CopingWithandRespondingtoPsychosisSymptoms

MonicaE.Calkins,Ph.D.AssociateProfessorofPsychologyinPsychiatry

UniversityofPennsylvaniaDepartmentofPsychiatry,NeuropsychiatrySection

May2,2016

SessionGoals

• Whensomeonehassymptomsofpsychosis,itcanbeconfusinganddistressingforfamilyandfriends

• Goalsofthissessionaretoprovide:– Furtherinformationaboutsymptoms– Somestrategiesandsuggestionsforcopingwithbehaviorsthatcanbeassociatedwithpsychosissymptoms

PsychosisSymptoms

Positive

Delusions

Hallucinations

Negative

Affectiveflattening

Anhedonia

Avolition

Alogia

Disorganized

Speech

Behavior

Developmental Trajectory of Psychosis

Pre-Illness Prodromal Psychosis Remission Relapse

OnsetofFirstEpisode

Firstsymptoms

Onsetofrelapse

Adapted from Knowles, 2004

Course of Psychosis

Challenges of Early Psychosis

GeneralTips

ForYou

• Understand• Youarenottoblame• Thisisanadjustmentforeveryone- notonlyhasyourfamilymember’sdevelopmentaltrackbeenthrownoff,yoursmayhavebeentoo

• Mostpeoplehaveverylittlepreparationforthissituation,soyoucannotbeexpectedtosimplyknowwhatishelpful/whattoavoid

ForYourFamilyMember

• Encourageandsupporttreatment• Becollaborativewithfamilymember(andtreatmentteam)

• Discussstrategiesorskillstheyarelearning– andwaysyoucansupportorparticipate

• Understanditcanbealongroadtorecovery,sojustaswithanyrecovery• Allowtimeandspaceforrecuperation

• Acknowledgeandappreciatesmallstepsandmilestones

DelusionsHelpful

• KnowthattoyourlovedonethedelusionsareREALandcanbeanxietyproducing

• Connectwiththeemotionofthedelusion– respondtotheseemotions

• Acknowledgeyourrelative’sfeelingswithoutreinforcingtheactual belief• Communicatethatyouareontheirsideandwanttohelp.“….thismustbeveryfrighteningforyou,maybeifwetalkaboutityoumayfeellessanxious….”

• Reassureclearlyandcalmly• Letthemknowyouunderstandbutthatyoubelievethereisnothreat“…Iknowyouthinkthepolicearefollowingyou,butIdon’tthinkthisistrue….”

• Sometimes youcantrytoexploretheevidence foraparticularbelief.• Thisisnotthesameaschallengingit• Encourageyourrelativetoconsidertheevidencefortheirbeliefbyaskingquestionsandbeingnonjudgmental

• Providealternativeexplanations– sympatheticallyandcarefully

• Takestepstode-escalate• Reducestimulationandaudience-reducethenumberofpeopleandnoisearoundtheperson

• Calmthingsdown

Avoid

• Laughingat, ignoring,orsayingthethoughtsarestupidornottrue

• Tellingthepersons/heis“crazy”– whichcanleadtoangerandhurt

• Arguingwiththepersonaboutthedelusions• Agreeingwiththebeliefs(orpretendingtoagree)asthismayreinforcethem

• Challengingthedelusionstoodirectlyasthiscanbackfire

• Doing/sayingthingsthatyouhaveobservedtoescalatethedelusion

• Continuingaconversationthatyoufeel isdistressing,orannoyingortooconfusingforyou.Oktosay“I’lltalktoyoulater.”

HallucinationsHelpful

• Staycalm• Offeradistraction• Involvehim/herinsomething interesting• Offersomethingto lookat,readorlistento

• Engageinpleasantconversation• Showunderstandingofthepersonsfeelingsaboutthehallucinations

• Canaskabouttheexperienceifthepersonwantstotalkaboutwhattheyareseeing/hearing

• Cansaywhensomethingisnotreal,whileacknowledgingtheyseemrealtoyourrelative

• Canhelphim/hertellthedifferencebetweenrealandimaginary(e.g.,“it’syourbrainchemistrywhichismakingsomethingappear,it’snotreallythere.”)

