Lake Forest Suicides; Remembering Why I Became a Psychologist

It was 1980 when the movie Ordinary People was released and today I decided to watch it again after watching a video of a community wide effort (Helping Parents in Difficult Times) put on by a Lake Forest Task Force in response the three recent public suicides in the Lake Forest community.  

Doing a short bit of research I also found that Sheridan Road magazine published an article today online titled "Ordinary People, Extraordinary Experience" (http://www.sheridanroadmagazine.com/article.php/vol/4/issue/3/title/article-Ordinary-People-Extraordinary-Experience).  So much for me being one of the few to remember the connection.

My own two son's made time today to poke their heads in as I watched (and for those that know me, yes it was a pirated copy found online and played through HDMI).  In response to their inevitable questions I informed them that this movie was one of the basic reasons I'd chosen Clinical psychology as a profession and the North Shore as the location of my practice.  Having moved them from Northbrook to our summer in Lake Geneva before they hit the upper grades of elementary school, I'd always felt that I'd gotten them out of harms way from the north shore but still felt the need to add that the movie was a fairly accurate portrayal of the north shore entitlement program I knew as a child and know so much about today.

When I watched the video of the Lake Forest presentation on youtube (http://www.youtube.com/watch?feature=player_embedded&v=e9YupNBVuJ4#!) posted by "enjoylakeforest" (http://www.youtube.com/user/EnjoyLakeForest) what struck me first was the effort that went in to making sure participation included all the possible stake holders.  Community Hospitals (Northshore University Heath System, Lake Forest Hospital) youth programs (CROYA), community outpatient programs, suicide prevention groups, etc.  What struck me next were the things that were not included.  Before I go on let me say I had no problem with the program or with the important ongoing effort being put forth to try and ensure that everything possible that can be done, is being done to try and ensure there are no repeats or additional losses.

What disappointed me was the lack of openness regarding the real nature of suicide and the environmental elements that accompany it.  That's where the movie, Ordinary People, came in.  Why is it that 30 years ago Robert Redford could make an Oscar winning best film (four Oscar's actually) and yet none of it's themes or honest portrayal make it into such an important discussion?  Having run a highly successful junior high program in Kenilworth for over 8 years, I know first hand about the level of work and responsibility that goes into living in an elite suburb.  I also know about the concept of "Lace Curtains" where a home (and what goes on inside) can have the appearance of being transparent but in actuality is very much closed off.

If you really want to learn about the suburbs and the mental health issues that effect it, take the time to watch Ordinary People.  32 Years later the film is just as accurate in all it's portrayals as it was then......except perhaps the idea of a bus as part of public transportation in Lake Forest.  That I believe is still a fallacy.

We Don't Seem To Be Learning About Suicide Clusters And Contagion

The recent loss of another young person in Lake Forest to an apparent suicide appears to have taught us little. Lake Forest Illinois has now had three highly publicized deaths of adolescents since January 1st of this year. Before that it was Barrington Illinois where 5 individuals took their lives over a three year period and where the media focused it's attention. Before that it was St. Charles, Naperville and Elgin that caught our attention.
 
Many have rightfully suggested that suicide clusters have been spurred by contagion, also known as the "Werther Effect" (a synonym for media induced imitation effects of suicidal behavior).

A suicide cluster is defined by scientists as three or more suicides in a specific location that occur over a short period of time. Contagion is a term used to identify those situations where there is some linkage between the deaths such as personal knowledge of each other, a shared identity as in school attendance or simply an age range within a specific geographical location. While the term cluster denotes a linkage of location, contagion describes an hypothesized relationship that is in some way related to cause and effect.

As a police psychologist in an affluent northern Illinois suburb I am directly aware of the various numbers and types of death that occur within our Village limits. Some are suicides, some due to accidents and some related to the normal aging process and health deterioration. Few of them are publicized except when the local press takes special interest such as obvious suicides or car accidents. I can tell you that each and every year there are more than enough self inflicted deaths that meet the criteria of a cluster, yet are not publicized. If I include the number of attempted suicides in our town (as well as others that touch our Village limits, based on the radio traffic of dispatchers) then there are easily 4 or more per month within a population of approximately 50,000.

