Psychosis: What is Psychosis?

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Psychosis:  What is Psychosis?




Guest:  Dr. Christopher Pelic – Psychiatry & Behavioral Sciences

Host:  Dr. Kevin Gray – Psychiatry & Behavioral Sciences


Dr. Kevin Gray:  Hello.  This is Dr. Kevin Gray, from the Medical University of South Carolina.  I’m talking with Dr. Christopher Pelic, an inpatient attending psychiatrist at the medical university.  We’re talking about a subject that’s one of the cornerstones in psychiatry, a broad subject called psychosis.  We’ve touched on that in talking about schizophrenia, but there are other causes of psychosis.  Thank you for being with us, Dr. Pelic.


Dr. Christopher Pelic:  Thank you, Dr. Gray.


Dr. Kevin Gray:  Now, I’m trying to put myself in the situation of a concerned family member.  Say I’m a father with the son that I’m concerned about, a son who had been doing well, but maybe has been more reluctant to leave the house and is saying things that don’t make a lot of sense, that are very confusing, and actually sound concerning enough that I think that he may be dangerous, and is really not the son that I remember.  What steps should I take in order to get him properly evaluated?


Dr. Christopher Pelic:  Well, I think the first thing that you bring up is that there needs to be some evaluation, and I think that’s an excellent point.  Although, it can be very difficult getting one’s loved one to a doctor or an emergency room, whichever is the appropriate setting.  And the example that you mentioned, you mentioned it towards the end, that there were some concerns about dangerousness or safety issues on top of the bizarre behavior or, as you said, talking out of his head. 


In most cases, if someone has been acting unusual or bizarre, you can set them up with an appointment with a local mental health center for at least an evaluation to see if there’s more going on.  When an element comes in where there’s some concern about safety or dangerousness, whether it was threatening statements or behavior, in most of those cases, we would consider that somewhat urgent.  Patients can act quite erratically if they’re ill.  So, what we would recommend in most cases like that, we suggest that the family try to get the patient to a local emergency room.  Or, if you’re fortunate enough to be in a community where you have a psychiatric ER, that would do just as well.  But, the main concern here is that you mentioned something about dangerousness, so the urgency of getting an evaluation, and getting one soon, would be stressed.


Dr. Kevin Gray:  So, say that I’ve brought my son to see you, say this is in the emergency room and you’re there to evaluate him, what sorts of things are you thinking might be causing this?


Dr. Christopher Pelic:  When we have someone with what we would call a new-onset psychosis, or a new-onset of bizarre behavior, or hallucinations, or paranoia, the first thing we do is take a very thorough history from the patient and the family and try to gather, really and truly, how long the symptoms have been going on, maybe they were present but just very subtle.  So, we take a very thorough history and ask some of those questions, if there’s a family history of mental health problems, and we’d ask questions about whether or not the person had been using drugs or had any major medical problems that could cause this.


The second piece to this would be that we would consider, potentially, doing some blood work, urine screens, and even a brain scan, mainly to look at potential medical causes that could present with similar symptoms.  So, in doing these two things, frequently, we can gather quite a bit of information that would point us at least in the direction of whether or not this sounds like it may be a primary mental illness or something else.


Dr. Kevin Gray:  One of the things you mentioned was drug use, and certainly that’s something that is not uncommon in adolescence and young adulthood.  What sorts of drug use patterns do you see associated with hallucinations, paranoia, psychotic symptoms?


Dr. Christopher Pelic:  Certainly, there are a variety of drugs that can cause symptoms of psychosis, particularly during use.  And there’s another subset of drugs, and alcohol, that can cause symptoms in withdrawal.  As far as some of the illicit drugs that can cause psychosis, or symptoms similar to schizophrenia, things like cocaine or crack, amphetamines, hallucinogens, ecstasy, even high-dose marijuana use.  Adolescents or young adults smoking heavy amounts of marijuana can make people paranoid, or even have vague hallucinations.  Those would be the main drugs.  And then there are some others that, on withdrawal, like alcohol, or medicines like valium, on withdrawal, can cause symptoms that are very similar, that can have psychosis present.


Dr. Kevin Gray:  You also mentioned medical illnesses that you would want to rule out or to explore for.  What are some common medical illnesses that may present with psychosis?


Dr. Christopher Pelic:  That’s a great question and, interestingly, the number is almost infinite as to different things that can cause it.  Although, some of things that even I’ve seen in my career, things like lupus, other things like cancers, especially cancers of the brain, or metastases of cancers to the brain, other conditions, we’ve even seen patients who’ve had heart attacks, or stroke, present with symptoms similar to psychosis or schizophrenia, so some very common things like that, but also some more rare things, like lupus.


Dr. Kevin Gray:  Now, in imagining myself as the parent of someone who is undergoing this evaluation and finding that the evaluation yields nothing, we don’t find a drug use that may have caused it, we don’t find a medical illness, what are we generally left with, and what does that mean for my child?


Dr. Christopher Pelic:  Well, frequently, especially if it’s what we call a first break of psychosis, it has not been diagnosed before, we will likely admit the person to the hospital, especially if there were concerns about safety in the first place.  And, during that time, we spend a lot of time observing the patient and try to differentiate if there is something else that might be going on, or whether or not it sounds like it may be something like schizophrenia.  And during that observation period, sometimes we’ll even try medications to see if they help target some of the symptoms. 


And then it becomes a little bit of a waiting game where, once the patient gets out of the hospital, you have to observe and see whether or not the symptoms get better, worse, or go away.  And that often gives us a clue as to what we’re dealing with.  Sometimes there are medical conditions that are missed initially that are later found, and other drug use that wasn’t discovered initially is later found.  And, in other cases, it just becomes clear that it’s most likely schizophrenia.


Dr. Kevin Gray:  Might there be some other psychiatric or mental illnesses that may present as psychosis, other than schizophrenia?


Dr. Christopher Pelic:  Absolutely.  I think even medical personnel don’t fully understand this well, that there are a lot of other psychiatric conditions that can cause psychosis.  For example, we mentioned withdrawal from drugs, delirium, which is a state of confusion that can happen after a significant medical problem.  Depression can even present with some symptoms similar to schizophrenia where people might hear voices telling them that they’re no good or that they should hurt themselves.  Bipolar mania often has symptoms of psychosis associated with it. 


There are various types of dementias that often present with psychotic symptoms, such as Alzheimer’s, dementia, or even Parkinson’s dementia.  Frequently, patients will feel paranoid that their spouse is cheating on them, that they’re seeing things that aren’t real.  So, there are a variety of other mental conditions that can cause psychotic symptoms, and not just schizophrenia.


Dr. Kevin Gray:  This is certainly a broad and very important topic.  Thank you for clarifying so much of this, Dr. Pelic.


Dr. Christopher Pelic:  Thank you, Dr. Gray.


If you have any questions about the services or programs offered at the Medical University of South Carolina or if you would like to schedule an appointment with one of our physicians, please call MUSC Health Connection:  (843) 792-1414.

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