When every word matters


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How to coach in extremely difficult situations. Think: a person with a personality disorder or somebody opposed to what you want, represent or are. There is much to be learned here that can also be used to achieve greater results more easily in every day coaching and counseling situations.

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When every word matters

  1. 1. WHEN EVERY WORD MATTERS Public Domain Compilation of articles about communication with persons who may be experiencing psychotic symptoms
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  3. 3. Title: When Every Word Matters Compiled by: Dean Amory Dean_Amory@hotmail.com Publisher: Edgard Adriaens, Belgium eddyadriaens@yahoo.com Cover Illustration by Tamara Adriaens ISBN: 978-1-291-64271-1 © Copyright 2013, Edgard Adriaens, Belgium, - All Rights Reserved. This book has been compiled based on the contents of trainings, information found in other books and using the internet. It contains a number of articlesindicated by TM or © or containing a reference to the original author. Whenever you cite such an article or use a communication model in a commercial situation, please credit the source or check with the IP -owner. If you are aware of a copyright ownership that I have not identified or credited, please contact me at: eddyadriaens@yahoo.com 3
  4. 4. WHAT DO I SAY? What do I say to you When you're almost as smart and powerful as God And I but a humble, stupid worm? How do we communicate When you know past and future, And know what others are thinking or saying anyway? What can I tell you When you can read my most intimate thoughts And all I say is so utterly boring? How can I make you understand That I am not your enemy, But your loving partner, reaching out to you? 4
  5. 5. WHEN EVERY WORD MATTERS How to communicate with someone who may be experiencing psychotic symptoms? 5
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  7. 7. Introduction The practical benefits of applying the techniques explained in "When Every Word Matters" go far beyond communicating with persons who are suffering from a psychosis. "When Every Word Matters" is about creating and expressing an attitude of empathy, which will prove useful every time when the way we see and experience things is different from the way our interlocutors do. Giving feedback, delivering bad news, dealing with criticism, conflict resolution, crisis communication, dealing with complaints, negotiating, intercultural communication, dealing with unreasonable requests, mediating, coaching, motivating and influencing people, ... are some of the situations in which this attitude may make all the difference. In fact "When Every Word Matters" teaches us a way of being in this world which will enhance our communication and hence our relationships with all the people we meet with. The present document is a compilaton of public domain publications by the very best experts in the field? Amongst which : - Professor Tony Jonn, - Rose Mc Cabe - Stefan Priebe - Xavier Amador - Geoff Brennan - Gary Winship - Christina Theodoridou - Marshall Rosenberg - Liv Monroe - Peter M. Sandman 7
  8. 8. Index 1. about the first episodes of psychosis What is psychosis? Typical and early signs of psychosis Is psychosis a diagnosis? What is the first episode of psychosis? Early onset of psychosis Young adults and new onset psychosis Later in life new onset psychosis Short term psychosis Trauma and it's relationship to psychosis The adverse childhood experience Causes of psychosis - Risk factors - Early warning signs - Substance use 2. Psychosis first aid guidelines How do I know if someone is experiencing psychosis? Common symptoms when psychosis is developing How should I approach someone who may be experiencing psychotic symptoms? How can I be supportive? How do I deal with delusions and hallucinations? How do I deal with communication difficulties? What if the person doesn’t want help? What should I do in a crisis situation? What if the person becomes aggressive? How to de-escalate the situation. About these guidelines 3. Communication and psychosis I: It’s good to talk, but how? Summary Declaration of interest Studying communication What should I say now? Interventions to improve communication Concluding remarks References Source 8
  9. 9. 4. Communication and psychosis II: Key Tips in communicating with a person who has psychosis Reflective Listening I'm not sick, I don't need help LEAP : Listen, Empathize, Agree, Partner 5. Nursing a patient with a severe psychotic illness About these guidelines Information about psychosis - What is psychosis? - Different types of psychotic disorder - What causes psychosis? - Prognosis: do people get better? - What are the treatments? What the generalist nurse or healthcare officer can do - Communication (engagement) - Observation (contribution to assessment) - Reassure, encourage and support the positives - Reduce stress and conflict - Look out for depression and suicidal thoughts - Medication - Coping with common side-effects of medication - Administering medication 6. Communication skills for nurses and others spending time with people who are very mentally ill Source Dedication Acknowledgements Preface Contents Inpatient nursing care and interaction. Nurse patient interaction Interpersonal and communication skills The nursing process, Isobel Menzies - Lyth, and primary nursing Outside the mainstream: Laing, Berke, Mosher and Barker Milieu therapy and modified therapeutic communities 9
  10. 10. Psychotherapy, solution focused therapy, person-centered therapy and pre-therapy Expressed Emotion, psychosocial interventions and cognitive behavioral therapy Potential lessons from dementia care Summary and aim of this work This study of interaction - The interviews - Analysis Moral foundations - Notice, do not ignore - Encouraging, supportive and gentle - Empathy and concern - Honesty - Don't intrude - Respect Preparation for interaction and its context - Observe first - Consult case notes - Consult friends and family - Choose the right nurse - Choose the best time of the day - Choose location - Set appointment in advance Being with the patient (Relationship building, maintaining and assessment) - Be with, sit with, be available, offer conversation - Introduce self, explain role - Light, casual, normal conversation - Focus on person - Here and now as topic - Joint activity - Humor - Apathy / withdrawal specific — Comfortable silence — One-sided conversation — Be creative - Hallucinations — Tolerating and making allowance for auditory hallucinations — Not too much too fast — Say their name — Be creative 10
  11. 11. - Thought disorder — Acceptance and listening — Name themes — Writing — Send away to think — Remind, prompt to topic — Keep it simple — Clarification - Agitation / over activity — Positive feedback — Set interaction limits — Reduce stimulation - Upset / Distress — Reveal self — Limit unnecessary interaction - Aggression / Irritability — Get them sat down — Get the patient to write — Maintain clarity — Choose topic in which they are expert — Avoid Nonverbal communication, vocabulary and timing - Slow pace, patience - Slow speech - Simple vocabulary - Short sentences - Repetition - Use silence - Quiet, not loud or shouting - Tone of voice - Writing and drawing - Less vs. more gesticulation and movement - Touch / close vs. no touch / distant - Short interactions - Frequent interactions - Persistence - Aggression / irritability — Choose language — Non-verbal non-threatening 11
  12. 12. Emotional regulation - No anxiety - No frustration or irritation - Optimism Getting things done - Suggest, not order - Give reasons - Be flexible - Break down task into small steps - Avoid, defer or postpone tasks - Maximize task choice and attractiveness - Prompting - Positive feedback, encouragement - Assist, do part of the task - Assertiveness - Delusions — Semi-collusion for greater good - Thought disorder — More gestures Talking about symptoms - Apathy / withdrawal — Hearing and respecting the experience — Mutually explore causes — Negotiating and agreeing a care plan — Structure, routine and purpose — Step by step - Hallucinations — Hearing the experience — Hearing the effect on the patient — Hearing to assess safety — Respecting the experience — Stress management — Negotiating and agreeing a care plan — Distract — Bolster coping — Casting doubt and challenging - Delusions — Acceptance and listening — Explore to understand the person — Explore delusions to assess risk — Monitor delusions for incorporation 12
  13. 13. — Don’t deny or dismiss — Gently question, cast doubt — Directly challenge the delusion — Don’t collude — Ignore the delusions — Find workarounds - Thought disorder — Acceptance and listening — Explore how it affects them - Upset / distress — Acceptance and listening — Give time alone — Stay calm and neutral — Don’t close them up — Persist to find out cause — Explore solutions — Take action to relieve cause — Distraction — Assess suicide risk - High arousal — Hear the patient, listen — Exercise, physical activity — Distract, calming activity — Request lowered arousal — Relaxation — Don’t argue or confront — Relationship leverage — Give choices, empower — Explain what the rules are and the reasoning behind them — Describe consequences — Forceful containment — Debrief later — Advance directives Lessons for practice - Summary of findings - Novel findings? - Barriers to nurse-patient communication - Psychotherapy and the acutely ill psychotic patient - Some implications Appendix – the interview schedule References 13
  14. 14. 7. Nonviolent Communication - Introduction - Steps - Violence provoking or life alienating communication - diagnosing - denying responsibility - demanding - NVC: purpose, background, what NVC is not - Components of an NVC expression - observation - feeling - need - request - 2 Ways of moving toward connection - honestly expressing own feelings and needs - empathically listening to other’s feelings and needs - The four ears: how we choose to hear difficult messages - Awareness, not content - Creating the internal space that nurtures learning and connecting - Creating the community space that nurtures learning and connecting - Taking responsibility for our feelings - Need versus request - Requests versus demands - Giving and receiving gratitude - Comparison of Jackal and Giraffe Language - Enriching “feeling” literacy - Feelings mixed with evaluations - Non Feeling Expressions - Feelings inventory - Needs inventory - Human Needs - Life and contribution - Autonomy and choice - Connection and Interdependence - Joy and Celebration - Template for writing public policy letters 14
  15. 15. 8. Empathy in Risk Communication Column Table of Contents The Essence of Empathy: Sort-of Acknowledgment Empathy and the Kinds of Risk Communication Ten Elements of Empathic Communication 1. Feeling and Attitude: Empathy Isn’t a Strategy 2. Candor and Humanity: Being Real 3. Deflection: You – I – They – Some People – It 4. Questioning: “How Does That Make You Feel?” 5. Listening and Echoing: “I Hear You” 6. Agreement: “I Think You’re Right about That” 7. Kinds of Empathic Statements: A Typology 8. Kinds of Interpersonal Statements: Another Typology 9. Proactive Acknowledgment: “Some Things You Should Know about Me” 10. Performatives: “I Hope the Situation Will Improve Soon” Some Examples from Earth Afterword by Jody Lanard 15