An interesting side point here is that for years, local writers have tried to get at some measure of how many actual suicides there are in the affluent North Shore Suburbs. When you combine that number with the suicides of persons who live here but take their life at other locations (downtown, at weekend homes or on trips of various types) my educated prediction would be it easily tops two per month and more. This prediction covers all age ranges and is not limited to adolescents who comprise a much smaller segment. A careful review of the local obituaries for a 6 month period should get you all the information necessary to concur.

Getting back to the issue at hand; are we learning from any of this? The answer is sadly, no. We continue to publicize suicides, especially those of adolescents and young adults, in a manner and fashion that promotes contagion. But please, before you try and burn me at the stake for my position consider the studies that have been done and the information learned from them. Then decide for yourself if we have learned anything.

Johansson, Lindqvist, and Eriksson (2006) found in Sweden that it is important to bear in mind the risk of further suicides and the risk of cluster formation in a society struck by a teenager suicide.

Niederkrotenthaler, Herberth, and Sonneck (2007) found that in "Austria, "Media Guidelines for Reporting on Suicides", have been issued to the media since 1987 as a suicide-preventive experiment. Since then, the aims of the experiment have been to reduce the numbers of suicides and suicide attempts in the Viennese subway and to reduce the overall suicide numbers. After the introduction of the media guidelines, the number of subway suicides and suicide attempts dropped more than 80% within 6 months. Since 1991, suicides plus suicide attempts - but not the number of suicides alone - have slowly and significantly decreased. The increase of passenger numbers of the Viennese subway, which have nearly doubled, and the decrease of the overall suicide numbers in Vienna (-40%) and Austria (-33%) since mid 1987 increase the plausibility of the hypothesis, that the Austrian media guidelines have had an impact on suicidal behavior."

The Austrian guidelines can be found here; http://www.iasp.info/pdf/task_forces/austrian_media_guidelines.pdf

The World Health Organization (WHO) has also published guidelines for media coverage of suicidal acts (2008).

1. Avoid language which sensationalizes or normalizes suicide, or presents it as a solution to problems.
2. Avoid prominent placement and undue repetition of stories about suicide.
3. Avoid explicit description of the method used in a completed or attempted suicide.
4. Avoid providing detailed information about the site of a completed or attempted suicide.
5. Photographs or video footage of the scene of a given suicide should not be used, particularly if doing so makes the location or method clear to the reader or viewer.
6. Use of the word ‘suicide’ in the headline should be avoided, as should be explicit reference to the method or site of the suicide.
7. Take particular care in reporting celebrity suicides.
8. Show due consideration for people bereaved by suicide.
9. Provide information about where to seek help.

http://www.who.int/mental_health/prevention/suicide/resource_media.pdf

When you take both guidelines into consideration, you can see that our press has learned very little when judging the reporting of the most recent Lake Forest tragedy.

I for one, fully expect even more sensational headlines and the resultant increase in adolescent suicides. I wish it wasn't so but it doesn't look like anyone is putting into practice what we've learned. I wish they would learn.

Classroom Bully Pulpits; When The Bully is The Teacher.

Bullying is a problem that affects all of our children - those who bully, those who are victimized, and those who are witnesses to interpersonal violence on either an emotional or physical level.

"Statistics on the rates of bullying and cyber-bullying vary between studies due to the measures used, the questions asked, and the population studied. However, the general consensus is that one out of three children are bullied at school, in the neighborhood, or online and that one out of three children bully others.

Additionally, the rates of bullying vary considerably across countries. Approximately 9% to 73% of students reported that they have bullied another child, and 2% to 36% of students said that they were the victim of bullying behaviors. When young people, aged 11, 13 and 15 were asked to report on their experiences with bullying and victimization within the preceding two months, prevalence rates ranged from 1% to 50% across 25 countries in Europe and North America" ( http://www.education.com/reference/article/how-widespread-is-bullying ).

