Guidelines for psychosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Useful information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Psychotic Illness: Notes for suffers,
families and friends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
What is psychosis: Factsheet 1 . . . . . . . . . . . . . . . . . . . . . . .13
Recovering from psychosis: Factsheet 2 . . . . . . . . . .16
Getting help early: Factsheet 3 ..................... 19
How can I help someone with psychosis:
Factsheet 4 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21
Resources on psychosis for carers .................. 24
What is bipolar disorder? ............................. 26
Lithium toxicity ........................................... 31
Treatments for problems with mood ............. 32
Resources for psychosis ................................ 38
Guideline for psychosis
This guideline gives general guidance only and cannot replace clinical judgement in individual cases.
Sources of detection Person presenting Action
Other agencies and community resources First episode
should have concerns attended to, they Assessment of safety Early detection and assessment of
often spot psychosis and are a valuable Reckless or appropriate risk-taking psychosis is essential. Information
source of information and support. behaviour needs to be given with hope of recovery.
For example: Attempts or thoughts of self-harming See toolkit.
Social Services Attempts or thoughts of harming Patient and carer to be advised
Family/carer others regarding psychosis/psychological
Health visitors Vulnerable to self-neglect and abuse by treatments/ medication
Probation Consider a benzodiazepine, eg
Prison diazepam 5, 10mgs qds for up to 7
Risk and suspected psychosis days. There is good evidence for
Urgent CMHT referral combining this with anti-psychotic
Universities, college and schools in acute psychosis
National Schizophrenia Fellowship
Consider risk assessment and Atypical anti-psychotic medication
management procedures may be used as a ﬁrst line
Glos Drugs and Alcohol Service
Detection of psychotic illness Anyone experiencing their ﬁrst
Higher risk group psychotic episode needs specialist
Glos Association for Mental Health
(GAMH) Family history of psychosis
Places of religious worship Substance misuers. Past history of
psychosis, onset at ANY age but most Existing psychosis
commonly in men from 15–35 years old,
Differential diagnosis for women 18–30 and also later onset Regular monitoring of physical and
45–55 years old mental health is essential including:
Co-existing medical conditions eg
epilepsy, multiple sclerosism, Core features Treatment effectiveness
cerebrovascular disease, Cushing’s Delusions
Delusions (beliefs, not shared by others
disease, thyroid disease, SLE, in the patient’s, social, cultural or ethnic
corticasteroid treatment, infectious Hallucinations
or febrile illness Mood
Hallucinations including hearing voices
Substance/drug abuse Compliance
Disorganised or strange speech
Organic psychosis eg dementia Change in psychological factors
Agitated or bizarre behaviour
Possible investigations: FBC+ESR, Extreme and labile emotional states Side effects:
U&Es, TFTs. LFTs urine drug screen
Social withdrawal Sexual dysfunction
Consult non-psychiatric specialist
services if appropriate. Unexplained decline in academic or work Weight gain
Did you know? Additional considerations for women
If treatment of psychosis is delayed Hyperprolactinaemia
longer than 6 months there is three Post-natal psychosis
times the risk of relapse in the ﬁrst Blood and urine.
Erotomanic delusions, delusion of
two years. pregnancy, jealousy This should be reviewed no less than
85% of people experiencing their ﬁrst Additional considerations for people with yearly.
episode will achieve remission on intellectual disabilities Discuss with specialist mental health
neuraleptic medication. People with intellectual disabilities may services should a change in medication
It is important to promote hope in not display a sufﬁcient range of symptoms be required, eg switching to another
to be diagnosed under standard criteria. atypical or depot.
the patient, family and carer.
Refer to Community Learning Disability
For specialist advice: Interventions for psychosis Contact Keith Coupland, Consultant
Refer to Community Learning Disability Team Nurse Psychosocial Interventions Tel: 01242 275070. Early intervention in psychosis
Contact Dr Eric Davis, Consultant Clinical Psychologist Tel: 01242 275070 Or your local
Specialist Mental Health Services
Gloucestershire Mental Health Toolkit – Psychosis 3
Useful telephone numbers Hearing Voices Groups
Milsom Street Day Centre 01242 512812
Hospitals Worcester House Day Centre 01242 525320
Weston Road Day Centre 01452 300631
Wotton Lawn Hospital 01452 891500
Apperley House 01684 293193
Charlton Lane Centre 01242 272181
Memorial Centre, Cirencester 01285 640933
Gloucestershire Hearing Voices Information
Mental Health Day Hospital/Resource www.hearingvoices.org.uk
Brownhil Resource Centre 01242 275070
Coleford Day Hospital 01594 529200 GDAS-Alcohol:
Denmark Road Day Hospital Cheltenham 01242 584881
Gloucester 01452 891200 Gloucester 01452 385757
Lexham Lodge Day Hospital 01242 576585 GDAS Drugs:
Moreton In The Marsh Mental Cheltenham 01242 570003
Health Base 01608 812636 GDAS-Drugs and Alcohol:
Park House Stroud 01453 562090 Cinderford 01594 825656
Stroud 01453 755711
Mental Health Day Centres
Gloucester Association for Mental Health:
Community Learning 01452 891340
Gloucester 01452 416575
Disabilities Team 01242 272122
Forest 01594 837691
Cotswold Counselling 01285 885830
Stroud 01453 767236
Domestic Violence Advice Line 01452 500115
Cirencester 01285 650523
Gay & Lesbian ‘Friend’ Helpline 01452 306800
Gloucester Clubhouse 01452 766310
Grafton Road Day Centre 01452 311599
Service 01453 766310
Milsom Street Day Centre 01242 512812
Gloucester Survivors Forum 01452 310991
Phoenix Club Matson N’hood Project:
Guide 01452 331131
Drop in Service 01452 521454
Weston Road Day Centre 01452 300631
Fellowship 01452 330383
White House Resource Centre 01608 652232
Worcester House Day Centre 01242 525320
Fellowship Dursley & Mid
Social Service Area Ofﬁces Glos Group 01453 832228
Cheltenham 01242 532500
Forest 01594 820500
Outreach Project 01242 525417
Gloucester 01452 426000
Rural Minds 02467 414366
Stroud 01453 751691
Samaritans 01452 300616
South Tewkesbury 01452 410345
Survivors of Childhood Sexual
Tewksbury 01684 275852
Abuse 01452 309026
Projects 01242 228999
4 Gloucestershire Mental Health Toolkit – Psychosis
Cultural Ethnic Support Groups Carers Groups
African-Caribbean Association 01452 813736 Crossroads-Caring for Carers:
Asian Women’s Resource Cheltenham 01242 584844
Centre 020 8696 0023 Cinderford 01594 823414
Bangladeshi Women’s Minchinhampton 01453 884176
Association 01452 520571 Gloucester Carers Projects 01452 386283
Black Mental Health Team 01452 387744
Gloucestershire Bangladeshi Child, Adolescent & Family Services
Association 01452 520571 Gloucester CAMHS 01452 891300
Roshini Women’s Centre 01452 331506 Cheltenham CAMHS 01242 275015
Tapestry Translation & Childline 020 7239 1000
Interpreting 01452 396909 Childline Helpline 0800 11 11000
(Bengali Speaking) 01452 396909 Parentline 0800 800 2222
(Chinese Speaking) 01452 396926 Chinese Parents & Children
(Gujarati & Urdu Speaking) 01452 396928 Association of Gloucester 01452 526170
Social Worker for Chinese Early interventions/young people
Citizens 01452 426000 affected by psychosis www.iris-initiative.org.uk
Educational Psychology Service 01452 425441
Grapevine Gloucester 01452 500080
Hearing Voices Network 0161 2283896 Share Young Peoples
Mind 020 8519 2122 Counselling 01452 524019
Samaritans 0800 800 500 Young Minds 020 7336 8445
Saneline 0345 678000 Young Minds (Parent Helpline) 0800 0182138
Gloucestershire Mental Health Toolkit – Psychosis 5
6 Gloucestershire Mental Health Toolkit – Psychosis
Notes for sufferers, families and friends. You will probably have asked yourselves, ‘What
(adapted from original material) is the matter? Is it serious? What happens
now?’ You may have found out some of the
By Dr. Julian Leff, Assistant Director, MRC
answers already, but not know how to apply
Social Psychiatry Unit, London and Dr Ruth
them. We hope these notes will help answer
Berkowitz, Dr Rosemarie Eberlein-Fries, Dr
some of these questions.
The things that have worried you are the signs
of well-recognised illnesses. We know quite a
lot about them. We know that sometimes a
These notes are an attempt to give you some person can see and hear things that are not
information about schizophrenia and other there. Thinking can get muddled so that the
psychotic illnesses, their effects, causes and person loses touch with what is really
treatment. In addition to the help and advice happening and then things he or she says or
of your Family Doctor, Community Mental does can look odd or unusual. Also, feelings
Health Nurse, Social Worker, Psychologist or may change; they may become more intense
Psychiatrist, you may ﬁnd it helpful to contact making you feel very miserable or very
the National Schizophrenia Fellowship or excited, or they may diminish so that you lose
MIND. interest in things around you or show less
We will try to describe what it is that has
happened to you and what it is called. People who have these sorts of experiences
suffer from a form of what is called psychosis.