  16. 16. 1. About the First Episodes of Psychosis Early identification and evaluation of the onset of psychosis is an important health concern. Early detection and intervention improve outcomes. Psychosis may be transient, intermittent, short-term or part of a longer-term psychiatric condition. It is important to understand the range of possibilities, both in terms of possible diagnosis associated with psychosis and the prospects for recovery. This NAMI website is a resource guide for your increased understanding of assessing, treating and living with new onset psychosis, including strategies to help the return to school, work and daily life. What Is Psychosis? Psychosis (psyche = mind, osis = illness) is defined as the experience of loss of contact with reality, and is not part of the person’s cultural group belief system or experience. Psychosis typically involves one of two major experiences: A. Hallucinations can take the form of auditory experiences (such as hearing voices); less commonly, visual experiences; or, more rarely, smelling things that others cannot perceive. The experience of hearing voices has been matched to increased activity in the auditory cortex of the brain through neuro-imaging studies. While the experience of hearing voices is very real to the person experiencing it, it may be very confusing for a loved one to witness. The voices can often be critical (i.e. “you are fat and stupid”) or even threatening. Voices also may be neutral (i.e. “the radio is on”) and may involve people that are known or unknown to the person hearing the voices. The cultural context is also important. For example, in some Native American cultures, hearing the voice of a deceased relative is part of a healthy grieving process. B. Delusions are fixed false beliefs. Delusions could take the shape of paranoia (“I am being chased by the FBI”) or of mistaken identity (a young woman may say to her mother, “You are an imposter—not my mother”). What makes these beliefs delusional is that these beliefs do not change or modify when the person is presented with new ideas or facts. Thus, the beliefs remain fixed even when presented with contradicting information (the young woman continues to believe her mother is an imposter, even when presented with her mother’s birth certificate and pictures of her mother holding her as a baby). Delusions often are associated with other cognitive issues such as problems with concentration, confused thinking and a sense that one’s thoughts are blocked. These experiences can be short lived (e.g. after surgery or after sleep deprivation) or periodic (as when associated with a psychiatric condition or persistent like bipolar disorder or major depression). Some typical and early warning signs of psychosis include - Worrisome drop in grades or job performance; - New trouble thinking clearly or concentrating; - Suspiciousness/uneasiness with others; - Decline in self-care or personal hygiene; - Spending a lot more time alone than usual; - Increased sensitivity to sights or sounds; - Mistaking noises for voices; - Unusual or overly intense new ideas; and - Strange new feelings or having no feelings at all. These signs are particularly important when they are new or have worsened in the last year and if the individual has a close relative that has experienced psychosis. Learn more about psychosis risks by visiting the Centre for Early Detection, Assessment and Response to Risk. Behaviour and thought processes are often impacted by delusions or hallucinatory experiences. People experiencing new onset psychosis may report trouble organizing their thoughts, feeling as if they are dreaming while awake or wondering if their minds are playing tricks on them. Hallucinations can distract a person’s attention and executive functioning (the ability to prioritize tasks and make decisions) may also be impacted. Agitation or withdrawal often accompanies these experiences, which can be experienced in a variety of ways but are often anxiety-provoking or terrifying. At times, people experience these altered perceptions of reality 16
  17. 17. with indifference or resignation, or they simply “fall into” the psychosis and lose interest in external reality. Shame and humiliation of being different often complicate the experience and make getting help more difficult. Is Psychosis a Diagnosis? No. Psychosis is like fever—a very important symptom. When a person has a fever, it could be from a virus in the respiratory system or a bacterial infection of the urinary tract. These are two very different causes of fever and each cause requires different treatments. The reduction of fever is one way to know the condition has been addressed properly. While we understand less about the three-pound “universe” that is the human brain than we do about infectious disease, the same broad principles apply. The goal of a comprehensive evaluation is to determine if there is an underlying, reversible medical cause of the condition and—if there is none—to determine the psychiatric diagnosis. After the symptoms, the associated history and relevant workup have been put into a diagnostic framework, the next step is to develop a collaborative and comprehensive plan with the person to address the symptoms in the context of this diagnosis. A comprehensive plan attends to the person interests and strengths and looks to school, work and relationships as the person’s goals dictate. What Is a First Episode of Psychosis? A first episode of psychosis is the first time a person experiences a psychotic episode. The first such episode often is very frightening, confusing and distressing, particularly because it is an unfamiliar experience. Unfortunately, there are also many negative stereotypes and misconceptions associated with psychosis that can further add to this distress. You are not alone if you are having this experience (estimates place the risk of psychosis at about three in 100. Help is out there both for the individual and the family, and this help comes in many forms. By exploring this web resource, you are already looking at the issue and seeing how your resilience and coping strategies can be employed to best deal with psychosis. Psychosis is treatable. Many people recover from a first episode of psychosis and never experience another psychotic episode. Finding support and resources is essential to managing the experience, whether it is short- lived or lasts a good deal longer. Early Onset of Psychosis When young children report hallucinations in the context of poor school performance social withdrawal or exhibit other odd behaviours then a diagnostic evaluation is required. The caregiver will assess the child, perform laboratory tests and may request developmental or psychological testing to help make a diagnosis. This could include neurologic problems, bipolar disorder, or childhood schizophrenia, which is a rare, but real, presentation. Schizophrenia typically occurs in a window of the mid- to late-teens to the early 30s (this age range is a few year later for females, often the presentation is early- to mid-20s as opposed to the teen years). Symptoms of schizophrenia in school-age children are rare, and this is unexpected and traumatic for the family while they are seeking help and assessment. As this is an uncommon condition, local caregivers may struggle to put together a comprehensive plan. A teaching hospital with a department of child and adolescent psychiatry would be a good place to begin. The National Institute of Mental Health (NIMH) has a research and clinical service centre in Bethesda, Md., to better understand childhood schizophrenia, while providing state-of-the-art care to children in care. This program offers diagnostic and treatment options to children who have had the onset of psychosis prior to the age of 13. Children aged 6-18 are eligible to enrol. Young Adults and New Onset Psychosis Young adults are the most common age group to be at risk for their first episode of psychosis. The experience of psychosis impacts young adults at a developmentally vulnerable time. This is a stage of life that usually 17
  18. 18. challenges young people to develop more independence, establish an identity, create intimate relationships and move away from the nest of the family home. Typically, young adulthood focuses on the external world and friends, while parents often serve a valuable—but less central—day-to-day role. Yet, if a young adult is having problems organizing his or her thinking or is distracted by hearing voices, functioning at a high level of independence will be problematic in many cases. Psychosis often impacts individuals in college years, and the culture in a college setting is not typically geared towards seeking help. Having a psychotic process separates the individual from peers and can impair social connections. The loss, or threat of loss, of social contacts adds stress to the person experiencing these symptoms. It is often scary and activates feeling of shame when one is having these experiences that are so difficult to discuss. This leads to isolation and may reinforce the power of the inner experience as withdrawal from external contacts occurs. With a young adult away at college, parents may think they are supposed to keep some distance in order to support independence in a college-age child, and may not have adequate information in order to appreciate the onset of psychosis. Psychosis requires intervention as soon as the person or the family realizes the seriousness of the situation. University counselling centres are increasingly aware of the need to get support and assessment to students experiencing this challenge. Young adults and families can be encouraged by the development of resources intended to help meet their unique needs. NAMI offers some resources, including NAMI on Campus, NAMI groups on some college campuses, and StrengthofUs.org, a social networking site specifically for young adults living with mental health conditions. These both offer young adults access to information and peer support from other young adults with a shared experience. Later-in-life New Onset Psychosis When the first presentation of psychosis is over age 40, this presentation raises the need for intensive medical evaluation. The probability that there is a detectable medical cause of psychosis increases with age, with increased use of medications, medical illness and surgical procedures. Delirium, which can present with psychosis (coupled with change in level of consciousness), is common in individuals who have other risks (i.e., post-surgery, on multiple medications) or neurologic vulnerabilities ( e.g. dementia, Parkinson’s disease, cognitive decline). Multiple neurologic and medical conditions can present with psychosis later in life, and many of these are reversible. Short-term Psychosis A brief psychotic disorder that lasts between one day and one month and is typically associated with severe stress or the post-partum phase is considered short-term. The return to a non-psychotic state is common in the condition. Trauma and Its Relationship to Psychosis Traumatic events impact body, spirit and brain. Research has demonstrated biological as well as psychological effects of traumatic events. The type of trauma as well as the developmental stage of the person and their brain also makes a difference in terms of how a traumatic event may manifest in the person’s experience. The field of mental health has moved towards a more sophisticated understanding of how traumatic events can influence a person’s experience, and a movement towards trauma informed care has been a focus of SAMSHA for years. This is an important departure as NAMI was founded in part by mothers who were falsely blamed for the neglect and reason their children had developed schizophrenia. The “schizophrenogenic mother” theory posited that cold and neglectful parenting caused schizophrenia. This “one size fits all” conceptualization blamed mothers and did not rely on empiric evidence. The relationship of traumatic event—of all kinds—and the development of psychiatric illnesses is emerging and reveals a significantly more complex story. We now know that the brain is plastic—it responds to its environment and that the way that environmental experiences manifests in a given person with their genetic makeup remains an important area of inquiry. The Adverse Childhood Experience (ACE) study demonstrated a relationship between self reported adverse childhood experiences and multiple adult health problems, spanning both physical and mental health concerns. 18
