see also p 227, 271
Summary points
Diagnostic criteria for psychosis are based on Western standards and maynot account for ways in which people of other cultures express distress
Intimate involvement of family members in the care of Asian patients withpsychoses may be at odds with concepts of patient confidentiality andprivacy
Primary care of Asian patients with psychotic disorders requires anunderstanding of the cultural differences in how psychotic disorders areexpressed and treated
A 25-year-old man lived in China until the age of 20 when he immigrated tothe United States. Initially, he lived with his family and worked in a smallChinese store. Over several months, he began to have difficulty relating tocustomers, feeling frightened and suspicious. He began to think that theChinese government was spying on him, and he heard voices telling him he wouldbe killed.
He became more withdrawn at work and was not functioning in his job. Athome, he became increasingly agitated and his family was concerned for hissafety. They sought urgent medical attention.
Clinical evaluation led to the diagnosis of “psychotic disorder, nototherwise specified.” The patient was hospitalized and treated withantipsychotic medication until the acute symptoms abated. He was then releasedfrom the hospital. The patient participated in regular weekly group sessionsthat focused on socialization, stress reduction, problem solving, andpsychological education. He continues to see a psychiatrist monthly forongoing monitoring of his mental status and medication.
PSYCHOTIC DISORDERS IN THE PRIMARY CARE SETTING
Psychosis is a syndrome of psychiatric signs, symptoms, and behaviors thatusually include hallucinations, delusions, disorganized speech andfunctioning, and impaired judgment. People with psychosis usually have animpaired ability to function in everyday life.
A patient with psychotic symptoms usually perceives aspects of everydaylife in a way that is not based in reality. The syndrome of psychosis is mostclosely associated with the diagnosis of schizophrenia, although it can alsobe seen in association with bipolar disorder, major depression,substance-induced psychotic disorders, delusional disorders, and briefpsychotic disorders.
Presentation and assessment
A patient with a first episode of psychosis often presents with anxiety,depression, poor concentration, irritability, suspiciousness, and socialwithdrawal. When psychosis is suspected, the physician should explore possiblechanges in social functioning, family relationships, cognition, and thoughtcontent. Changes in the person's personal hygiene, speech pattern or content,and outbursts of anger may also be part of a developing psychosis. Informationfrom the family can be useful to gain a complete picture of the patient'sbehavior.
Acute symptoms and aggressive or self-injurious behavior may call foremergency measures such as immediate medication, calling on personnel trainedin emergency care, enactment of security measures, or hospitalization. Thepriority for the primary care physician seeing patients with a psychoticdisorder is to ascertain if they are a danger to themselves (including lack ofself-care that may result in harm) or to others. Even if the plan is to referthe patient immediately for assessment by a mental health professional, adetermination must be made that the patient is stable enough to leave thepremises.
Prompt referral to a psychiatrist is recommended, because early psychiatricintervention is associated with better response to treatment. Evidenceindicates that lengthy delays in initiating drug treatment (delays of 6 monthsor more from onset) are associated with a greater need for inpatient care anda worse social and vocationaloutcome.1,2,3If an immediate referral is not required, then patients must be activelymonitored for changes in their mental status.
Patients presenting for the first time should always receive a full reviewof symptoms and a thorough physical examination. This is because psychoticsymptoms may be due to organic causes—such as brain trauma or metabolicabnormalities. Inappropriate dosages of medications, drug interactions, drugabuse or misuse, over-the-counter remedies, and herbal preparations can allcause psychotic symptoms.
Barriers to diagnosis and treatment
Psychotic symptoms on initial presentation may be more severe in Asianpatients than in other ethnic groups. The reason for this disparity is thatthe stigma and shame associated with mental illness in Asian cultures delaysappropriate and timely care. In addition, patients' symptoms are often keptwithin the family until the symptoms become intolerable or unmanageable, orlegal involvement occurs.
The diagnosis of psychosis relies to a great extent on the evaluation of aperson's language, behavior, thoughts, and perceptions. Evidence-basedalgorithms, such as those from the Harvard Medical School Department ofPsychiatry (available atwww.mhc.com/Algorithms),may be used to assist in accurate diagnosis. Issues such as cultural diversityand racism, however, can still impede both diagnosis and treatment.
The conflicting demands experienced by a person of one culture having toadapt to another may lead to personality and relationship difficulties,anxiety, and identity confusion. The economic and environmental changes thataccompany moving between cultures may aggravate pre-existing physical andpsychologicalvulnerabilities.4Racism—in the form of not having control over one's fate and repeatednegative encounters with other, more dominant, cultures—may produce apattern of helplessness and a belief that the environment is hostile, morepowerful, and ultimately interested in hurting the person affected.Practitioners who are uninformed about another culture and their experiencesof racism, or who harbor negative stereotypes about that culture, may tend todiagnose psychosis when symptoms are better accounted for by a mood disorder.For example, the negativism experienced as a result of racism can bemisinterpreted as paranoia. Primary care providers should consider thesefactors or consult with a specialist who is knowledgeable about the culture ofAsian patients before making a definitive diagnosis.
The beliefs that patients have to explain their illness may influence themto first seek out non-medical or non-psychiatric assistance, for example,family members and traditional healers, thereby delaying necessary care andworsening the presentation.
A common finding in Asian patients is that complaints are solely physical,without any cognitive complaint. In fact, the culture may not include anyterminology for psychiatric distress, further confusing the presentation tothe primary care provider.