In the past you or others may have found that
Psychosis is an illness. It affects people in
you were not your usual self, that you do not
different ways. The difﬁculty is, that the sort of
talk as you used to, that you prefer to spend
experiences it gives rise to seem completely
time alone, or that you see or hear things that
real to the people suffering from it but they
others do not. If people try to talk to you
are hard to explain. For instance, someone
about these things they cannot persuade you
who hears voices may talk back to them
that they are not true.
because they think they are voices of people
who are actually there. Someone who seems
Gloucestershire Mental Health Toolkit – Psychosis 7
to be very cold may not be able to be friendly may lose the thread of what you are saying.
because their feelings have been swamped by This kind of thing can make communication
the illness. Someone, who is very awkward or between you and your family very difﬁcult.
does not want to do ordinary things with the
What happens is that you may lose your ability
rest of the family, may be like that because the
to think clearly and keep your thoughts in
illness has made them completely wrapped up
order. Thoughts can become jumbled, so they
in themselves and they do not realise that they
don’t always make sense. Sometimes it may
are upsetting others.
feel as if you have too many thoughts and that
Because the person cannot usually explain you can only get rid of them by sharing them
what is happening, it is not easy for those who with someone. You may talk endlessly,
live with them to realise that many of the odd although others may ﬁnd it hard to follow
or upsetting things are due to illness. It is your meaning. On the other hand, you might
especially hard because it is a mental and not suddenly stop talking because your mind
a physical illness, so there are no outward seems to have gone ‘blank’. All this can be
signs of anything being wrong. For example, it very frightening, as it is hard to understand
is much easier to understand why someone what has happened to your thoughts. You are
with rheumatism can’t do so much around the likely to spend a lot of time worrying about it
house, or perhaps can’t get to work, than it is and trying to work out what is going on. For
to understand why someone with psychosis instance, you might think that the neighbours
may not be able to do these things. are to blame for what is happening, or that
your family is being unfriendly towards you.
Psychosis are not rare illnesses. More than one
You may have the feeling that you are
out of every hundred people will probably
someone special and whatever anybody says
suffer from one form or another during their
cannot be persuaded that this is not true. This
can mean that the illness changes your whole
It can affect anyone. They are illnesses that world to a point where you can lose touch
starts mainly in young people in their with what is really happening.
twenties, when most people are getting
Another thing that often happens is that
married or moving out of home. Both men
psychosis can cause a person to see or hear
and women can suffer, although it tends to
things that are not there. They may hear
start some years earlier in men. Psychoses
noises or voices. Sometimes they understand
occur all over the world; it is not something
what they hear; at other times they can make
that just affects people in Britain.
no sense of it at all. They may hear voices
talking to them or about them. When this ﬁrst
Symptoms starts to happen it is often very frightening
and people understandably search for an
Now we would like to go into more detail
explanation. They are usually able to ﬁnd
about the sort of things that can happen to
some explanation that makes sense to them,
someone who has a psychotic illness.
for instance that the voices are coming from a
Individuals suffering from psychosis can have
transmitter or from the television, or that they
very different experiences. However, certain
are spiritual in nature, from God or angels.
things happen to almost everyone at some
Less often, people realise that they come from
stage of the illness.
their own mind. These voices can say
Disturbances of thinking are very common. unpleasant things and the person often talks
People may have noticed you have said things or shouts back at them, even when other
that were unexpected or that they did not people are present. Occasionally, they might
understand. It may not make sense or you tell them to do things like opening the front
8 Gloucestershire Mental Health Toolkit – Psychosis
door at night, or to stay awake. They seemed to enjoy it. Some people feel that
sometimes feel they must obey these voices strangers in the street stare at them or pass
and this can become very distressing. remarks about them so they avoid going out.
Psychosis can also affect feelings. It can cause Often, the person with this illness sleeps a lot
a person to lose the ability to feel the right of the time and may refuse to get up in the
emotion at the right time, so they may laugh mornings. They may be asleep and awake at
about bad news,or cry when everyone else is completely different times from the rest of the
laughing. Your family may have noticed that family and this can make it very hard for them
you do not seem to care for them as you did to hold down a job.
before, or show your love in the same way.
A big problem can be when they show little
There may be fewer and fewer times when
interest in anything and have no idea how to
you can really talk to each other and they may
ﬁll their day. Their mind may seem a complete
question whether you still feel anything for
blank so they pester those close to them for
them at all. You can’t help all of this. The
things to keep them occupied. A lack of
illness can swamp your usual feelings and
energy can cause them to take a long time
cause you to become wrapped up in yourself.
over such things as housework or a job. This
There may be times when you threaten to
can be very hard to live with.
smash things or harm someone you are fond
of, being unaware of the effect this can have Finally, many arguments can arise over
on other people. More often, though, a personal cleanliness, again due to a lack of
person with this illness will be shy and interest and energy. They may neglect to comb
withdrawn raher than threatening and may be their hair or wash it, refuse to bath or clean
easily upset, particularly if others become their teeth. They may dress unusually or
irritated by the things he or she does. refuse to change their clothes, not bothering
From time to time the person may realise how
much they have changed and how different Sometimes, being careless about some things,
their life has become. This can make them they become unusually fussy about others.
miserable or desperate and they may say that They may insist that their room is kept in a
life is not worth living. Occasionally, they may certain way, or that you do not disturb their
become very excitable and overactive and say possessions.
they have no problems at all.
These then, are the general ways in which
Something else commonly affected by psychosis can affect people, but as we have
psychosis is the amount of energy the person said before, each individual will be affected in
has and their willingness to do things. What a somewhat different way.
usually happens is that the person prefers to
be by him or herself. They may sit in their own Cause and course of the illness
room for hours on end listening or talking to
voices or pacing up and down. They may We have mentioned the sorts of things that
hurry through meals, hardly noticing what can happen to someone with psychosis. Now
they eat and then go back to their room. At we would like to tell you what is known about
times they may refuse to eat at all with the why it may appear, the likelihood of further
family. This happens because they ﬁnd they attacks and how it might affect the future.
can no longer feel at ease with other people;
We know that inheritance plays some part in
they feel awkward and unable to do or say the
the development of psychosis but by no
right thing. They may even actively avoid
means explains fully why the illness appears in
other people’s company, whereas before they
a particular person. Just because psychosis
Gloucestershire Mental Health Toolkit – Psychosis 9
occurs in one person in a family, it does not recovery is not always complete, some people
necessarily mean that other family members being left with difﬁculties, but the overall
will develop it. Often there are no other response to treatment is good.
relatives at all who have such attacks. Neither
For example, with medication, nine out of ten
does it mean that a person with schizophrenia
people with schizophrenia stop hearing or
or other psychotic illness should not have
seeing things that aren’t there and loose their
children because they will be affected. All we
strange beliefs. About one in four people have
do know, for example, is that there is an
an attack of schizophrenia from which they
increased risk of schizophrenia for children if
make a complete recovery and then stay well
a parent has had schizophrenia; one out of ten
for many years. Others, luckily only a small
of these children will develop it in later life.
number, do not respond to treatment at all.
There are factors that seem to inﬂuence the However, most people, although they recover
occurrence of psychosis. Research work has from the attack are likely to have other
been done on many of these factors but at attacks. These may occur within weeks of
present we can hold no single cause to be recovery, or may happen years later. During
responsible for psychosis; there seem to be a further attacks new kinds of odd behaviour
number of different contributory factors. We can appear, but often the same pattern will
would like to look in detail at one of these repeat itself.
causes that may be particularly important to
In between attacks others may notice you are
you as members of the same family.
not the same as you were before. For instance,
A lot has been written about the inﬂuence of you may take a long time to get things done.
the family on psychotic illness. We have no You may say very little when with other
evidence that a family’s inﬂuence on a child people. You may loose interest in things and
can cause schizophrenia or any other be content to sit all day doing nothing. This
psychosis. But, once the illness has appeared can lead to difﬁculties in getting or keeping a
the family can play an important part in job and you may remain unemployed for long
helping the person stay well. Other features periods.
help to decide whether the person will do
If you do the housework you may ﬁnd, or
well, such as their personality and the
others may notice that you cannot manage as
progress they have made in life before the
much as before. Chores remain undone and
illness ﬁrst appears. However, we will
the house may get neglected. This means the
concentrate mainly on the part played by the
rest of the family has to rally round and do
family and will discuss this in more detail later.
Also, we know that the more things a person
Finally, even when you are well, you may not
with this illness has to cope with in life, the
be as involved in the family as before. You may
more likely they are to have an attack.
stay aloof from family events and seem much
Increased stress can affect anyone badly, but
less affected by them.
people with psychosis seem to be particularly
sensitive to it. Changes and conﬂicts in their These things are not done to be annoying.
lives can also bring on further attacks. We will They are partly the result of the medication,
talk about this later as well. partly due to the illness itself and partly due to
the person’s own attempts to avoid becoming
Well then, what happens to someone who has
upset and ill again. However, some of these
psychosis? It is important to stress that most
things improve with time, particularly if the
people will get better with treatment. They
family can manage to be supportive and
will think more clearly and then many of the
unusual ideas will go away. Unfortunately,
10 Gloucestershire Mental Health Toolkit – Psychosis
Treatment when you feel better. A lot of people ﬁnd it
very hard to stay on their drugs when they
You have probably been given some sort of feel well, because it seems pointless.
medication. This plays an important part in Unfortunately, psychotic illness does not
the treatment of psychosis. It may stop voices usually just go away. Like many of those with
in your head and help you to think more diabetes, who have to take a daily injection
clearly. It can make you feel less anxious and even when feeling well, people with
restless, protecting you from the stresses schizophrenia often have to stay on drugs to
coming from your own experiences and prevent further attacks and to remain well.
