1. Additional Case 2- Cameras in the Drain Hole

2. Aaron is a 19 year old male studying science. He lives at college. Presents with his girl friend They had been at a party four nights previously and had smoked marijuana heavily. Aaron states  he has been smoking cannabis regularly since he was 14 years old.  Initially, he just smoked at parties but now he smokes most days before going to lectures.  he reports that he felt there was something different about the cannabis on this occasion. He initially felt very tired after smoking “more than 10 cones” and later felt anxious and had racing thoughts. He couldn’t sleep that night in spite of feeling tired and he noticed that sounds were very loud and frightening.  he has never had problems with smoking cannabis and both he and his girlfriend deny that he has had this paranoia before. Girlfriend reports  that since then he has developed some strange ideas.  His girlfriend reports he is normally relaxed and happy usually and has never been threatening or aggressive.  She says he has really changed and is worried about him. The ideas…. He believes that the drug squad are now pursuing him and a drug dealer wants to kill him because he owes money (this is true that he owes money but his drug dealer has never threatened Aaron). He says he thinks there are cameras in all the drain holes at college and refuses to have a bath or shower or go near the sinks. He says he knows this because the pipes make a shuddering noise when the taps are turned on and he thinks this might be the sound of cameras filming. (The shuddering noise in the pipes has always been there but Aaron has never been worried previously). He also says that he can hear whispering voices outside his door and he believes that the students in his college might have conspired with the drug dealers to have him killed. He knows that he is unwell and he thinks he might be paranoid but says that he really does believe people are trying to kill him.

3. Q 1. What is the provisional diagnosis and differential diagnosis? Justify the reasons for your answer.

4. Q 2. What are the risk issues associated with this presentation? How will you manage these?

5. Psychosis is associated with risk issues of  Agitation, aggression, and impulsivity  Harm to self or others  The inability to provide for one's basic needs (food, clothing, and shelter) Management  Assess suicide risk  Ask if has/will confront drug dealer or other who are following him  Ask if able/willing to return to parental home to ensure away from college and basic needs are meet  Discuss willingness to stop marijuana use  Begin on antipsychotic medication and assess patients likelihood to comply “We recommend treatment for psychotic symptoms, whether or not a diagnosis has been established.”  Treatment for psychosis should be voluntary whenever possible, but the nature of the illness may lead patients to fear or avoid treatment. In most venues, dangerousness to self or others, or the inability to provide for one's basic needs of food, clothing, and shelter, is sufficient cause for involuntary treatment. “Overview of psychosis” – Up to Date

6. Trigger 2 Aaron is not suicidal - he is actually fearful of dying He is keen to return home to live with his parents He agrees to your calling his mother and explaining that he has an illness. He agrees not to continue using marijuana until he recovers and he agrees to taking olanzapine 10 mg at night. His mother collects him from your surgery and agrees to bring him back for review the next day. He returns the next day having slept for 13 hours after taking olanzapine. He is much less agitated and anxious and is very upset by his recent experience. He returns two days later and has further improved. His symptoms have resolved. He has looked up the internet to see if the cannabis caused his mental health problems and has found conflicting advice.

7. Q 3. Aaron and his mother want you to explain the link between cannabis and psychosis. How would you explain this association?

8. Previous heavy marijuana use was not associated with adverse health affects – physical, mental, quality of life or sociodemographic, following abstinence. Substantial evidence exists to suggest that cannabis use causes psychosis beyond transient intoxication Study found a dose-response risk for developing psychosis. Caused through its effect on dopamine release. Genetic aspects ; this is why the majority of cannabis users do not develop psychosis THESE STUDIES ALSO STATED THAT THE RESULTS MAY BE EXPLAINED THAT PSYCHOSIS MAY LEAD TO CANNABIS USE Acute adverse reactions during cannabis intoxication can resemble psychosis

9. Q 4. Aaron's mother wants to know if he has schizophrenia? How will you answer this question?

10. Although Aaron exhibits the characteristic symptoms of possible schizophrenia, such as auditory hallucinations and delusions, it is too early to tell and his symptoms have resolved with treatment. Normally a person would need to be suffering these symptoms for at least a month and before that he would need to show disturbed behaviour for around 5 months where he was having difficulties socially or with his work or studies. In addition, Aaron said that the marijuana, which he smoked in a large amount at the party, may have been laced with any number of drugs, such as amphetamine, LSD, ketmine or PCP-Angel Dust, any of which could have caused his psychosis. In this case the symptoms would likely resolve once the drug was metabolized and excreted from his system and his recovery would be a distinct possibility. However, there is always a slight chance that Aaron is susceptible to developing a psychosis, which was exacerbated by the use of these compounds, and he will need to be followed up for several months to determine the best course of action

11. Q 5. Aaron wants to know how he can avoid future episodes of psychosis. What advice would you give him?

12. Preventing psychosis http://nhslocal.nhs.uk/my- health/conditions/p/psychosis/preventionhttp://nhslocal.nhs.uk/my- health/conditions/p/psychosis/prevention It is not always possible to prevent psychosis. For example, schizophrenia is caused by a combination of biological, psychological and environmental factors that you may not be able to avoid. However, you can prevent psychosis that is caused by substances by not taking illegal drugs. Cannabis Research has shown that regular cannabis users are 40% more likely to develop a psychotic illness, such as schizophrenia, than people who do not use the drug. Cannabis is known to increase the levels of dopamine (a chemical that helps transmit messages) in your brain. Therefore, long-term cannabis use may cause permanent changes in your brain's chemistry that could lead to psychosis. People who regularly use "skunk" (the herbal type of cannabis that is specifically bred for its increased strength) are thought to be most at risk. You should also avoid using other recreational drugs, such as cocaine and ecstasy, because they will also increase your risk of developing psychosis.

13. Stress and depression Experiencing prolonged bouts of stress can sometimes trigger an episode of depression. Both stress and depression are major risk factors for psychosis. The advice listed below may help to reduce your stress levels, helping to prevent depression and subsequent psychotic episodes. Use a problem-solving approach to deal with stress and worries. Try to identify negative thoughts and change them to positive thoughts. Assess your symptoms regularly and consult your GP or counsellor if problems arise. Take regular exercise. Exercise triggers the release of a mood-boosting brain chemical called serotonin. Learn how to relax using relaxation exercises and tapes. Practise yoga and meditation, or have a massage to help relieve tension and anxiety. Join a self-help group to discuss your feelings and concerns. This can help you to feel less isolated. Avoid smoking, taking illegal drugs and drinking alcohol. These may make you feel better in the short-term, but they will usually make you feel much worse in the long- term.

14. In schizophrenia (FirstCONSULT) Strategies to prevent relapse, and which need to be combined, include: Acceptable medication: atypical antipsychotics (e.g. risperidone, olanzapine) carry a reduced risk of side-effects such as sedation, tardive dyskinesia, and parkinsonism, and their use may improve compliance; a brief educational program, 'compliance therapy,' may also help Psychotherapy: supportive problem-solving and cognitive behavioral therapy may substantially reduce risk of relapse Family therapy: treatments that reduce negative emotion in families substantially reduce relapse rates Social measures: improvement in housing and social network, case management, and assertive community treatment all reduce relapse rates Both patient and caregivers should be encouraged to set treatment goals. These will vary widely depending, for example, on patient's age