5-minute first aid for psychosis

Current Psychiatry. 2005 January;04(01):36-48

January 1, 2005|Current Psychiatry

Narsimha R. Pinninti, MBBS, MD;Neal Stolar, MD, PhD;Scott Temple, PhD

Defuse crises, help patients solve problems with brief cognitive therapy

Universality is the understanding that many people have experiences similar to the patient’s.

In a collaborative therapeutic alliance, the patient is not a passive recipient but an active collaborator in therapy. He or she contributes to decisions—such as the length of therapy and topics to be discussed—and gives feedback on interventions and therapist style.

Focusing on life goals makes therapy meaningful to the patient.

Set priorities. Because only one or two therapeutic interventions can be tried during a medication-monitoring visit, problems need to be prioritized. As with Ms. W, the first visit’s goal was crisis intervention: to reduce suicidal thoughts and prevent hospitalization. Table 1 offers a framework for effective therapeutic interventions.

Save time by giving patients out-of-session assignments, which:

collect important information to review with patients during the next monitoring session
help empower patients to manage their symptoms.

Adaptive strategies—such as drill and practice¹⁷—can help improve learning in patients with cognitive impairment, which is common in psychotic disorders.¹⁶ Give the patient a pocket notebook to write down what he learns in sessions, and encourage him to review the material at home. Call this a book of coping skills.

IMPROVING ADHERENCE

Medication nonadherence and partial adherence can result from:

illness-related factors such as lack of insight
patient-related factors such as attitudes and beliefs about medication
treatment factors such as side effects
physician-related factors such as showing an authoritarian attitude toward patients
system-related factors such as treatment access problems.

Interventions that respect individual autonomy and responsibility enhance long-term adherence ( Table 2 ), whereas those that invoke fear—such as threats of hospitalization—are ineffective and demoralizing. Improved medication adherence can reduce hospitalization and health care costs.¹⁸

Table 2

Interventions to improve patient medication adherence

Issue	Intervention
Assessing medication adherence and beliefs	Specific questions (“Did you miss any doses since we last met?”) give most-accurate information Questions such as “What does taking medication mean to you?” help clarify patients’ beliefs
Dysfunctional beliefs about medication (“Taking it means I am weak.” “It can turn me into a zombie.” “I will be dependent on medication.”)	With the patient, examine evidence for dysfunctional beliefs about medication Acknowledge possible adverse effects; encourage patient to persist through mild side effects Provide objective information about the medication, including views of patients who did well on it
Lack of insight (“I do not need medication”)	Help patient identify early subjective psychotic symptoms (insomnia, restlessness, racing thoughts) Encourage patient to examine what life is like when on versus off medication Have patient ask a trusted family member or friend how he or she is different on and off medication
Forgetting to take medication	Help patient set up medication routine and stick with it Advise patient to buy an alarm clock and set it to sound when medication is to be taken Encourage patient to keep medication in a prominent place, such as at bedside Encourage him/her to use a medication organizer
Lack of a shared understanding of the illness between patient and physician	Encourage patient to state why he/she takes medication Explore patient’s understanding of the diagnosis Develop an explanation that makes sense to the patient and provides a reason to take the medication (such as, “Medication can help me achieve my goals”)

CASE: NOT REALLY HER FATHER

By the second session 1 week later, Ms. W’s suicidal thoughts had become infrequent and mild, and she was using the coping card as needed. This visit focused on visual hallucinations associated with anxiety about facing her father. We encouraged her to describe the hallucinations in great detail, and she realized that she visualized her father as he had looked 20 years ago, not as he looks today. Her anxiety decreased as she considered that she might be seeing not him but an image. Her homework assignment was to closely observe the hallucinations. Because she was more stable, the next visit was scheduled in 2 weeks.

By the third session, she reported that the visual hallucinations had disappeared, and the focusing technique had helped her. She continued to hear voices, however, particularly in the evening when she was alone and anxious or depressed. With prompting, she identified activities she could engage in at night, such as calling her mother and praying with her mother on the phone. This reduced her loneliness and helped her relax.

Table 3

Interventions to manage auditory and visual hallucinations

Problem	Intervention
Acting on hallucinations	Ask questions such as:
	“What do you say to yourself when the voices command you and you ignore them?” “What do you say to yourself when the voices command you and you follow the command?”
	Tell patient, “It is not the voices themselves but the thoughts in your mind in response to the voices that determine whether or not you follow them”
	List thoughts patient generates when choosing not to follow voice commands and encourage patient to read the list when hearing voices
Triggers of negative emotions that cause voices	Ask questions such as:
	“What kind of moods bring on the voices?” “Are the voices more likely to be triggered by anxiety, anger, frustration, or boredom?” “Can you keep track of what triggers the voices from now to the next visit?”
	Identify techniques to deal with triggers and rate their effectiveness
Dysfunctional beliefs that voices cannot be controlled or are prophetic	When voices are strong, coach patient to rate them on a scale of 0 to 10, try different distraction techniques, and rate them again
	Encourage patient to write down what the voices say and whether their prophecies come true; reviewing the record in subsequent session shows voices are not prophetic
Voices during the session	Hum a familiar tune with patient
Voices during the session	Ask patient to read out loud
Visual hallucinations	Encourage patient to examine details of what they see; this alone can make hallucinations disappear
Visual hallucinations	Encourage patient to try to make hallucinations funny, such as making the image’s nose long (personal communication: e-mail Morton Sosland MD)

References