In the same way that there is no sudden
If drug treatment is started the effects cannot improvement when people start drug
always be seen straight away. It may take days treatment, there is no sudden change if they
or even weeks before you improve. Even so, stop it. When a person has not taken their
the tablets have to be taken regularly. They are tablets or if they have missed an injection, the
not like aspirins, which you just take when a illness does not return immediately. It can take
headache comes on. Some people are not months until symptoms reappear, depending
given tablets, but are put on injections. These on the amount of difﬁculty the person has to
have the same effect as tablets but can be cope with.
given less often. This is because one injection
Drug treatment is not the only thing that
lasts for several weeks. It is sometimes more
helps. The atmosphere in the home and the
convenient for people to have their drug
way daily problems are tackled are equally
treatment in this way, but again it is important
to have these injections regularly.
This is because people suffering from
Unfortunately, the drugs used for psychosis
psychosis are very sensitive to things
have a number of side effects. They often
happening around them. They are much more
make the muscles stiff, or the person may start
easily upset, than other people, by the ups
to shake or feel a physical restlessness, usually
and downs of daily life. Changes in routine can
in the legs. Reducing the dose may get rid of
make them feel unsettled and things like
these side effects, or the person may need to
moving into a new house or having to face an
take another pill, which acts as an antidote.
examination can bring on another attack.
There are many different types of medicine,
When such events can’t be avoided it is a
which help the person with schizophrenia,
good idea to tell the person well in advance if
and sometimes changing from one type to
any changes are expected. It is a good idea to
another will relieve side effects.
try to manage only one change at a time if at
When the person is ﬁrst treated with drugs, all possible.
the dose is usually increased until the illness
Life with a person with psychosis can be
begins to get a bit better. At this stage the
extremely difﬁcult. They may behave oddly,
drugs often have the effect of making the
talk to themselves, spend all day lying in bed
person quite sleepy. Once the person is
and take hours to get things done. This can
recovering, it is possible to reduce the dose,
cause other members of the family to get
and the sleepiness should improve. However,
angry or lose their temper. Or they may
if it continues once you have returned home,
become intensely worried, wondering what
you or your family should inform the doctor,
will happen next. The inevitable questions
who may then reduce the dose further.
arise, what happens in the future, how are you
Once medication has been found to be going to cope and you get angry and upset.
helpful, it has to be taken for a long time even
Gloucestershire Mental Health Toolkit – Psychosis 11
It is not surprising that you ﬁnd yourselves Secondly, if you HAVE to be together a lot of
reacting like this. Unfortunately, it is not the time, it is best if you can try not to shout
helpful and can even make things worse. This or get too annoyed by day to day problems.
is because the person with psychosis is easily This is easier said than done, but it is helpful
upset as we have said, and may ﬁnd for all of you to try to keep a calm atmosphere
arguments or being fussed over much more and to keep difﬁculties in perspective. Talking
difﬁcult than in the past. with others in a similar situation to your own
can help with this.
The best thing for you to do in this situation is
ﬁrstly, not to spend so much time together so In some families, relatives and the person with
that you don’t get on each other’s nerves. psychosis get extremely involved with each
Sometimes the local mental health team will other; both sides can become extremely
make arrangements for you to spend time at a worried and upset about everything. The best
day centre or college, or try to help you ﬁnd a thing to do in this case is, to get your family to
job. try to gradually let you make your own
decisions. They might ﬁnd this difﬁcult to do,
It is important that the person with psychosis
feeling that they are not caring enough,
leads as independent a life as possible. It helps
worrying that you will think they are not
them to gain conﬁdence, to begin to take
interested. However, in the long run, it is
responsibility and look after themselves again.
better for both of you: your relatives will feel
Sometimes, if they live at home with parents,
less strain and you will ﬁnd things easier if
it is a good idea for them to start the normal
they care by being less involved.
process of leaving home and living elsewhere,
perhaps in a hostel. It may be difﬁcult to Most people with psychosis and their families
accept, but the person actually does better if have solved similar problems. The purpose of
they live their own life as much as possible. It these notes is to begin to give you some
is also important for relatives to look after information, to let you know some of the
their own needs. They need time away from things you can expect, and some ideas on
the person to develop their own interests, what you can do to help.
relax and forget about illness for a while.
12 Gloucestershire Mental Health Toolkit – Psychosis
What is psychosis? Factsheet 1
The word psychosis is used to describe Hallucinations
conditions which affect the mind, where there
has been some loss of contact with reality. In psychosis, the person sees, hears, feels,
When someone becomes ill in this way it is smells or tastes something that is not actually
called a psychotic episode. there. For example, they may hear voices
which no one else can hear, or see things
Psychosis is most likely to occur in young which aren’t there. Things may taste or smell
adults and is quite common. Around 3 out of as if they are bad or even poisoned.
every 100 people will experience a psychotic
episode making psychosis more common than Changed feelings
diabetes. Most people make a full recovery
from the experience. How someone feels may change for no
apparent reason. They may feel strange and
Psychosis can happen to anyone. Like any cut-off from the world with everything moving
other illness it can be treated. in slow motion. Mood swings are common
and they may feel unusually excited or
What are the symptoms? depressed.
Psychosis can lead to changes in mood and People’s emotions seem dampened – they feel
thinking and to abnormal ideas, making it less than they used to, or show less emotion
hard to understand how the person feels. In to those around them.
order to try to understand the experience of
psychosis it is useful to group together some Changed behaviour
of the more characteristic symptoms. People with psychosis behave differently from
the way they usually do. They may be
Confused thinking extremely active or lethargic sitting around all
Everyday thoughts become confused or don’t day. They may laugh inappropriately or
join up properly. Sentences are unclear or become angry or upset without apparent
don’t make sense. A person may have cause. Often, changes in behaviour are
difﬁculty concentrating, following a associated with the symptoms already
conversation or remembering things. described above. For example, a person
Thoughts seem to speed up or slow down. believing they are in danger may call the
police. Someone who believes he is Jesus
Christ may spend the day preaching in the
streets. People may stop eating because they
It is common for a person experiencing a are concerned that the food is poisoned, or
psychotic episode to hold false beliefs, known have trouble sleeping because they are scared
as delusions. The person is so convinced of of something.
their delusion, that the most logical argument
Symptoms vary from person to person and
cannot make them change their mind. For
may change over time.
example, someone may be convinced from
the way cars are parked out side their house
that they are being watched by the police.
Gloucestershire Mental Health Toolkit – Psychosis 13
What is ﬁrst-episode psychosis? usually given. Diagnosis means identiﬁcation
of an illness by a person’s symptoms and the
First-episode psychosis simply refers to the diagnosis will depend on what brought on the
ﬁrst time someone experiences psychotic illness and how long the symptoms last.
symptoms or a psychotic episode. People
When someone is experiencing a psychotic
experiencing a ﬁrst episode psychosis may not
episode for the ﬁrst time, it is particularly
understand what is happening. The symptoms
difﬁcult to diagnose the exact type of
can be highly disturbing and completely
psychosis, because many of the factors which
unfamiliar, leaving the person confused and
determine the label remain unclear.
distressed. This distress is increased by
Nevertheless, it is useful to be familiar with
negative myths and stereotypes about mental
some of the labels which you might hear.
illness which are still common in the
community. A psychotic episode occurs in
three phases. The length of each phase varies Drug-induced psychosis
from person to person. Use of, or withdrawal from, alcohol and drugs
can be associated with the appearance of
Phase 1: Prodrome psychotic symptoms. Sometimes these
symptoms will rapidly resolve as the effects of
The early signs are vague and hardly
the substances wear off. In other cases, the
noticeable. There may be changes in the way
illness may last longer, but begin with drug-
some people describe their feelings, thoughts
Phase 2: Acute
Sometimes psychotic symptoms may appear
Clear psychotic symptoms are experienced,
as part of a head injury or a physical illness
such as hallucinations, delusions or confused
which disrupts brain functioning, such as
encephalitis, AIDS or a tumour. There are
usually other symptoms present, such as
Phase 3: Recovery memory problems or confusion.
Psychosis is treatable and most people
recover. The pattern of recovery varies from Brief reactive psychosis
person to person.
Psychotic symptoms arise suddenly in
People recover from ﬁrst-episode psychosis. response to a major stress in the person’s life,
such as a death in the family or change of
Many never experience another psychotic
living circumstance. Symptoms can be severe,
but the person makes a quick recovery in only
a few days.
What are the types of
psychosis? Delusional disorder
Everyone’s experience of psychosis is different The main problem is strong beliefs in things
and attaching a speciﬁc name or label to the that are not true.
psychotic illness is not always useful in the
early stages. Schizophrenia
However, when someone has a psychosis, a Schizophrenia refers to a psychotic illness in
diagnosis of a particular psychotic illness is which the changes in behaviour or symptoms
14 Gloucestershire Mental Health Toolkit – Psychosis
have been continuing for a period of at least What causes psychosis?
six months. The symptoms and length of the
illness vary from person to person. Contrary to A number of theories have been suggested as
previous beliefs, many people with to what causes psychosis, but there is still
schizophrenia lead happy and fulﬁlling lives, much research to be done.
with many making a full recovery.