As a psychologist I've watched anxiously as this long time behavior in our schools has appropriately been singled out for necessary change.  I believe we are on the verge of getting it right, now that our understandings go past the proverbial bully and victim and encompass the wider reality that there are bullies, victims, enablers (the rest that watch and quietly support it through inaction) and others who, through social castigation, help fill the ranks of both bullies and victims.

There is however, a major element missing from this equation.  What about the classroom teacher who openly bullies in the classroom through emotional intimidation and ridicule?  I bring this up after once again listening to the story of a High School client who came to my office because of what she and her parents identified as depression.  I wish I had kept track all these years of the vast numbers of kids such as this client, who are and were honor students, good athletes and by all outward appearances, strong kids, who inside are being emotionally crushed under the weight of fear at school.  Before you go off half cocked, no I am not saying all High School teachers are bad in some way, nor am I saying a large number of them are.  What I am saying is that there seem to be some teachers in every school whose classroom conduct includes openly belittling and degrading students who fail to live up to expectations or are the source of other classroom disturbances.  I am also saying that I fear this is more than just one or two bad apples, so to speak.  Judging by one such incident that was the subject of a recent Today Show story ( http://today.msnbc.msn.com/id/45302947/ns/today-parenting/t/teachers-caught-tape-bullying-special-needs-girl/ ) things may be worse than anticipated.

Science tells me that before I open my mouth about how to fix this perceived problem, I need to know how much of a problem this is.  My gut tells me that accurately measuring the number of bullies in any school that hold the title of teacher and thus classroom leader, is far from an easy task.  The applied practitioner part of me says that my job is not so much to find out how many bullies there are, masquerading as teachers, as it is to find a positive solution for those affected.  In fact I've done a good deal of that in my years working with and supporting children and adolescents simply trying their hardest to navigate an otherwise none to reinforcing context known as the school system.

I got wise through 4 years experience as a H.S. Board member and have tried to incorporate that experience ever sense.  I started by looking at those kids who did well in school in my attempt to understand how to navigate the system.  What I found was children and adolescents who did the best seemed to have the inside track in understanding how to best help the system work for them.  One of the first things I noticed was that those parents and/or kids who openly and frequently supported the system, seemed to receive the most benefit.  Likewise, those parents and/or kids who openly rebelled against the system were often the ones most at odds with the system and the teachers within.  The degree to which one is at odds with the system says much about who is either likely to be bullied or is likely to have a history of being bullied.

It may be self evident but it is far easier to start by being supportive than it is to go from rebellion to support of the system.  In fact I'm not sure one can functionally make the change to support and actually receive the benefit?  It may be that once one is identified as a non-supporter, no amount of change will alter the initial label of non-supporter.

I also know that paying attention to what your son or daughter has to say about how their teachers treat students is a very good idea.  It can certainly offer valuable insights into how they are being treated.  Even if it is more their perception than reality, the perception is important.  Do not assume that bullying in school is a student versus student problem and be open to the possibility that the bully may be an adult who is also the leader of the classroom.

Creating Intensive and Successful Therapeutic Relationships; Functional Analytic Psychotherapy (FAP)

Will Hunting (Matt Damon) has genius-level intelligence. He works as a janitor at MIT and lives alone in a sparsely furnished apartment in an impoverished South Boston neighborhood. An abused foster child, he blames himself for his unhappy upbringing and turns this self-loathing into a form of self-sabotage in both his professional and emotional lives. Hence, he is unable to maintain either a steady job or a steady romantic relationship.

In the first week of class, Will solves a difficult graduate-level math problem that Professor Gerald Lambeau (Stellan Skarsgård) is hoping someone might solve by the semester's end. Everyone at MIT wonders who solved it, and Lambeau puts another problem on the board -- one that took him and his colleagues two years to prove. Will is discovered in the act of solving the problem, and Lambeau initially thinks that Will is vandalizing the board and chases him away. When Will turns out to have solved it correctly, Lambeau tries to track Will down. 

Meanwhile, Will attacks a youth who had bullied him years ago in kindergarten, and he now faces imprisonment after attacking a police officer who was responding to the fight. Realizing Will might have the potential to be a great mathematician, such as the genius Évariste Galois, Lambeau goes to Will's trial and intervenes on his behalf, offering him a choice: either Will can go to jail, or he can be released into Lambeau's personal supervision, where he must study mathematics and see a psychotherapist. Will chooses the latter even though he seems to believe that he does not need therapy.

