Ask the psychiatrist...

We feel and believe our daughter was recently misdiagnosed with having a personality disorder. After what we believe was a period of psychosis, she was prescribed antipsychotics and made quite an improvement. During the diagnosis of personality disorder, her family was not consulted about her behaviour, or even family history. I am her mother and have bipolar disorder, and her father’s father has schizophrenia.

 

She confided to us that she felt the treatment she was attending specifically for personality disorder was not beneficial and that she wanted to leave. Her GP has now told her that she cannot be referred to another psychiatrist, or have her community psychiatric nurse reassigned to her. They have also made a decision to withdraw her antipsychotics, and we are already starting to see signs of her pre-medicated behaviour.

 

We are really worried and are wondering if there is any way we can insist she gets a second opinion before everything becomes a living hell again?

 

Your daughter should certainly be able to get a second opinion. Although there is no legal right to get one on the NHS, medical professionals will only very rarely refuse. If your daughter is an adult, she will have to request this (or at least make it very clear that she agrees to your seeking it). As a first step, I would suggest you ask to meet her existing psychiatrist with her to point out the family history and clarify the signs of pre-medicated behavior you are observing. If this does not prove satisfactory she can still request a second opinion.

 

Are you still able to travel to the United States of America after being under Section 3 of the Mental Health Act? Will a Section 3 affect the visa requirements?

 

You need to clear the current situation with the US embassy. However, I can reassure you that several of my patients have had successful holidays in the USA and visited families there. Your psychiatrist may have to prepare a brief medical report to help with the visa application and, of course, to provide some information about the condition and any medication that can be taken on holiday.

 

Can my family access mental health services without seeing a GP? My son is hearing voices and feeling generally very unwell and we went to see the GP about 3 weeks ago. He said he would refer us to a specialist, but we still have not heard anything. When I ring the surgery to find out what is happening they make me feel like I am being pushy and a pest. Meanwhile, my son, who is 19, is getting worse. He told me Jesus is talking to him through the television and he is spending long periods locked in his bedroom. I have read all of this website and am not scared of a diagnosis of psychosis, but just want some help quickly. Everywhere it says see your GP first of all, but what if the GP doesn't offer the right sort of help?

 

It sounds like this is the first ‘episode’ of illness, in which case try to track down the contact details for your nearest Early Intervention for psychosis team. It will usually be a specialist service provided by your local mental health trust and you will be able to find the details on the trust’s website. Give them a call and explain the situation. The evidence is very strong now that quick effective treatment in the early stages is essential, so while it is the usual and the best practice to get your GP involved from the start, most teams I know would assess first and worry about the niceties of the referral pathway later.

 

I've been experiencing ‘psychotic symptoms’ – hearing voices, paranoia – for over two years now but have never been given a diagnosis, although I've seen a psychiatrist who was quite vague and prescribed sulpiride. I feel I'm in a grey area. Can you explain any further?

 

Your question is quite difficult to answer without knowing much more about you. Psychotic symptoms do not necessarily amount to a diagnosis. Some otherwise healthy people can experience transitory psychotic symptoms and some people who have had very traumatic experiences earlier in life also seem to be prone to hallucinations. Even when they are severe or persistent as in your case, there may be any of a number of underlying conditions such as drug or alcohol dependency, severe depression, schizophrenia, or even physical illness. 

 

I heard on the radio something about diagnosis being changed and that in future people would be diagnosed as being at risk of psychosis. What does that mean? Who is changing the diagnosis? I couldn't understand what the lady who was being interviewed was saying.

 

Psychiatric diagnoses are not like many other medical diagnoses because we still do not have a very good understanding of the changes in the brain that underlie symptoms of mental illness. Some of the diagnoses we currently use, like schizophrenia, may well turn out to be more than one disorder, and the diagnostic label may need to change one day to reflect this.