There is some indication that psychosis is
caused by a poorly understood combination of
Schizophreniform disorder biological factors which create a vulnerability
This is just like schizophrenia except that the to experiencing psychotic symptoms during
symptoms have lasted for less than six adolescence or early adult life. These
months. symptoms often emerge in response to stress,
drug abuse or social changes in such
Bipolar (manic-depressive) disorder vulnerable individuals. Some factors may be
more or less important in one person than in
In bipolar disorder, psychosis appears as part another.
of a more general disturbance in mood, in
which mood is characterised by extreme highs In ﬁrst-episode psychosis, the cause is
(mania) or lows (depression). When psychotic particularly unclear. It is, therefore, necessary
symptoms are present, they tend to ﬁt in with for the person to have a thorough
the person’s mood. For example, people who examination to rule out known medical causes
are depressed may hear voices telling them and make the diagnosis as clear as possible.
they should commit suicide. Someone who is This usually involves medical tests, as well as a
unusually excited or happy may believe they detailed interview with a mental health
are special and can perform amazing feats. specialist.
Psychosis has many forms. Course and
Schizoaffective disorder outcome vary from person to person.
This diagnosis is made when the person has
concurrent or consecutive symptoms of both Further information
a mood disorder (such as depression or
Other information sheets are:
mania) and psychosis. In other words the
picture is not typical of a mood disorder or Recovering from Psychosis
Getting Help Early
Psychotic depression How Can I Help Someone With Psychosis?
This is severe depression with psychotic These are available from
symptoms mixed in, but without periods of http://www.vicnet.net.au/eppic/infosheets.html
mania or highs occurring at any point during
the illness. This distinguishes the illness from
Gloucestershire Mental Health Toolkit – Psychosis 15
Recovering from psychosis:
Sometimes people with psychotic symptoms recover. A shared belief and commitment from
are reluctant to seek treatment. Perhaps they people helping them. A strategy for recovery;
believe there is nothing wrong, or hope the a recovery plan; adequate and appropriate
symptoms will go away without help. They resources which facilitate recovery; a
may be concerned about the actual treatment willingness to share the journey of recovery
or worried about what people may think. with others; a process that is different from
cure but the person begins to feel more in
An increased understanding of psychosis has
control of their ‘illness’ and life. Recovering is
led to new drugs and therapies being
perhaps a better word.
developed. People with psychosis are likely to
be treated at home, usually visiting a local
mental health clinic an a regular basis. Home What will treatment involve?
visits by local mental health services can be
The ﬁrst phase of treatment involves
arranged and if hospitalisation is required, this
assessment. This means having a series of
is usually only for a brief period.
interviews with a mental health specialist, such
Psychosis, like other illnesses, can be treated as a psychiatrist, clinical psychologist or
and most people make a good recovery. community psychiatric nurse. The specialist
Recovery is about seeing people and people will spend time getting to know the person, as
seeing themselves as capable of recovery well as speaking with family and friends. Blood
rather than as passive recipients of tests and x-rays will probably be organised to
professional treatments. It is about working exclude a physical cause for the symptoms.
out strategies and taking control of our own This is a frightening and confusing time for
lives. Within the recovery approach, everyone concerned and a great deal of
developing in states in America, New Zealand reassurance and tolerance is needed. It is
and elsewhere, individuals are encouraged to important to establish a good trusting
learn more about their experience, and ﬁnd relationship wherever possible.
ways to deal with their mental health Information obtained from the person with
experiences. People are actively supported to the psychosis and their family and friends,
acquire the skills, knowledge and strength to together with the test results, will provide
reduce the prevalence or harmful experiences some idea about the type of psychosis being
in safe, simple and effective ways. A key experienced, the cause, and how the person
element to recovery is about people taking can best be helped.
control and moving away from a negative
Sometimes psychotic symptoms go away
mental health system. It is about people
rapidly and people resume a normal life
working out ways of helping themselves,
immediately. Other people take several weeks
taking responsibility and having hope. Each
or even months to recover. Like after any
person's recovery is individual and there are
illness, they may want to spend some time
differing views on it but there are also
convalescing or they may wish to use a variety
of different treatment options. Determining
Key Elements of Recovery: An individual belief the best treatment will depend on factors such
and commitment that they can and will as personal preference, how severe the
16 Gloucestershire Mental Health Toolkit – Psychosis
psychotic symptoms are, how long they have When should hospital be
been present, and what the apparent cause is.
Medication Most people with psychosis can be supported
at home by relatives or friends as long as they
Medication can be a crucial treatment for
are provided with skilled and regular support
psychosis. Along with other forms of
from mental health professionals. First
treatment, it plays a fundamental role in
episode patients should be treated at home, if
recovery from a psychotic episode and in
possible, to minimise distress and disruption
prevention of further episodes. There are a
to the young person.
number of different types of meditation which
are very effective in reducing the symptoms of Home-based care can be provided by your
psychosis and the anxiety and distress these local community mental health service; crisis
symptoms ran cause. Treatment commences assessment and treatment (CAT) services, who
with a low dose of medication and details provide intensive 24-hour support to the
about how much to take and when to take it person and their family, are often a part of
will be worked out with a doctor. Medication these community mental health services.
will be monitored and if side-effects develop Sometimes, however, there are beneﬁts in
the type of meditation or the amount taken spending a period of time in hospital before
may be changed. This is critical in order to continuing with home treatment.
avoid distressing side effects which can lead to Hospitalisation allows symptoms to be
a per son being unwilling to accept observed more fully, assists investigations and
medication which is central to their recovery. helps with the start of treatment. Sometimes
people request hospitalisation so they can rest
Counselling and psychological and feel safe.
therapy Today, hospitalisation is more commonly
Having someone to talk to is an important reserved for situations where psychotic
part of treatment. The exact method may vary symptoms are placing the person or other
to suit the individual and the phase of the people at risk. For example, the person may
psychotic episode. A person with acute be seriously considering suicide. In such cases,
psychotic symptoms may simply want to know hospitalisation allows assessment and
there is someone who can understand their treatment to be continued and ensures that
experience and provide reassurance that they the person is safe. In some cases, admission
will recover. As the recovery phase progresses, may need to be arranged against the person’s
people may ask why me and learn practical will or on an involuntary basis, at least at the
ways to prevent further episodes, such as beginning. However, treatment at home is
stress management and early recognition of resumed as soon as possible.
Counselling or therapy can take place on an How can the person be
individual basis or in groups. involved?
People with early psychosis are encouraged to
be actively involved in their own treatment.
Treatment can also involve assistance with day- There is a need to learn about psychosis,
to-day things, such as getting back to school about the recovery process, and what the
or work, arranging accommodation or individual can do to promote and maintain
obtaining ﬁnances. recovery. Sometimes there are secondary
Gloucestershire Mental Health Toolkit – Psychosis 17
problems to be dealt with, like how to catch Further information
up with missed school or work, or how to
cope with feelings of depression and stress Other information sheets are:
related to the experience. It is important for
What is Psychosis?
the person to know their rights and to ask
questions when something is not clear. Getting Help Early
How Can I Help Someone With Psychosis?
What about recovery? These are available from
The pattern of recovery from psychosis varies http://www.vicnet.net.au/eppic/infosheets.html
from person to person. Some people recover
quickly with very little intervention. Others
may beneﬁt from support over a longer
Recovery from the ﬁrst episode usually takes a
number of months. If symptoms remain or
return, the recovery process may be
prolonged. Some people experience a difﬁcult
period lasting months or even years before
things really settle down. The important thing
to remember is that psychosis is treatable.
Most people recover to lead satisfying and
18 Gloucestershire Mental Health Toolkit – Psychosis
Getting help early: Factsheet 3
Getting help early involves recognising What are the early signs?
psychosis at the earliest possible time and
ﬁnding appropriate specialist treatment. Usually there are some changes in a person
before the obvious symptoms of psychosis
develop. These changes are called early signs
and this phase just before the psychosis is
The initial episode of psychosis can be a called the prodrome. The early signs are vague
particularly confusing and traumatic and hardly noticeable. The important thing to
experience. The change in the person’s look for is if these changes get worse or
behaviour causes concern and distress simply do not go away.
because no-one really understands what is Early signs vary from person to person. In the
happening. prodromal phase, there may be changes in the
This lack of awareness often leads to delays way some people describe their feelings,
seeking help. As a result, these treatable thoughts and perceptions. However, they have
illnesses are left unrecognised and untreated. not started experiencing clear psychotic
symptoms such as hallucinations, delusions or
Even when help is sought, further delays may
occur before the right diagnosis is made
because recognition of these disorders can be
difﬁcult. Early signs
Why is it important to get help A person may become
Often there is a long delay before treatment Depressed, anxious
begins for the ﬁrst episode of psychosis. The Tense
longer the illness is left untreated the greater
the disruption to a person’s family, friends, Irritable
study and work. Angry
The way they feel about themselves can be
affected, particularly if treatment is prolonged. A person may experience
Other problems may occur or intensify, such Mood swings
as unemployment, depression, substance
abuse, breaking the law and causing injury to Sleep disturbances
themselves may occur or intensify. Appetite changes
In addition, delays in treatment may lead to Loss of energy or motivation
slower and less complete recovery.
Disruption need not occur. If psychosis is A person may feel
detected early, many problems can be
Their thoughts are speeded up or slowed
Things are somehow different
Gloucestershire Mental Health Toolkit – Psychosis 19
Things around them seem changed Remember these changes in behaviour may
nat be early signs but it is a good idea to get
Often family and friends are the ﬁrst to
them checked out. If a psychotic disorder is
notice the changes.
developing the sooner the young person gets
help the better.
Family and friends may notice when
The earlier psychosis is recognised and
A person’s behaviour changes
treatment commences, the better the
A person’s studies or work deteriorate outlook.
