What is psychosis?

Psychosis generally starts with early warning signs that can persist over several years. The age of onset is typically in the mid teens for boys and late teens for girls. This article gives special attention to a new model of early intervention for emerging psychosis among youth, and the condition we still know as schizophrenia.

Psychosis refers to the presence of one or more negative or positive symptoms in a youth's appearance, behaviour and mood over time. Negative symptoms refer to social withdrawal, marked decline in school grades and participation, significant decline in self care and hygiene, lethargy, lack of motivation, lack of interest, psycho-motor slowing, decreased focus or concentration; symptoms that cannot be explained by circumstances or learning difficulties, drug use, illness or injury.

Positive symptoms include psycho-motor agitation such as pacing, auditory or visual hallucinations such as hearing voices or messages projected from an external source, unfounded suspicion or paranoia, aggression and agitation, self harm.

Early warning signs

The following symptoms often appear in the early stage of an emerging psychosis.

• disturbances of receptive language: not getting the conversation
• visual anomalies or distortions : things look or sound strange, unreal
• thought interference : stopping in the middle of a sentence, voices interrupting one's thoughts

The time frame in which symptoms progress is called the prodrome or prodromal phase.A prolonged prodromal phase appears to cause damage to neuron pathways and structures in the brain. It seems the longer it takes to get treatment the more difficult it is to recover.

The question of cause and effect in mental health is like the chicken or egg puzzle; which came first? It's like the old TV ad "Is it a breath mint or a candy mint?" Well, the answer is this; "It's two mints in one!"

First of all, no single gene is enough on its own to cause any sort of mental health condition. The genetic component involves many gene combinations and mutations which then interact with environmental factors to create risk.

Below, in figure 3, we have to imagine that the first jar represents genetic vulnerability, the second jar includes stars that represent adverse events or stress over time which puts youth at risk. The full jar represents a person - brimming with genetic and environmental factors which result in a full psychotic episode.

Early Prevention and Intervention Programs (EPI) for Youth at risk

Youth at risk for schizophrenia are those with sub threshold symptoms which cannot be clearly diagnosed. Consider the second jar, this is good news! It means that a full symptom cluster has not appeared. At this point, Early Prevention and Intervention (EPI) programs hope to avoid jar 3 which shows how symptoms progress into full psychosis. Effective early intervention can lead to recovery in about 6 weeks.

Benefits of early prevention and intervention (EPI)

The benefits of early detection and treatment of first-episode psychosis are to

1) Reduce stress

2) Prevent harm to self or others.

3) Improve individual and caregiver coping

4) Speed recovery

New treatment methods

EPI programs offer a three pronged treatment approach:

1) Medication

• Early intervention generally considers low dose, second generation neuroleptic medication. These are newer drugs with fewer side effects and fairly speedy, positive effects. Medication is usually recommended and prescribed only by a psychiatrist and can be very helpful for someone who is suicidal or agitated, aggressive or violent.
• Another useful new treatment is omega - 3, essential fatty acids. Bio-active lipids, such as omega-3, are thought to improve neuronal structure and function in several ways, and have been effective with young people according to controlled studies.

2) Family counselling, education and support

• Families are encouraged to be involved from the beginning. Reduction of stressful psycho-social factors is helpful both youth at risk and for those who are experiencing a full symptom, first episode of psychosis.

3) Individual counselling and support

• The greatest benefit of individual counselling is to reduce the personal distress and anxiety surrounding the personal fears and stigma of mental health treatment. For many young people, individual counselling can restore their confidence in maintaining relationships and boost their self esteem. Sometimes a youth worker is an asset, being able to expand their social horizons, reduce social isolation and engage them in structured enriching activities outside of home and school.

• Don’t argue with hallucinations or delusions and don’t make fun them.

• If you’re asked about it, just say you don’t see or hear the same things.

• Provide safety, structure and supervision for the young person.

• If your own anxiety and stress is getting too much, seek help for yourself.

• Listen patiently, affirm the person’s feelings and experience, but focus the here and now.

• Remove and reduce stress, stop fighting, be a calm, reliable presence in their life. Provide household routine and structure.

• Maintain easy eye contact.

• Focus on concrete things in a positive way.

• High levels of criticism and rejection are stressful to anyone, but especially if someone’s thoughts and emotions are confused or volatile.

• Words of violence, actions of violence, punitive threats are all triggers.

• If your teenager is at risk of self harm or harm to others, do not leave them alone, either at school or after school. Talk this over with them and find ways for them to have their own space, but not be entirely alone.

• These are only a few tips, check out the many excellent resources and web links about early psychosis.

Source: Amminger and Klier. Prodromal Research and Interventions. In Ehmann, MacEwan and Honer. Eds. (2004). Best Care in Early Psychosis Intervention: Global Perspectives.

Canadian Mental Health Association: Offers education, policy, practice and parent links. Describes early psychosis intervention.http://www.cmha.ca/english/intrvent/

Early Psychosis Intervention Program (EPI) - Vancouver-Richmond, British Columbia, Canada. http://www.hopevancouver.com/

Embrace the Future is an Australian program being developed in collaboration with young people up to the age of 24 to educate young people in strategies and skills which promote and sustain resiliency and positive mental health.". http://www.embracethefuture.org.au/

F.O.R.C.E. Society BC, Canada, Education/Advocacy/Links.http://www.bckidsmentalhealth.org/education

Just Therapy in New Zealand informed by Maori and Pacific Island indigenous peoples. Prescribes a radical shift in how we understand mental health.http://www.familycentre.org.nz/

Just Therapy (Scotland).http://www.justtherapy.org/