  19. 19. The researches noted higher rates of many health problems that correlate with the number of adverse childhood experiences in a large HMO population, including heart disease, lung disease, hypertension and mental health concerns including suicide. ACE were not limited to a few of the subjects followed---more than one fourth of individuals were exposed to substance abuse in the home and over two thirds of the sample reported at least one adverse experience. One individual in 10 had more than five adverse experiences and this population had more health concerns of all kinds later in life. Traumas impacted both health outcomes and also adult life choices— including substance abuse, domestic violence and sexually transmitted diseases. This is a powerful and provocative study and promotes more research in this area. There is no simple if A then B in this compelling area of inquiry. Neuro-developmental conditions like psychosis have many possible influences than span genetic, stress and environmental aspects. It does appear that adverse experiences are more common in people with psychotic disorders, yet a trauma history is not present in many individuals with psychotic disorders. In a review of two large data sets researchers found a relationship between multiple adverse experiencing and the later development of psychosis. “Experiencing two or more traumas significantly predicted psychosis and there appeared to be a dose response relationship.” For more on this research review, visit “Cumulative Traumas and Psychosis: An Analysis of the National Co morbidity Survey and the British Psychiatric Morbidity Survey” Shevlin et al., Schizophrenia Bulletin 2008 34 (1). The experience of psychosis can also be experienced as traumatic. The experiences can have many manifestations but terror and fear are key elements of traumatic experiences and these are common responses to the onset of psychosis. As the field goes forward, integrating awareness of the interaction of experience on brain and body development will improve approaches to individuals experiencing psychosis. Causes of Psychosis Risk Factors When it comes to psychosis, the interplay between genetics and the environment is not yet fully understood. Researchers are continuing to explore the underlying genetic risks associated with psychosis. Research suggests that a wide range of environmental factors (such as birth injury, severe stress, sleep deprivation, maternal infection in the second trimester, head trauma and substance use) may trigger an underlying genetic risk and lead to an episode of psychosis. There is no one gene or stress that causes psychosis. Like asthma and diabetes, vulnerability to psychosis likely is the interplay of genetic risk and environmental factors. Much more needs to be understood about this interplay. The mapping of the human genome in 2003 begins what promises to be a long and challenging process to better understand the relationship between genetics, the environment and mental illness. Of the many conditions that have psychosis as a symptom, schizophrenia is the best-studied in terms of the interplay between genes and environment. For example, using careful population records in Europe, researchers have shown the relative correlations of how the condition travels in families. Having first-degree relatives (parents, siblings) with schizophrenia increases your risk of having schizophrenia. For example, if you have an identical twin that was diagnosed with schizophrenia, your overall risk would be in the range of 50 percent. If you have a parent with the condition, you would have about a 10 percent chance of developing the disorder. These are probabilities only, as there have been no developments in determining any one person’s risk with scientific precision. There exists no single gene test for illnesses associated with psychosis, such as schizophrenia. There is evidence that vulnerability to psychosis may be increased in individuals who have a gene variant and who also smoke marijuana. It is best to avoid this substance, especially if you have any risk factors for development of psychosis. 19
  20. 20. Early Warning Signs For some psychiatric conditions that later develop psychosis symptoms, there is often a prodromal (early) phase. In this phase, the following may be noted: - Isolation and withdrawal - Loss of interest in peers - Declining self-care/hygiene - Change in thought pattern including disorganized thinking - Preoccupations/paranoid thinking - Lack of motivation Getting a comprehensive assessment of these symptoms is important to understand the possible explanations for the change in the person’s behaviour. Substance Use For many individuals, the use of substances increases the risk of developing psychosis. In general, the younger the person and their developing brain are, the greater the risk posed by the use of substances. Substances known to have links to possible psychosis include: - Marijuana/hash/THC - Methamphetamine (including crystal meth) - PCP/Psilocybin/Peyote /Mescaline - LSD - Ketamine Prescribed medicines may also produce psychosis: - Steroids - Amphetamines/stimulants 20
  21. 21. 2. Psychosis First Aid Guidelines • How do I know if someone is experiencing psychosis? • Common symptoms when psychosis is developing • How should I approach someone who may be experiencing psychotic symptoms? • How can I be supportive? • How do I deal with delusions and hallucinations? • How do I deal with communication difficulties? • What if the person doesn’t want help? • What should I do in a crisis situation? • What if the person becomes aggressive? • How to de-escalate the situation. Source: The MHFA Training & Research Program Orygen Youth Health Research Centre Department of Psychiatry The University of Melbourne AUSTRALIA www.mhfa.com.au How do I know if someone is experiencing psychosis? It is important to learn about the early warning signs of psychosis (see box) so that you can recognize when someone may be developing psychosis. Although these signs may not be very dramatic on their own, when you consider them together, they may suggest that something is not quite right. It is important not to ignore or dismiss such warning signs, even if they appear gradually and are unclear. Do not assume that the person is just going through a phase or misusing alcohol or other drugs, or that the symptoms will go away on their own. Common symptoms when psychosis is developing: Changes in emotion and motivation: Depression; anxiety; irritability; suspiciousness; blunted, flat or inappropriate emotion; Change in appetite; reduced energy and motivation Changes in thinking and perception: Difficulties with concentration or attention; sense of alteration of self, others or outside world (e.g. feeling that self or others have changed or are acting differently in some way); odd ideas; unusual perceptual experiences (e.g. a reduction or greater intensity of smell, sound or colour) Changes in behaviour: Sleep disturbance; social isolation or withdrawal; reduced ability to carry out work or social roles (Adapted from: Edwards, J & McGorry, PD (2002). Implementing Early Intervention in Psychosis.)Martin Dunitz, London.) You should be aware that the signs and/or symptoms of psychosis may vary from person to person and can change over time. You should also consider the spiritual and cultural context of the person’s behaviours, as what is considered to be a symptom of psychosis in one culture may be considered normal in another. 21
  22. 22. How should I approach someone who may be experiencing psychotic symptoms? People developing a psychotic disorder will often not reach out for help. Someone who is experiencing profound and frightening changes such as psychotic symptoms will often try to keep them a secret. If you are concerned about someone, approach the person in a caring and non-judgemental manner to discuss your concerns. The person you are trying to help might not trust you or might be afraid of being perceived as “different”, and therefore may not be open with you. If possible, you should approach the person privately about their experiences in a place that is free of distractions. - Try to tailor your approach and interaction to the way the person is behaving (e.g. if the person is suspicious and is avoiding eye contact, be sensitive to this and give them the space they need). - Do not touch the person without their permission. - You should state the specific behaviours you are concerned about and should not speculate about the person’s diagnosis. It is important to allow the person to talk about their experiences and beliefs if they want to. As far as possible, let the person set the pace and style of the interaction. - You should recognise that they may be frightened by their thoughts and feelings. Ask the person about what will help them to feel safe and in control. - Reassure them that you are there to help and support them, and that you want to keep them safe. If possible, offer the person choices of how you can help them so that they are in control. - Convey a message of hope by assuring them that help is available and things can get better. - If the person is unwilling to talk with you, do not try to force them to talk about their experiences. - Rather, let them know that you will be available if they would like to talk in the future. How can I be supportive? Treat the person with respect. You should try to empathise with how the person feels about their beliefs and experiences, without stating any judgments about the content of those beliefs and experiences. The person may be behaving and talking differently due to psychotic symptoms. They may also find it difficult to tell what is real from what is not real. You should avoid confronting the person and should not criticise or blame them. Understand the symptoms for what they are and try not to take them personally. Do not use sarcasm and try to avoid using patronising statements. It is important that you are honest when interacting with the person. Do not make any promises that you cannot keep. How do I deal with delusions (false beliefs) and hallucinations (perceiving things that are not real)? It is important to recognise that the delusions and hallucinations are very real to the person. You should not dismiss, minimise or argue with the person about their delusions or hallucinations. Similarly, do not act alarmed, horrified or embarrassed by the person’s delusions or hallucinations. You should not laugh at the person’s symptoms of psychosis. If the person exhibits paranoid behaviour, do not encourage or inflame the person’s paranoia. How do I deal with communication difficulties? People experiencing symptoms of psychosis are often unable to think clearly. You should respond to disorganised speech by communicating in an uncomplicated and succinct manner, and should repeat things if necessary. After you say something, you should be patient and allow plenty of time for the person to process the information and respond. If the person is showing a limited range of feelings, you should be aware that it does not mean that the person is not feeling anything. Likewise, you should not assume the person cannot understand what you are saying, even if their response is limited. 22
