Breaking from Reality: Responding to acute psychotic episodes

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Published: 07th July 2010
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Felt on the verge of a nervous breakdown at some point in their life. However, the term is more popular than clinical, in that individuals who suffer from a breakdown may seek to avoid the negative stigmatization and stereotypes that are frequently associated with certain diagnoses. In the Middle Ages, this phenomenon was often referred to as vapors or melancholia and in the early 1900s, it was known as neurasthenia. Some physicians originally thought this was a disease of the peripheral nerves, but modern psychiatry has generated further classification, where a variety of disorders have now been identified, each encompassing a set of specific and descriptive features. These include, Generalized Anxiety Disorder, Panic Disorders, Post- Traumatic Stress Disorder, Acute Stress Disorder, Schizophrenia, certain Mood Disorders, and Psychotic Disorders.



The focus of this article will be to address the symptoms, appropriate responses, and treatment considerations related to people who experience acute psychotic episodes. The word psych comes from the Greek word psyche and literally means breathe, but also carries a broader connotation that refers to life, the mind, the soul, and the spirit of a person at any given time. Psychosis is a state of being where there is a noticeable break from reality, as well as in the persons level of awareness and ability to function.

Online therapy can be helpful to get rid of such problems.



Assessment

According to the Diagnostic and Statistical Manual of Mental Disorders (4th Edition), psychotic disorders include one or more of the following symptoms: (1) delusions; (2) hallucinations; (3) disorganized thinking and speech; and (4) grossly disorganized or catatonic behavior. To be considered as a brief or acute psychotic break, the episode must have a duration of at least one day, but also be less than one month, with the eventual return to a normal pattern of functioning. Furthermore, the episode cannot be better accounted for by other disorders or due to the physiological effects of substance abuse or a general medical condition. As there are a number of disorders that may encompass psychotic features, including the ability for certain drugs (i.e., hallucinogenics such as LSD) and certain physiological problems (i.e., brain injury or tumors) to produce the same effects, an accurate diagnosis is essential for effective intervention strategies. Delusions are marked by a set of false beliefs in which a person misinterprets their experiences or what they perceive to be going on in their environment. The focus of the delusion can revolve around different themes such as the notion that one is being purposely tormented and persecuted, when there are unfounded somatic complaints, or by having an abnormal sense of grandiosity.

A delusion of reference describes a person who avidly believes certain statements, gestures, news stories, or other environmental cues are expressly being directed at him/her in order to produces a loss of control over mind and/or body. The two most common themes in this category are thought withdrawal where the person believes his/her thoughts have been unwillingly removed by some outside force and thought insertion, or the belief that ones thoughts and actions are being directed or manipulated externally.



In making an assessment, clinicians often attempt to determine the degree of bizarreness in a particular delusion since it is sometimes difficult to separate what may be a diagnostic feature from a strongly held belief. This can be especially true when addressing certain cultural or religious beliefs. The distinction is usually g centered on whether or not the belief can be supported by any credible evidence and is understandable within the context of ordinary life experiences. Hallucinations, like delusions, represent completely unfounded or mistaken impressions having no basis in reality, but they occur in a persons sensory modalities.

This includes hallucinations that are visually based, are auditory, olfactory related (referring to the sense of smell), gustatory related (referring to the sense of taste), and tactile related (referring to the sense of touch). However, auditory hallucinations, often described as hearing voices, are significantly more frequent than any of the other sensory distortions. It is also possible for someone experiencing a psychotic episode to hear more than one voice conversing simultaneously. A distinguishing feature for auditory hallucinations is that the voices are perceived as being external to the person hearing them. This is in contrast to individuals diagnosed with Dissociative Identity Disorder, where the voices are internal.



Typically, hallucination-like experiences that may take place during normal periods of falling asleep or waking up, are not considered to be pathological, per se. The same could be said for certain religious experiences that are derived from various cultural belief systems. For example, people of faith may use terminology that describes, hearing Gods voice or having a vision of God. Disorganized thinking, unlike delusions or hallucinations, often presents a more complex process for the clinician when making an assessment. This is because of the somewhat subjective nature of the task, the fact that it can be a very continuum-based phenomenon, and that it must demonstrate substantially impaired communication.

Having a formal thought disorder is usually seen as the predominant feature for those diagnosed with Schizophrenia, but the primary means to determine the correct level of acuity comes through the evaluation of individual speech patterns. The most universal examples of disordered thinking include loose associations, where topics seem to switch frequently and automatically; a high level of tangentiality, where verbal responses appear disconnected and unrelated; and finally, incoherence, where words and sentence structure components are linguistically jumbled. Grossly disorganized or catatonic behavior is the fourth criterion that needs to be considered when looking at potential levels of psychosis.