A person becomes more withdrawn or
isolated Further information
A person is no longer interested in Other information sheets are:
What is Psychosis?
A person becomes less active.
Recovering from Psychosis
Families often sense that something is not
How Can I Help Someone With Psychosis?
quite right even though they don’t know
exactly what the problem is. These are available from
These behaviours might be a brief reaction to
stressful events like hassles at school or work
or trouble with relationships. On the other
hand they may be early warning signs of a
developing psychosis. It is important that
these behaviours are checked out.
The ﬁrst step
When these prodromal or psychotic
symptoms appear it is important that the
young person gets help. A good place to start
is with a local doctor community health centre
or community mental health service. School
counsellors might also be available.
20 Gloucestershire Mental Health Toolkit – Psychosis
How can I help someone with
psychosis? Factsheet 4
It can be very distressing to realise that the possibility of psychosis or contact
someone close to you is experiencing advocacy and support agencies, such as
psychosis. You may feel shocked, confused, National Schizophrenia Fellowship.
bewildered and guilty. There is no right or
wrong way to feel.
How can I help during
Recognising the problem may have been treatment?
difﬁcult, as it is easy to mistake early psychosis
for the normal ups and downs of young Once you have found a professional or service
people. You have lots of questions and may experienced in dealing with psychosis you
not know what to do next. You want to help, may ﬁnd it useful to:
but are not sure how. Try to think of yourself and the
professional as having the same goal to
Where can I get help? help the person with psychosis and work
towards recovery It is like a partnership
It can be very confusing to know where to get between yourself and the treating person
help. Families, partners or friends ﬁnd it hard or team.
to make the decision to obtain help for lots of
reasons. The person experiencing a psychotic Find out who else is in the treating team –
episode may not wish to get help or even ask for their names and contact numbers.
acknowledge that they are unwell. It can be Ask the staff speciﬁcally what their role is
extremely hard to cope alone with a person now and what it will be in the future.
who is in a psychotic state. Ask who is the best person to contact and
Help is needed for the unwell person to ﬁnd make a note of all this information.
out exactly what is happening and what type Ask for a meeting with the key people in
of treatment is required. Help is also needed the team and prepare a list of questions to
for families, partners and friends so they can take with you. Feel free to write the
understand what is happening and ﬁnd out answers down at the meeting. Ask for
how to be involved in the assessment, regular meetings and obtain an
treatment and recovery process. appointment time for your next meeting.
A good place to start is with your local doctor, Ask for speciﬁc information. If you don’t
community health centre or mental health understand what you are being told, say
service. They will tell you what to do next and so and ask for a clearer explanation.
where treatment can be obtained. Initially,
Ask where you can obtain additional
your biggest concern will be understanding
information. For instance, are there
what is happening and getting the right sort of
speciﬁc education sessions you can attend
or is there material available to read?
If you have difﬁculty getting advice or help, or
feel you are getting nowhere, you may need to
shop around. Talk to your local doctor about
Gloucestershire Mental Health Toolkit – Psychosis 21
How should I relate to the How can I help recovery?
person who is ill? Family, partners and friends are very important
If you are with a person when they are in the process of recovery. When a person is
psychotic and behaving strangely, you may feel recovering from their psychotic episode you
frightened or frustrated. It is important to can provide love, stability, understanding and
remember that they are still your son, reassurance, as well as help with practical
daughter, brother, sister; wife, husband, issues.
partner or friend. It is very difﬁcult for a However, you may need your own period of
person who is ill to be how they usually are. recovery and adjustment to all that has
Often families and friends ask how they happened. It can be useful to understand
should behave and talk to a person who is some of the stages you may have gone
psychotic. There are no set rules, however, through.
some general guide lines can be helpful.
Be yourself It is quite common for families and friends to
Gain information and understand that the go through the following stages:
person may be behaving and talking Initially you may be in crisis as you
differently due to the psychotic symptoms. become aware that something serious is
Understand that psychotic symptoms are happening and your family member or
stressful for everyone and that you may have a friend is unwell. You may feel very
range of feelings – shock, fear, sadness, anger anxious, worried and frightened at this
frustration, despair time.
Talking with other people will help you to deal As it becomes clear that something is not
with these feelings. Believe a person will quite right you start to seek help. This is
recover-even if it takes time. Be patient. also a time where you may be adjusting to
the fact that your family member or friend
When a person is in an acute stage they may is unwell and the situation cannot be left
seem child-Iike. Sometimes they need to be in to clear up by itself
a safe, comforting environment and
sometimes they need others to help with As you ﬁnd help you will probably have
decisions. lots of questions and worries – ‘What is
happening? What is psychosis? What
Try not to take it personally if a person says causes it? Will this happen again? How is it
hurtful words to you when they are unwell. treated? What can we do to help? What
When a person has acute psychotic symptoms will we tell other people? Will our family
they may be ﬁxed in their beliefs and ideas. member or friend understand why help
Don’t get involved in a long disagreement, but was needed? Should we have got help
listen with interest to gain an understanding of earlier?’ You will have mixed emotions and
their current reality show sympathy and for reactions during this time. Any feeling you
future reference, to discuss when they are have is appropriate.
As the person begins to recover and starts to
Take care of yourself. It is a balance between show signs of being well, you may experience
care and concern and not getting too run great relief and pleasure. You may also have
down yourself. started to understand the illness more by this
time and start to feel more hopeful about the
22 Gloucestershire Mental Health Toolkit – Psychosis
As recovery progresses you may ﬁnd your Remember that families, partners and friends
anxiety questions or worries start to increase also need a period of recovery and time to
again as your family member partner or friend understand and accept what has happened.
starts to reintegrate back into the family and Don’t keep things a secret – talking with
community. Often family members ﬁnd others, whether it be with family members,
themselves watching the person for signs of friends or professionals, can be very helpful.
relapse or strange behaviour. You may feel
protective and anxious, wanting the patient to
be well as quickly as possible and not do
anything that may cause a relapse. It can be Other information sheets are:
difﬁcult balancing the needs for independence
What is Psychosis?
Recovering from Psychosis.
As recovery continues, there is a gradual
adjustment by everyone concerned. You feel Getting Help Early.
reassured that recovery is occurring and some
These are available from
normality returns to your life. You speak with
the patient about psychosis, what it was like
for everyone and how to help each other in
Gloucestershire Mental Health Toolkit – Psychosis 23
Resources on psychosis for
Early diagnosis and treatment leads to psychosis because many of the diagnostic
signiﬁcantly improved recovery and outcome factors need time to become clear. Everyone’s
in psychosis. experience of psychosis is different.
80% of ﬁrst-episode patients with When someone in the family has symptoms of
psychosis are aged between 16–30 at on- psychosis, it can be frightening, confusing and
set with a median age of 19 years in males distressing for the family. In this time it can be
and 22 in females. helpful to learn what to expect and what to
If treatment of psychosis is delayed longer
than 6 months there is three times the A psychotic illness makes it hard to tell what is
risk of relapse in the ﬁrst two years. real from what is not real. The illness also
makes the person feel overwhelmed by things
85% of people experiencing their episode
going around them, especially social contact.
will achieve remission on anti-psychotic
medication and two thirds recover. Individuals may feel very confused, distressed,
afraid, and lacking in self-conﬁdence. This
Anyone experiencing their ﬁrst psychotic
sometimes persists for a long time. They may
needs specialist psychiatric assistance.
feel they have been through a frightening
The word psychosis is used to describe experience. The illness has probably caused
conditions that affect the mind, where the them to loose control of their thoughts and
individual ﬁnds it hard to tell what is real from feel overwhelmed by the world around them,
what is not real. When someone becomes ill or they may also hear voices and feel
with this problem it is called psychotic depressed.
episode. There are different types of psychotic
The person you may care for may on
illness. For example, a psychotic episode may
occasions talk in ways that you may ﬁnd
be associated with the use of, or withdrawal
difﬁcult to follow. The talk may be seem
from alcohol or drugs. This is known as Drug-
incoherent or irrelevant to the conversation at
Induced Psychosis. Sometimes psychotic
times. Or your relative may make unexpected
symptoms arise suddenly in response to a
remarks that do not make sense. This odd
major stress in the person’s life and the
conversation happens because the balance of
person makes a quick recovery. This is known
the brain chemicals makes it hard on
as Brief Reactive Psychosis. Schizophrenia
occasions to think clearly. Sometimes it is
refers to a psychotic illness in which the
because the person is hearing voices that
changes in behaviour or symptoms have been
seem very real to them, although you cannot
continuing for a period of at least 6 months.
Contrary to previous beliefs, many people
with schizophrenia lead happy and fulﬁlling They may have unusual patterns of sleeping or
lives, with many make a full recovery. A eating.
separate leaﬂet, What is Schizophrenia is
They may on occasions appear to behaving in
available. When someone is experiencing a
unusual or embarrassing ways. These
psychotic experience for the ﬁrst time, it is
behaviours are also part of the disorder and
difﬁcult to diagnose the exact type of
24 Gloucestershire Mental Health Toolkit – Psychosis
do not mean that they are stupid or trying to Be gently encouraging and not be critical
embarrass you. or hostile.
It is important to remember that the person Avoid direct confrontation unless there are
with a psychotic illness often acts and speaks issues of safety.
quite normally as well. Symptoms often get
Look after yourself and keep ﬁt as this is
better and may re-appear only under stress. It
good for both of you.
is helpful to treat the person normally, except
when you are dealing with fairly severe Be hopeful as most people recover and
symptoms. the affected person needs to understand
this to prevent feelings of hopelessness.