  23. 23. Should I encourage the person to seek professional help? You should ask the person if they have felt this way before and if so, what they have done in the past that has been helpful. Try to find out what type of assistance they believe will help them. Also, try to determine whether the person has a supportive social network and if they do, encourage them to utilize these supports. If the person decides to seek professional help, you should make sure that they are supported both emotionally and practically in accessing services. If the person does seek help, and either they or you lack confidence in the medical advice they have received, they should seek a second opinion from another medical or mental health professional. What if the person doesn’t want help? The person may refuse to seek help even if they realise they are unwell. Their confusion and fear about what is happening to them may lead them to deny that anything is wrong. In this case you should encourage them to talk to someone they trust. It is also possible that a person may refuse to seek help because they lack insight that they are unwell. They might actively resist your attempts to encourage them to seek help. In either case, your course of action should depend on the type and severity of the person’s symptoms. It is important to recognise that unless a person with psychosis meets the criteria for involuntary committal procedures, they cannot be forced into treatment. If they are not at risk of harming themselves or others, you should remain patient, as people experiencing psychosis often need time to develop insight regarding their illness. Never threaten the person with the mental health act or hospitalisation. Instead remain friendly and open to the possibility that they may want your help in the future. What should I do in a crisis situation when the person has become acutely unwell? In a crisis situation, you should try to remain as calm as possible. Evaluate the situation by assessing the risks involved (e.g. whether there is any risk that the person will harm themselves or others). It is important to assess whether the person is at risk of suicide [please see the MHFA Guidelines for Suicidal Behaviour. These can be downloaded from www.mhfa.com.au.]. If the person has an advance directive or relapse prevention plan, you should follow those instructions. Try to find out if the person has anyone s/he trusts (e.g. close friends, family) and try to enlist their help. You should also assess whether it is safe for the person to be alone and, if not, should ensure that someone stays with them. It is important to communicate to the person in a clear and concise manner and use short, simple sentences. Speak quietly in a non-threatening tone of voice at a moderate pace. If the person asks you questions, answer them calmly. You should comply with requests unless they are unsafe or unreasonable. This gives the person the opportunity to feel somewhat in control. You should be aware that the person might act upon a delusion or hallucination. Remember that your primary task is to de-escalate the situation and therefore you should not do anything to further agitate the person. Try to maintain safety and protect the person, yourself and others around you from harm. Make sure that you have access to an exit. You must remain aware that you may not be able to de-escalate the situation and if this is the case, you should be prepared to call for assistance. If the person is at risk of harming themselves or others, you should make sure they are evaluated by a medical or mental health professional immediately. If crisis staff arrives, you should convey specific, concise observations about the severity of the person’s behaviour and symptoms to the crisis staff. You should explain to the person you are helping who any unfamiliar people are, that they are there to help and how they are going to help. However, if your concerns about the person are dismissed by the services you contact, you should persevere in trying to seek support for them 23
  24. 24. What if the person becomes aggressive? People with psychosis are not usually aggressive and are at a much higher risk of harming themselves than others. However, certain symptoms of psychosis (e.g. delusions or hallucinations) can cause people to become aggressive. You should know how to de-escalate the situation if the person you are trying to help becomes aggressive. Take any threats or warnings seriously, particularly if the person believes they are being persecuted. If you are frightened, seek outside help immediately. You should never put yourself at risk. Similarly, if the person’s aggression escalates out of control at any time, you should remove yourself from the situation and call the crisis team. When contacting the appropriate mental health service, you should not assume the person is experiencing a psychotic episode but should rather outline any symptoms and immediate concerns. If the situation becomes unsafe, it may be necessary to involve the police. To assist the police in their response, you should tell them that you suspect the person is experiencing a psychotic episode and that you need their help to obtain medical treatment and to control the person’s aggressive behaviour. You should tell the police whether or not the person is armed. How to de-escalate the situation: • Do not respond in a hostile, disciplinary or challenging manner to the person; • Do not threaten them as this may increase fear or prompt aggressive behaviour; • Avoid raising your voice or talking too fast; • Stay calm and avoid nervous behaviour (e.g. shuffling your feet, fidgeting, making abrupt movements); • Do not to restrict the person’s movement (e.g. if he or she wants to pace up and down the room); • Remain aware that the person’s symptoms or fear causing their aggression might be exacerbated if you take certain steps (e.g. involve the police). About these guidelines Purpose of these guidelines These guidelines are designed to help members of the public to provide first aid to someone who may be experiencing psychosis. The role of the first aider is to assist the person until appropriate professional help is received or the crisis resolves. Development of these Guidelines The following guidelines are based on the expert opinions of a panel of mental health consumers, carers and clinicians from Australia, New Zealand, the UK, Ireland, the USA and Canada about how to help someone who may be experiencing a psychotic episode. Details of the methodology can be found in: Langlands RL, Jorm AF, Kelly CM, Kitchener BA. First aid recommendations for psychosis: Using the Delphi method to gain consensus between mental health consumers, carers and clinicians. Schizophrenia Bulletin 2008; 34:435-443 How to use these Guidelines These guidelines are a general set of recommendations about how you can help someone who may be experiencing psychosis. Each individual is unique and it is important to tailor your support to that person’s needs. These recommendations therefore will not be appropriate for every person who may have psychosis. Also, the guidelines are designed to be suitable for providing first aid in developed English-speaking countries. They may not be suitable for other cultural groups or for countries with different health systems. 24
  25. 25. Although these guidelines are copyright, they can be freely reproduced for non-profit purposes provided the source is acknowledged. Please cite these guidelines as follows: Mental Health First Aid Training and Research Program. Psychosis: first aid guidelines. Melbourne: Orygen Youth Health Research Centre, University of Melbourne; 2008. Enquiries should be sent to: Professor Tony Jorm, Orygen Youth Health Research Centre - Locked Bag 10, Parkville VIC 3052 Australia - email: ajorm@unimelb.edu.au 25
  26. 26. 3. Communication and psychosis / I: It’s good to talk, but how? Rose McCabe and Stefan Priebe Summary Communication between clinicians and patients is at the heart of psychiatric practice and particularly challenging with psychotic patients. It may influence patient outcome indirectly or be therapeutic in its own right. Appropriate conceptual models, evidence on effective interventions and specific training are required to optimise communication in everyday routine practice. Declaration of interest None. This work was, in part, supported by the Medical Research Council (grant GO401323) Rose McCabe is a senior lecturer at Barts and the London School of Medicine and Dentistry. Her research focuses on linking treatment processes, particularly therapeutic relationships and interactions, with outcome. Stefan Priebe is Head of the Social and Community Psychiatry Research Unit at Barts and the London School of Medicine and Dentistry. His research addresses concepts, processes and outcomes in mental healthcare. Clinicians communicate with patients. In psychiatry, this is arguably the main part of what they do in their daily practice. Yet, does it matter how they communicate? Both the General Medical Council and the Royal College of Psychiatrists highlight the role of good communication in achieving therapeutic relationships. Effective communication, and the related construct, the therapeutic relationship, may have an impact on patients’ engaging in treatment in the first place, following treatment suggestions, satisfaction, symptom severity, referral to other services and willingness to file lawsuits.1 It may even be therapeutic in its own right. The therapeutic relationship is negotiated and reflected in patient–clinician communication and appears to predict outcome in different samples and settings across mental healthcare. If communication may be influential in patient outcome, there is a challenge to understanding how these processes work in psychiatry. This may feel especially difficult when communicating with patients with psychosis whose contributions may appear to be inappropriate both in their content and placement in the interaction. The first step is good research. Studying communication Communication is difficult and cumbersome to study. A typical approach involves recording the interaction. Videotaping one session can be the minimum. This is easier in a clinic setting than in various community settings. Audio taping alone is problematic given how much information is contained in non-verbal aspects such as posture and gaze. A long gap in a consultation has a different meaning if the clinician is writing notes in that gap or has eye contact with the patient and is not responding to a patient’s question. Most methods involve transcription, ranging from basic (content only) to highly detailed transcripts (content plus intonation, pauses, overlap, gaze, etc.) followed by time-consuming and labour-intensive analysis; linking one-off consultations with long-term clinical outcome is inappropriate given the complexity of treatment processes. It is likely that a series of consultations need to be studied to establish factors that have an impact on clinical outcomes. Simpler methods may need to be developed to capture intermediary outcomes of communication so that they can be assessed in pragmatic studies with sufficiently large samples. Setting aside the methodological problems, a key conceptual issue is that, even in the social sciences, there is no definitive model of ‘good communication’. A focus of positive communication throughout healthcare is patient- centredness. One component is shared decision-making. People with schizophrenia have a slightly stronger 26
  27. 27. preference for shared decision-making than primary care patients. Among those with schizophrenia, younger people and those with more negative views of medication want more participation. Some research has been carried out on shared decision making in relation to antipsychotics. Seale et al audio taped psychiatric consultations and interviewed psychiatrists about their negotiating styles. In interviews, psychiatrists were committed to achieving concordant relationships with patients although they felt there were obstacles particular to psychiatry, mainly if the patient was deemed too ill to make decisions and the patient’s honesty about their medication use. Analysis of the consultations themselves showed how side-effects may remain unaddressed (by offering no response, changing the subject or disagreeing with the patient’s interpretation of the experience) or be acknowledged through sympathetic and supportive listening. What should I say now? In a detailed study of how psychiatrists and patients communicate about psychotic symptoms in out-patient consultations, patients repeatedly attempted to raise the content and emotional consequences of their hallucinations and delusions. Psychiatrists frequently avoided engaging with these concerns, leaving both patients and doctors very uncomfortable. One patient asked ‘Why don’t people believe me when I say I’m God?’ to which the doctor, after initial avoidance, replied ‘What should I say now?’ In ‘normal’ interaction, avoiding sensitive issues that might expose conflicts of opinion is typically a good strategy. This might also apply here where the clinician avoided a confrontation about beliefs on which agreement was unlikely to be reached. Yet, in interactions with patients with psychosis, initial avoidance by clinicians seems to lead to explicit confrontation and disagreement about the very reason the patient is there. With patients who are not well-engaged, this might lead to further disengagement during treatment. Despite the fact that communication about psychotic symptoms is a frequent challenge and regarded as fascinating by many clinicians, there is little systematic, theoretically informed training on how clinicians should respond. Many state that the recommended approach is not to ‘encourage’ the patient to talk about their symptoms because it amounts to inadvertent collusion about the illness. Because the patient is uncertain about reality, the clinician might feel that they should be firmly rooted in reality and respond to the God question with ‘because it is not true’. There are alternative ways to respond. For instance, a client-centered approach might respond to the emotional content of the patient’s statement with ‘You feel misunderstood and puzzled by it’. A cognitive approach might ask for evidence about the belief. One could take the patient’s perspective with a response like ‘Why should people believe you? They did not believe Jesus either’. Further responses are possible using other therapeutic approaches. Yet, most psychiatrists are not specifically trained in this nor is there much theoretical debate on such a core aspect of everyday communication with patients with psychosis. Communication is not only technical. It also involves emotions, particularly when communicating about profoundly disturbing experiences. Jaspers6 discussed the challenge of communicating with another person whose experience is so remote from the ‘normal’ realm to render it ‘non-understandable’. However, in order to establish ‘non-understandability’ the clinician first has to try to understand the patient’s experiences, which requires communication about symptoms, emotions and their meaning for the patient. Clinicians themselves may need to be supported in their response to patients’ disturbing experiences. Communication involves at least two people and so far we have considered only the role of the clinician. However, doctors and patients construct the interaction together so how are patients with psychosis communicating? It is clear that patients are representing concerns that have been discussed many times before. They raise the same issues time and time again, often expecting that the clinician will disagree. It may be important to understand if (and how) patients are breaching ‘normal’ communicative practices both for understanding the disorder and identifying appropriate ways to respond. 27
