How to Support Someone with Psychosis: 5 Tips

Hey there everybody, and welcome to this presentation on supporting functional individuals with psychotic symptoms. I'm your host, Dr. Donnelly Snipes. In this presentation we're going to review what psychotic symptoms are, exactly what symptoms we're talking about and the disorders they're associated with. Psychotic symptoms are present in a lot of disorders, not just schizophrenia. We'll discuss the causes of breakthrough symptoms and medication non compliance and identify strategies to support those who are experiencing symptoms but are still functional disorders with psychosis. And the reason I bring this up is because I want us to recognize that if somebody is presenting with psychotic symptoms, we need to make sure that they get an effective differential diagnosis. We also need to make sure that if you're working with, with somebody who is getting over encephalitis, for example, or has a history of traumatic brain injuries, you may see some psychosis. It doesn't necessarily mean they have schizophrenia. However, we still need to treat those psychotic symptoms. So Vi. Encephalitis, that's viral or what they call hepatic encephalopathy. And hepatic encephalopathy occurs mainly in people who have cirrhosis of the liver, but ultimately it's the liver's inability to remove toxins from the blood. So then it becomes a toxic environment and those toxins make it to the brain causing inflammation. That's no good. Traumatic brain injuries, brain tumors, strokes, Parkinson's disease, Alzheimer's disease, dementia, HIV and aids, just a few of the things. Lupus, interestingly enough, multiple sclerosis is another one. Psychosis and multiple sclerosis can present with various symptoms such as depression, irritability, severe fatigue and loss of energy. We'll talk about the different symptoms of schizophrenia. Remember, there's positive symptoms, things that appear that we wouldn't expect, and negative symptoms. And those are things that we would expect the person to have that just really aren't there. But it is important to understand that the presentation can be different between people with psychosis and even within the individual between different psych psychotic episodes. So we do need to be a little bit cognizant of that. Hypoglycemia, less than 70ml per deciliter and and diabetes can also be associated with hallucinations and delusions with psychotic symptoms. We need to be sensitive to this because there's an increased prevalence of abnormal glucose metabolism in patients with schizophrenia. Therefore we know that they're at risk for developing diabetes to begin with. Not exactly sure why, but it just is. And second generation antipsychotic medications increase the development of diabetes type 2. When we have a person who has a psychotic disorder and they've got diabetes, the diabetes itself can be causing the breakthrough symptoms if their blood sugar is not controlled. Somebody with severe sleep deprivation. Many people with schizophrenia, and I know I said psychosis occurs in other disorders besides schizophrenia, but it does obviously occur in schizophrenia. And many people with schizophrenia have ongoing sleep disturbances. They feel too vulnerable going to sleep. When they start trying to get to sleep, that's when they may start hearing the voices or having the hallucinations. We do need to recognize this and make sure that the people that we're working with, if they have psych, well, when they're having psychotic symptoms, are getting adequate sleep, are feeling safe enough to lay their head down and get that quality deep sleep. Other disorders with psychosis, all of your schizo disorders, including schizophrenia, schizoaffective schizophreniform, brief psychotic disorder, psych psychosis, not other otherwise specified or delusional disorder. Affective psychosis include which is. These are disorders that occur in the general population. They impact people's moods and a symptom of an affective psychosis or is a symptom of that disorder is having psychosis anyhow. Major depressive disorder, you can see psychotic symptoms. Postpartum psychosis, you can see psychotic symptoms, hence the name and bipolar disorder. And you can see psychotic symptoms both in the depressive pole as well as the manic pole. We need to be aware of that. Now addiction related psychosis, with the exception of persistent hallucinogen related perceptive disorder I believe is what it's called. But most addiction related psychosis is very transient and related to either intoxication or withdrawal. So it's not something we're going to be managing on a long term basis. It's probably going to subside within a few hours to a few days. 40 to 60% of patients with schizophrenia can reach remission. I know I paused there because I want you to hear that A lot of times we think that people who have schizophrenia are always in a psychotic episode and that's not true. However, just like anything else that goes into remission, we need to be aware of the signs and symptoms of, of an impending acute episode. And that's what we call the pro, prodromal symptoms. You have prodromal symptoms or beginning onset symptoms before the first psychotic episode. But then you will also have those symptoms start to emerge before future psychotic episodes. Being aware of what those prodromal symptoms are for your individual is huge. It's Huge. Because early intervention can help potentially stave