Five various mental health professionals fail to connect with Will. Out of sheer desperation, Lambeau finally calls on psychologist Sean Maguire (Robin Williams), an estranged old friend and MIT classmate of his who grew up in the same neighborhood as Will. Sean differs from his five predecessors in that he is from Will's neighborhood and systematically pushes back at Will and is eventually able to get through to Will and his hostile, sarcastic defense mechanisms.

How did Sean, in this fictional work, get through to Will when 5 previous therapists had not?  Through the development of an intense and curative therapeutic relationship.  Often the general public, when faced with trying to understand why or how a therapeutic encounter was successful, will look at the personal characteristics of the client and the theoretical orientation of the therapist and conclude that a good match occurred, the result of which was a successful therapeutic outcome.  Although fictional in nature, the story of Good Will Hunting is a good example of a therapist and client forming a functional therapeutic relationship that allows the client to grow and develop in his personal life.  In psychology we know the basic factors that allow this to happen and well trained therapists can often duplicate this fete with many of their clients.  These basic factors are combined in a fairly simple set of procedures or therapeutic model known as Functional Analytic Psychotherapy; often referred to as FAP for short. 

Who Does FAP work best for?  What type of client benefits most from FAP?  FAP techniques work best with clients who seek an intensive, emotional, in-depth therapy experience.  It is also well suited for individuals who have not improved adequately with traditional behavior therapies, who have difficulties establishing emotionally intimate  or functional relationships, and/or who have diffuse, pervasive, and chronic interpersonal problems typified by one or more axis II disorders in the DSM-IV-TR.

Who developed FAP?  Dr. Robert Kohlenberg of the University of Washington in Seattle and Dr. Mavis Tsai, a Clinical Psychologist in Seattle published their first work on FAP in 1987.  Since that time they have refined it and have written several books about it.  It has been studied extensively and has been shown experimentally to be a highly effective EBP (Experimentally based Procedure) for a variety of psychological disorders.

What is FAP?  How does FAP work?  Outpatient psychotherapy typically takes place one-on-one in a therapist's office and is scheduled for one or more hours per week.  It is relevant to ask how something that occurs inside an office between two people for a few hours per week can generalize to a clients outside world on a daily basis?  The answer lies in the careful identification of behaviors that occur inside the office setting that relate to the clients behavior outside of the office that either increase or decrease functional social relationships.  In FAP we call these "Clinically Relevant Behaviors" or CRB's.  In FAP we can reinforce desirable CRB's and reduce undesirable CRB's.  Everything a therapist can do to help a client can and does occur during a session.  Therapist actions that help clients during a session include identifying, eliciting and reacting to CRB's.  For the well trained and experienced therapist, every therapist action in session has one of these three effects.

OK, what are CRB's specifically?  Are they the same of different for each client?  In a general sense CRB's are different for each client but they do tend to share some common factors.  Three general commonalities include but are not limited to 1) learning to ask for what one wants, 2) trusting, and 3) the acceptance of love or being valued by others.

How can I find a therapist who is trained in and understands FAP? The best way is to ask ahead of time. Do some reading on your own and then ask some questions of your potential therapist.  Competent therapists welcome educated clients and will appreciate your efforts in finding them.  I've taught advanced intervention techniques including FAP to hundreds of graduate students and believe me, nothing would be more welcome to them then a motivated and well read client looking to make successful changes in their life through the development of an intensive and curative therapeutic relationship.

For further reading see; http://www.amazon.com/Guide-Functional-Analytic-Psychotherapy-Behaviorism/dp/0387097864 

Evidenced Based Practice; Knowing When a Treatment Fits an Individuals Needs.

Over the past 10 or so years, the focus of mental health treatment for the support of individuals and families has increasingly been on “evidence based practices (EBP's).” EBP's are treatments that have been shown through clinical research to produce positive outcomes for individuals and their families. In short, the practices have been shown through research to be effective.  I like this shift in our field and you should too.

