Introduction

The patient whose name was Jack had gone to a local restaurant with his friends at night when he began to exhibit the following symptoms: He was restless; he kept pacing around in spite being urged to do stop doing so by his friends and the staff at the restaurant. His movements around the restaurants were ill co-ordinated. He was agitated and disorientated and insisted that he did not want to be touched. In spite being disorientated, he was cognizant of my arrival. He would make utterances regarding the world and how “screwed up it is.” In between talking about how screwed up the world is, he would go quiet and stand unsteadily on his feet. He also expressed the need to desperately call his sister.
My initial diagnosis is that Jack is suffering from acute psychosis. This is drawn fro the fact that patient exhibited the following symptoms which are characteristics of acute psychosis: delusions of “a screwed up world”, disorganized speech, agitation, confusion and apprehension. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, acute psychosis is an illness that is characterised by the presentation of the following symptoms for a period of between a day and a month: hallucinations, emotional volatility, disorganized behaviour, delusions, disorientation and catatonic behaviour. It must however be mentioned that a person suffering from acute psychosis may not necessarily exhibit all of the symptoms at once. Based on the fact that Jack was delusional, disorientated, agitated and emotionally volatile for a period of a day, it is possible that he could be suffering from acute psychosis. This essay shall therefore discuss the diagnosis of acute psychosis; its relationship to schizophrenia, the incidence, causes and management of schizophrenia.

Justification for the diagnosis

Medical assessment
In order to rule out any medical causes of the psychoses, I would take a medical history of the patient. A medical assessment of the patient would be difficult given that the patient has expressly made it clear that he does not want to be touched. I would therefore rely on the friends of the patient to rule out medical causes. I would find out if the patient has experienced any trauma to the head as a head trauma could cause a subdural haematoma which could trigger a psychotic episode. I would also find out if the patient has experienced seizures in the recent past which could result in psychotic episodes. After ruling out the two, I would find out if the patient has experienced any neurological symptoms. Neurological symptoms include: impaired vision, frequent headaches, speech deficits such as aphasias, memory losses and tremors. I would also seek to establish if the patient has been taking prescription medicines that are known to induce psychosis such as corticosteroids, anticholinergic drugs, thyroid hormones, adrenergic drugs and dopamine drugs. In doing this, I would seek to establish the dosage of drugs the patient was taking, the time the patient started taking the drugs and any changes to the dosage being administered. I would also find out the family history in order to rule out any metabolic or neurological disorders that cause psychosis. Wilson’s disease is known to cause psychosis.

Schizophrenia: incidence, current theories of development and management strategies.

Schizophrenia is a devastating mental disorder that affects both the brain and the mind which impairs the perception and the behaviour of the individuals suffering from the disease. The symptoms of schizophrenia are classified into two categories: positive and negative. As determined by Positive symptoms are:

Disorders of commission.

They include the things that are done by the patients or their thoughts. Positive symptoms include: hallucinations, delusions and outlandish behaviour. Negative symptoms are disorders of omission which include; apathy, anhedonia, alogia and asociality. Schizophrenia often commences during early adulthood; between the ages of 15 and 25. It is estimated that 1.1% of the world’s population over the age of 18 years suffers from schizophrenia. In a year, 1 out of every 4,000 people will be diagnosed with schizophrenia.
There are several theories on the etiology on schizophrenia. These theories include: neurotransmitter theories, receptor theory and psychosocial theory. There are two neurotransmitter theories that have been advanced: the dopamine theory, the specific dopamine pathway theory. According to the dopamine theory, schizophrenia is caused by an increase of dopamine in the central nervous system. Evidence of this is provided by the fact that drugs used for the treatment of schizophrenia are dopamine blockers and could result in psychosis. However, these drugs could also be used in the treatment of other mental disorders hence it has been revised to offer a more specific explanation. According to the specific dopamine pathway theory, there are two specific dopamine pathways that are associated with schizophrenia: mesolimbic and mesocortical system. The hyperactivity of the mesolimbic dopamine neurons and the hypoactivity of the mesocortical system is postulated to be the cause of the positive and the negative symptoms of schizophrenia respectively. The psychosocial theories attempt to bring out the role of psychosocial factors in triggering schizophrenia. It has been found that schizophrenics are often individuals of low economic status. The downward drift theory postulates that schizophrenics generally descend further into poverty as they cannot hold a steady job.
It is well known that a mutation of certain genes predisposes an individual to developing schizophrenia. Genetic factors along with social factors increase the likelihood of an individual developing schizophrenia. Mutations on genes such as DISC1, dysbindin, neuregulin put one at risk of developing schizophrenia. It has also been found that the risk of developing schizophrenia increases ten fold if an individual has a first degree relative with schizophrenia.. Stress and substance abuse are some of the psychosocial factors which together with genetic factors aggravate the symptoms of the schizophrenia. It has been found that the use of marijuana can exacerbate the symptoms of schizophrenia. In addition to this, amphetamines can also severely worsen the symptoms of schizophrenia. Emerging research indicates that there is a biological link between autism and schizophrenia. The negative symptoms of schizophrenia and autism are quite similar. The clinical symptoms shared by autism and schizophrenia include: impairment of social skills and communication skills and poor eye contact. There is also evidence of schizophrenia and autism sharing some genetic factors. Some of the specific deletions associated with schizophrenia such as 22q11.2, 1q21.1, and 15q13.3 are also associated with autism.
It has been found that child sexual abuse and child physical abuse is a causal factor of psychosis and more specifically schizophrenic symptoms which include hallucinations and delusions. This finding is corroborated by evidence from several studies: In one study involving female outpatients, 78% of those who were diagnosed with schizophrenia were sexually abused as children. In another study involving a sample of adult out patients, 85% of those who were diagnosed with schizophrenia were abused or neglected as children. Several theories have been advanced in an attempt to explain the link between child abuse and schizophrenia. From a biological perspective, it is postulated that traumatic experiences interfere with stress regulation mechanisms in the hypothalamic pituitary adrenal axis. From a psychological perspective, it is possible that the traumatic experiences impair cognitive abilities and behaviour therefore making an individual prone to psychosis.
Currently, there is no known cure for schizophrenia therefore management involves taking antipsychotic drugs. Some of the antipsychotic drugs used in the management of schizophrenia include: ziprasidone, olanzapine, clozapine and aripiprazole.

