Understanding Psychosis

 

The word psychosis is used to describe a mental health problem that can affect the brain, so that there is a loss of contact with reality. When someone develops a mental health problem in this way it is called a psychotic episode. According to Rethink Mental Illness charity, about 3 out of every 100 people will experience a psychotic episode, making psychosis more common than diabetes. Most people make a full recovery from the experience.

The word ‘psychotic’ relates to ‘psychosis’, which is a psychiatric term, and describes experiences, such as hearing or seeing things or holding unusual beliefs, which other people don’t experience or share. Psychotic experiences are surprisingly common, but can also lead to diagnosis such as schizophrenia, bipolar disorder, schizo-affective disorder, paranoia, several depression or puerperal psychosis (a very severe form of postnatal depression).

One sign of psychosis is that a person lacks insight into their own state of mind. Psychosis distorts the senses, making it very difficult for the ill person to tell what is real from what is not real. Someone experiencing a first-episode psychosis may not understand what is happening. Symptoms are unfamiliar and frightening, leaving the person confused and distressed. If they do not know the facts and have no real understanding about mental illness, their distress may be increased by negative myths and stereotypes.

A psychotic episode occurs in 3 phases: (1) Prodrome, (2) Acute, (3) Recovery.

1. PRODROME - refers to the early symptoms and signs of an illness that precede the characteristic manifestations of the acute, fully developed illness. It is defined as the period of time from the first change in a person until development of the first frank psychotic symptoms.

2. ACUTE - clear psychotic symptoms are experienced, such as disorganised thinking, hallucinations or delusions.

3. RECOVERY - psychosis is treatable and most people recover, however, the pattern of recovery varies from person to person.

CAUSES OF PSYCHOTIC EXPERIENCES

Almost anyone can have a brief psychotic episode. In general, psychotic experiences may be caused by:

• Physical causes, such as illness: For example through a lack of sleep or high fevers (including malaria, pneumonia, other viral infections). They can also be a result of damage to the brain or dementia, lead and mercury poisoning, or changes in blood sugar levels.
• Drug use: Alcohol, street drugs, prescription medication (including steroids) can result in a psychotic experience that may continue even if the drug has worn off.
• Changes in brain chemistry: It’s not clear though whether these changes are the cause or the effect of the psychotic experience.
• Inherited vulnerability: However, no single gene has been found to be responsible, though, and the majority of people who have these experiences have no known family history.
• Traumatic events such as abuse: Many people who have psychotic experiences have been physically, emotionally, or sexually abused, and feel a need to push their feelings and memories away, because they are so painful. Psychotic experiences may be an expression of these overwhelming feelings and forbidden thoughts, and a way of coping with trauma.

TREATMENT OF PSYCHOSIS

Treating psychosis involves education, medication, close monitoring of symptoms, stress management and creating a strong, supportive environment. These treatments all help to speed up the recovery process and promote good quality of life for both the person and the family. 

RECOVERY

Some of the most recent and hopeful news in psychosis research is emerging from studies in the field of Early Intervention. New studies challenge several long held myths in psychiatry about the inability of people with psychosis to recover. It now appears that such myths, by maintaining an overall pessimism about outcomes, may significantly reduce a persons opportunities for improvement and/or recovery. After three decades of empirical study, it is now clear that early intervention is an important part of the treatment strategy. Furthermore, the importance of family input for treatment and the benefits of supportive partnerships between clinicians and families are well established (Rethink Mental Illness Charity).

Cognitive Enhancers in Schizophrenia: non-pharmacological approach

This post is a follow up part to the previous post, which introduced the pharmacological approach to the enhancement of cognition in schizophrenia.

With no major clinical success to date in targeting cognitive deficits in schizophrenia, attention shifted to behavioural, neuro-cognitive interventions. These approaches are based on the assumption that a broad and intensive activation of neural processing systems can stimulate neural resources to improve their functioning. It is believed that intense activation of cognitive (mental) systems damaged in patients with schizophrenia could effectively lead to a general and lasting functional improvement. As a result, several cognitive training strategies have been developed and these can generally be divided into either (1) COGNITION-ENHANCING or (2) COMPENSATORY approaches. The former approaches train patients with laboratory tasks designed to improve specific abilities in various cognitive domains, such as perception, learning, or memory. On the contrary, the latter approaches attempt to bypass cognitive deficits and teach strategies to compensate for them by relying on aids or other processes (Tomás, Roder, & Ruis, 2010).