Back in the 80's a common question I received from my peers was "what's your therapeutic orientation?"  I have to laugh now as I look back.  For me, being trained in both applied behavior analysis and clinical psychology often meant I had t o choose my answer based more on the characteristics of who was asking the question than on any particular merits of the elements of the treatment procedures themselves.  This also meant the needs of the assumed client took a backseat position to the need to appear competent in the eyes of the person asking the question.  The most often heard response by ethical but sensitive clinicians was a confident exclamation that one was "eclectic."

I'd like to say with confidence that the situation has truly changed however I can say the situation is quickly evolving and with some help from consumers, will change greatly in the next few years.  With that in mind lets take a closer look at EBP's, how the research works and why it benefit's consumers so significantly.

This focus on EBPs in mental health follows the release of a series of national reports calling for the broader dissemination of EBPs.  These reports include those by the U.S. Surgeon General (1999), the Institute of Medicine (2001), the President’s New Freedom Commission Report on Mental Health (2003), and more. Also, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Center for
Mental Health Services (CMHS) released Evidence-Based Practice Implementation Resource Kits for the mental health system regarding children and adolescents.

Before going farther, one word of caution.  Although there is a growing emphasis on the use of EBPs, individuals and families must maintain their right to choose the most appropriate treatment that meets their unique needs. Choice is necessary and highly valued by individuals and families because proposed EBP treatments may conflict with an individuals or family’s beliefs, may have been tried and failed, or an individual or family may know that a proposed treatment will not work for the current situation based upon other previous experiences.

How was the research done to determine the best EBP's?  The research in this area is ongoing so we tend to know more about the current best treatment procedures than we do about the all-time best treatment procedures.  In a typical study, participants are assigned to one of two groups. One group receives the treatment that is being studied to better understand its effectiveness, while the second group does not receive that treatment, and may instead be given usual treatment, placed on a wait list, or given an alternative treatment. The two groups are compared to see whether the outcomes for the group receiving the treatment being studied are better than the outcomes for the group that did not receive that treatment.

The studies typically use uniform training and a treatment manual to guide providers (psychiatrists, therapists, social workers, and other health care providers) in the treatment. They also provide supervision
and oversight to help ensure that providers follow the treatment protocol or procedures.  In general, those treatments qualify as an EBP that produce positive outcomes in two or more studies and are preferably conducted by more than one research group.

The outcomes typically measured in studies include some combination of the following:

1. Symptom Reduction and Improved Functioning
                • Improved school attendance and/or work performance;
                • Improved significant other, family and peer relationships;
                • Decreased involvement with law enforcement or the juvenile justice system;
                • Decreased rates of substance use and abuse; and
                • Reduction in self-harm and suicide related behaviors.
2. Prevention of Deep End Service Use
                • Decreased hospital admissions, institutional care, and other types of out-of-home placement.

Cautions About EBPs.  Much has been learned in the last decade about evidence-based practices in mental health and more remains to be done. First, the development of EBPs does not mean that these practices are widely available. There are many EBPs that are only available in a limited number of communities around the country. Many mental health providers have not been trained in EBPs and thus lack the training to provide these interventions for individuals and their families. Some providers also resist change in the way they practice, often believing that their clinical judgment, based on years of experience, produces the best outcomes. Individuals and Families need to find providers that are open to change and are willing to partner with them to provide the most effective and appropriate interventions.

Just because a individual or family is receiving treatment that has not been recognized as an EBP, does not mean that the intervention will not be effective. Many factors lead to successful service outcomes, and some of them can be difficult to evaluate. For example, the benefit of a strong therapeutic relationship between a provider, individual, and family can be a factor leading to positive outcomes as long as the provider uses the skills necessary to change concerning behaviors. Families highly value mental health providers who respect the family’s expertise about their child or loved one, and spend adequate time with the family through a thoughtful needs assessment and in developing and implementing an effective treatment plan. How these factors play into positive outcomes for the individual and family can be hard to measure, but are important factors in positive change.