Avoid

• Blamingyourselforanotherfamilymember• Panickingorgettingangry• Tryingtofigureoutwhats/heistalkingaboutortowhoms/heistalking

• Laughingaboutthehallucinationsorstrangetalk,orallowingotherfamilymemberstomakejokes/criticize

• Askinghim/hertotrytoforcethevoicestostop

• Minimizingtheexperience– rememberitisrealtohim/her

Avolition andAnhedoniaHelpful

• Rememberthesearesymptoms,notwillfuldisobedienceor“laziness”

• Offerorsuggestsomesimpleactivities–experimenttofindoutwhats/hewillenjoy

• Aimforaregulardailyroutinesothingsarepredictable

• Ass/hestartstogetbetter,givesimpledailychores(breakdownintosmallsteps)– offerincentives/praise(evenifnotperfect– maymakemistakes)

• Focusonthefuture,notthepast- discusstreatmentgoals,andhowyoucanhelp

• Focusontheprocess,ratherthantheoutcome

• Progressmaybeslow,butreassureandencouragebynotingandpraisingeachsmallsuccess

Avoid

• Insistingthats/hedotoomuchorgoout(puttingtoomuchpressure)

• Overwhelminghim/herwithtoomanysuggestionsorinstructionsatonce– yourrelativesthinkingmaybeslowedatfirst,soshortstepsaremorelikelytobeachieved

• Suggestingactivitiesorchoresthataretoocomplicated

• Criticizingorlabelingrelativeas“lazy”• Expectingrelativetodothingss/heisafraidofdoing(e.g.,goingouttoaparty)orfindstooconfusing

• Arguingabouttasks/chores/activities• Remindingrelativehowtheyusedtobe–mayaddtonegativefeelingsabouthowthingshavechanged

SocialWithdrawalandIsolationHelpful

• Lowerexpectations- leavetheperson alonebutmakeregularcontact

• Letyourrelativeknow youarethereifneeded•Gentlyencourageotheractivitiesthatarenottoodemandingatfirst– provideundemanding anduncomplicatedsocialactivitytorebuildconfidenceandinterest

•Understandthatyourrelativemayfeelvulnerableinsocialsituations– inviteandinvolvethepersoninfamilyactivitiesiftheyarewilling

•Offerpraiseforgettingup, beingmoresocial,andfortheireffort

•Askwhatwouldbehelpful – wherewoulds/hefeelmostcomfortable

•Remembers/hemayneedsleepwhilerecovering– lateron, offertohelp thepersontosetupaschedule forsleep/wake

•Askhim/her tosharegoals– discusswaysyoucansupport thosegoals

•Understandthats/hemayfeelisolatedbecauseofstigmatheyhaveexperiencedorthinktheywillexperience

Avoid

• Takingitpersonally orblamingyourself• Puttingtoomuchpressureonhim/her• Tryingtocoaxthepersonoutofhis/herroom•Worrying orfussing toomuchoverhim/her•Avoidingorisolatinghim/her• Invitingalotofvisitors home– itmaybeoverwhelming

•Tryingtoforcehimorhertotalktopeople• Expectingyourrelativetostayillorincapableofdailyroutineactivities

AffectiveFlattening

Helpful

• Beawarethatthisisasymptom• Knowthatjustbecausethepersonisn’tshowing theirfeelings, itdoesn’tmeantheyarenotfeelinganything

Avoid

• Takingitpersonally• Gettingfrustratedorhurtthatthepersonisn’t showinghis/herfeelings

ProblemswithThinkingandSpeech

Helpful

• Trytobepatientandlistentoyourrelative

• Iftheystartdriftingoffontounrelatedsubjects,gentlytrytosteerthemback

• Speaktothepersoninaclearandsimpleway

• Ifnecessary,repeatthings,talkingslowly

• Allowplentyoftimeforhim/hertoanswer

• Givestep-by-stepinstructions

Avoid

• Criticizingthepersonfortheproblemsinthinkingandspeech

• Comparingthewaytheirthinkingis“now”tothewayitusedtobe

OddorEmbarrassingBehavior

Helpful

• Rememberthatyouarenotresponsible• Ignorethebehaviorifyoucan,especiallyifnotserious