Try to understand the feelings and
experiences the person is trying to This has been adapated from Vistonia &
express. Piatkowska (1988). Mental illness
Keep calm and reassure the person. Information Manual: a self-help guide for
relatives and carers. Sydney: Dept of Health,
Allow the person to do as much as they
NSW, quoted in Andrews G & Jenkins R. eds.
can for themselves.
Management of Mental Disorders (UK
Be careful to look for signs of depression Edition). Sydney: World Health Organisation
such as lack of motivation, hopelessness collaborating Centre for Mental Health and
and suicidal ideas. Substance Abuse.
Gloucestershire Mental Health Toolkit – Psychosis 25
What is bipolar disorder?
(Also called manic depression)
We all experience minor changes in our mood of mania or depression lasts for a while and
from one day to the next or from one week to then stops. The person usually then feels
the next. Sometimes we may feel happy and completely well again.
sometimes we may feel sad. There is usually a
People are usually completely well between
good reason for these changes in mood.
episodes of mania and depression.
Perhaps we may be happy because we have
just had a nice meal with a close friend. Or The length of time that a person remains well
maybe we are sad because we have lost between episodes of illness varies from one
something or someone that was very person to the next. Some people may have
important to us. only two or three episodes of illness in their
entire lives. Other people may have four or
Generally our mood is appropriate for what is
more episodes of illness per year (referred to
happening in our lives at the time. However,
as ‘rapid cycling’). The good news, however, is
people who have bipolar disorder tend to
that with regular medication you can reduce
have major changes in mood for no obvious
or even prevent further episodes of illness.
reason. They may be extremely excited and
happy when there is no reason to be. At other This disorder can be controled with regular
times they may feel very upset or sad even medication.
though lots of good things are happening in
their lives. When a person has repeated mood The severity of the illness
swings which are very severe and which do
not seem to occur for any good reason, it is Although everyone feels very happy at times
likely that the person has a bipolar disorder. and quite sad at other times, it is usually
possible to keep up our normal tasks.
People who have bipolar disorder tend to
However, in bipolar disorder these mood
have major changes in mood for no obvious
swings may be so severe that they interfere
with normal activities and everyday living.
The mood changes involved in bipolar Behaviours may change completely and may
disorder range from one extreme to another. disrupt the person’s work or relationships.
At one extreme the person may feel
Mood swings may be so severe that they
excessively happy and excited with a huge
disrupt work and relationships.
increase in energy and activity. This extreme
mood swing is called ‘mania’. At the other The severity of illness differs from one person
extreme the person may be severely to another. Some people may have frequent
depressed with a great loss of interest or and severe episodes of mania and depression.
energy. These mood swings usually last Other people may only rarely become unwell.
anywhere from a few weeks to a few months. Also, for each person the severity of illness
differs from one episode of illness to another.
Some episodes may be so severe that the
Frequency of illness
person needs to spend time in hospital.
A person who has bipolar disorder does not However, other episodes could be very mild
always feel manic or depressed. Each episode and may not need hospital care. If you think
26 Gloucestershire Mental Health Toolkit – Psychosis
you are becoming unwell again, seek medical Chemical disturbance
People with this disorder seem to have a
With early treatment the episode of illness is disturbance of the chemicals in the brain. It is
likely to be less severe and hospital likely that the faulty gene causes the body to
admission may be avoided. produce the wrong balance of chemicals.
How common is bipolar Personality factors
disorder? It seems probable that personality factors may
inﬂuence the onset of this disorder. Many
Bipolar disorder is quite a common illness.
people who have probably inherited the faulty
About one person in 100 will develop this
gene from their parents do not go on to
disorder at some time in their lives. The
develop bipolar disorder. It is possible that,
disorder usually starts before the age of 30 but
among people who carry this gene, those who
may occur at any time in the life span. Women
tend to have a moody personality and who do
and men are equally likely to be affected.
not handle stress very well may be more at
There is some suggestion that many of the risk of developing the disorder.
people who develop this disorder have an I.Q.
that is higher than average. Certainly there are Stress
many successful people who have had bipolar
disorder. These people include American Stressful life events (such as the loss of a loved
statesman Abraham Lincoln, painter Vincent one or childbirth) may increase the chance of
Van Gogh, writer Virginia Woolf, and actresses developing bipolar disorder among those who
Vivien Leigh and Frances Farmer. These are at risk. Stressful events such as these may
people all led productive and creative lives. also make further phases of mania and
depression more likely among those who
already have this disorder. Stress alone,
What causes bipolar disorder? however, does not seem to be enough to
cause the disorder among people who have
No one knows exactly what causes bipolar
no other risk factors.
disorder. However, most people now believe
that this disorder is caused by a number of Bipolar disorder is caused by a number of
factors. factors including heredity, brain chemicals,
personality factors, and stress.
We know that this disorder can be inherited Mediation for bipolar disorder
and runs in families. These ﬁndings suggest
Bipolar disorder involves a disturbance of the
that there is likely to be some kind of faulty
chemicals in the brain. This disturbance can
gene in the body. If someone in the family has
be treated with medication. Ask your doctor
bipolar disorder, other family members are
for information about the medication used to
more likely to develop this disorder than
treat bipolar disorder.
people who do not have a relative with bipolar
disorder. However, just because one member
of the family has this disorder does not mean Coping with mood swings
that all family members will develop this
Although medication is very useful for
disorder. Other risk factors may add to the
managing mood swings, a lot of people have
likelihood of developing this disorder.
found that sensible life changes can also help.
Gloucestershire Mental Health Toolkit – Psychosis 27
Some useful tips are listed below: Copng with depression
Learn to recognise the onset of Ask your doctor for a leaﬂet on ‘Depression
mania or depression Factsheet1’. There are a wide variety of
methods and not all work for everybody. You
Very few people go high or low overnight. If a need to ﬁnd out which ones work best for
mood swing is developing you will usually you.
have time to notice it. The signs of depression
and mild mania are widely known. The
important thing is to ﬁnd out what your
warning signals are. You can then seek medical The signs of hypomania (mild mania) are
help straight away – quick action can often quite different. Here are some common signs:
stop the illness from becoming too severe. feeling unusually excited, happy and
The key thing is to catch the mood swing optimistic OR feeling cranky and irritable
early. The longer you leave it, the harder it if others don’t share your enthusiasm and
will be to control. ideas
Recognising depression sleeping poorly and waking early
Think back to the last time you were poor concentration and short attention
depressed. You probably felt a number of span
these: rapid, pressurised speech
tiredness poor judgement (eg overspending;
poor concentration reckless behaviour such as dangerous
self centredness – being rude or
social withdrawal insensitive to other people
suicidal thoughts increased interest in sex, with sexual
loss of interest in sex behaviour that is unusual for you
loss of self-conﬁdence grandiose ideas
changes of appetite
My signs of beginning to get
feeling sad or guilty
waking early feeling anxious
lack of interest in things you used to enjoy
My signs of beginning to feel
Coping with a high
If you suspect you are becoming unwell again,
it will be useful to reduce excess stimulation.
28 Gloucestershire Mental Health Toolkit – Psychosis
By doing your best to remain calm and relaxed Avoid alcohol or any drugs other than
you may be able to reduce the severity of the those prescribed by your doctor.
manic phase. The following tips may be useful:
Seek a quiet and restful place to spend Exercise regularly
your time. This place may be a room in Regular exercise can help you cope with
your house, your garden, or a park. stress. If you are ﬁt your anxiety level and
Avoid crowds, busy streets, shops, and blood pressure will stay lower when you are
parties. under stress. Thirty minutes of fast walking
three to four times per week is good exercise.
Avoid games and group activities. Swimming is also very good for keeping ﬁt.
Avoid making important decisions about
your life while you are unwell. Learn to relax
Spend time with a friend who is calm and Take regular time out to walk, look at the trees
relaxed. and birds, take a hot bath, or go for a swim. If
work makes you tense, stop off at the park on
Listen to relaxing music.
the way home, play with your dog, or do an
Ask your friends to try and stay calm when activity you enjoy like gardening or painting.
you are unwell. It will help if they try to Take time to unwind and be kind to yourself.
ignore silly jokes or comments you may
Another way to reduce tension and stress is
make, or inappropriate behaviour. Keep
through progressive muscle relaxation. This
things low key, noncompetitive and
technique allows you to control your
relaxing. Friends can try to slow you down
breathing rate while you slowly relax all the
by example rather than by demand (eg,
muscles in the body. You will be surprised at
they can speak slowly, walk slowly, and
how much tension and stress you carry
engage in calm activities).
around in your body every day. By relaxing
Avoid arguments wherever possible. your body and your mind (daily and when
needed) you handle everyday stress more
Household members can set clear limits
easily. Ask your health worker for a leaﬂet on
for your behaviour. They can show ﬁrm,
progressive muscle relaxation.
calm disapproval for inappropriate
behaviour (eg, spending money, sexual
harassment or comments, aggressive or
Use structured problem solving
irritable behaviour, being a ‘show-off ’). It techniques to reduce stress
also helps if they avoid laughing about By increasing your ability to solve everyday
your behaviours, or joining in with your problems (large and small) you will lower your
excitement. stress levels. The ﬁrst step in structured
Spend nights in your bedroom even if you problem solving is to deﬁne a speciﬁc
are not sleeping. Lie down and relax as problem that is worrying you. In the next
best you can. (Your health worker can stage you think about all possible ways of
teach you some relaxation techniques.) solving this problem. After weighing up the
Do not play music or the radio at this pros and cons of each possible solution you
time. A simple repetitive task may also be then decide which solution is the best one.
useful at night-time (eg, a solo card game Having made this decision you then write
such as Patience). down exactly how you will put this solution
into action. Finally, you come back and review
Avoid drinking tea, coffee, cola, or other how well the solution worked. You may need
drinks that contain caffeine (a stimulant). to try another solution if the one you chose
Gloucestershire Mental Health Toolkit – Psychosis 29
did not work. Ask your health worker for a Further reading
leaﬂet about the structured problem solving
technique. Inside Out: A Guide to Self-Management of
Manic Depression, Manic Depression
Increase useful activities Felowship, 1995
It is important that family members do not try Living without Depression and Manic
to stop all your activities. If you are stopped Depression: A Workbook for Maintaining
from being active during a manic phase you Mood Stability, Mary-Ellen Copeland. New
are likely to become frustrated, irritated, and Harbinger Press (USA), £11.95.
even violent. You will usually beneﬁt more
from spending your time doing useful and Summary
relaxing activities. These activities will need to
be carefully planned and clearly deﬁned. People who have bipolar disorder tend to
have major changes in mood for no
Arrange a list of activities for each day.