Acute psychosis and schizophrenia

Research has shown that there is a link between schizophrenia and acute psychosis on several fronts. To begin with, some of the environmental factors that are trigger acute psychosis such as stress, brain damage, poor nutrition and autoimmune diseases have also been implicated as aetiology of schizophrenia. It is also possible that there is some overlap between the pathophysiological mechanisms underlying acute psychosis and schizophrenia. It has been found that many cases of schizophrenia are developmental in nature. The likelihood of developing schizophrenia or psychosis increases as a result injury to the brain during the early years of life or later on in life. The earlier the occurrence of the brain injury, the greater the likelihood of developing a psychotic illness such as schizophrenia. The severity of the psychosis is dependent on the severity of the brain injury and the period of occurrence i.e. early childhood, late adolescence or during adulthood.

Treatment of schizophrenia

Schizophrenics may be asocial therefore any attempt by a paramedic to touch them or help them may be unwelcome. It is therefore imperative for the paramedic to establish a therapeutic alliance with the patient. According to , a therapeutic alliance is defined as:

A collaborative relationship between the patient and the medical practioner

The paramedic should forge such n alliance and avoid any form of coercion when handling the patient. Insults and threats should not be directed towards the patients. A good medical and personal history of the patient ought to be taken by the paramedic in order to determine whether the patient requires further psychiatric evaluation. For patients with violent tendencies, it may be necessary to calm the patient down first before proceeding with any form of treatment.
The duration and occurrence of psychosis in schizophrenics can be prevented by the use of antipsychotic medications. Regular use of antipsychotic medications significantly reduces the psychotic occurrences while irregular intake of antipsychotic medications increases the occurrence of psychotic relapse. Numerous psychotic episodes could eventually lead to intellectual impairment. Most individuals who suffer from schizophrenia need to use antipsychotic medications for the rest of their lives in order to manage the condition. Some of antipsychotic drugs used to manage schizophrenia include: chlorpromazine, haloperidol, seroquel, risperdal, zyprexa and clozari, fluphenazine. However there are numerous side effects that are associated with long and short term use of antipsychotics. Some of the short term effects include: drowsiness, muscle spasms, blurred vision and constipation. In the long run, antipsychotics can result in tremors, panting, grimacing and facial ticks.
It is also necessary for schizophrenics to get support from their family members and their loved ones since most of them cannot hold a steady job. It is also imperative for them to undergo psychological counselling in order to cope with their condition. Psychotherapy helps the schizophrenic acquire the necessary social skills, adhere to their treatment, set and attain personal goals. Being part of a support group could also go a long way in helping an individual cope with schizophrenia in the long term. Schizophrenics often have a problem adjusting to the real world and confronting everyday issues. Group therapy can be particularly helpful if it revolves around addressing relationships, equipping an individual with life skills and engaging in recreational or work related activities.

Conclusion

The episodes of psychosis among schizophrenics can be significantly reduced through the use of antipsychotic medications. In addition to taking antipsychotic medication, it is also important for the patient to undergo counselling and participate in group therapy in order to enhance their social skills.

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