 

Another challenge is that many of the symptoms of mental illness occur in healthy people in a mild or very fleeting form, so that many experts now think of disorder in terms of a continuum of gradually increasing numbers and severity of symptoms (so called ‘sub-clinical symptoms’) with a clinical disorder being defined at some agreed point when people experiencing that level of severity of symptoms and disruption of their lives could be said to be ‘ill’. In recent years, this way of looking at disorder as a point on a continuum has been used to try to identify people who are at risk of developing psychosis. This is done by looking for a particular pattern of these sub-clinical experiences that seem to be worsening and where there is also a family history of psychosis or a decline in educational /employment performance. The results of the research suggests that it is indeed possible to detect some people at risk and that this risk can be reduced with treatment.

 

The American diagnostic system* is currently being reviewed in the light of all this and it is likely that there will be recommended changes for some diagnoses to take better account of the research and thinking about psychiatric disorders.

 

*The American diagnostic system is called the Diagnostic and Statistical Manual of Mental Disorder (DSM), which is published by the American Psychiatric Association, the main professional organisation of psychiatrists in the USA. The DSM is currently being updated and the update is due to be published in 2012.

 

How does someone arrange a voluntary admission to a psychiatric unit?

 

Admission to a psychiatric unit is made through discussion with the treating psychiatrist and his/her decision that admission is in the best interests of the patient. There are many fewer psychiatric hospital beds than there were 10 years ago and this, together with the introduction of crisis home treatment teams, means that admission tends to be used as a last resort for people who are severely unwell and who are at too great a risk to themselves or others to be safely managed at home. When hospitalisation is necessary, a voluntary admission is always preferable to an involuntary one.

 

What does ‘labile’ mean?

 

It is a term usually applied to a person’s mood. In this context, it means changeable over a very short period of time. So for example, someone’s mood may swing back and forth from being apparently cheerful and laughing one minute and angry or in tears the next.

 

Whenever I see my psychiatrist they always want to know what the voices are saying and whose voice it/they are. I have a diagnosis of psychotic depression but why is it important for them to know what the voices say etc? Why can't they keep treating me without having to know?

 

Knowing about voices is helpful for diagnosis and for monitoring safety.

 

There are several different types of voice experiences that go along with different diagnoses. So, for example, hearing two or more voices discussing and commenting on your actions tend to go along with psychoses that are not related to depression, while hearing critical and blaming voices talking directly to you tend to occur in depression. Of course, this is just one indication but, with other experiences, helps the psychiatrist to come to a diagnosis.

 

Knowing the content of the voices can also be helpful. For example, some people experience voices that give commands to actions that may be dangerous to themselves or others. Sometimes this is so powerful that the person feels compelled to obey even though they do not want to. Knowing about the voices, how distressing they are, how long they last for and what they stop a person doing is also useful as a measure of recovery and widely used to measure the effectiveness of psychological therapy.

 

How long does an episode of psychosis last? Is it weeks, months or years?

 

This is quite variable depending on whether this is a first episode and the type of psychosis. The majority of first episodes last a matter of weeks or a couple of months at most, but recurrences tend to be longer. Around a fifth of patients suffering from schizophrenia will experience continuing symptoms for years.

 

Are there any known links between severe pre-menstrual tension and bipolar disorder? Has there been any research studying this matter?

 

Pre-menstrual tension is a common condition that affects many healthy women. It is characterised by a cyclical pattern of mood disturbance and physical discomfort. Although around 2/3 of women with bipolar disorder report a worsening of mood with pre-menstrual symptoms, it is difficult to prove a definite link, partly because PMT is so common. There is research but this is still inconclusive. For example, in an intensive study of 17 women suffering from bipolar disorder, Rasgon et al (2003) measured daily mood symptoms, menstrual data and life stress over a 3-month period and found that the majority of women reported significant mood changes across the menstrual cycle. However, all the women were on psychiatric medication and a third were also taking oral contraceptives which complicate the interpretation of the results

 

Rasgon et al 2003 Menstrual cycle related mood changes in women with bipolar disorder. Bipolar Disorders 5: 48-52

 

My daughter has been diagnosed with schizophrenia but I don’t trust the psychiatrist. Can I get a second opinion and how do I go about getting one?