  28. 28. Interventions to improve communication In medicine generally, alerting clinicians to the patient’s concerns/ emotions and changing clinicians’ beliefs about communication have led to communication change. However, interventions to improve communication, and in turn outcome, in psychosis are rare. A simple communication checklist completed by patients before seeing their clinician improved communication and resulted in treatment changes. An intervention structuring patient–key worker communication elicited the patient’s satisfaction with a range of life domains, their needs for care and wishes for different help. Patients receiving the intervention had a better quality of life, fewer needs for care and higher treatment satisfaction after 1 year. It remains unclear, however, whether the structuring, focusing on the patient’s view, the forward-looking emphasis on treatment changes or a combination of these factors was crucial to the intervention’s success. Finally, an intervention to increase shared decision-making with in-patients with schizophrenia did not take up more of the doctor’s time, increased the uptake of psycho education and increased involvement in medical decisions. As in medicine generally, different approaches have been tried on a more or less ad hoc basis without explicit theoretical frameworks specifying key communication processes and the pathway through which they may influence health outcomes. The current state of the art cannot begin to address the question ‘Does one size fit all?’ (Which is unlikely). Different clinicians may have different communication styles and strengths which might have to be enhanced rather than eradicated. Also, a particular clinician’s communicative style may suit one patient and not another. Future research might address matching the right patient with the right clinician to achieve the best possible communication. Concluding remarks If psychiatrists want to make better use of everyday communication as a core component of their trade, the ambition must be to develop better competence and skills to maximise its therapeutic effect, preferably based on sound conceptual models and evidence derived from them. Some of the required skills may be generic, whereas others are likely to be specific to communicating with patients with psychosis. Jaspers stated that ‘the ultimate thing in the doctor–patient relationship is existential communication, which goes far beyond any therapy, that is, beyond anything that can be planned or methodically staged’ (p. 798). Thus, not all aspects of how psychiatrists and patients communicate might be identifiable in research and teachable in the classroom or individual supervision. Yet, the challenge is to advance the state of the art to reveal as much as possible so that patients benefit from communication that is, either indirectly or directly, therapeutic. Clinicians may also benefit from enriching their therapeutic options and professional expertise. Rose McCabe, PhD, and Stefan Priebe, FRCPsych, Unit for Social and Community Psychiatry, Barts, and the London School of Medicine and Dentistry, Queen Mary, University of London, UK Correspondence: Dr Rose McCabe, Unit for Social and Community Psychiatry, Newham Centre for Mental Health, London E13 8SP, UK. Email: r.mccabe@qmul.ac.uk First received 11 Dec 2007, final revision 11 Dec 2007, accepted 14 Feb 2008 28
  29. 29. References 1 Cruz M, Pincus HA. Research on the influence that communication in psychiatric encounters has on treatment. Psychiatr Serv 2002; 53: 1253–65. 2 Castonguay LG, Beutler LE. Principles of Therapeutic Change That Work. Oxford University Press, 2006. 3 Hamann J, Cohen R, Leucht S, Busch R, Kissling W. Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatry 2005; 162: 2382–4. 4 Seale C, Chaplin R, Lelliott P, Quirk A. Sharing decisions in consultations involving anti-psychotic medication. A qualitative study of psychiatrists’ experiences. Soc Sci Med 2006; 62: 2861–73. 5 McCabe R, Heath C, Burns T, Priebe S. Engagement of patients with psychosis in the consultation: conversation analysis study. BMJ 2002; 325: 1148–51. 6 Jaspers K. General Psychopathology (trans. J Hoenig, M Hamilton). Manchester University Press, 1959. 7 Hinshelwood RD. Suffering Insanity: Psychoanalytic Essays on Psychosis. Brunner Routledge, 2004. 8 McCabe R. Specifying interactional markers of schizophrenia in clinical consultations. In Against Theory of Mind (eds I. Leudar, A. Costall). Palgrave Macmillan, in press. 9 Van Os J, Altamura AC, Bobes J, Gerlach J, Hellewell JSE, Kasper S, Naber D, Robert P. Evaluation of the Two-Way Communication Checklist as a clinical intervention. Br J Psychiatry 2004; 184: 79–83. 10 Priebe S, McCabe R, Bullenkamp J, Hansson L, Lauber C, Martinez-Leal R, Ro¨ ssler W, Salize H, Svensson B, Torres-Gonzales F, Van Den Brink R, Wiersma D, Wright DJ. Structured patient–clinician communication and 1-year outcome in community mental healthcare. Cluster randomized controlled trial. Br J Psychiatry 2007; 191: 420–6. 11 Hamann J, Langer B, Winkler V, Busch R, Cohen R, Leucht S, Kissling W. Shared decision making for in- patients with schizophrenia. Acta Psychiatr Scand 2006; 114: 265–73. Source: BJPsych: The British Journal of Psychiatry (2008) - 192, 404–405. doi: 10.1192/bjp.bp.107.048678 29
  30. 30. 4. Communication and psychosis / II Key Tips in communicating with a person who has psychosis Since psychosis directly affects a person’s ability to perceive, interpret and communicate information, family members have to learn new communication skills. A few key tips in communicating with a person who has psychosis: Psychosis generally makes people much more sensitive to emotional tones and stimulation. It will help to keep the environment as low-key as possible, and to speak to the person with a kind, matter-of-fact voice.  Use short sentences. Don’t try to go into long explanations.  Be concrete and specific. Avoid abstractions and generalities.  Be careful about word choice to avoid communicating negative judgment.  Provide consistent, sincere praise and positive feedback.  After you speak, give the person plenty of time to digest the information and respond. If there is something particularly important you are trying to communicate, use simple words and repeat the same language rather than using different language. Don’t argue with people about delusional beliefs. Remember that their perception of reality is just that to them: reality. Directly confronting delusions usually causes people to become defensive and less prepared to consider alternatives. Don’t “go along with” or agree to delusions, either. Learn reflective listening techniques. Agree to disagree. Approach delusions in a spirit of shared inquiry. Don’t push if the person starts to get upset. Reflective Listening No matter how hard it is to understand what a person is saying, there is ALWAYS a grain of truth. When a person is experiencing psychosis, their communication gets mixed up, but through reflective listening you can find a common ground. The steps in reflective listening with a person who has a psychosis:  Listen to what they’re saying. Look for elements of reality. Ask yourself what they are feeling, or how you would feel in the situation.  Ask clarifying questions only. Comment about the feeling, without stating any judgments about the content.  Give the person time to respond.  Comment about feeling again, and maybe gently begin to reframe/create a shared context.  Give the person time to respond.  Begin to identify “common ground”- reality you can agree on, or a way of addressing the feelings the person is having. Here are a couple of examples: Example 1 - Person with psychosis: “God told me he doesn’t want me to take my medicine.” - Family member: “How did God tell you that?” - Person with psychosis: “God created the world in seven days, and on the seventh day He rested, and I can’t rest on this medicine”. 30
  31. 31. - Family member: “Wow, resting is so important. You must be totally exhausted if you can’t rest.” - Person with psychosis: “Yeah, they put me on this really high dose.” - Family member: “How about if we talk to the doctor about doing something to help you rest.” - Person with psychosis: “Can you talk to him for me?” Example 2 - Person with psychosis: “Everybody in town is after me.” - Family member: “That sounds terrifying to think everybody’s after you.” - Person with psychosis: “It IS terrifying.” - Family member: “No wonder you’re so upset. What led you to feel that everybody’s after you?” - Person with psychosis: “There are all these cars outside.” - Family member: “Hmm, that’s interesting (going to look at the cars). Gee, there’s a shopping center across the street. Do you think that might be part of why there are so many cars?” - Person with psychosis: “Well, maybe… but I still think people are after me.” - Family member: “It sounds like you’re feeling really scared. What can we do to help you feel safe?” “I’m Not Sick, I Don’t Need Help” The book by Xavier Amador, "I’m Not Sick, I Don’t Need Help", is particularly useful for families trying to communicate with a person who does not accept that they are ill. Amador makes several key points: Sometimes it is actually better for people not to accept a psychiatric label, if they have negative beliefs about what that label means. By using their language rather than insisting that they accept a particular diagnostic label, they are more likely to choose treatment. Usually adapting to medical diagnoses such as psychosis and schizophrenia involves a process of “de-stigmatizing”, re-thinking what those labels do and don’t mean. Amador also points out that people with schizophrenia (and psychosis in general) often experience cognitive problems which are not immediately obvious. In particular, he discusses “anasignosia”, a brain condition in which individuals are unable to recognize medical symptoms. He hypothesizes that this may be a significant factor for some people who “lack insight” about their illness; they may, in fact, be literally unable to recognize the symptoms. Amador reinforces the importance of reflective listening, and offers the “LEAP” model: “Listen, Empathize, Agree, Partner”. The bottom line is to listen for what the person finds motivating, empathize with them, find common ground you can agree on, and partner with them to address common goals. 31
