Long road to peace of mind
Seventeen-year-old Yin-ling had been withdrawn and sleeping at strange hours for six months, something her parents initially put down to exam stress. But when she accused her mother of poisoning her food, her mother realised something was wrong.
'I just wanted to be by myself,' says Yin-ling (whose real name has been withheld for reasons of patient confidentiality). 'My friends used to text me, but I couldn't be bothered to reply. I could hear voices coming from the TV talking about me, even though it wasn't on. I tried telling the voices to shut up, but they just got louder.'
Initially, Yin-ling's mother had been reluctant to discuss her daughter's symptoms with anyone. She thought Yin-ling might just get better on her own. But on a drive home from work one evening, she listened to a radio programme where a doctor spoke about early psychosis. She was struck by the similarity of Yin-ling's symptoms, and decided to seek medical help for her daughter's condition.
'Often, the first sign of psychosis is withdrawal from normal social activities and deterioration of function, such as a worsening of self-care and exam results,' says Professor Sham Pak-chung of the University of Hong Kong's psychiatry department.
Every year in Hong Kong, about 700 people between the ages of 15 and 25 develop symptoms of early psychosis, which include disorganised thinking with jumbled up ideas, irrational and often bizarre beliefs (delusions), and hearing voices when nobody is around (auditory hallucinations).
The symptoms can be quite difficult for others to comprehend. 'Some sufferers become convinced that they are under the persecution or surveillance of others. Such ideas are sometimes elaborated into a complex system of beliefs. Equally difficult to understand is the sense that their thoughts are somehow being broadcast to others, or conversely that others' thoughts are being inserted into their minds,' Sham says.
Those with psychosis can also suffer from a wide range of altered mood states, including depression, elation, the inability to feel emotions and having inappropriate emotional responses, such as laughing in a grave situation.
This pattern of mental symptoms can result from many brain diseases and conditions. 'What these conditions have in common is that they increase the reactivity of the brain chemical dopamine, which is important for controlling alertness and evaluating the significance of situations,' Sham says. 'Hyper-reactivity to dopamine causes a person to be overly anxious and to misinterpret trivial situations as having undue significance.'
This hyper-reactivity could be caused by the use of drugs such as amphetamine and ketamine, or brain damage due to long-term overuse of alcohol or cannabis. Most cases, however, do not have a clear-cut cause, but result from a combination of biological and psycho-sociological factors.
Biological factors include genetic predisposition and maternal illnesses during pregnancy such as infections and malnutrition. Another high-risk group is immigrants who grow up in an alien culture that they find difficult to understand.
One of biggest obstacles in identifying and treating psychosis sufferers is that they are often deeply immersed in their vivid mental experiences, and ignorant that these experiences are a result of mental illness. Consequently, few sufferers seek medical help, and many are reluctant to accept treatment.
'The symptoms of psychosis often come on very gradually over a number of months or even years, and can be very difficult for family members or friends to pick up [on] at first,' says Professor Eric Chen Yu-hai, also from HKU's psychiatry department, who is a pioneer of the early psychosis clinical service in Hong Kong.
'To make matters worse, there is widespread ignorance, fear and prejudice in society against psychosis. This means that sufferers and their families are often reluctant to accept or even consider the possibility of psychotic illness.'
The sad consequence is that there is often a long delay between onset and treatment. According to Chen, a study of patients in Hong Kong who developed psychosis for the first time found that half of the patients did not seek help until six months after their symptoms had surfaced, and as many as one-third did not do so for up to a year. Studies from other countries also found an average delay of one to two years before treatment was received.
This is unfortunate because early detection and intensive treatment through a multidisciplinary approach involving doctors, nurses, social workers and psychologists are usually effective in alleviating symptoms and improving function.
'If psychosis isn't tackled early, it can easily develop into more serious mental illnesses. Studies have shown that psychosis can lead to a several-fold increase in suicide risk,' Chen says.
An intervention programme called Early Assessment Service for Young people with Psychosis (Easy) was set up by the Hospital Authority in 2001. The public can ring the hotline at 2928 3283 to refer cases to the Easy team, which conducts an initial assessment on the phone and, if necessary, schedules an appointment with a doctor within seven days.
Yin-ling was diagnosed with an early stage of psychosis, and her symptoms have been controlled by a low-dose anti-psychosis drug and cognitive therapy. A year on, she is still on medication and attends regular follow-ups at a hospital outpatient clinic.
'I go to a support group now, and I get to meet other people who are like me,' says Yin-ling. 'The sharing is really useful; it shows that I am not alone and that I can keep the symptoms under control and get on with my life.'
Yin-ling thinks she no longer needs medication, but the results of a study led by Chen, published in the British Medical Journal last year, showed that patients who discontinued medication were 30 per cent more likely to relapse than those who did not.