1) COGNITION-ENHANCING PROGRAMMES

• Cognitive Remediation Therapy (CRT)
• Cognitive Enhancement Therapy (CET)
• Integrated Psychological Therapy for Schizophrenia (IPT) 

CRT aims to improve attention, working memory, cognitive flexibility, planning and executive functioning. CRT is usually administered via use of a computer, with the tasks appearing on the monitor. Research to date demonstrates small to moderate durable effects of CRT and that irrespective of therapy characteristics CRT can provide benefits to patients with cognitive difficulties. Although having more symptoms is associated with smaller effects, all participants were shown to benefit from CRT.

CET is a recovery-phase intervention for symptomatically stable schizophrenic out-patients with reduced relapse risk (Hogarty et al., 2004). This programme tackles areas and disabilities of a wider functional range. For example, specifically designed exercises target analytic logic, decision making, strategic and foresightful planning, as well as the intuitive thinking that supports social cognition (thinking). CET is a small-group approach that combines approximately 75 hours of progressive software training exercises in attention, memory and problem solving with 1.5 hours per week of social cognitive group exercises. Consistent positive results are fund in processing speed and verbal memory. A drawback of this approach is that it is only applicable to patients with a certain intellectual level (with an IQ above 80) who are psychopathologically stable (Tomás et al., 2010).

IPT integrates neuro-cognitive and psychosocial rehabilitation methods.IPT is administered to groups and consists of five, hierarchically organised sub-programs: cognitive differentiation, social perception, verbal communication, social skills and interpersonal problem solving. Studies typically reveal the largest improvements in neuro-cognitive functioning, however, effects on psychosocial functioning tend to be smaller (Roder et al., 2006). More research is currently needed to evaluate the effectiveness of this approach.

2) COMPENSATORY REHABILITATION PROGRAMMES

• Errorless Learning (EL)
• Cognitive Adaptation Training (CAT)

EL involves two main procedures: prevention of errors during the learning phase and automation of perfect task execution (Terrace, 1963). It refers to teaching procedures that are designed in such a way that a learner/patient does not have to - and does not- makes mistakes as she/he learns new information and new procedures.

CAT uses environmental supports and various clues such as signs, check-lists or alarmed drug packaging. It also encourages organisation of belongings and the sequencing of appropriate routines.

In effect, compensatory strategies work to some extent, however, they do not succeed in achieving pre-morbid levels of performance (Tomás et al., 2010). Moreover, they are aimed at people with significant cognitive impairment that is difficult to restore and thus renders them less suitable for people with recent illness who are more intact.

References

Roder, V., Mueller, D. R., Mueser, K. T., & Brenner, H. D. (2006). Integrated psychological therapy for schizophrenia: is it effective? Schizophrenia bulletin, 32 Suppl 1, S81-93. doi:10.1093/schbul/sbl021 

Terrace, H. S. (1963). Discrimination learning with and without errors. Journal of the Experimental analysis of Behaviour, 6, 1-27.

Tomás, P., Roder, I. F. V., & Ruiz, J. C. (2010). cognitive Rehabilitation Programs in Schizophrenia: Current Status and Perspectives. International Journal of Psychology and Psychological Therapy, 10(2), 191-204.

Enhancing Cognition in Schizophrenia - pharmacological approach

Cognitive impairment is a core feature of schizophrenia, with more than 80% of patients showing significant impairments (Keefe & Fenton, 2007). The range of cognitive impairments in individuals with schizophrenia is broad, with the more robust and replicable deficits typically found in the domains of processing speed, episodic memory, working memory and executive function. These impairments have been shown to be associated with various impaired functional outcomes and thus development of new therapies to enhance cognition has become one of the most pressing challenges. Cognitive deficits persits throughout the course of the illness and as such, negatively affect daily functioning, work outcomes and treatment adherence. While anti-pscyhotic medications can control psychotic symptoms for the majority of patients, such improvements do not automatically transfer into the functional outcome, such as community functioning. Additionally, anti-psychotic drugs that are currently the main form of treatment in schizophrenia demonstrate only a modest positive effect on cognition.