 

There is no automatic right to a second opinion but it would be very unusual for this request to be refused. Of course if your daughter is an adult you need to have her consent before anything further can be done. I am assuming you would not wish the opinion to be provided by one of the psychiatrist’s colleagues in the same Trust in which case your daughter’s GP is in the best position to refer to a different hospital service for the second opinion. He/she will have to state that this is for a second opinion as it may be necessary to access the original assessments.

 

Our niece (age 19) was sectioned (2) and admitted to a psychiatric hospital after a psychotic crisis.

 

She opposed her section and asked me to be present at the tribunal, which I did. Her appeal was refused and she had to stay in the ward, but was allowed up to 2 hours leave with a relative. I visited her several times alone or together with my wife. The first visit of her parents took place 10 days after her section and they wanted the section to be lifted and to take her home to Scotland, to a tiny hamlet, where the parents moved only in Jan 2010 and where she has never lived and does not know anybody. She opposed this with the help of her psychiatrist.

 

Although she consented that I could be given information about her diagnosis and treatment, the (new) psychiatrist refused and told me he would prefer to inform the wider family through the parents. The parents arrived and took her back to Scotland to their home.

 

Her initial medication was olanzapine and diazepam, which seemed to stabilise her, but I don't know the dose. The medication was changed from olanzapine to aripiprazole, continuing with diazepam, both at quite a high dose. On my visits with my wife she was extremely sedated and subdued. I don't suppose that her condition had changed a lot when the parents came and picked her up, 5 days after a change of medication.

 

What I don't understand, is the fact that she has was released so shortly after a change of medication, where a result couldn't possibly be already achieved, and to a place where she continuously during her hospitalisation refused to go.

 

It is not possible for me to comment without knowing the clinical details for the individual and the discussions between the psychiatrist, the patient and her parents that led up to her discharge. In terms of the medication change, it is possible that her condition was already improving with the olanzapine but that there were side effects that meant a switch to an alternative drug was necessary.

 

Is it sensible for me to want to make something of my life? I'd like to study and become a hygienist, but is it ok and realistic?

 

I am a 38-year-old female and over the past 10 years, my life has turned 360 degrees. I was a student in dentistry, my parents were going through a divorce without telling me and I found this out. My grandparents died shortly before and I was abused when I was 6-7 yrs old. It was just too much. I went downhill so much so that I was sent to hospital. I was diagnosed first with depression, then post traumatic stress followed by episode of psychosis, and finally schizoaffective disorder. I am stable and take 30mg paroxitine and 10mg aripiprazole.

 

Yes of course you should want to make something of your life. If you are stable and feel ready to study then there is no absolute reason why you should not. The benefits are obvious. However the condition that you are suffering from is sensitive to stress so there are risks that can be anticipated and hopefully reduced. For example, you may well need to stay on medication and I would suggest you seek advice not only about the best way to maintain your health but also on the selection of the course and on what to disclose to the college/university about your health so that proper educational support is available to you.

 

Can you explain tactile hallucinations? Most of the literature available to us focuses on hearing voices.

 

Tactile hallucinations are feeling that something or someone is touching you when there is nothing external to explain the sensation. A broad range of sensations are included such as burning, crawling, stinging etc and they are usually accompanied by a delusional explanation, such as a belief that the sensation is being caused by an invisible ray or other electronic gadget.

 

The normal sensation of touch originates in a pressure receptor in the skin and travels as an electrical impulse up nerves to the brain where it activates special sensory brain cell pathways. It is known that if these sensory cells are stimulated directly (during brain surgery, for example), the person feels the sensation at the location where the nerve to those cells originated (ie in the skin). Tactile hallucinations are an instance of spontaneous activity of these brain circuits.