• Ifyoucan’tignore,askthepersonclearlyandpleasantlynottodothebehavior

• Ifthepersoncan’thelpthebehavior,aimtosetparameters

• Stateclearlythatthebehaviorisnotacceptabletoothers

• Ifyoucan,changetheenvironmentsoastolessenthebehaviors– ifitissetoffbystress,seeifthestresscanbereducedorlessened

• Findtimestopraisethepersonforactingmoreappropriately

Avoid

• Tellingyourselfthatthebehaviorisareflectiononyouoryourfamily

• Actingupset• Gettingintolongdiscussionsaboutit• Lettingotherfamilymembersandfriendspayattentiontoorlaughaboutthebehaviors

• “Nagging”apersonaboutthebehavior

AggressionHelpful

•Rememberthatanger/aggressionmaybedirectedagainstyoubecauseyouaretheclosestperson tothem– itisnotnecessarily apersonalattack

• Listentoyourrelativeandtrytoworkoutwhytheyareangry/upset•Askhim/her toexplain• Summarizewhatyouthinktheymeanandaskifcorrect

•Developaplan•Givecleardirectionsuchas“stopplease”• Ifs/hedoesn’t stop,leavetheroomorhousequickly

•Doleavetheperson aloneuntilthepersonhascalmeddown

•Takeanythreatsorwarningsseriously• Trytoseewhattriggersaggressionandtrytoavoidthebehavior/situation (e.g.,certaintopicsofconversation)

• Ifallelsefails,callemergency

Avoid

• Sayingangry,criticalthings•Arguing•Gettingangryyourself – useacalmvoiceandkeepneutralfacialexpression

• Stayingintheroomifthepersondoesn’t calmdown

• Ignoringverbalthreatsorwarningofaggressiontoyouoryourfamilyorothers

• Tryingtoreasonitoutonyourown– askforhelp

SuicidalIdeationHelpful

• Listentoyourrelativesfeelingsbutalsopointoutthathelpisavailable

• Showappreciationofyourrelative’sfeelingsandthefactthats/heconfidedinyou

• ContactteamifSIpersists• Encourageyourrelativetobeinvolvedinpleasant,lowkeyactivities

• Helpthepersontobewithsomeonewhoacceptsthemsotheydon’tfeelisolated

• Considerwhetheranystressorscanberemoved

Avoid

• Panicking,butdotakefeelingsseriously

• Tellingthepersonthingslike,“Pullyourselftogether,”or“Youdon’treallymeanthat.”

• Keepingthisasecret– talkaboutitwiththetreatmentteam

AlcoholorStreetDrugsHelpful

• Knowthatdrugsandalcoholcanmakesymptomsworseandtrigger relapse

• Remindrelativethatdrugsareharmful

• Assisthim/hertodevelopwaysforavoidingoffersofdrugs/• Letyourrelativeknowit’soktoletfriendsknowthatsubstancesarenothelpfulwhenrecoveringfrompsychosis

• Discussalternatewaysto• Copewithstressors• Besocialorbewithfriends (mayneedtolearnnewthings)

Avoid

• Criticizinganyuseofsubstances• Lettingfamilyorfriendsencouragedrinking ordrug taking

• Denyingthatyour relativewillbetemptedtousealcoholordrugs– it’sbettertotalkaboutit

ConcludingTipsForYou

• Managestressofcopingwithyourrelativesdisorder• Practiceacceptance• Recognizeyourownlimits• Avoidblame• Tryoutsomenewstrategies

• Putonyourown“oxygenmask”first• Maketimeforyourself• Lookafteryourhealth• Joinasupportgroup

ForYourFamilyMember

• Understandtheremaybeset-backsorrelapses(butavoidcatastrophizing)

• Watchforsignsofrelapse• Prepareforacrisissituation(haveanemergencyplan)

• Advocatebutavoidtakingmattersinyourownhands–collaboratewithtreatmentteam

QuestionsandDiscussion

ContactUsPennPsychosisEvaluationandRecoveryCenter

10GatesBuildingHospitaloftheUniversityofPennsylvania

DepartmentofPsychiatry3400SpruceStreet

Philadelphia,PA19104Tel:(215)615-3292Fax:(215)615-7903

www.med.upenn.edu/perc