A.As a community psychiatrist in the public health system, I treat primarily people at the most severe end of the spectrum for mental illness, especially those with psychotic illness. One of those patients, Lauren, was recently referred to me after her first admission to a psychiatric hospital.
Lauren is 28 years old and lives alone. She usually works in a nursing home and has supportive parents who live nearby. Notably, she has a cousin with schizophrenia and was in a bicycle accident at the age of 13 that left her in a coma for a week.
Three months ago, Lauren’s relationship ended and she felt overworked at work, so she started using cannabis to cope. Around this time, he began to notice various police cars around his area. Little by little she developed the anguished belief that she was being persecuted for a crime she did not commit.
Lauren was distraught. He stopped going to work and isolated himself. He increased his cannabis use to relieve stress, which exacerbated his symptoms. Over time, she began to hear voices telling her that she would be imprisoned and that she should flee before they caught her.
Things came to a head one day when she confronted some police officers and asked why they were chasing her. She was in a state of extreme anguish, so she was transferred to the local hospital where she was evaluated and admitted. The initial impression was “first episode psychosis”. At the hospital, Lauren was started on antipsychotic medications. The voices and paranoia gradually improved. She recovered and was discharged after three weeks.
Psychosis is a general term for a variety of symptoms in which a person has misunderstandings about reality. Psychotic symptoms are quite common, with a prevalence of 5% in the general population, and generally transient: up to 90% disappear over time. For those people who reach the threshold for a full episode of psychosis, most experience a partial or full remission within a year of starting treatment. Although relapse is common, for Lauren the relatively late onset of the disease, being female, previously high functioning and well supported, indicates a better prognosis.
The “stress vulnerability” hypothesis explains that the more vulnerable your brain is, the less stress is needed to trigger an episode of psychosis. Lauren’s family history of mental illness and head injuries as a teenager increased her vulnerability. The breakdown of the relationship, difficulties at work, and drug use provided enough stress to trigger the episode.
Often the initial diagnosis for someone with these symptoms is “first episode psychosis” as in Lauren’s case, as it is usually too early to be definitive. Schizophrenia, one of the most common psychotic illnesses, requires one month of symptoms and six months of functional decline for a diagnosis, for example. However, psychotic symptoms can occur in a variety of conditions, including mania (the ‘high’ phase of bipolar disorder), depression, physical health conditions, and drug use.
In our initial review, I was pleased to see that Lauren was feeling much better. He spent his time watching movies, listening to music, and seeing his friends and parents. She hadn’t taken drugs since discharge, so I congratulated her. She no longer believed that the police were chasing her, but she still heard voices from time to time. Overall, she was able to ignore them and they continued to improve so we agreed to monitor this.
People with psychotic illnesses are at risk for depression, so I asked him about his mood. He described it as “up and down” but had no other depressive symptoms, such as changes in sleep, appetite, or enjoyment of life. Reassuringly, she had no thoughts of harming herself or others, or of taking her own life. I did a short cognitive therapy with her to help her improve her mood and come to terms with recent experiences, which she found helpful.
Lauren had been taking her antipsychotic medication as prescribed. He asked how long it should continue, so I informed him that we normally advise continuing for at least a year after recovery to help prevent a relapse. Side effects are often a problem with antipsychotics, but luckily Lauren wasn’t experiencing any that improve the chances that it will persist.
Finally, we agreed that Lauren’s case manager (a psychiatric nurse on our team) would catch up with her every fortnight and keep in touch with her parents. He will also support her to return to work when she is ready, as requested by Lauren. I will see Lauren again in three months, or sooner if necessary.
He is hopeful for his future, as he is for me.
Kamran Ahmed is a psychiatrist and filmmaker, writing on mental health, culture, politics, and healthcare.