Choose simple activities that do not need
much concentration. Avoid tedious, People are usually completely well
lengthy, or possibly frustrating activities. between their phases of mania and
Good activities include such things as depression.
gardening, handy work, cleaning, This disorder can be controlled with
mopping ﬂoors or vacuuming, drawing or medication.
painting, writing letters to friends, or
watching ﬁlms. Mood swings may be so severe that they
disrupt work and relationships.
Go for a walk. Plan to walk in a peaceful
area. Take a calm and relaxed friend with With early treatment the episode of illness
you. Do not take the dog – an added is likely to be less severe and hospital
distraction. admission may be avoided.
The mood swings in bipolar disorder
See the humour in life involve phases of mania and phases of
Try not to take yourself too seriously. Even the depression.
most embarrassing or stressful moments often Bipolar disorder is caused by a number of
have a funny side when you think about them factors including heredity, brain chemicals,
later. If you feel low or sad do something that personality factors, and stress.
you enjoy. If you feel excited and high
Medication can help you control your
remember that you do not have to save the
world today! Relax for a while.
Simple changes in lifestyle can also be
Sources of further help and helpful.
information World Health Organisation Collaborating
Centre for Research & Training for Mental
Manic Depression Fellowship Health, eds. WHO Guide to Mental Health in
020 8974 6550 Primary Care. London: Royal Society of
Medicine Press, 2000.
May have a group in your area. It provides
advice, support and publications list for
people with manic depressive illness.
30 Gloucestershire Mental Health Toolkit – Psychosis
What is lithium toxicity? Drink plenty of ﬂuids – at least 6 glasses of
water (or milk, fruit juice, soft drink) each
Lithium toxicity occurs when the level of day. If you become dehydrated, the level
lithium in the blood becomes too high. of lithium in your blood will increase.
Also, hot sweaty weather, strenuous
What are the signs of lithium exercise, and vomiting or diarrhoea all
increase water loss. It will be important to
toxicity? drink extra water if these events occur.
Shaking and trembling Do not start a salt-reduced diet while
Confusion taking lithium. A low salt intake can
increase the level of lithium in the blood.
Slurred speech (Note also that a high salt intake can lower
Nausea and vomiting the level of lithium in the blood.)
What to do if you notice the signs
Abdominal pain of lithium toxicity?
Unsteadiness on the feet Contact your doctor immediately or go to
Coma a hospital casualty department.
Seizures Drink a few glasses of water if possible
while waiting to see the doctor.
People who have lithium toxicity usually look
sick, pale, grey and weak. Lithium toxicity is Do not take any more lithium until you
very serious; however, it can nearly always be have seen the doctor.
prevented. Reprinted, with permission, from Andrews G
and Jenkins R, eds, 1999, Managing Mental
How can lithium toxicity be Disorders (UK edition) Sydney, World Health
prevented? Organization Collaborating Centre for
Mental Health and Substance Abuse.
Have regular blood tests as advised by
your doctor. These tests will allow your
doctor to see how much lithium is in your
blood. If you have a high level of lithium
in your blood, your doctor may reduce
your dose of medication for a while to
prevent lithium toxicity from developing.
Gloucestershire Mental Health Toolkit – Psychosis 31
Treatments for problems with
Drugs known as: Mood How should I take it?
Sometimes known as anti-manics and mood
normalisers. Tablets should be swallowed with at least half
a glass of water whilst you are sitting or
Drug: Lithium standing so that they reach the stomach and
do not stick in the throat.
Drugs Lithium carbonate Lithium citrate
available ‘Litarex’, ‘Liskonum’, ‘Camcolit 400’, and
Brand Camcolit Litarex ‘Priadel’ tablets should be swallowed whole
name(s) Liskonum Priadel
Priadel Li-liquid and not chewed. These tablets are made so
Forms available that they release the lithium over a longer
period of time. This can help to reduce side-
Sugar free effects or reduce the number of times a day
you need to take this medicine. If you cannot
swallow them whole they can be broken. Do
not crush, chew or dissolve them as this will
cause the drug to be released too quickly and
What is lithium used for? you may get more side effects.
Lithium is most often used to help to normal
ise or even-out mood swings It can help if you Liquids
get either low or high. It can also help to Your pharmacist should give you a medicine
prevent mood swings in the future in people spoon or oral syringe. use it carefully to make
who suffer from manic-depression (known as sure that you measure the correct amount.
bipolar mood disorder or bipolar affective Ask your pharmacist for a medicine spoon if
disorder). It is one of a number of drugs you do not have one.
which can help to stabilise moods. Lithium is
also used to help treat many other conditions
When should I take it?
Take the doses as directed on the medicine
How does lithium work? label. You should take it at regular times or a
regular time each day. Taking a dose at
It is not known exactly how lithium works. mealtimes may make it easier to remember as
There are many theories, but it probably there is no problem about taking lithium with
evens-out or stabilises the speed at which the or after food. If the instructions say to take
brain passes messages around, and stabilises lithium ONCE a day this is usually best at
cells and nerves and ‘secondary messengers’. bedtime.
Lithium itself is similar to the sodium in salt.
32 Gloucestershire Mental Health Toolkit – Psychosis
How long will lithium take to What should I do if I forget to
work? take a dose?
It may take several weeks before you begin to Start again as soon as you remember unless it
feel better. For people who suffer from manic is almost time for your next dose, then go on
depression it may take many months before as before. Do not try to catch up by taking two
the depressive part of this illness improves. or more doses at once as you may get more
side-effects. You should tell your doctor about
this next time you meet. If you miss several
How long will I need to keep
doses start again when you remember and tell
taking lithium for? your doctor. You may need a new blood test
You should talk about this with your doctor as to check that there is enough, but not too
people respond differently. People usually much, lithium in your blood. If you miss an
need to take lithium for quite some time after occasional dose (e.g. a day or two every few
it has been started. As well as treating the weeks) it is unlikely that you will become ill
illness, lithium also helps to prevent the again.
symptoms returning. Once you have started If you have problems remembering your doses
lithium, you may need to take lithium for a (as very many people do) ask you pharmacist,
long time, probably for at least two or three doctor or nurse about this. There are some
years and quite possibly much longer. For it to special packs, boxes and devices which can be
continue keeping you well, lithium must be used to help you remember.
taken each and every day.
What sort of side-effects might
Is lithium addictive? occur?
Lithium is not addictive as such but a some
people do get some short-term effects if Common
lithium is stopped suddenly (but see below).
Can I stop taking lithium
suddenly? Fine shaking of the hands
It is very unwise to stop taking lithium What to do about it:
suddenly, even if you feel better. Recent This is not dangerous but can be irritating. If it
studies have shown that if you stop lithium annoys you, your doctor may be able to give
suddenly (ie over 1 to 14 days) you have a 1 in you something for it (e.g. propranolol). If it
2 (50%) chance of becoming ill again within gets worse and spreads to the legs or jaw, stop
six months and a 90% chance of becoming ill taking the lithium and see your doctor.
again within 3 years. If you need to stop
lithium, it should be gradually over at least Side effect:
three weeks, preferably four. (See also ‘How Stomach upset
long will I need to keep taking lithium for?’ What happens:
above) This includes feeling and being sick and
What to do about it:
If it’s mild, see your pharmacist. If it lasts for
more than a day, see your doctor
Gloucestershire Mental Health Toolkit – Psychosis 33
Side effect: What to do about it:
Polyuria This is not serious. Tel your doctor the next
time you see him or her. It may be necessary
to take some thyroid replacement.
Passing a lot of urine.
What to do about it: Rare
Don’t drink too much alcohol. Tell your
doctor about it. Some blood and urine tests Side effect:
may be needed. Skin rashes
Side effect: What happens:
Metalic taste Blotches seen anywhere.
What happens: What to do about it:
Your mouth tastes as if it has had metal or Stop taking and see your doctor.
something bitter in it. Side effect:
What to do about it: Blurred vision
This should wear off after a few weeks. If it What happens:
does not, mention this to your doctor next Things look fuzzy and you can’t focus
time you meet. A change in dose may help. properly.
Side effect: What to do about it:
Polydipsia Your lithium level may be too high. Stop
What happens: taking and contact your doctor now.
