelines on Advanced Prescribing in Psychosis offers a resource that puts the focus on the need to treat the individual needs of a patient. The authors – noted experts on the topic – offer an alternative to the one-size-fits-all treatment of psychosis and shows how to build psychiatrist and patient relationships that will lead to effective individual treatment plans.

The book provides up-to-date data and information about commonly used anti-psychotic drugs and drugs used in bipolar disorder. The text weighs both the upsides and downsides of each pharmaceutical presented, and helps prescribers and patients weigh the costs and benefits of various options to reach an appropriate treatment plan. The authors highlight the treatment at a population level and the systems in which individual treatments take places. This important resource:

• Facilitates the tailoring of an appropriate treatment plan for clients manifesting signs of psychosis
• Offers a comparative strategy that helps gauge the suitability of one treatment plan over another
• Provides at-hand data and information about commonly used anti-psychotic drugs
• Includes an understanding of the origins and side-effects of each drug presented

The Maudsley Guidelines on Advanced Prescribing in Psychosis offers psychiatrists and other mental health practitioners an essential guide for treating psychosis on an individualized level.

Chapter 1
Psychosis

1.1 What is psychosis?

Psychiatry has always struggled with terms and definitions. Canvass the opinions of a modern community multidisciplinary team, and there are likely to be a range of opinions on what psychosis actually is [1]. Yet very few will object to the phenomenological perspective, which captures the seriousness of just what is at stake in psychosis. That is because psychosis impacts upon the highest and most personal faculties of the human mind.

In short, psychosis describes a disturbance of perception, thinking, beliefs, or selfhood in which the patient experiences a fundamental transformation in their experience of lived reality. This transformation can be terrifying as in paranoid psychoses or thrilling as in mania. Psychosis can emerge and dissipate quickly or become ingrained in the mind/brain over many months. Some patients seek safety by withdrawing from the world, whereas others attract attention to their mental state through excited, agitated, bizarre, or catatonic behaviour.

1.2 Lack of insight

The most common feature of psychosis is not hallucinations, delusions, thought disorder, paranoia or suspiciousness as is commonly believed but lack of insight [2]. Lack of insight denotes the blind‐spot a patient has in regard to the falseness of their new reality and the abnormal nature of their mental state [3]. For some the term ‘lack of insight’ exemplifies the power imbalance within psychiatry.

Regardless of terminology, the blind‐spot is what makes the care of many patients suffering psychosis particularly challenging. Why would anyone take treatment, let alone engage with mental health professionals if they think their experiences are real rather than a manifestation of psychiatric illness.

1.3 Causes of psychosis

Mental states have material correlates. For some patients, a material dysfunction is the direct cause of their psychosis. The list of causes includes endocrine disorders (e.g. thyroid disease), metabolic disorders (e.g. porphyria), auto‐immune conditions (e.g. N‐methyl‐D‐aspartate, NMDA‐receptor encephalitis), infections (e.g. herpes‐simplex encephalitis), epilepsy (e.g. temporal lobe epilepsy), nutritional deficits (e.g. vitamin B12 deficiency), basal ganglia disorders (e.g. Wilson's disease), medications (e.g. acyclovir), dementias (e.g. Alzheimer's disease), and most common of all, psychoactive drugs, as causes [4].

• The following psychoactive drugs can elicit an acute psychotic episode after a single administration: serotonin 5HT_2A receptor agonists (e.g. lysergic acid diethylamide, LSD), glutamate NMDA channel blockers (e.g. ketamine), and cannabinoid CB₁ receptor agonists (e.g. delta‐9‐tetrahydrocannabinol, THC) [5].
• Repeated, heavy use of stimulants can elicit a classic paranoid psychosis by impacting upon dopamine signalling (e.g. methamphetamine) [5, 6].

Psychosis can occur in the following syndromes: schizophrenia, delusional disorder, bipolar disorder, post‐partum psychosis, schizoaffective disorder, and depression. Psychotic experiences can also manifest in severe obsessive compulsive disorder (OCD). There are also brief, acute, full‐blown psychotic episodes occurring outwith any of these syndromes, which even in the era before antipsychotic drugs, tended to show a full recovery of insight and restoration of the former reality [7, 8].

Auditory pseudo‐hallucinations and ‘paranoia’ can occur in people prone to emotional instability, but insight is maintained, and the prominence of deliberate self‐harm in the context of early abuse steers the formulation away from a psychotic disorder [9–11]. Indeed, psychotic‐like phenomena including voices and paranoia occur in the general population, but such experiences do not overwhelm the self to the extent that there is a fundamental transformation of lived reality, and should not be over‐psychologised as markers of mental illness [12–14].

• Robin Murray and Jim van Os have made the elegant observation that, ‘the boundaries between normal mentation, common mental disorder and schizophrenia become blurred, if positive psychotic symptoms are used as a distinguisher’ [15].

Precise diagnosis might not be possible, but in some cases it is vital. For instance, psychosis arising from antibodies targeting the NMDA‐receptor requires urgent immunological treatment [16]. In such cases antipsychotics and psychological therapy are of no value and lead to delays.

Given the multitude of causes of psychosis, patients require a skilled assessment and careful biopsychosocial formulation before treatment, whether pharmacological or psychological, is embarked upon [17].

1.4 Schizophrenia: loss of personality and psychosocial decline

Psychosis and schizophrenia are not synonymous. Only about one in eight patients who experience an acute psychosis will go on to develop schizophrenia over a period of three to five years [18].

Schizophrenia is not a single syndrome [19]. From the outset, the term subsumed a collection of phenotypes [20–22].

• Paranoid form, dominated by psychotic symptoms.
• Hebephrenic form, dominated by severe thought disorder and bizarre affect.
• Catatonic form, dominated by psychomotor signs.
• Simple form, dominated by severe psychosocial decline but no psychotic symptoms.

The precise definition and demarcation of schizophrenia is as uncertain as ever, and some authorities have suggested dropping the term altogether because of the associated stigma [23, 24].

On the other hand, there are a proportion of patients who exhibit such marked social decline and loss of personality for whom no alternative descriptor is forthcoming.

• Many consider that psychosocial decline and loss of personality are the hallmarks of schizophrenia [25]. Essentially the same meaning is conveyed by the term, negative symptoms, originally formulated in nineteenth‐century neurology to describe the loss of a function which is normally present in health. In schizophrenia the loss encompasses; drive, motivation, ambiti...

Table of contents

• Cover
• Table of Contents
• List of tables
• Preface
• Glossary
• Acknowledgments
• COI statements
• Chapter 1: Psychosis
• Chapter 2: Towards evidence based treatments for psychosis
• Chapter 3: The antipsychotics
• Chapter 4: Bipolar disorder
• Chapter 5: The role of talking therapies in the treatment of psychosis
• Chapter 6: Side effects of antipsychotic treatment
• Chapter 7: Services: pathway specific care
• Chapter 8: Measuring outcomes
• Appendix 1: Pharmacokinetics of selected psychotropicsPharmacokinetics of selected psychotropics
• Appendix 2: The metabolic syndromeThe metabolic syndrome
• Appendix 3: Physical health monitoring for patients prescribed antipsychoticsPhysical health monitoring for patients prescribed antipsychotics
• Appendix 4: Physical health monitoring for patients prescribed mood stabilisersPhysical health monitoring for patients prescribed mood stabilisers
• References
• Index
• End User License Agreement