DIAGNOSIS AND TREATMENT



How is a diagnosis of psychosis made?


Diagnosing a psychotic episode in its early stages can be difficult. Often, because psychosis affects young people, the early symptoms are mistaken for normal teenage behaviour. Frequently, the earliest changes (the "prodrome") are very general and may reflect depression, adjustment to stressful life situations, or street drug use. In many cases families, friends, teachers and counsellors do not recognize the subtle changes that psychosis causes in a young person.

Sometimes, others may see that something is wrong, but are afraid to label the problem. They may fear offending the person or their family.

To complicate matters, individuals with psychosis themselves may not know anything is wrong. Since they don't know what is wrong, they may not reach out for help. People may also fear what others might think and so stay quiet about what they are experiencing.

Even when acute psychotic symptoms are present, they are sometimes not properly diagnosed. This can be due to lack of knowledge by the person or mental health services from whom or which the person seeks help. People also may have had previous experiences trying to get help that were not successful. They may have been discouraged by or dissatisfied with the mental health services they contacted. These experiences may make them less willing to try and seek help again.

Diagnosis may take some time and can be frustrating for patients and families who want to know what is happening. Once a person is in contact with mental health services, the pattern of symptoms is assessed. This is done to diagnose the specific type of psychotic disorder an individual has. This can take many months. However, taking the time that is needed to do a comprehensive assessment is more likely to lead to a proper diagnosis.

It is recommended that individuals with psychosis and their families participate in assessment and treatment together. Medical professionals will figure out what is happening by using different sources of information. These can include a medical history, family history, physical examination and specialized types of assessments, such as a brain scan or assessment of cognitive functioning.

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Why does the diagnosis change sometimes?


There are a range of psychiatric disorders that can produce psychotic symptoms. Some examples are:

In the first episode of psychosis, distinguishing between these disorders can be difficult. Usually, about one-third (1/3) of the diagnoses made in the beginning are changed within three months. While this can be frustrating, finding the right diagnosis can help mental health professionals give the person and his/her family the best possible treatment.

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How is early psychosis treated?


Early psychosis is best treated with specialized early intervention services. These services provide a specialized treatment strategy that involves:

The treatment strategy is specialized in two ways. First, early intervention means intervening as early as possible once people become ill. The treatment strategy is designed for the early stage of the illness and differs considerably from treatment for more chronic mental illness. Second, the treatment is specialized in that is designed to address the developmental and social issues affecting young people who are primarily struck by this illness. The goal is to keep them connected to their families, friends, schools and workplaces.

Early intervention programs have demonstrated the capacity to substantially reduce the duration of illness, the use of medications and the need for inpatient care. Specialized early intervention helps people to get better faster and return to their regular lives more quickly.

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Whom are early intervention in psychosis services for?


Early intervention in psychosis services in Toronto typically serve people between the age of 14 and 35 years old who are experiencing a first episode of psychosis, or who have not received previous treatment for psychosis of longer than one year in duration. There is some flexibility with respect to the age range and amount or duration of previous treatment received for psychosis depending on the individual's specific situation.

It is the experience of psychosis that determines an individual's appropriateness for an early intervention in psychosis program, not any particular diagnosis. This is important since establishing a diagnosis to explain the underlying cause for psychosis may take a considerable length of time.

Individuals experiencing prodromal symptoms only, without clear symptoms of psychosis are not included within the priority population for early intervention services because there is currently no adequate evidence for doing so (i.e., it has not been proven that early intervention services are effective for this group of people). The point at which intervention is recommended may change as knowledge in this area develops.

It will be determined during the person's assessment whether early intervention services would be helpful to the person. If not, the person's assessment team will help connect the person to services that are more appropriate to their specific needs.

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What is the range of services provided?


Early intervention treatment services can provide a range of services including:

These treatments and supports all help to speed up the recovery process and promote good quality of life for both the person and their family.

Medication

Medication is an important part of the treatment of psychosis. It relieves symptoms of psychosis. It can be critical in preventing relapse. There are many different medications available to treat psychosis. These medications are called antipsychotics (or sometimes neuroleptics).

There are two main types of antipsychotic medications:

Young people typically should start taking the lowest possible dose of antipsychotic medication. Other medications are sometimes used along with antipsychotics, depending on the symptoms. For example, antidepressants or mood stabilizers may be used for problems with mood. Medication may not immediately clear up all symptoms, but it is an important step in the recovery process.

Monitoring of symptoms and medication side effects

Antipsychotics have different types of side effects. Some people do not experience any side effects. Other people experience side effects which diminish over time. For many people, the atypical antipsychotics are a dramatic improvement over the older types of medications. As such, the atypical antipsychotics are usually tried first. However, like all medications there are some common side effects, including:

If side effects develop, mental health professionals may recommend trying:

Some people experience significant side effects. Decisions about which and how much medication is needed should be discussed by the person and his/her healthcare team, and be based on the person's individual situation and responses to the medication he/she has tried.