  32. 32. L.E.A.P Four steps to successful communication (source: Dr. Xavier Amador, I’m Not Ill, I Don’t Need Help): 1) Listen to your loved one. Sounds simple enough, but more difficult then you would think. When you listen the goal is to gain an understanding of what your loved one wants, feels and believes in. The goal is to not just to listen but to learn. To listen without learning is pointless. You want to gain a full understanding of their experience, not yours of the illness and treatment. 2) Empathize Empathize with your loved one regarding their experiences with the illness and treatment despite how out of touch with reality they may sound to you. This would include listening and empathizing when they tell you they won’t take medicines. If you want someone to seriously consider your point of view, be certain that they feel you have considered theirs. 3) Agree Agree on a common ground. Work on observations together, while remaining neutral, to discover what motivation the person has to change. Common ground always exists between the most extreme opposing positions. “What happened after you stopped taking your meds?” vs. “This happened because you stopped taking your meds”. 4) Partner Partner with your loved one. The aim of this step is to help you collaborate on accomplishing the goals you have agreed on. 1) Listen 1) What to learn by listening a) Their beliefs about having a mental illness. b) Their attitudes on medications. c) Their concept of what they can and cannot do. d) Their hopes and expectations for the future. e) Cognitive deficits caused by the illness. 2) How to listen effectively to someone with a mental illness. a) Set aside a time to talk Set aside time to talk, such as after dinner, going for walk, while smoking etc. During difficult times, sit close to the person, not face to face (can increase paranoia), and attempt to share a couple of words without pressure or an agenda. If you are the type that insists of getting something accomplished then let your accomplishment be that you were just there. Although this seems pointless, it builds trust and openness. What to do during difficult times 1) Sit side by side other than face to face. 2) Avoid direct eye contact. 3) Identify with rather than fight with family member. 4) Don’t rationalize, Share mistrust. 5) Postpone (temporarily) psycho-education. 6) Reassure. 32
  33. 33. 7) Leave them alone if necessary. b) Agree on an agenda. If this can’t happen, then just listen, but learn! Your loved one may be tired of hearing what he or she can and cannot do. When they learn you will not do that, they may be more apt to talk abut “hot topics” (medicines). To establish agenda follow lead of your loved one. If they are pontificating on that they won’t take medicines then ask, “I would really like to understand what it is about meds you don’t like”. Don’t second-guess at this point just listen and empathize. c) Listen for beliefs about the self and the illness. Find out what they want out of life without being judgmental. If they want to work, don’t tell them it is unrealistic. Listen! And Believe! Attempt to learn if they even believe they are not ill and what medications/therapy do for them (both positive and negative). d) Don’t react! I’m not saying ignore, just don’t give your opinion. Empathize with the experience instead of telling them it is not true. Use a statement like “anything is possible” I’m not saying agree with delusions just don’t disagree. With exceptions to urgent matters, but be assured it is urgent. e) Let chaos be. There will be times when your loved one does not make sense or is out of touch with reality. Don’t interrupt or attempt to fill in the blanks. You can still get the information you need by letting them just talk. f) Echo what you have heard. Make it a point to assure them that you have heard them this can be done simply by repeating it back to them in your own words. If they feel you understand them, they are more likely to be open to your opinions later. g) Write it down. Complete Attitudes and Beliefs checklist. Do this after the conversation. Unless it would cause defensiveness in your loved one. “Would it be ok if I use this form I have?” 2) Empathize 1) Your listening will naturally lead to empathy. When someone you are working with is in pain it is hard not to empathize. It is however easy to tell someone what you think is best also because your care and think you know what is best. The former will ultimately lead to a real interest in your thoughts; the latter will lead to resentment and frustration. 2) What should I be empathizing with? a) Any feeling your loved one is willing to talk about. b) Frustrations about pressures to take medicines and personal goals not met. c) Fears about medicines, being stigmatized, and failing. d) Discomfort attributed to medicines (i.e. weight gain, feeling groggy, tired, stiff) e) Desires to work, get married, have kids, return to school and to stay out of the hospital. 3) How to empathize. a) Use reflective listening. Reflecting back statements and feelings in the form of questions. 33
  34. 34. b) Recognize your loved one’s point of view. c) Establish that loved one’s point of view is only one point of view. d) Supply an alternative, in non-parental manner. e) Anticipate setbacks. f) Talk about yourself. g) Talk in fashion that allows your loved one to “save face”. h) Maintain a positive attitude. i) Use admiring and approving statements. j) Provide education about negative symptoms. 4) How not to empathize. a) Telling your loved one they are not ready for a goal they have set for themselves (i.e. work, school, sexual relationship) and focusing on “maintenance” Telling your loved one he/she needs to be on medicines to get better and he/she will always have to take them. b) Focusing on the labels of illnesses. c) Imposing your standards of living on them. d) Taking a parental stance/controlling privileges such as money or driving. “Ex. I told you if you would have taken your meds this wouldn’t have happened”. 3) Agree 1) Having listened and empathized with your loved one’s frustrations, goals, etc., you will ultimately have something that you all can agree on. It won’t be everything and it may not be much, but if the door is cracked put your foot in it (i.e. wanting to work, they may feel they have not because they have been in the hospital although you may feel it is due to symptoms you can both agree it is good to work and to stay out of hospital). 2) What to do when you notice the door is opening and defences are down. a) Normalize the experience (i.e. I would feel the same way if I were in your shoes) b) Discuss only perceived problems. “I can’t sleep because of the shadows” You may recognize this as paranoia or hallucinations; however you need not use those words. c) Review perceived advantages and disadvantages of treatment. If they miss a disadvantage feel free to point it out. (I understand that medicine also makes you gain weight). d) Correct misconceptions if possible, such as assuring neuroleptics (I try to avoid the term anti-psychotics) are not addictive and MI is not caused by upbringing or illicit drugs. e) Reflect back and highlight perceived benefits. (I understand the medicines suck, but it sounds like you feel if you take them you stay out of trouble with the judge). f) Agree to disagree. This can be important when your loved one feels threatened by you. You can agree to disagree. Point out disagreements can be non-threatening such as in sports or politics. g) Remember the goal is to collaborate and not pontificate. 4) Partnership 1) Once you have established an agreement work together on how it can be completed on their terms (i.e. how they believe they can return to work or stay out of the hospital.) 2) If possible attempt to agree on goals that are reachable. 34
  35. 35. 5. Nursing a patient with a severe psychotic illness About these Guidelines For general nurses and healthcare officers Nurses play a central role in the assessment and treatment of patients with severe, psychotic mental illnesses. Nursing such patients is a skilled job that requires special training. Sometimes, general nurses or healthcare officers without mental-health training may augment the care provided by mental-health nurses. This section provides information to help them to do that. It covers two topics. • Information about psychotic illness. • What a generalist nurse can do to contribute to assessment and treatment. It does not cover specialist topics such as how to assess hallucinations and delusions. Information about psychosis What is psychosis? The word psychosis is used to describe a broad range of mental disorders that affect the mind, where there has been some loss of contact with reality. These types of disorders can vary greatly, though certain types of symptoms are characteristic. They include unusual and often extremely distressing experiences such as the following. • Disturbances of thinking: thoughts become confused and may seem to speed up or slow down. Sentences are unclear or do not make sense. Patients may feel as if their thoughts are being put into their head and are not their own thoughts. They may have difficulty concentrating, following a conversation or remembering things. They may then appear to be unresponsive or uncooperative. • Delusions: false beliefs that seem real to the patient and are not amenable to logical argument. They are often very frightening. For example, a person may believe that their food is being poisoned. Common themes for delusional beliefs are persecution, punishment, grandiosity and religiosity. For example, someone acutely ill may believe that he is Jesus. • Hallucinations: patient sees, hears, feels, smells or tastes something that is not actually there. For example, they may hear voices that no one else can hear. Food may taste or smell as if it is bad or poisoned. Hearing voices is a very common symptom of schizophrenia. The hallucinations can range from occasional voices through to an almost constant barrage of derogatory comments from a large number of different voices. • Changed feelings: patients may feel strange and cut off from the world. Mood swings are common and patients may feel unusually excited or depressed. Their emotions may seem dampened — they feel less than they used to or show less emotion to those around them. Different types of psychotic disorder There are different types of psychotic illness. These include the following. • Substance-induced psychosis: use of, or withdrawal from, alcohol or drugs may be associated with the appearance of psychotic symptoms. Sometimes the symptoms remit as the effects of the substances wear off. Sometimes the illness lasts longer. It is possible for a patient to both have a more long-term psychotic illness and to misuse substances. It is not possible to tell from the symptoms alone whether someone has a substance-induced psychosis or whether they have another psychotic disorder. It is a mistake to think that because a prisoner is a drug user they cannot also have a severe psychotic illness such as schizophrenia. 35
