The typical development of a psychotic disorder can be conceptualized as occurring in stages:
Before psychosis develops, there are often vague and non-specific changes that occur for weeks or months before the onset of psychosis. These changes may include feelings of anxiety and depression, irritability, difficulties concentrating; sleep disturbances, perceptual aberrations, and social withdrawal. If a person develops psychosis, these disturbances should be taken as an indication of the prodrome. Note that the prodrome always needs to be identified retrospectively as the symptoms are vague and non-specific.
Researchers are now attempting to better understand the changes that occur before the onset of psychosis and combine these with other risk factors (e.g., family history) in order to be able to predict who will develop psychosis. While these efforts to detect individuals who are at higher risk (aka “At Risk Mental State” or “Ultra-High Risk”) for psychosis have resulted in higher detection rates of individuals who will go on to have psychosis (approximately 20-30% in one year), the risk of false positives still remains very high. Even if the rate of detection was higher, what would be the effective treatments to provide remains unknown at this time (so treatment is limited to the presenting problems and close monitoring). Therefore as a clinician working with early psychosis, your focus will remain on the detection and treatment of individuals who have developed psychosis rather than on those individuals thought to be at-risk.
Standardized tools to detect those at Ultra-High Risk have been developed and include the CAARMS – the Comprehensive Assessment of the At-Risk Mental State. For more information about the CAARMS please click here. Here is a link to the CAARMS. Another tool, the PQ-B a self-report 21 question tool, may be used to support your assessment. You may wish to review the Powerpoint “UHR Self-Report Scales: Use and Misuse” presented by Dr. Tom Ehmann to the EPI Advanced Practice group in June 2018.
NOTE: there is more information on this topic contained with your additional readings. Don’t forget to look at the overview page for each module for what additional readings you need to do in your “course text” (the text is a pdf located at the start of this module on the course outline, schedule and text page).
It is during this phase that psychotic symptoms emerge including both positive and negative symptoms. This phase often will not subside until treatment is provided. Long durations of untreated psychosis (DUP) have been associated with poorer outcomes. For this reason, it is important to begin appropriate treatment as soon as possible. However, forcing treatment on someone who is not ready to accept it may create problems with adherence in the longer-term. Therefore, it may be justified to delay treatment in some cases until the client is engaged and accepts the need for treatment. This may not be possible when the client’s psychosis is severe and there are safety risks present. The focus of treatment in this phase is to ensure safety, control the psychosis, engage the client and their family, provide practical information and support, and communicate the expectation of recovery.
With treatment, the great majority of people recover well from their initial episode of psychosis. Positive symptoms usually respond quickly to treatment and so it is during this phase that negative symptoms often become predominant and persistent and require more active efforts. A wide range of interventions including medication, client and family psychoeducation, and treatment for comorbidity (including post-psychotic depression, anxiety, social functioning problems, drug and alcohol abuse, altered sense of self and loss of self-esteem) all require intensive treatment. Treatment needs to be maintained over at least one year in order to decrease the risk of relapse and achieve the best possible outcomes. Some researchers have hypothesized that there is a “critical period” of three to five years during which treatment must be maintained to achieve good long-term outcomes and there is now preliminary evidence to support this. Further research is necessary to better understand for exactly how long and with what intensity services need to be provided.
There is a handout and a worksheet on “What is Psychosis” on the care pathway page. Click on the care pathway icon and scroll down to see the handout and the worksheet and look these over. This handout was prepared for family and other support people, and clinicians are encouraged to share this information
with any members of the “care team”.
NOTE: You will be introduced to other handouts and tools contained on this care pathway page as you progress through the course modules.
Experiences of Psychosis
In the following three brief video clips, we’ll hear from the same three young people that we saw earlier in the video on stigma. In these video clips, they now describe their personal experience of psychosis. (* The sound is easier to hear with earphones/earbuds.)