Education about psychosis and treatment

Becoming educated about psychosis is an important part of treatment. It allows the person and their family to understand the experience of psychosis. They have a chance to learn what to expect from the recommended treatments and supports. Early intervention services may use videos, brochures, booklets, websites, and group education sessions to share information on psychosis with people and their families.

Learning about psychosis helps young people understand the nuances of their symptoms. Some symptoms are so subtle that they are easily missed as being a part of the illness. It is important for the person with psychosis to learn to recognize them because the earliest signs are often not seen by other people. The monitoring of symptoms is vital to a person's recovery because it can help prevent relapses. Family members and friends can lend a hand by keeping an eye out for more obvious changes in a loved one's personality or behaviour.

Relapse prevention training

Many of the treatments offered are important to help prevent the acute symptoms of psychosis from returning. This is called a relapse. Taking medication as prescribed can help prevent relapses. Education about psychosis and learning how to manage stress will also help. A relapse can often be prevented, or be less severe if it does happen, if people learn the early warning signs. This can help them make a plan of action and respond quickly.

Counseling

Having someone to talk to is an important part of treatment. There are different types of therapy used with people with psychosis. Counseling or therapy may take place on an individual basis or in groups. The type and format used will be chosen to suit the individual and the phase of psychosis. A person with acute psychotic symptoms may simply want to know that there is someone who can understand their experience. They may be provided reassurance that they will recover. As the recovery phase progresses, people may ask and need support to understand "why me?" They may want to learn practical ways to prevent further episodes. Counseling on stress management and early recognition of warning signs can help.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) is a specialized form of therapy that helps people increase their control over and cope with psychotic symptoms. It can also help treat additional problems such as depression or anxiety. In CBT, the individual and the therapist work together to:

Stress management training

Stress can worsen a person's symptoms. It can impact their ability to function. Managing stress starts with learning to recognize stress. Stress symptoms include many mental, social and physical changes. Each person's response to stress is unique. Common symptoms include:

People under stress may use poor ways of coping, such as increased use of alcohol and/or drugs.

By anticipating stress, people can prepare for it. They can work out how to control it when it happens. Different stress strategies work better for some people than others. Trying out a number of different strategies will help people to figure out what works best for them. Some ways to reduce stress include:

Case management/care coordination services

Case management or care coordination services help people connect with and stay connected with the different services that can help them. A person having a first episode of psychosis typically needs access to a range of services and supports. These needs will change over the course of his/her illness and recovery. It can be challenging to find out about, get connected with and keep track of the different services and supports that a person and their family need over time and that's where case management services can help.

Psychosocial supports

A critical component of early intervention treatment is the planned return of the person back to their regular daily activities including school, work and leisure and social activities.

Services that help with this are called psychosocial supports. Some early intervention programs have in-house psychosocial support services to help with this. Others link people with community support agencies that provide this kind of help. The types of psychosocial supports that are available can include:

Everyone needs to work together including families, friends, early intervention professionals, other mental health personnel and peers who have lived through similar experiences. When they do, youth and young adults experiencing psychosis are helped to get on with their lives. They can work toward their goals or plan new goals. They can regain and keep good mental health.

Substance use/abuse treatment and supports

Many people with psychosis use and abuse substances. There does not seem to be a single way that substance use/abuse and psychosis are linked. For some people, use of substances pre-dates their experience with psychosis by either a short or a long time. Some people report using substances to help them cope with or manage their symptoms of psychosis.

It is known that using and abusing substances can undermine success in recovery. Use and abuse of substances can cause problems in a person's ability to function, lowers their quality of life and increases a person's risk of hospital admission and readmission.

The assessment process will usually include discussion of substance use/abuse. If needed, people will be provided with and/or connected to substance use/abuse treatment and supports.

Family education and support

The family and friends of a youth or young adult experiencing psychosis are a critical part of the person's recovery. They can help create a loving, supportive environment that best supports the person. Family and friends of people experiencing psychosis also can benefit from services and supports in their own right.

Family education and support helps families understand and cope with their relative's illness. The goal is to minimize disruption in their lives. Families' own empowerment, health and recovery are promoted. Depending on the family's unique situation, the following services may be provided:

Services and supports to families may be provided by professionals. Families who have experienced similar challenges may also support each other. The services may be provided at the family home, in the community or at a community agency or hospital.

Some early intervention programs provide education and support services themselves to families whose relative is in the program. If they don't offer family education and support directly, they may connect families with other community services. Family support organizations typically provide services and supports to families whether the person experiencing psychosis is taking part in treatment or not.

Peer/mentor and self-help group support

Having the support of others who have experienced psychosis can be very helpful. Many people have said that having access to someone who truly understood their experience because they had lived it themselves was critical to their recovery.

Some early intervention services have peers/mentors who provide this kind of support to people in their programs, either individually or through groups. Groups provide a safe environment to meet with others who have been through similar experiences. Groups offer education and support about psychosis through videos, presentations, written material and discussion. They are also a great way to learn and be positive about recovery.

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