Understanding Psychosis

What is Psychosis?

Psychosis is a symptom involving the distortion or loss of contact with reality, often accompanied by hallucinations, delusions and disorganized thoughts and/or behavior. There are many causes of psychosis including substance intoxication or withdrawal, an adverse effect of prescribed medications, metabolic abnormalities, infection and sleep deprivation, to name a few.

What are Psychotic Disorders?

Psychotic disorders are mental health conditions characterized by repeated episodes of psychosis or ongoing psychotic symptoms. The most severe and disabling psychotic disorder is Schizophrenia. Another is Schizoaffective Disorder which is similar to Schizophrenia, but has mood symptoms as well. Bipolar Disorder or Major Depression can be accompanied by psychotic symptoms in some, during a severe manic or depressive episode.

What does Clinical High Risk mean?

Clinical High Risk refers to those who are having very early psychotic symptoms that have not yet reached the threshold of a first psychotic episode. In many medical illnesses there is a period of time when various warning signs appear that suggest that an illness is developing. With psychotic disorders, there is a period from one to five years, with an average of two years, during which young people experience symptoms before having a first episode. During this period they are "at risk" with about 33% going on to have an episode within the next 2 years. With treatment that risk can be reduced to less than 10%.

A minority of people are at risk because a first degree relative (mother, father, sibling) has a psychotic disorder. By itself this genetic risk is minor, but a significant decline in functioning in someone with genetic risk indicates that they are at Clinical High Risk. Treatment is helpful in preventing the onset of symptoms.

Being "at risk" does not mean one will go on to have a psychotic episode. It does mean one is at higher risk than the general population. Research indicates that treatment during the CHR phase is the most effective way to reduce the progression of symptoms and possibly prevent a psychotic episode from occurring.

While psychotic symptoms may be much milder at this time, the young person is often highly impacted by them. The goal of treatment during this phase is reducing stress, preventing psychosis, and supporting individual and family functioning.

How do you know if you are at risk?

If you are having any combination of the Early Warning Signs, the best course of action is to call and speak with one of our clinicians. We can help sort things out. First we will talk with you on the telephone. If we believe a further assessment is warranted, we will schedule a time for you to be seen in person. We use a standardized interview that has been in use for over a decade that can tell you more about your risk and need for services.

What is First Episode Psychosis?

Psychotic symptoms can worsen to the point where they take over a person's mind. It becomes difficult to separate reality from fantasy. Hallucinations, disturbing thoughts or ideas, feelings of dread or doom, and mistrust of others' intentions may predominate. Familiar people and places may seem unfamiliar or unreal, accompanied by confusion, anxiety and panic. The person is said to have experienced a First Episode.

For some people, the experience of a psychotic episode is not unpleasant. They may experience a feeling of expansiveness or spiritual connection with others or a higher power or purpose. Often others are more concerned about them than they are about themselves and they may not be interested in treatment. The goal of treatment is not to discredit such experiences but to integrate them into everyday life.

With time alone, or with time and treatment, symptoms may improve, but once someone has crossed the threshold of a First Episode, they are no longer simply "at risk." The risk at this point is further episodes and difficulty regaining one's functioning. Even though symptoms may abate, it may take many months before a person feels that they have recovered.

Research has shown that treatment within 18 months following a First Episode offers the best chance for regaining one's functioning. There is some research suggesting that there is an early window of opportunity during which good treatment substantially changes the overall prognosis.

What is the Course of Psychotic Disorders?

People with psychotic disorders often experience psychosis in episodes, often with low level symptoms between episodes. The overall course of psychotic disorders can be described as follows:

• At Risk - The person does not experience any symptoms but has risk factors (genetic, traumatic, prenatal or perinatal complications, substance abuse) for developing psychosis.
• Clinical High Risk (CHR/Prodromal) - The person has some changes in their emotions, motivation, thinking and perception and/or behavior (See Early Warning Signs). This period may last 1-5 years, with an average about 2 years. This is the phase in which early intervention is most effective in preventing progression.
• Acute Psychosis – The person is unwell with psychotic symptoms such as delusions, hallucinations, disorganized thinking and reduction in ability to maintain social relationships, work or study. People often require hospitalization during this phase.
• Recovery – Follows an acute episode. While psychotic symptoms may decrease with treatment, it may take months to regain functioning and well-being. Many people experience some loss of functioning compared to their previous level. People who seek help immediately following the first episode of acute psychosis do best.
• Relapse – Recurrence of an acute episode after a period of stability. While some people have only one psychotic episode in their lifetime, the majority go on to have other acute episodes periodically. Each episode takes longer to resolve and is more difficult to treat, and often results in a decrease in functioning.

What is the Impact of Psychotic Disorders?

Psychotic disorders are of major social and public health importance. The personal and societal cost of these disorders is considerable. Psychosis can severely disrupt a person's life, making relationships, school, work, and self-care difficult to initiate or maintain. These conditions affect a significant number of individuals in our community. If we consider all psychotic disorders together, around 3% of people will experience a psychotic episode at some stage in their life and 1% will be diagnosed with Schizophrenia. Usually a first episode occurs in adolescence or early adult life, an important time for the development of identity, relationships and long-term vocational plans. And, when the impact on the individual's family is also considered, the indirect effects of these conditions are enormous.

What Helps?

Family support and involvement. Psychosis is no one's fault! Families do not "cause" psychosis. However, family involvement and support is a key factor in recovery. We do not believe families are to blame when their child develops psychotic symptoms. We do believe that families hold a unique power to heal if they are willing to participate in treatment. We know from experience that young people do best when families are willing to face their challenges, to listen closely to their child, even when they don't seem to be making sense, and to engage in all aspects of treatment.

We encourage all members of the family to be involved, especially siblings who can be surprisingly affected by their sibling's suffering and their parents' distress, and uniquely beneficial to the treatment process.

At First Hope we welcome anyone who has a close relationship and wants to be involved in supporting the young person with psychosis. Our starting assumption at First Hope is that you and your family are the experts on you and your family! We work alongside you. Many families find participation in our Multifamily Groups to be very helpful in learning how to cope and finding community and support. Research supports this as well.

Maintaining hope. It is easy to lose hope when psychosis sets in. Knowing that many people have moved past psychosis and are living positive and meaningful lives is important to remember when times are rough. It takes a while. Over time, things can get better. A whole lot better!

What Hurts?

Stigma. Though unwarranted, the world continues to hold prejudice against people with mental health problems. People may blame themselves or their families for the problems they are experiencing. They may be ashamed to admit they or their loved one needs help. Stigma can interfere with people getting the help they need, especially seeking help early. Problems may escalate until they can't be ignored.

Denial and delay. Almost everyone's initial response to the earliest warning signs is to wish they would just go away or to deny they are happening. Delays in treatment are associated with a slower and less complete recovery.

Substance Use. Street drugs complicate and worsen outcomes. This includes the use of marijuana which poses special risk to people with early psychosis, increasing the risk of developing a psychotic disorder at a younger age.