First Episode Psychosis: Identification, Intervention, & Recovery Strategies March 19, 2018 2018 ICB Spring Conference Itasca, Illinois Workshop C

Psychosis: Symptom not diagnosis. Loss of contact with reality (what is real or unreal). Can be seen at any age (late teens/early 20s most common). Onset: sudden or gradual (differential insight common). Three of 100 will experience a psychotic episode (most will not develop chronic psychotic disorder).

Psychosis primary features Hallucinations: unreal sensory experiences. Auditory, visual, olfactory, tactile, vestibular. Delusions: false/unreal objective beliefs. Beliefs are fixed and can not be challenged or changed in spite of new information, ideas, or facts. Extreme shift in thinking patterns or mood. Significant unexplained change in behavior.

Culture-related Issues Cultural and socioeconomic factors should be considered. Ideas that could be considered delusional might be common in other cultures or subgroups, i.e. witchcraft, spiritual experiences. Auditory/visual experiences in a religious context such as communicating with God can be commonplace. (Bill W. & Dr. Silkworth) Beware of 2nd language confusion.

First episode: Dx. considerations Embrace diagnostic uncertainty. Many of the symptoms seen in the early stages may be transiential or may be a function of normal development. Early diagnosis is often unreliable and may engender pessimism for the patients, their families, and staff. Symptom-based approach treatment can be effective until a complete diagnostic picture is clear.

Diagnostic Considerations Medications/drug induced Psychosis Symptoms typically subside as the drug/s run their course. Organic Psychosis Result of physical illness or head injury with or without delirium. Acute withdrawal syndrome, ETOHic OBS, Korsakoff syndrome. Brief Psychotic Disorder Typically sudden onset and related to major stressor. Generally lasts less than a month.

Dx. Considerations (continued) Bipolar Disorder Symptoms relate more to mood disturbance rather than thought disturbance and are often mood congruent…..when depressed the persona may hear discounting voices of low self-worth, while in a manic state might have grandiose beliefs or amazing powers. Do not confuse with schizoaffective disorder which is identified primarily by thought with an affective component. Depression with psychotic features Severe depression without episodes of mania. May or may not be mood congruent. Catatonia may also be present.

Dx. Considerations (continued) Postpartum Depression Onset may occur during preganancy or after delivery. Effects 3-6% of women and is the most common medical complication of pregnancy (approx. 20%). PPD with psychotic features occur in 1 of 500 up to 1 of 1000. Schizophreniform Disorder Same as schizophrenia however the disease has lasted less than six months. May resolve or could transform to schizophrenia, bipolar disorder, or shizoaffective disorder.

Dx. Considerations (continued) Schizophrenia Minimal gender/cultural differences. Effects approx. 1% of the population. Onset is most often during late teens or early 20s. Chronic, long term disorder with varying degrees of severity. Often improves in later life. Positive Symptoms: Delusions, Hallucinations, Disorganized speech, disorganized behavior, or catatonia. Negative Symptoms: diminished affect, avolition, etc….

Phases of Psychosis Phase 1: Prodrome (early signs) Signs may be vague or hardly noticable. Common signs may include: reduced concentration, racing thoughts, decreased motivation or energy, sleep problems, social withdrawal/isolation, anxiety, and decreased functioning. These can be individualized for each client and personalized as “warning signs” just as we can identify the “warning signs of relapse” for clients in recovery from ETOHism/Addiction.

Phases of Psychosis Phase 2: Acute Also known as a “critical period”. Symptoms are predominant during this period, most often hallucinations, delusions, or confused/disturbed thinking or speech. The person may become extremely distressed with their behavior and/or symptoms but may also have no insight to the degree of disturbance. Consequently, the person may be reluctant to accept help and may be very suspicious of others, especially health treatment providers and first responders.

Phases of Psychosis Recovery With effective treatment most people will recover from their first episode of psychosis and may never have another episode. Early treatment is correlated with improved outcomes. Treatment in the “least restrictive environment” is recommended and with strong family support may be achieved within the home. Community ACT teams can be especially effective as well.