Feeling very thirsty. Your mouth is dry and Side effect:
there may be a metalic taste. Drowsiness
What to do about it: What happens:
Drink water or low calorie drinks in Feeling sleepy and sluggish in the daytime.
moderation. Suck sugar-free boiled sweets.
What to do about it:
Your lithium level may be too high. Stop
taking and contact your doctor now.
Eating and drinking more and putting on
Your mind is al mixed up.
What to do about it:
What to do about it:
Your lithium level may be too high. Stop
A diet full of vegetables and ﬁbre may help
taking and contact your doctor now.
prevent weight gain. See also a separate
question in this section. Seek help from a Side effect:
Side effect: What happens:
Hypothyroidism A fast heart beat.
What happens: What to do about it:
Low thyroid activity – this makes you feel Your lithium level may be too high. Stop
tired. taking and contact your doctor now.
34 Gloucestershire Mental Health Toolkit – Psychosis
Adapted from UK Psychiatric Pharmacy lithium therapy is feeling thirsty, and drinking
Group leaﬂets, with kind permission (www. large amounts of high calorie drinks can cause
ukppg.org) people to put on weight. If this happens, try
drinks which are low in calories e.g. low
Do not be worried by this list of side-effects.
calorie squash or water, and cut down on
You may get none at all. There are other rare
sugar and milk in your tea and coffee. It is
side-effects. If you develop any unusual
impossible to know what the effect on your
symptoms ask your doctor about them next
weight may be because each person will be
time you meet.
effected differently. It is important that you do
The following side-effects may show that the not ignore feelings of thirst as this can lead to
level of lithium in your blood is too high: lithium poisoning. This is very important
especially if you go on holiday to a hot
country where you may be sweating heavily
Diarrhoea and vomiting too (see side-effects above).
Unsteadiness If you do start to put on weight or have
Difﬁculty in speaking problems with your weight, your doctor can
arrange for you to see a dietician for advice.
A bad tremor Any weight you put on can be controlled while
Clumsiness you are still taking this medication, with
expert advice about diet. In some people
Much increased thirst or passing water weight gain can be a serious problem. If it
Severe drowsiness, confusion or causes you distress make sure your doctor
sluggishness. knows about this. A change in your dose may
be necessary in extreme cases.
If you get any of these side-effects do not take
any more tablets and contact your doctor as
soon as possible. Will lithium affect my sex life?
You should avoid exercise in hot weather or Drugs can affect desire (libido), arousal
other things that cause heavy sweating (e.g. (erection) and orgasmic ability. Lithium has
having a sauna). If your dose and blood is not been reported to have a major adverse
monitored well, lithium does not really have effect on these three stages. However, if this
any major long term side-effects. does seem to happen, you should discuss this
with your doctor, as a change in dose may
help minimise any problem.
Will lithium make me drowsy?
Lithium may make you feel drowsy at ﬁrst. You Can I drink alcohol while I am
should not drive (see below) or operate
machinery until you know how it affects you.
You should be careful as this may affect your There is not a complete ban on drinking
reﬂexes or reaction times. alcohol if you are taking lithium, try not to
take more than about one or two drinks a day
Will lithium cause me to put on as this may affect the level of lithium in your
blood. It may also cause you to feel more
drowsy. This is especially important if you
It is not uncommon for people to put on need to drive or operate machinery as it can
some weight when taking lithium. This may in affect your reaction times. You should seek
part be because a common side-effect of advice on this.
Gloucestershire Mental Health Toolkit – Psychosis 35
Are there foods or drinks that I Will I need a blood test?
should avoid? The aim of treatment with lithium is for the
It is important that you do not drink too much amount of lithium in your blood to reach the
or too little ﬂuid (e.g. do not ignore feelings of level needed to help your symptoms, but not
thirst) as this can lead to lithium poisoning. to get high enough to give you side-effects.
Drinking lots of high calorie drinks can, Everybody is different and so your lithium
however, cause you to put on weight (see dose needs to be exact for you. It will depend
weight gain above). on your age, weight, height, etc. To do this, a
blood sample needs to be taken and checked.
Drinks containing caffeine e.g. coffee, tea, This will need to be done about every week at
cola etc. can cause an increased lithium the start of treatment but later on only about
effect, so having some decaffeinated every three months. When you are stable,
drinks is a good idea. make sure that you have a blood test at least
Do not take a low-salt diet. Lithium is every three months. You may need to have
closely related to sodium salts in the body extra tests if you get any increase in side
and this can lead to lithium poisoning. effects (see previous pages for a list of these),
if you get diarrhoea (the ‘runs’), you have to
take any drugs which might interact with the
Will lithium affect my other lithium or if the weather is very hot. All these
medication? things can upset your lithium level and give
There are a number of drugs which can affect
the lithium levels in your blood. You should The level of lithium in your blood needed to
tell your doctor before stopping or starting give you the right balance between positive
any other medication. You should also show effects and side-effects will be a personal
your lithium card to any doctor, dentist or thing. In general, the accepted wisdom is that:
pharmacist who may treat you.
Below 0.4mmol/L – generally accepted as
If you get a headache or pain, you should take below the effective level, although some
paracetamol rather than aspirin or ibuprofen people still seem to do well
(‘Nurofen’ etc.) if you need to. Aspirin and
0.4-0.6mmol/L – low side-effects but
ibuprofen can cause the lithium level in your
some evidence of slightly higher rates of
blood to rise which can lead to lithium
poisoning. Some of the other drugs which can
‘interact’ with lithium include treatments for 0.6-1.0mmol/L – the usual effective range,
high-blood pressure (e.g. diuretics), arthritis, although side effects will increase with
asthma and infections. This does not increased level
necessarily mean the drugs can not be used
1.0-1.2mmol/L – sometimes used with
together, just that you may need to follow
people for whom mania or hypomania is
your doctors instructions very carefully.
more of a problem
1.2 and above – generally accepted to be
IIf I am taking a contraceptive
higher than needed, with increased risk of
pill, will this be affected? side-effects
It is not thought that the contraceptive pill is Please note that these are general comments
affected by lithium. for advice only, and your individual case may
be different. Please discuss this with your
36 Gloucestershire Mental Health Toolkit – Psychosis
doctor or other carer if you have any It is a good idea to let your insurance
questions about this. company know if you are taking lithium. If you
do not, and you have an accident, it could
If you normally have a dose in the moming
effect your insurance cover.
and a blood test within about four hours, you
should delay this morning dose until after
your blood test or it will upset the result. Additional information
You should not take lithium if you are, or are
Can I drive while I am taking planning to become, pregnant. You should not
You may feel drowsy and/or confused at ﬁrst Your pharmacist or doctor should give you a
when taking lithium. Until this wears off, or lithium card when you collect your ﬁrst course
you know how your drug affects you, do not of lithium unless you are on a very low dose.
drive or operate any type of machinery. You You should carry this with you all the time.
should be careful as this may affect your Show the card to your doctor and pharmacist
reaction times or reﬂexes. each time you get a new supply. You should
also show it to any doctor, dentist or
It is against the law to drive or attempt to pharmacist who may treat you. If you lose the
drive when unﬁt through drugs or to be in card, ask for a new one. Your pharmacist
charge of a vehicle when unﬁt through drugs. should be able to give you one.
Gloucestershire Mental Health Toolkit – Psychosis 37
Resources for psychosis
National organisations Cirencester Tel: 01285 640933
Tewkesbury Tel: 01684 293193
Hearing Voices Network
Gloucestershire Association for
Dale House, 35 Dale Street, Mental Health
Manchester M1 2HF
1 Brunswick Square, Gloucester
Tel: 0161 228 3896 (Mon, Tues, Wed, Fri
Tel: 01452 540001
10am–3pm – answerphone at all other times.)
National Schizophrenia Fellowship Gloucester Clubhouse
(local groups) 17 St Marys Square, Gloucester
Tel: 01452 766310
28 Castle Street, Kingston-upon-Thames,
Surrey KT1 1SS
Tel: 020 8547 3937 Crossroads – Caring for Carers
Cheltenham Tel: 01242 584844
Manic Depression Fellowship Cinderford Tel: 01594 823414
Minchinhampton Tel: 01453 884176
Castleworks, 21, St Georges Road,
London SE1 6ES
Tel: 020 7793 2600 Gloucestershire Carers Project
15 College Green, Gloucester
Local organisations Tel: 01452 386283
National Schizophrenia Fellowship
Matson Neighbourhood Project
1 Park Road, Gloucester GL1 1LH
Tel: 01452 521454
Tel: 01452 330383/330735
Mental health drop in service.
National Schizophrenia Fellowship
Dursley & Mid Glos Group, Highclere,
Watledge, Nailsworth, Glos GL6 OAY Healthy Living with Schizophrenia by the
Tel: 01453 832228 Health Education Authority, 0207 4131991
Working with Voices by R Coleman & M
NSF Cheltenham Outreach Project Smith. Handsel, 1997
5 Pakistan House, Marsland Road, Living with Schizophrenia: A Holistic
Cheltenham GL51 0HU Approach to Understanding, Preventing &
Tel: 01242 525 417 Recovering from Negative Symptoms by John
Watkins. Hill of Content, 1996.
Gloucestershire Hearing Voices
The Voice Inside – A Practical Guide to
Coping with Hearing Voices by Paul Baker,
Cheltenham Tel: 01242 512812 Handsel Publishing/Mind, 1997.
Gloucester Tel: 01452 300631
38 Gloucestershire Mental Health Toolkit – Psychosis