Understanding Psychosis treatment strategies
Depression, Mental Health | May 29, 2014 | Author: The Super Pharmacist
Psychosis is a condition that results in loss of contact with reality.
- 3-4% of the population will experience some psychotic episode during their lives.
- The average Family Doctor will see only two new cases a year.
- 15% of patients with psychosis commit suicide.
- 45% of patients with psychosis have concurrent physical disease.
- Psychosis can affect all age groups, but often occurs in younger people and mistaken for teenage rebellion associated with drug and alcohol use.
- Hallucinations - which can take the form of hearing voices; seeing people or objects; tasting, smelling or feeling things that no one else can.
- Delusions - perceived threats or grandiose roles .
- Disorganised thinking – causing difficulty coping with daily life.
Shifting emotions and behaviours may also accompany psychosis, giving the form of being happy and over active or depressed and lethargic. Muddled speech making little or no sense, loss of interest in daily activities, inability to function and neglect of personal hygiene. Laughter and anger may be expressed for no obvious reason.
Some of the symptoms have variable intensity and may be disguised by other illnesses. Psychosis rarely presents itself 'out of the blue', psychotic symptoms can be experienced for 1-2 years prior to diagnosis (4).
- Physical illness can manifest in visual hallucinations and delusions – e.g. AIDS, Brain Tumors and Head Injuries; Encephalitis; Dementia; Metabolic issues and Nutritional problems. If the underlying cause is treated, these types of psychosis may resolve completely.
- Psychosis can be caused by psychiatric disorders such as schizophrenia or bipolar disorder. One of the biggest risks factors of developing psychosis is a family history of schizophrenia (which alone can cause delusions and auditory hallucinations). Bipolar and depression can also have psychotic symptoms reflected in mood, but delusions of grandeur or worthlessness also exist.
- Drugs and Alcohol. The use of drugs and alcohol (and withdrawal) can cause confusion and visual hallucinations. Psychotic symptoms usually disappear once the substance has worn off or the withdrawal is completed. Use of Cannabis (particularly 'Skunk') increases dopamine levels, causing permanent changes in the brain’s chemistry especially in the adolescent brain or on people who have suffered traumatic Head Injuries, and will lead to psychosis.
- Psychotic symptoms can sometimes occur after a major life stress event such as a death in the family or pregnancy.
First Episode Psychosis
The patient is at high risk of relapse in the first three years if treatment of the first episode is delayed for longer than 6 months. First Episode Psychosis needs specialist psychiatric assistance from an Early Intervention Team (5). Early Intervention Teams are made up of healthcare professions (Psychiatric Nurses, Psychiatrists, Psychologists, Social Workers, Support Workers and Counsellors) who specifically work with people who have experienced their first psychotic episode. They sometimes work with specific age groups (e.g. 14 -35). Provision covers -
- A full assessment of the symptoms
- Diagnosing causes or conditions contributing to psychosis
- Recommending and prescribing medication treatments
- Accessing psychological services
- Social, occupational and educational interventions
Treatment goals - to enable patients to return to their normal life, including the return to education and employment.
- 80% of first episode psychosis are aged between 16 – 30 with a median age of 19 in males and 22 in females.
- 85% of people experiencing their first episode will achieve remission on neuroleptic medication.
- If there is a delay in treating the initial psychotic episode, there is a high risk of self-harm. 10% of people with psychosis have a history of self-harm.
- Without intervention 80% will relapse within 5 years. Every relapse increases the likelihood of drug resistant symptoms.
If someone close to you has a psychotic episode, the experience can be alarming and terrifying. The person may not recognise that there is a problem and resist any support. As a carer you can talk to them about how they are, and try to persuade them to visit a doctor, suggesting that the doctor may be able to help with things that are bothering them. Never assume a diagnosis. Talk to other members of the family, don't try to cope alone. Be patient, persuasive and persistent and always try to be reassuring. As a Carer of someone living with Psychosis, you will need emotional support, help with dealing with the delusions, risky behaviours and withdraw from other people. As well as family and friends there may be local support groups (contact SANE). You should be involved with decisions regarding care plans, but due to confidentiality rules you can only be part of that process if the person you care for gives their consent. As a carer you can focus on social roles and everyday life (money issues, securing work, diet and physical health).
Prognosis - What are the chances of leading a 'normal life'?
If Psychosis is due to a mental health problem then prognosis is not as good as if it originated through a physical problem. People who already have schizophrenia and experience a psychotic episode, have a:
- 1 in 3 chance of an improvement
- 1 in 3 will stay the same, and
- 1 in 3 will be debilitated by the episode.
The later in life that schizophrenia starts the better the prognosis. People who are at the highest risk of permanent difficulties from psychosis are the ones who have experienced early onset of schizophrenia; have family history and poor functioning prior to any psychotic symptoms People who are treated within the first 6 months of the episode are shown to have improved prognosis and overall improvements in quality of life. Support from doctors, family members, friends and a dedicated Early Intervention Team have been shown to increase chances of recovery.