Despite a large number of compelling rationales and significant body of preclinical data, there are no dramatic or consistent results that any one medication has the power to increase cognitive skills to the level of normal functioning. While a wide range of cholinergic, dopaminergic, glutamatergic and cannabinoid compounds have been developed, the Food and Drug Administration (FDA) has not yet approved any of the drug development programmes specifically aimed at treating cognitive impairments in schizophrenia.

Pharmacological approach: Potential Cognitive-Enhancing Drugs in Schizophrenia

1. Antipsychotic Drugs (APDs)

While numerous studies have demonstrated the dramatic efficacy of APDs in suppressing psychotic symptoms and preventing their recurrence, they have also revealed their inability to alleviate the negative and cognitive symptoms of the illness. There are, however, some studies that suggest that some of the newer atypical antipsychotics e.g. aripiprazole, clozapine, quetiapine, olanzapine, risperidone and ziprasidone, may provide minimal benefits in certain specific areas of cognition.

2. Donepezil, Rivastigmine, Galantamine

Researchers sometimes focus on drugs that have proved effective in other cognitively impaired conditions, such as in dementia. Several drugs approved for dementia stimulate acetylcholine by blocking its breakdown, which has been shown to improve cognition and slow cognitive decline. Donepezil belongs to this type. The results in schizophrenia field, however, are not very encouraging, with only a few studies showing somewhat minimal memory improvement.

Rivastagime has also been investigated but only in smaller-scale studies. No significant findings have been reported to date.

Evidence of cognitive benefit with galantamine has been mixed so far. The overall trend indicates that at lower doses galantamine exerts a positive effect on cognition but at higher doses it is consistently associated with negative results. The most effective dosage is yet to be established.

3. Nicotine and nicotinic receptors

It is now widely accepted that nicotinic receptor abnormalities are present in schizophrenia. The vast majority of studies found some positive effects, improvements were frequently recorded in working memory and attentional/executive control functions and in episodic memory. However, nicotine did not improve every measure examined in each study and the magnitude of the effects was not large. Additionally, nicotine as a therapeutic agent may be limited by tachyphylaxis.

4. Modafinil

Modafinil is a wakefulness-promoting agent, shown to be effective in enhancing cognition in sleep-deprived and healthy individuals, as well as in some psychiatric disorders. While having effect on many neurotransmitter systems, modafinil has an uncertain mechanism of action. Results at this stage appears to be inconclusive. Benefits demonstrated by early studies were not replicated by larger-scale studies.

NB: Non-pharmacological applications will be reviewed in a future post

Reference

Keefe, R. S. E., & Fenton, W. S. (2007). How should DSM-V criteria for schizophrenia include cognitive  impairment? Schizophrenia bulletin, 33(4), 912-20. doi:10.1093/schbul/sbm046

New combat stress helpline announced | BPS

New combat stress helpline announced | BPS

Problem solving for personality disorder

Mary McMurran and Stephen Coupe describe a promising approach to a distressing disorder

 

What is problem-solving therapy?

Problem-solving therapy has a solid evidence base for alleviating distress and improving social functioning in people with a range of psychological and health problems. This approach has considerable appeal for both therapists and clients, in that its basic principles are easy to understand, it does not pathologise individuals, and it empowers people to solve those problems that they prioritise. Applications of problem-solving therapy for people who are diagnosable with personality disorders have been pioneered by researchers and clinicians in the UK.