These possible situations must be handled with sensitivity andunderstanding. Most patients in distress need to feel that they are firstsafe, then understood.
TREATMENT
Overview of treatments
Patients with psychosis generally receive both pharmacologic andnonpharmacologic treatments. The goal of pharmacologic treatment is tostabilize and control the acute symptoms and behaviors associated withpsychosis (see p 271). Nonpharmacologic treatment provides the patient and thefamily with support, education, and the work and social skills necessary tolive and function in the community.
Once it is determined that psychotic symptoms are present, managementrequires identification of target symptoms and behaviors. These are observedand monitored to determine the patient's response to treatment and the needfor further intervention. Definitive diagnosis of the exact type of psychosiscan wait until after further observation of the patient and the patient'sresponse to treatment as well as elucidation of predisposing factors andfamily history.
After acute symptoms are stabilized, the physician monitors the patient forsymptoms and behaviors that indicate a possible relapse. The physician shouldbe aware that even grossly psychotic patients are able to control behaviorsand act according to cultural expectations. Patients may lack insight abouttheir illness, which affects how they respond to the physician's questionsabout symptoms and behaviors. The physician must work with the family as acorroborating source of information about the patient's status and condition.Even moderate changes in behaviors, mood, or thoughts may indicate a possiblerelapse.
Patients with chronic illness who are stable may only require infrequent,but regularly scheduled checkups for evaluation of medication side effects,compliance, and blood tests. At the very least, a complete blood count anddifferential to monitor for agranulocytosis, and liver function tests for rarehepatotoxicity, are recommended for patients receiving antipsychotic therapy.When psychiatric consultation is unavailable or limited, primary carepractitioners who understand the target symptoms and the medications used tocontrol them can manage treatment. This decision depends on the severity,chronicity, and frequency of the disorder, the nature of the pharmacologic andbiopsychosocial treatment given, and the availability of social supportsystems for the patient.
Psychiatric symptoms can prevent patients from following medicalrecommendations for their physical diseases. This is one of the reasons whypsychiatric patients have higher morbidity and mortality associated with arange of physical conditions compared to the generalpopulation.5
Monitoring psychotic illness
The signs and symptoms that are important to consider when monitoring apatient's level of psychosis and response to treatment are shown inbox 1.
Box 1.
Symptoms and signs of psychosis
| Hallucinations |
| Auditory hallucinations are the most common type of hallucination seen withpsychosis. Visual, tactile, and olfactory hallucinations may occur, but theseshould increase the index of suspicion of a biological cause such as headtrauma or withdrawal syndromes, especially if symptoms are new or of suddenonset. |
|
| Delusions |
|
| Thought process |
|
| Behaviors |
|
| Affect |
|
| Impulse control |
|
| Insight |
|
| Danger to self or others |
|
Referral to a mental health specialist
Indications for requesting consultation with a psychiatrist include thefollowing:
Acute stages ofpsychosis
Initial presentation of psychotic symptoms or behaviors
A possibility of danger to the patient or others
Prescribing medications
Box 2.
Additional reading
|
Because the use of bilingual and culture-specific treatment programs canimprove the treatment of psychosis in Asians and Asian Americans, referral tosuch services should be made wheneverpossible.6
Arranging hospital admission
Hospitalization is primarily indicated for:
Diagnosis
Stabilization of medication delivery
Suicidal or homicidal ideation or behavior
Disorganized or inappropriate behavior, including patients' inability tocare for themselves or to meet their basic needs
Hospitalization decreases patients' stress by providing a structured andsupportive environment. The length of stay depends on the severity of theillness, availability of outpatient treatment, and the level of family orcommunity support. Whenever possible, patients should be sent to facilitieswith culturally competent, bilingual staff.
Outpatient therapy
Traditional outpatient therapy consists of individual, group, and familytherapy and is an important adjunct to pharmacologic treatment of psychoticdisorders. Regularly scheduled meetings with a physician, therapist, orcounselor provide ongoing structure and support. Therapy sessions includemonitoring treatment progress and status of target symptoms, providingeducation about illness and treatment, and assisting with problem-solving andstress reduction.
Group therapy may be useful, especially in providing a way to improvesocialization, problem solving, and coping skills with others. The group mustbe culturally similar and cohesive or group therapy may not help Asianpatients.
When treating Asians with psychotic disorders, inclusion of the family intherapy is important. They are an important source of information and supportfor the patient. Families need to understand what to expect in the course ofthe patient's illness, how to recognize signs of relapse of psychosis, whattreatment options are available, and the expectations of treatment.
Culturally specific treatment programs
In our experience, culturally relevant treatment services that addresslanguage issues, use ethnic clinical staff, and respond to specific ethnicneeds of the clients are more successful than usual care services in treatingpsychotic patients. Often, however, culturally relevant treatment services areunavailable.
Some treatment programs provide cultural relevance by providing translatorson site or translation services; others replicate traditional treatmentservices with Asian bilingual staff. Culturally specific treatment programsincorporate different Asian cultural values, customs, and attitudes intotreatment. Issues of immigration status, acculturation and assimilation, andthe role of family and social organization within an ethnic community areconsidered in relation to treatment. Referral of Asian patients to culturallyspecific treatment programs is recommended whenever possible. If this type ofcare is not available, involvement of linguistically and culturally competentindividuals can facilitate communication.
Figure 1.
Physical examination and medical management of physical illnesses shouldnot be overlooked in patients with psychosis
Competing interests: None declared
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