off a full blown, full blown episode. Causes of ongoing symptoms of psychosis and this is across diagnoses. The person may be unmedicated by choice. They don't want to take antipsychotic medications because of the impact on their energy, because of the impact on their motivation. Lots of reasons people don't like taking antipsychotic medications. It could be episodic psychosis like in bipolar disorder or major depressive disorder or as I said, substance induced. If it's episodic. The question is, how is it being managed? A lot of people who have bipolar or major depressive disorder are not always on antipsychotic medications. It may be something that is prescribed for breakthrough symptoms. So we, we need to be aware of that and aware of whether the person is willing to take their medication. If the person is habitually unmedicated because they forget, it happens. I take medication, I have a hard time remembering it. And so we want to help them figure out how not to forget. A lot of the antipsychotic medications that are available now can be injectable once a month, which is helpful because it ensures treatment compliance if they're going in every month to get their injection. But not everybody is, number one, good with needles and number two, able to take those medications that are available in an inject, in injectable stress. I know you, I feel like a broken record. So many times. Stress is a huge trigger for an acute episode. The more we can reduce people's stress levels, the more likely they are to stay in remission or be able to manage their symptoms. And we're going to talk about the different types of stress as we go through here. Medication imbalances. If you're working with somebody who has occasional psychotic episodes or is in remission from a situation with psychosis, it's important to recognize that there are things that can cause their medication to be ineffective. And it's not their fault. They're not forgetting or not, you know, messing with their meds. They may have an imbalance. Hydration. Your anti, antipsychotics are extremely sensitive to hydration levels. So if the person's over hydrated or under hydrated, it's going to impact the blood levels of the antipsychotic, which is going to affect its abilities. Heat for people who don't have air conditioning, for people who work outside, or even for people with schizophrenia or some of these other disorders who are exercising especially in the heat, if they sweat a lot, it can reduce their hydration and alter the levels of their medications. And if they're taking diuretics, that's going to do it. Certain foods will alter the levels of their medications and their doctor should have talked with them about this. Body weight changes. Most of your mood stabilizers and your antipsychotics are sensitive to to significant changes in body weight. Now, a pound here, pound there, not a big deal. But we do know that people with schizophrenia tend to have alterations in their body weight. Some gain a lot of weight because they don't have a lot of energy. They don't have a lot of motivation to get out and do stuff. Others actually lose a lot of weight. But when that happens, when you notice your patient's weight is significantly changing, it's important that they are re evaluated so they don't have breakthrough symptoms. It's a preventative measure. I already mentioned duretics and remember, caffeine is also a duretic. When you drink a lot of caffeine and other cytochrome P450 medications and substances. Cytochrome P450 is an enzyme in the liver that helps your body break down and clear medications and toxins. Now, there's only so much of it, so if you have one thing that needs cytochrome P450, you're golden. There's plenty of it. But if you have three different things in your system that need that cytochrome P450, then it's going to have to be divided among those three and it will take your body longer potentially to clear it from your system. Now, some interactions can increase the availability of your medication, some can decrease the availability, depending. And so it's important to look at cytochrome P450 interactions. Things that interact with cytochrome P450, besides your antipsychotics are antibiotics. Wow. If you have a client, you know, you can think about this. They get sick, they're put on a particular antibiotic for 10 days. It may impact their medication levels. Oral antifungals like metronidazole, any of those things that end in Zol z can be problematic. Now, the stuff that you just spray on your athlete's foot or something, not a big deal. But the oral medications do have to be broken down by P450 pain medications, some over the counter herbs like St. John's wort, illicit drugs like cocaine, nicotine and caffeine. Now, if you've worked with people with psychotic disorders, especially people with schizophrenia, you may be aware that smoking and drinking coffee is extremely prevalent in this community. Caffeine, a lot of times is something that people who are on antipsychotics and mood stabilizers use in order to try to get some energy, because the antipsychotics will reduce dopamine levels and reduce energy and motivation levels. So people are trying to pump themselves up any way they can. If they're drinking a lot of caffeine, we need to make sure that they're talking with their doctor and factoring that in to their dosage levels. If something happens and they suddenly start not getting enough sleep and they're