Thursday, October 13, 2011

Young Adults and Psychosis; Diagnosis and Treatment.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) refers to psychosis in varied terms depending on the diagnosis.  For instance in schizophrenia, psychosis is defined as 2 or more of the following symptoms over the course of a one month period * ;
1.  delusions
2.  hallucinations
3.  disorganized speech
4.  grossly disorganized or catatonic behavior
5.  negative symptoms - affective flattening, poverty of speech, etc.

*  For a diagnosis of schizophrenia an entire clinical picture, consisting of additional signs and symptoms, must be present for 6 months or more.

The question faced by most family members and significant others, when these signs and symptoms present themselves, is whether this is in fact the start of a schizophrenic disorder or the result of the use of various substances or, due to a medical condition.  An important second question is whether or not the individual agrees that they are suffering from psychosis and what, if anything, they are willing to do about it.

Many in the mental health field are concerned that there appears to be more psychosis these days than previously seen.  While the prevalence of schizophrenia appears to hold steady at about 1% of the general population (the same for most countries), the prevalence of psychosis is thought to be on the rise.

When we see psychosis in the hospitalized elderly or others post surgery, the diagnosis is almost always delirium and resolves itself within a few hours or days.  It's frightening to unprepared family members as there is a rapid change in consciousness or cognition.  It is almost always related to a medical condition or procedure and/or in some cases, medication or substance use.

When we see psychosis outside of medical settings and in young adults, with an onset over several weeks or months, the story is normally much different and of a much greater concern.  Is it the start of schizophrenia, a schizophreniform or a schizo-affective disorder?  Or is it the result of a drug induced psychosis?  How people proceed once they see the above signs and symptoms, can determine to a significant extent, what the eventual outcome is (prognosis).

A bit more background is important here, before proceeding on to diagnostic and treatment considerations.  Schizophrenia, schizophreniform and schizo-affective disorders tend to start in the late teens through the mid 30's.  It is thought to affect men slightly more than women with the onset for men tending to be younger (teens to mid 20's) whereas women tend to succumb between their mid 20's to early 30's.  For both there is a generally accepted sequence of 3 stages; (prodromal, active, and residual or remission).

The prodromal stage is almost always marked by a 6 month or more time frame of a gradual appearance of both positive and negative signs as well as a social distancing.  Often these signs and symptoms tend to come and go.  Often they are not even recognized fully for what they are until after the individual proceeds into the full blown active stage.  In hindsight family members then recall that some behaviors seemed odd but because of their transient nature, easily ignored or overlooked.

The positive signs are things that are not supposed to be there such as the symptoms of psychosis above.  The negative signs are things that are supposed to be there but aren't such as a cognitive slowing or decline, the ability to experience pleasure, and normal speech patterns.  Instead of over-looking these issues it is best for people to identify them and discuss them.  Often people who are experiencing a psychotic disorder of some type are not able to see it as a problem and/or actually prefer to operate at that level.  They resist treatment or even discussing the issue and often their denial equals or exceeds that seen in alcohol or drug dependent individuals.

I believe it's best to proceed in treating psychosis by assuming a default position of an etiology of a drug induced psychosis unless other factors rule that out from the start.  Today, more than ever, a variety of substances could be, and often are, the cause including but not limited to the use of alcohol, marijuana, a variety of so called "club drugs" and even the excessive use of caffeine, energy drinks, a variety of diet supplements or just about any stimulant compound.

Too often a default diagnosis of schizophrenia is arrived at prematurely and people are left with little hope or understanding.  Medications known as anti-psychotics (neuroleptics) are started without adequate patient and family preparation and the large number of side effects quickly begin to produce significant problems in treatment compliance.  Instead of having the start of treatment begin on a sour note, it makes much more sense to start with an educational approach and to develop a functional therapeutic alliance with the individual.  It is likely that an anti-psychotic will have to be used at some point but only once the individual and family are prepared for the short term difficulties of treatment and understand the long term nature of the care necessary.

Once individuals and family members are "on board" so to speak, high potency-low dose medications can be started and plans for stopping all mood altering substances put in place.  When done right, treatment with medications can be very short term and side effects minimized.  When necessary a once per month shot can be used along with therapy.  Drug induced psychosis can be effectively treated within 8 to 12 weeks and the likelihood of relapse minimized.  Once the intensive phase of treatment is completed, treatment can be scaled back over the next 3 to 6 months to do all that is possible to eliminate the possibility of relapse.

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