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

One month later, the voices had diminished greatly, and Ms. W returned to her regular medication monitoring appointments of every 6 to 8 weeks.

MANAGING POSITIVE SYMPTOMS

In serious mental illnesses such as schizophrenia, the most common hallucinations are auditory ( Table 3 ),¹⁹ followed by visual and other types.²⁰ Sometimes patients view hallucinations as helpful, providing reassurance, advice, or companionship. The content may be an expression of the patient’s own beliefs.

Table 4

Interventions to help patients examine common delusions

Symptom	Questions to ask the patient
Behaviors of acting on delusions	“Let’s examine how your belief and behavior in response to it affect your life, both positive and negative” “Is this belief helping you advance in life or hindering you?” “Is this belief helping you reach your goals?”
Delusion with changing conviction	“When does this belief bother you the most?” “When does this belief bother you the least?” “How are you feeling right this minute? Is it bothering you at all?” “What is it about some situations that make you less bothered by this belief?”
Delusion with complete conviction	“When did you first have these thoughts?” “Did you believe in them right away, or did you have doubts?” “What were some of the doubts you had?” “Do you still have those doubts?”
Addressing underlying beliefs	“What does it mean to you to believe in this?” “How would life be different if you did not have this belief?”
Delusion associated with lack of real world knowledge	Provide real-world knowledge. For example, for delusion that people can read a patient’s mind, inform patient that scientific experiments have shown that no one can read complex thoughts of others
Delusion involving physician	For example, say, “It is normal for you to sometimes question my intentions and believe that I am part of the conspiracy. I can assure you that is not the case. Anytime you have those doubts I would like the opportunity to clarify those for you. Can I rely on you to bring those doubts to my attention?”
Delusion involving physician	When patient’s body language or behavior changes, ask if patient is suspicious and paranoid about you
Behavioral experiment for delusions	For example, a patient believed people parking cars on his street would break into his apartment. Homework was designed with two columns on a paper, one for him to check when someone parked and the other if they broke in. Next visit, patient returned with no checks in the break-ins column

When a patient such as Ms. W has hallucinations, consider four questions:

Are the hallucinations distressing, and does the patient want them to stop?
What triggers them (usually depressed mood, anxiety, anger, or boredom)?
What coping mechanisms has the patient used, and how effective have they been?
What is the source of the patient’s distress?

Patients may be distressed by the hallucinations’ content or by their belief that they lack control over them. When you identify negative emotions as a trigger, focus on interventions to deal with those emotions.

Table 5

Interventions for managing schizophrenia’s negative symptoms

Symptom	Intervention
Anergia/anhedonia	With the patient, list activities he thinks he can do daily Have the patient rate his pleasure and competence on a 10-point scale every time an activity is completed Tie accomplishing daily activities to patient’s long-term goals Ask a family member to encourage patient to stick to the schedule Examine automatic thoughts relating to expectations of failure
Impaired attention	Identify specific situations where attention needs to be improved Identify environmental factors that interfere with attention and encourage patient to make appropriate changes Encourage patient to read a passage in session and recap what he read; start with 2 or 3 minutes and gradually increase the duration Try loud reading if silent reading does not help
Alogia	Link effective communication to patient’s goals Make pact with patient not to answer in monosyllables Avoid yes/no questions Ask him to educate you on a topic that interests him; give positive feedback for increased speech output

Delusions tend to develop gradually, and patients initially doubt them. Even when delusions are very firm, situations can change the strength of conviction. Base interventions on logical responses to delusions ( Table 4 ) and the patient’s coping skills. Sometimes they experience delusions because they lack real-world knowledge.

Never dispute a patient’s delusional beliefs. Maintain an attitude of benevolent curiosity to elicit the reasoning processes by which he or she came to believe the delusions. By encouraging the patient to become curious about the experience, you can create a chink of insight and help the him or her achieve important goals despite disturbing sensory experiences and beliefs.

Thought disorder can be addressed by gently pointing out that you are having trouble understanding the patient’s speech. Ask if other people whom the patient trusts have commented on his or her speech.

References