Social problem solving is the process by which individuals attempt to discover and apply adaptive means of coping with the wide variety of stressful problems encountered in the course of everyday living (D’Zurilla & Nezu, 2007). There is abundant evidence of an association between social problem-solving deficits and psychological distress, physical ill health, substance misuse, hostility and aggression, and mental health problems. Problem-solving therapy can help people to cope better with everyday problems and can lead to better mental and physical health. Problem-solving therapy teaches the skills required for effective social problem solving. These are the ability to recognise problems when they arise, define the problem clearly and accurately, set realistic goals for change, produce a diversity of possible solutions, anticipate outcomes, devise effective actions plans that have stepwise stages, and carry out those action plans to solve problems effectively. 

Click on the following link to read more about: Problem Solving Therapy

Coping with Suicidal Thoughts

There are times in life when we might feel totally, hopeless, helpless, overwhelmed with emotional pain. It can seem like there is no other way out of our problems, we've run out of ideas, possible solutions. Our problems seem unfixable. The pain feels like it will never end. We believe we've run out of options, and suicide is the only answer left.

Maybe the suicidal thoughts come to mind, and you might have mixed feelings about them. They can be frightening and confusing.

For some people, suicide may be a way of getting back at others, or showing them how much pain you're in. But after suicide, you won't be there to see that they feel guilty, or finally understand your pain.

Suicide is a permanent solution to a temporary problem.

Feelings will pass. Depression feels permanent, but it's transient. Things will change. Depression comes, and it goes. Depression and pain distort our thinking. It can seem like we're wearing very dark tinted 'gloomy specs'. Everything looks different to how it really is. Thoughts are thoughts - not necessarily how things are, although it certainly feels like the thoughts are true. Thoughts affect the way we feel, and thoughts and feelings affect the way we react, what we do.

Suicidal thoughts can result when we experience too much pain, without having enough resources to cope.

We therefore have two ways to get us through this horrible time:

1. Reduce the pain
2. Increase coping resources

REDUCE THE PAIN:

Self-soothing

Do something that will help you feel better, right now.

Perhaps collect items into an emergency bag or box that you can turn to.

Use all five senses to find things that will soothe you.

VISION – Focus your attention on looking at something nice, nature, a painting, watching a favourite programme or movie.

HEARING – Listen to a favourite piece of music, sound of nature, sing.

SMELL – Really notice smell – favourite soap, food, essential oil.

TASTE – Use sensation of taste to focus your attention. Eat mindfully -savouring each moment.

TOUCH – Wear soft comforting socks, stroke a pet, give yourself a hand massage.

Avoid drugs and alcohol

Whilst it seems like they help for a while, they will make your problems worse.

Ask yourself:

Are these thoughts facts or my opinion?

What has helped me feel better in the past?

What can I do right now that will help me feel better?

What gives my life meaning? What are my goals, dreams or life values? E.g. Family, friends, pets, helping others, faith, spirituality, community life, connecting with nature.

Tell yourself:

I've coped this far, I can get through the next .... (day, hour, 10 minutes)

Things will look better in time.

Depression is temporary - this will pass.

Suicide is a permanent solution to a temporary problem.

Depression is distorting my thinking - these thoughts are the voice of depression. They are not facts. I don't have to act on them.

The vast majority of people get better from depression. I will look back and be pleased that I chose to live.

Write things down

Safety Plan worksheet & Safety Plan Cards

INCREASE COPING RESOURCES – IMMEDIATE STEPS

Read and put your Safety Plan into action! 

Keep the Safety Plan where you can easily find it when you need it. Maybe make several copies – and keep them in several places (e.g. your room, your car, your purse).

Take one step at a time

Take things a little at a time. Set out to get through the next day, the next week or month, perhaps the next hour or even less. Tell yourself: "I've got through so far, I can get through the next hour".

Distraction

Do something else, and focus your attention fully on what you're doing (e.g. gardening, physical exercise, something creative, sudoku).

Talk to someone - now!

• A friend or family member
• A telephone helpline (E.g. Samaritans 08457 90 90 90)
• A health professional
• Go somewhere you'll feel safe - be with other people
• Go to the local Accident & Emergency department
• Call the local emergency number (E.g. 999, 112, 911)

Reference:

A huge thank you to Carol Vivyan who has put together an incredibly useful set of resources.

Vivyan, C. (2011), www.getselfhelp.co.uk