  36. 36. • Brief reactive psychosis: psychotic symptoms arise suddenly in response to a major stress in the patient’s life. The patient makes a quick recovery in a few days. • Organic psychosis: physical injury or illness, such as a brain injury, encephalitis, AIDS or a tumour, may cause psychotic symptoms. • Schizophrenia: psychotic illness in which the symptoms have been continuing for at least 6 months. The symptoms and the length of the illness vary. • Bipolar disorder (manic depression) and psychotic depression: psychotic symptoms appear as part of a more general disturbance of mood. When psychotic symptoms are present, they tend to fit in with the person’s mood. For example, someone who is depressed may hear voices telling them they should kill themselves. Someone who is unusually excited (manic) may believe that they have special powers and can perform amazing feats. What causes psychosis? Schizophrenia is probably caused by a combination of biological factors (such as a family history of schizophrenia) that create a vulnerability to experiencing psychotic symptoms. The symptoms often emerge in response to stress (e.g. breakdown of a relationship, being held in solitary confinement, bullying), drug abuse or social changes in vulnerable individuals. This theory of causation is known as the ‘stress–vulnerability model’. It helps to explain why psychosis is usually an episodic problem, with episodes triggered by stress and patients often quite well between episodes. It also helps to guide management. International studies show that once a person has schizophrenia, the environment in which he/she lives can help them to stay well or can make them worse. In a calm environment and one where people provide plenty of support and encouragement, those with schizophrenia will suffer fewer psychotic episodes than if they are surrounded by people who push, frighten or criticise them. Prognosis: do people get better? Schizophrenia usually begins in early adult life but may occur at any time in an individual’s life. Those who develop schizophrenia at a very early age do not tend to do as well as those whose illness begins in middle or old age. Although for some schizophrenia will be a life-long concern, others experience only one episode of the illness and never have a further episode. Generally, 20% of people recover completely, 35% are stable for long periods but have some further episodes of psychosis, and 45% experience long-term problems requiring continuing care. One-quarter of the latter group deteriorate more severely and rapidly and need very high levels of care and support. When someone is in a very distressed, acutely ill state, it can be hard to believe that they will ever get better. Realistic hope is one of the most important treatments a nurse or healthcare officer has to offer. What are the treatments? • Assessment: first stage of treatment involves assessment, usually over some time. Mental-health specialists need to develop an understanding with the patient of how and why these symptoms affect them. A range of measures may form part of the assessment, eg the ‘Delusion Rating Scale’ and the ‘Belief about Voices’ questionnaire. • Medication: along with other forms of treatment, medication plays a fundamental role in recovery from a psychotic episode and in the prevention of future episodes. The monitoring of side-effects is critical to avoid or reduce distressing side-effects that can lead to a patient being unwilling to accept the medication central to their recovery. 36
  37. 37. • Counselling and psychological therapy: having someone to talk to is an important part of treatment. A person with acute psychotic symptoms may need to know that there is someone who can understand something about their experience and provide reassurance that they will recover. As recovery progresses, different forms of psychological therapy can:  help the patient and those caring for them (on ordinary location) learn how to keep stress levels low in order to prevent further episodes  help the patient and those caring for them (on ordinary location) recognise early warning signs that a further psychotic episode is developing and  help the patient learn ways of reducing the impact of hallucinations and delusions. • Practical assistance: treatment often also involves assistance with employment, education, finances and accommodation. What the generalist nurse or healthcare officer can do 1. Communication (engagement) (The section on communication was adapted from ‘The guide to communicating with people who have serious mental health problems’, developed by Katie Glover when she was at START, a Homeless Mentally Ill Initiative Project in London.) In order for the healthcare team to help the patient, the patient has to feel that the team is on their side and be prepared to communicate and, at least to some extent, to cooperate with the team. A trusting relationship with any member of the healthcare team is therefore important to the success of the treatment. Building such a relationship is especially hard with a patient who is psychotic as, at least in the acute stage, they may believe that you intend to harm them. When you talk to the patient, it is likely that you will have to adapt your usual communication style as the patient’s memory, concentration and tolerance levels may all be reduced. • Talking with someone with a severe mental illness:  Never leave someone who is mentally ill to guess your intentions or the intentions of other members of the healthcare team. Their imagination will run riot. Always explain why you, the doctor or other person wants to talk with them.  Try to ensure that the environment is comfortable and safe for both you and the patient. Ask where in the healthcare centre the patient feels safe/OK to talk.  Remember that social interaction can be very stressful for the patient and be prepared to acknowledge this: ‘I can see how hard this is for you. I appreciate you making the effort to talk to me’.  Be warm and friendly but also prepared to spend time in silence.  Always be aware of cultural issues. If you are not sure, ask. Finding out as much as you can about the patient’s culture will help communication. • Talking with someone who is hearing voices. If you are not sure someone is hearing voices at this particular time, ask them. If they are, do the following:  Acknowledge the difficulty and distress that voices cause. For example, ‘It must be really difficult for you having this conversation. I really appreciate you making the effort’.  Do not challenge the fact that the patient can hear voices. They are real to the patient. However, you can say in a gentle and matter-of-fact way something like, ‘It’s your brain playing a trick on you just now’.  Talk clearly and slowly if necessary and be prepared to repeat questions.  Be prepared to take longer even for a simple matter.  If someone is obviously in distress, ask them if they have had enough. Be prepared to come back later. 37
  38. 38. • Talking with someone who mentions their delusional beliefs:  Show some understanding of the person’s feelings, eg ‘It must be really scary to think that someone else is controlling your thoughts’.  Do not argue about the strange ideas but do not pretend to agree with them either. Focus instead on how the delusions make them feel and then change the subject to something neutral or pleasant in real life (eg what is for dinner?).  If the conversation is distressing to the patient or to you, it is OK to say, ‘I’ll talk to you later when you’re feeling a bit better’. • Relating to someone who is withdrawn or isolated:  Be prepared to sit with the patient in silence.  Doing practical tasks close to the patient can be comforting. Sharing activities without talking can also be helpful.  Gently encourage other activities which are not too demanding (eg watching television, washing dishes, playing a board game).  Be prepared to keep trying. It can take a long time for some people to respond. • Talking with someone who is angry or aggressive. People with schizophrenia are usually shy and withdrawn. However, they may also become aggressive, especially when they are experiencing fear or paranoia (feeling that they are being persecuted and that other people are out to get them) or voices (voices can, rarely, command a person to injure others). To reduce patient fears and the potential for aggression, it may be helpful to do the following: — Give the patient space. Do not crowd them. — Inform the patient about what you are doing and intend to do. — Tell the patient that you do not mean them any harm. — Talk calmly and evenly. — Talk to the patient in a quiet environment. — Continually reassure them. — Keep your hands in view. — Keep your movements to a minimum. — Ask them why they are upset. 2. Observation: contribution to assessment Nurses and healthcare officers may spend long periods with patients. Your observations of the patient’s behaviour are a very valuable part of the assessment. General information about conducting observations is provided in Observation. In psychotic illness, helpful observations include the frequency, intensity and duration of ‘positive symptoms’ and the extent of ‘negative symptoms’. Positive symptoms include: Negative symptoms include: • Hallucinations. • Lack of motivation. • Delusions. • Social withdrawal. • Thought disorder. • Emotional withdrawal. • Paranoia. • Difficulty in forming relationships. • Lack of spontaneity. 38
  39. 39. Make your observations as concrete and objective as possible, e.g. ‘Spent all morning in bed. Appeared to watch television in afternoon but showed no reactions to the programmes or to changes of channel by others. Unresponsive to efforts to hold conversation’ (rather than ‘withdrawn’). 3. Reassure, encourage and support the positives People with a psychotic illness are likely to feel confused, distressed, afraid and lacking in self-confidence, both during the acute phase and for a long time afterwards. The illness has probably caused them to lose control of their thoughts and to feel overwhelmed by the world around them. As they recover, it is common for patients to: • sleep for long hours every night (or during the day) for 6–12 months after the psychotic episode • feel the need to be quiet and alone more often than other people and • be inactive and feel that they cannot or do not want to do much. It is helpful to explain to the patient what is happening to them, e.g. that psychotic symptoms usually appear as a response to severe stresses (see What causes psychosis above) and that additional sleep and inactivity is the body’s natural way of slowing down to allow the brain to recover following the shock of an acute episode. It is also helpful, as the patient recovers from the most acute stage of the illness, to encourage them to resume activities gradually that they have been able to do and have enjoyed in the past. Encourage the patient to help with simple jobs around the healthcare centre or to chat with you or to join in any art or other therapeutic activity on offer. If the patient refuses, do not pressure them but make it clear that they are welcome to come when they feel able to join in. Make it clear that they are welcome simply to sit in the company of others and watch or listen to people without joining in more actively. You may find that the patient likes to listen to loud music a lot of the time. This may be a way of drowning out distressing voices or thoughts. Earphones or a Walkman may be helpful. Most importantly, it is helpful to relate to the patient as a human being who has interests and strengths separate from his/her psychotic symptoms or lack of them. This may be crucial in rebuilding some self-esteem and hope for the future. Find out what the patient’s interests are and, if you can, discuss them with the patient. If the patient has contact with family members who are supportive, try to arrange a visit. It may be very helpful for the family members to have information about psychosis. This can be provided by an organisation such as the National Schizophrenia Fellowship (for details, see Resource directory). 4. Reduce stress and conflict Because environmental stress plays such a prominent part in triggering episodes of psychosis, reducing such environmental stress is an important part of both treatment and prevention. The particular kind of stress that studies have found to be detrimental to patients with schizophrenia consists of high levels of ‘expressed emotion’. This means: • hostility: not only just bullying or physical aggression, but also angry shouting • emotional over-involvement, eg ‘Can you tidy your cell for me?’ and • criticism, eg calling a patient ‘lazy’, blaming him/her for being uncooperative. Staying calm and using the communication tips in Communication/engagement above will be helpful. Ensuring that the patients are in an environment safe from bullying is also important. If the patient returns to normal location when the acute episode is over, residential managers should be aware that the way the patient is treated by staff and prisoners will significantly affect the likelihood of relapse. Additional patience and ‘giving leeway’ may be required. 5. Look out for depression and suicidal thoughts People who have psychotic illnesses are at significantly higher risk of depression and suicide. They tend to have low self-esteem, to feel hopeless about their lives, to misuse drugs and alcohol, to lose their social role and be unable to attain their personal goals. In addition, some may hear voices telling themselves to kill themselves. 39
