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Patients experiencing psychosis

 

 

What do we mean by psychosis?

Psychosis is an umbrella term which includes the diagnosis of schizophrenia. The experience of psychosis, when a person’s reality is not shared by people around them can be terrifying; confusing; highly distressing or at times magical and uplifting for the individual experiencing it. Nowadays psychosis is the term used to refer to the experience of hallucinations (especially voices) or delusions (unusual beliefs) or odd behaviour as a result of these.

 

Schizophrenia has blurred borders not only with ‘normality’ (people without a diagnosable mental illness also have unusual beliefs) but especially with depression and bipolar disorder which can also result in experiences of psychosis. This overlap is why patients can be given different diagnoses by different clinicians. With psychosis you’re thinking of four areas of symptoms:

  1. Psychotic symptoms – hallucinations and delusions
  2. Poorly regulated mood – depression, mania and anxiety
  3. Negative symptoms – lack of motivation and social withdrawal
  4. Cognitive difficulties – difficulties with memory, retaining information and such like.

There is a real stigma attached to a diagnosis of psychosis – thank goodness for Frank Bruno (the people’s hero) as he has helped many people to understand this disorder. As Sir Robin Murray has said:

‘Imagine suddenly developing an illness in which you are bombarded with voices which you cannot see, and stripped of your ability to understand what is real and what is not. You discover that you cannot trust your senses; your mind plays tricks on you, and your family or friends seem part of a conspiracy to harm you. Unless properly treated, these psychotic experiences may destroy your hopes and ambitions, make other people recoil from you, and ultimately cut your life short. Some 220,000 people in England have such psychotic experiences-we probably all know a family member who is affected but the stigma is such that they may be keeping it a secret’. (The Abandoned Illness Report, by the Schizophrenia Commission, 2012).

 

What causes psychosis?

We can’t point to any one cause which fits all but there are a number of risk factors and the more of these you stack up the more at risk you are. Stressful life experiences are risk factors:

  • Childhood adversity and trauma, sexual abuse and bullying
  • Abuse of non prescription drugs amphetamines, cannabis, ‘legal highs’ etc
  • Migration and discrimination
  • Bereavement or separation in families
  • Dysfunctional parenting
  • Rape or physical assault as an adult
  • Poverty, urban living
  • War trauma

In psychosis there is an imbalance of neurotransmitters in the brain, in particularly dopamine but this biochemical imbalance is not the whole story and so the answer is never only medication. Currently there is no genetic ‘cause’ identified but risk factors can run in families.

 

Why do I need to know this?

We need to understand a patient and their life story, not just give medication and think this is all we need to do. Get to know the patient, listen to them and be your usual kind self. This is the most important thing we can do as health workers. Never avoid these patients because you’re frightened of them – this is the stigma – get to know them and you’ll find the real personality beyond the symptoms there. If they are frightened and feel unsafe ask them what would make them feel safe and if doable, do it.

People who have some thoughts which are highly unusual, or very disturbing, will also continue to have ‘normal’ thoughts, and certainly normal feelings. And when part of your life is feeling very out of control, it is stabilising and comforting to have an ordinary conversation with someone else.

One of the main difficulties a patient may be experiencing is the effects of their medication. This can make concentrating, or even thinking clearly, very difficult. You can work out how complex a conversation they can manage by starting with simple, everyday things, such as asking them how they’re feeling, or if they’ve had visitors. Or instead of asking them something, you could kick off with something about you – a programme you saw on TV last night, or what your weekend plans are.

Source: ‘Beyond Belief’ by Tamasin Knight, 2009

 

How do I answer???

We want to know what to say when a patient experiencing delusions says something like: “M15 are outside the hospital, they’re out to get me, I’m really frightened. You do believe me don’t you?”

Your dilemma is – if I say ‘yes’ the patient will think it’s true, if I say no the patient will try and convince me because they’re frightened and think they’ll be harmed. This could turn into a real confrontation. The best response to this I’ve ever heard was by a professor of psychiatric nursing who said in response to the question ‘Do you believe me?’…. ‘I have no reason not to’.

What should you do if you can’t understand what the patient is talking about? As with everyone else, it’s usually best to say ‘I’m sorry, I didn’t quite understand that. Could you say it again please?’ If, when they repeat it, you still don’t understand what they mean, you could reflect back to them what they’ve said, for example: ‘I think you’re saying that you can hear someone talking to you from the television, even though the television is switched off.’ You don’t have to believe this is really happening; but it’s very important to accept that it’s certainly very real for that patient.

The experience of psychosis can be terrifying and distressing, especially if the voices or hallucinations are threatening or abusive. Patients appreciate staff acknowledging just how distressing the experiences are. A great concept is to use validation techniques which respond more to the person’s feelings rather than focusing on the facts or accuracy of what they’re saying. Rather than being diverted into a mutually frustrating ‘debate’ about whether an individual is a member of the royal family, the focus becomes what the patient feels about this identity and role.

Patients’ comments or ideas that might appear to be very random, meaningless, or completely out of touch with reality, are actually very significant. As with dreams, there is often a strong reason why their minds or sub-conscious come up with particular images or scenarios. However, this is very sensitive territory and unless you have a very strong relationship with the patient, it’s definitely best not to get into Freudian, interpretive mode! We don’t need to understand what a particular image or voice means to the patient, we need to recognise that it does have meaning, respect its importance, and respond in an appropriate way.

Another way of thinking about these experiences, experiences a patient is having which are impossible for us to really understand, is that they are like complex poetry. Each has its own rhythms, meaning and validity and can be understood and responded to on different levels.

At some point when they’re feeling less frightened the patient themselves may begin to question their beliefs .

 

Sources:

  • Psychological Perspectives on Distress and Unusual, by Coles S and Houghton P, 2012
  • The abandoned illness: a report from the Schizophrenia Commission, by The Schizophrenia Commission, 2012 www.rethink.org
  • The traumatic neurodevelopmental model of psychosis revisited, by Read J, Fosse R, Moskowitz A, Perry B, 2014

 

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