Treatment usually involves a combination of psychological therapies, social support and medication.
Medication prescribed will depend on the underlying mental health causes of the episode.
- Bipolar - anti-psychotic medication may already be prescribed together with lithium and anti-depressants as a mood stabiliser. A psychological therapy such as Cognitive Behavioural Therapy (CBT) should also be considered effective.
- Schizophrenia is usually treated with a combination of anti-psychotic medication with social support groups, CBT and/or family therapy.
- Psychosis in relation to drug or alcohol use, benefits from trigger withdrawal. In some cases, a short course of anti-psychotic or sedative medications may be prescribed to alleviate the symptoms of withdrawal along with addiction counselling and/or social support groups.
Anti-psychotic medications work by assisting the brain to restore chemical balance by blocking chemical messengers of the central nervous system (e.g. dopamine), they have a calming effect on the brain. They can be effective within a few hours by minimising anxiety associated with psychosis, but take several days to reduce delusional thoughts and hallucinations. These medications are usually taken short term until the psychosis subsides. Most patients respond well to anti-psychotics, but side effects may lead to non-compliance with the treatment. These side effects include:
- drowsiness (affecting the ability to drive and operate machinery);
- muscle spasms;
- blurred vision;
- lack of sex drive; and
- dry mouth.
People with epilepsy and cardiovascular disease are not usually prescribed anti-psychotics. When taken over long periods, complications such as weight gain and diabetes may arise (Metabolic Syndrome & Tardive Dyskinesia (TD)). Weight gain can occur because the metabolic rate slows down, meaning energy is burned at a slower rate. Also, those medications can increase the appetite leading to increased calorie consumption. Withdrawal from the medication should be gradual and under medical supervision. Sudden withdrawal may cause the psychosis to return or cause unwanted symptoms.
- Talking Therapies - such as counselling can help reduce levels of anxiety.
- Cognitive Behavioural Therapy (CBT) - helps people make sense of the experience, and provides strategies to reduce stress. It helps identify negative thinking patterns and behaviours and replace them with realistic and balanced thoughts. The focus of the therapy is to support patients return to work or studies, and regain control over their normal lives.
- Family Therapy (FT) - helps the family address issues associated with living or caring for people with various forms of psychosis. Family members provide care and support, often suffering from stress, anxiety and depression themselves as a result of the high impact on their daily lives of such activities. FT is a series of informal meetings over about a six month period. Typically they cover, information; support methods; and ways to solving practical problems in the event of a future psychotic episode. Family interventions can can effectively prevent psychotic relapse for periods of two years (2). Contact with a family and care group gives the opportunity to share feelings of loss, guilt and confusion, drawing support from other families. (3).
- Self-Help or Social Support Groups – These groups focus on connecting people in similar circumstances to trade effective techniques and methods they have found helpful. SANE is an example of such a group network in Australia.
Written instructions in the form of an Advanced Decision, can allow the patient to inform family and friends of their treatment protocols for specific circumstances, should they experience another psychotic episode in the future. The details on this document are legally binding.
It is not always possible to prevent psychotic episode but there are some steps that can be taken to reduce the probability.
- Cannabis users are 40% are more likely to develop psychosis. Avoidance taking illegal drugs and drinking alcohol reduces the risk.
- Schizophrenia is a combination of biological, psychological and environmental factors that are hard to avoid or control.
- Depression and stress experienced over long periods increases the risk. Relaxation exercises, meditation, and yoga may be help reduce future episodes. Exercise addresses psychological and physical aspects of health and will have positive effects for prevention.
- Cognitive behavioural therapy attempts to change negative thoughts to positive thoughts by the use of a problem solving approaches.
- Joining a self-help or social support groups can reduce feelings of isolation.
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Birchwood, M. & Spencer, E. (1999) Psychotherapies for Schizophrenia: a review. In Schizophrenia (eds M Maj & N. Sartorius), pp. 146-214.Chichester: John Wiley & Sons
Falloon, I.R.H. (1985) Family management in the prevention of morbidity of schizophrenia: clinical outcome of a two-year longitudinal study. Archives of General Psychiatry, 42, 887-896.
Larsen, T.K.., et al (1996) First Episode in Schizophrenia. I. Early Course Parameters. Schizophrenia Bulletin, 22, 241-256
Spencer, E., et al, Management of first-episode psychosis. Advances in Psychiatric Treatment (2001)vol. 7 pp. 133-142.
Walker, P., et al. Cognitive behavioural therapy for psychosis, lessons in history and hopes for the future. InPsych 2013 (Australian Psychological Society.
Yung, Alison., et al. Monitoring and Care of Young People at Incipient Risk of Psychosis. American Psychiatric Association, January 01, 2004