Like disorganized thinking, behaviors can sometimes be more difficult and subjective to gauge and care should be taken not to utilize this criterion across the board too generally. For instance, not every display of anger, irritation, restlessness, or idiosyncratic behavior is necessarily dysfunctional, especially when taken into proper context or in consideration of certain cultural or religious activities. Nevertheless, when a persons behavior deteriorates to the point that they cannot cope or function in normal, everyday, or goal-directed routines such as preparing meals, maintaining personal hygiene, going to school or work, etc., a higher level of disturbance may be evident. Catatonia typically refers to gross or fine motor behaviors ranging anywhere from rigid posturing or even being in a stupor, to excessive motor activity that is not the result of some kind of overt stimulation.



A thorough assessment must also take into account any possible negative side effects from the long-term use of certain antipsychotic or neuroleptic medications. Acute psychotic episodes are usually accompanied by severe emotional turmoil and an overwhelming sense of confusion. Research has shown a slightly increased risk among individuals who have certain pre-existing personality disorders such as Paranoid, Histrionic, Narcissistic, Schizotypal or Borderline. The onset of Brief Psychotic Disorder occurs most commonly in late adolescence to early adulthood. There is also evidence that genetic factors can play a role in the biological basis of these disorders. If an episode does occur, the more acute the onset was (i.e., within a period of two weeks or less), the quicker the recovery will also be. In fact, encountering a significant stressor such as the loss of a loved one, loss of a job, the psychological distress of combat, severe abuse, and other traumatic events can trigger an episode in some individuals. Usually, complete recovery takes place within a matter of two to three months and sometimes within weeks or days. Only a small percentage of people who have a psychotic break go on to develop a more persistent or disabling condition.



Interventions

The following are some practical considerations should an intervention be necessary in the management and treatment of someone who is having an acute psychotic episode:

¢ Since the person is experiencing a break from reality, the first priority is to ensure that he/she, as well as any others who may be present, are safe. Self-injury, suicide attempts, and assaultiveness are common behavioral a responses and care should be exercised so that no one is injured. This may necessitate a call to emergency services, the police department, or other mental health professionals who are capable of advising and/or assisting in the process. Attempting to engage the person in rational conversation about their behavior is usually ineffective at the time. Typically, immediate hospitalization is required for both safety and further evaluation.

¢ An accurate diagnosis is absolutely essential as many conditions and diseases share the same symptoms. This will help avoid unnecessary delays in appropriate treatment for what may be a serious underlying problem. As already mentioned, there are psychological, biological, and environmental factors that could be primary sources for the occurrence of the episode. An understanding of the big picture is critical.

¢ Antipsychotic medication may need to be prescribed based on the severity of symptoms and proper psychopharmacological supervision can help facilitate recovery and the avoidance of further collapse. However, close management of these medications is important as their long-term use can increase the risk to develop serious side effects affecting involuntary muscle movement, such as Neuroleptic Malignant Syndrome and Tardive Dyskinesia.

¢ Once the acute phase of the episode is under proper control, talk therapy has been shown to be an effective treatment protocol. The benefits of psychotherapy include the ability to explore, monitor, and manage stress levels; process traumatic events and major losses in ones life; make needed lifestyle adjustments; develop effective coping strategies; address any cognitive and/or spiritual distortions; and assist family members in their own awareness and concerns. It should also be noted that recognition of the early signs of mental and emotional deterioration, and addressing them directly, can help move the person past normal minimization or denial responses and encourage them to seek evaluation and treatment early enough to potentially avoid the onset of an episode. God is Able Acute psychotic episodes can be traumatic not only for the person experiencing them, but for family and friends as well. When it comes to a loss of cognitive and emotional control, many Christians struggle with shame and guilt in this area because they often attribute what is happening to a weakened faith or even the judgment of God in their lives.

Many may even view psychosis solely as a form of demonic oppression or possession. Prayer and the integration of Biblical principles are vital considerations, and while discernment and wisdom are essential prerequisites in the process of any intervention, the Body of Christ should not be an army that shoots its own wounded. Effective treatment options are available and, Since we have a great high priest who has passed through the heavens, Jesus the Son of God, let us hold fast to our confession. Let us therefore draw near with confidence to the throne of grace that we may receive mercy and may find grace to help in time of need.

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