  40. 40. If the patient expresses depressed or suicidal thoughts to you, do the following. • Listen to their feelings, but also point out that help is available. • Express appreciation of the patient’s feelings and the fact that he/she confided in you. • Let the doctor and mental-health nurse know and consider opening a 2052SH form (in Scotland, an Act to Care form). • Distract the patient by involving him/her in pleasant, low-key activities. • Help them to be with someone by whom they feel accepted. • Let the patient know that you accept and care about them. • Consider whether any stressors can be removed that might be depressing the patient (eg worries about going back to a location on which he had been bullied). 6. Medication If you become aware that a patient is not taking the medication, do the following: • Remind them calmly that the medication helps to keep them well. • Ask if they are having any side-effects. • Let the doctor or mental-health nurse know that the patient is refusing to take the medication. Medications used for mental-health problems Information for non-specialist nurses General Nurses may be involved in administering psychotropic medication. This section is a brief guide to the main types of drugs used to treat mental disorders. The aim is to help you answer simple questions that patients may ask, and to know what to do if the patient does not turn up to collect their medicine. Further training is needed to help you recognise and deal with the side-effects of medication. The things to remember are the following: • A patient can only be given medication they have agreed to take (consent). • Consent must be voluntary and reflect a continuing agreement to take the medication. • Patients can change their mind about taking medication. • When information is given to a patient about their illness and medication, it can increase the chance of consent being given. • If a patient refuses to take the medication, you should record their views in the notes and report the fact to the prescribing doctor. 40
  41. 41. MEDICATION Anxiety and insomnia Benzodiazepines What are they? Benzodiazepines are drugs used primarily to treat symptoms of the following. • Severe anxiety, eg tension, feeling shaky, sweating and a difficulty in thinking straight. The drugs, known as anxiolytics and (misleadingly) minor tranquillisers, include diazepam (Valium), lorazepam (Ativan), oxazepam (Serenid) and chlordiazepoxide (Librium). • Short-term problems with sleeping. Drugs known as hypnotics include loprazolam, nitrazepam (Mogadon) and temazepam (Normison). Benzodiazepines also have muscle-relaxing properties and some (e.g. diazepam) can help the following: • Epilepsy: particularly ‘status epilepticus’. • Symptoms of alcohol withdrawal (usually chlordiazepoxide). When someone has been heavily dependent upon alcohol, giving benzodiazepines during withdrawal may help prevent very serious, even life-threatening symptoms such as delirium tremens. Side-effects Common side-effects Drowsiness, sleepiness and an inability to concentrate during the day. Rare but important side-effects • Patient becomes aggressive, excitable, talkative or disinhibited. Ask the doctor to review the medication. • Rash: if this occurs, patients should stop the drug and see the doctor. When are they not helpful? Benzodiazepines are not ideal for the treatment of anxiety and insomnia because they only give symptomatic relief, do not treat the underlying illness and are addictive. They should not be taken regularly for more than 4–6 weeks. Taking them once per day or every other day (for insomnia) or irregularly, eg for 1 or 2 weeks for panic attacks, reduces, but does not eliminate, the risk of addiction (for more efficacious and longer-term treatments, see the guidelines on Sleep problems, Panic and Generalised anxiety disorder). Benzodiazepines should be avoided wherever possible during pregnancy, childbirth and breast-feeding. They can sedate the baby and cause breathing problems. They should not be used routinely to deal with sudden stress (eg bereavement, imprisonment) (see the guidelines on Bereavement and Adjustment disorders). 41
  42. 42. Important notes about benzodiazepines General • They are commonly traded illicitly on the street and in prison. Ensure that the drug goes to, and is taken by, the person for whom it is prescribed. • If a patient misses a dose, do not give two or more doses together next time. • They add to the effect of alcohol. Advise patients who may be released that alcohol is best avoided. • Many people become addicted to benzodiazepines because of legal prescribing by their doctor. Withdrawal • Benzodiazepines should not be stopped suddenly if they have been taken regularly for more than 4–6 weeks. • Withdrawal should never take less than 6–8 weeks — and often much longer • Withdrawal symptoms can include anxiety, tension, panic attacks, poor concentration, difficulty in sleeping, nausea, trembling, palpitations, sweating, and pains and stiffness in the face, head and neck. • The risk of suicide and self-injury increases during withdrawal and the regular monitoring of the suicide risk is required. • During withdrawal (especially if it occurs quickly), the patient may behave unpredictably and pose a management problem. Advise officers that this may be part of the withdrawal syndrome. They should deal with the patient as calmly as they can. It may be possible to postpone adjudications until after the withdrawal is complete so that any improved behaviour can be taken into account. Individuals withdrawing from benzodiazepines may benefit from help with anxiety-coping skills. Help lines and organisations providing support for those wishing to withdraw from benzodiazepines is provided below. 42
  43. 43. Beta Blockers What are they? Beta Blockers include oxprenolol (Trasicor) and propranolol (Inderal). In lower doses, they can help treat the physical symptoms of the following. • Anxiety, eg palpitations, sweating, shakiness. They do not affect the psychological symptoms (eg worry, tension and fear). • Heart conditions such as hypertension (high blood pressure), angina and arrhythmias. Side-effects Common side-effects Fatigue, cold extremities. Rare but important side-effects Rash or itchy skin, dry eyes, very slow pulse. Advise the patient to consult the doctor immediately. Important notes about Beta-blockers People with asthma should not take them. • There is no evidence that they are addictive but they should be stopped gradually because of the likelihood of rebound tachycardia. • If the patient misses a dose, do not give two or more doses at once. This may cause more side-effects. 43
  44. 44. Hypnotics What are they? Hypnotics are used as a short-term treatment for insomnia. • Non-benzodiazepine hypnotics include chloral hydrate, chloral betaine (Welldorm), clomethiazole (Heminevrin), promethazine (Phenergan), diphenhydramine (Nytol), zaleplon (Sonata) and zopicline (Zimovane). Promethazine and diphenhydramine are antihistamines. Chlormethiazole (Heminevrin) can help agitation and restlessness as well as alcohol-withdrawal symptoms. Side-effects Common side-effects All hypnotics: drowsiness, dizziness, reduced reaction times during the day. Rare but important side-effects • Chloral: rashes/blotches, wheeziness (especially if the patient has asthma). • Antihistamines: wheeziness (especially if the patient has asthma), palpitations/fast heart beat. • If any of the above occur, advise the patient to stop the drug and consult the doctor immediately. Important notes about hypnotics • They are commonly traded illicitly on the street and in prison. Ensure that the drug goes to, and is taken by, the person for whom it is prescribed. • They may cause addiction if taken regularly for longer than 4–6 weeks and should be taken in as low a dose as possible for the shortest time possible. Taking them only when required or every few days (eg on alternate nights) can be a useful way to use the drugs safely. • It is recommended that chlormethiazole is taken for no longer than 9 days if used to help alcohol withdrawal. • If dependence occurs, withdrawal symptoms can include anxiety, tension, poor concentration, difficulty in sleeping (‘rebound insomnia’), palpitations and sweating. 44
  45. 45. Antidepressants What are they? Antidepressants are used to improve mood in people who are feeling low or depressed. Certain antidepressants may also be used to help the symptoms of panic disorder, obsessive-compulsive disorder, social phobia, bulimia nervosa, post-traumatic stress disorder (PTSD) and chronic pain syndrome. All these drugs seem to be equally effective for depression at the proper dose, but they have different side-effects. If one drug does not suit a patient, another may be tried. There are three main types of antidepressants. • Tricyclics (TCAs): include amitriptyline (Typtizol), amoxapine (Asendis), dothiepin or dosulepin (Prothiaden), Imipramine (Tofranil) and lofepramine (Gamanil). • Selective serotonin re-uptake inhibitors (SSRIs): include citalopram (Cipramil), fluoxetine (Prozac), fluvoxamine (Faverin), paroxetine (Seroxat) and sertraline (Lustral). • Irreversible monoamine oxidase inhibitors (MAOIs): include isocarboxazide (Marplan), phenelzine (Nardil) and tranylcypromine (Parnate). A special kind of MAOI is known as a reversible inhibitor of monoamine oxidase type A (RIMAs). These include moclobemide (Manerix). There are, in addition, a number of other antidepressants, such as venlafaxine (Efexor), mirtazapine, nefazodone, reboxetine and trazodone. Side-effects Common side-effects • TCAs: sedation, dry mouth, blurred vision, weight gain, constipation, sweating. • SSRIs: insomnia, stomach upsets, sexual dysfunction. • MAOIs: blurred vision, dizziness, drowsiness, dry mouth, constipation. • RIMAs: dry mouth, nausea, headache, dizziness, insomnia. Rare but important side-effects • TCAs: skin rashes: stop medication and consult the doctor immediately. • SSRIs: skin rashes: stop medication and consult the doctor immediately. • MAOIs: urine retention: refer to the doctor immediately. Sweating, blurred vision, skin rashes, headache: stop medication and consult the doctor immediately. Important notes about antidepressants • If a patient misses a dose, seek them out and ask how they are. Ask the staff too. It is possible that the patient has not come to collect the medication because he/she has become more depressed, with increased lethargy, hopelessness and an increased risk of suicide. • If a patient misses a dose, do not give two or more doses next time as this may increase side-effects. • They may require at least 2 weeks before their mood starts to lift and 6 weeks before a full effect is achieved. Some changes (eg increased appetite, energy levels) may occur before this. Inform the patient about this lag in effectiveness. The risk of suicide may rise during this time. Careful monitoring is required. 45
  46. 46. • With TCAs, overdose attempts are serious and often fatal due to cardiac complications. The symptoms of overdose include: agitation, confusion, drowsiness, difficulty in breathing, convulsions, bowel and bladder paralysis, dilated pupils, and disturbances with the regulation of blood pressure and temperature. • Tranylcypromine (a MAOI) by virtue of its amphetamine-like properties has a high abuse potential. Take extra care to ensure that the drug is given to, and taken by, the right patient. • With MAOIs, dietary restrictions are necessary to prevent a tyramine-induced and potentially fatal hypertensive crisis. Tyramine is found in many common foods. Patients should not take any other drug at all (including over-the-counter cough and cold remedies) without consulting a doctor. If a throbbing headache develops, medical attention should be sought immediately. • Most people may need to continue taking antidepressants for at least 4 months and some may need to continue for 12 months or more, especially if they have been depressed more than once, to reduce the chance of relapse. • Antidepressants should not be stopped suddenly, even if the patient feels better. Their depression may return. In addition, they may experience ‘discontinuation’ symptoms. At worst, these could include headache, restlessness, diarrhoea, nausea, ’flu-like symptoms, lethargy, abdominal cramps, sleep disturbance and mild movement disorders. These are usually short lived and can even occur with missed doses. • Despite the discontinuation symptoms, antidepressants are not addictive because they do not produce craving for the drug, or tolerance (ie needing more of the drug to get the same effect). 46