Not all, but many EBPs have been studied in culturally and racially diverse communities. Consequently, the existing research base for some of the interventions in children’s mental health does not address the effectiveness of the practices in all communities. Fortunately, more attention is being paid to the need to adapt EBPs, whenever possible, to better meet the values, needs, and culture of individuals and families in diverse communities.

Co-occurring disorders are common in mental illnesses. This is especially true for substance abuse disorders, attention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder. It is important for families to understand whether research supporting an EBP includes studies with children, adolescents, and adults with co-occurring disorders. If not, families may want to request several interventions which are likely to improve the outcomes for the disorders that are impacting them.

Research gaps persist in effective treatment for a number of serious mental illnesses that impact the lives of children and adolescents, including bipolar disorder, early-onset schizophrenia, and eating disorders. There is limited research on child use of psychotropic medications, outside of research on the use of stimulants to treat attention deficit/hyperactivity disorder. The limited research that has been done on medications tends to focus on the short-term effects of medication, without examining the long term safety and effectiveness of medications. Fortunately, the scientific understanding of medications continues to grow, with increased information about combining medication with other therapeutic interventions—often involving parents and families as co-therapists, to produce the best results.

New research is being conducted so that more EBPs will be available to treat early-onset mental illnesses. Unfortunately, there is currently not a central clearinghouse or single resource for families to access to learn more about EBPs in mental health and the availability of those EBPs in communities.  We will get there so stay tuned and ask questions in the meantime.

Getting to Diagnosis in Autism and Autism Spectrum Disorder's; What Does Our Road Look Like?

I recently read an excellent blog post (http://bestpracticeautism.blogspot.com/ ) titled “How many doctors does it take to diagnose and autism spectrum disorder.”  The bottom line was the average age of first diagnosis of autism in the UK was 5.5 years of age and for higher functioning ASD’s such as Asperger’s it was 11 years of age.

Perhaps a more frustrating realization was less than10% of parents received a confirmed diagnosis at their first clinic visit.  For another 40% it took two clinic visits and in total only 63% of parents reported having a confirmed diagnosis on or after their third clinic visit.  According to the article, “in many instances, parents waited more than 5 years before a diagnosis was confirmed.”  Given the knowledge that the earlier the intervention, the better the outcome and that most research points to age 4 or before as the ideal starting point, the protracted diagnosis time would seem detrimental to both parents and children.

Not surprisingly 40% of parents said they were not happy with the diagnostic process.  It hardly seems surprising that the more professionals parents saw on this quest for a diagnosis, the more negatively they viewed the process.  Often these parents were given the advice of “wait and see if they grow out of it” rather than encouragement to seek treatment help asap.

In my opinion, the problem lies not so much with the lack of standardized assessment criteria as it does with general knowledge of where to go initially to get a diagnosis.  I know my own experience, having children with mild to moderate hearing impairments, was that there was no obvious place to go.  Our local hospital at the time had no children’s center and our regular family doc’s didn’t have the right equipment.  If it wasn’t for the lucky location of a large University within 10 miles of our home, we could have spent countless hours and days going from one expert to another.  As it was they were able to make the diagnosis on the first visit and then to identify for us, a list of professionals capable of treating our kids.

It seems likely that the point of first contact for parents who suspect a developmental problem is the pediatrician.  It also seems to me that the creation of local and stand alone, multidisciplinary developmental diagnosis and treatment programs are a good option.  I look forward to the publication of research in the US that looks at experiences of parents of children with ASD’s here, so we can accurately understand the process they go through to receive a diagnosis in order to unlock access to the necessary treatment.

Ref’s

Howlin, P. & Moore, A. (1997) Diagnosis in autism: A survey of over 1200 patients in

the UK. Autism: International Journal of Research and Practice, 1, 135-162.

Howlin, P and Asgharian, A. (1999) The diagnosis of autism and Asperger syndrome: findings from a survey of 770 families.  Developmental Medicine and Child Neurology. Dec;41(12):834-9.

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.

Related Article;  

http://www.nbclosangeles.com/news/health/The_Real_World__Recognizing_Mental_Illness_in_Young_Adults.html