drinking a lot more caffeine than usual, it's important to monitor for breakthrough symptoms and have them talk to their doctor. All right, so basically there are a lot of things that as clinicians, caseworkers, social workers, whatever your role is, we need to be aware of in people who do have occasional psychosis, psychotic related disorders, however you want to phrase it. That way, we can prevent breakthrough symptoms or address prodromal symptoms. When we start to see them, we can say, oh, we're seeing these symptoms start to appear. What changed? What's going on that is triggering an acute episode? Develop an emergency plan. And what I mean by that is when you start to see prodromal symptoms, make sure there is a plan for what you're going to do to address it. Stress is a huge contributor to relapses in schizophrenia and psychotic disorders. We need to have a relapse warning sign, a relapse plan or an emergency plan for how to handle that the person starts showing prodromal symptoms. Okay, what can we do to reduce your stress right now? Now is not the time to be taken on more projects. What can we do? What changed and what can we do to address that? When we're talking about stress, we're talking about stress on the body, stress on the mind, stress on emotions. We want to recognize relapse warning signs for the individual. And it's helpful if the person has caregivers or clinicians or whomever that they're interacting with that they have access to a list of these relapse warning signs, especially if they are in like supported living where they may not see the same caseworker all the time. It can be really helpful to have this available, provide tools to the person to reduce stress in this emergency is in this acute time where they could be going into an acute psychotic episode or they may be able to prevent that. We want to evaluate and mitigate physical, affective and cognitive stressors and symptoms. Now what are these prodromal symptoms that we keep Talk that, I keep talking about chronic anxiety. If suddenly somebody's anxiety starts to ramp up, that's an indication that something may be getting ready to happen. When people are having psychotic symptoms, it can make them feel very unsafe and very anxious. And their body almost knows ahead of time that, hey, we're, we're teetering right on the brink here. If you start seeing that, it's important to address it. If they've got it anyway, we need to see what we can do to help them, even in their remission periods, reduce, manage, mitigate their anxiety to the best extent possible. A lot of people who have psychotic disorders have experienced rejection. They may have rejection sensitivity, they may have trauma in their past, very likely. So we need to address all of those things that could, could contribute to them feeling unsafe and powerless. They may start having more frequent mood swings. As the stress response gets dysregulated, we see more mood swings, we see more insomnia and sleep disturbances. Harder to get to sleep well when you're anxious all the time, it's hard to relax. Memory problems, difficulties with concentration and focus, social isolation or withdrawal, inability to perform job duties or fulfill responsibilities, and a decline in hygiene and self care. Just like with depression and anxiety, no two people with psychotic disorders are going to have the exact same prodromal symptoms. So we want to know what it looks like for this person. We also want to know what this person looks like when they're having a, a good day, when, when they're in remission, what does that look like? So we can notice if there starts to be any changes. Even if it's not their typical prodromal symptoms, we can notice a change in affect, cognition and behavior. Now, in terms of psychotic symptoms, when they are having breakthrough symptoms or they're in a psychotic episode. Hallucinations and delusions. Now, hallucinations are perceiving. Something is there that is not there. You're seeing it, you're hearing it, you're feeling it, sometimes even tasting it. Delusions are firmly held beliefs that are not grounded in our reality. Cognitive behavioral therapy for psychosis is a tool that can be used, but it typically is not effective. In an acute episode, when somebody is floridly psychotic, they are in a different reality than you are in. And it can be hard, if not impossible, to help them see how your reality, which you perceive as right, is different than theirs. What they see, what they're experiencing, is what they're experiencing. So we need to, in this initial phase, join them in their reality and help them figure out how to create safety. If they believe that people are reading their minds. Okay, what can we do to help you feel safe so you don't feel like they're intruding on your brain? We don't want to spend a whole lot of time focusing on all of the different hallucinations or delusions. But we do want to help the person feel safe. And that's what it comes down to. As soon as they start feeling safe, their stress level is going to go down. Disorganized behavior are behaviors that don't fit the situation and including difficulty in completing activities of daily living such as cooking or self care. If they are having symptoms, examine the function of the behavior. This is true whether you're working with somebody who has depression or trauma or dementia or psychosis. Behavior is communication. What are they doing or not doing if they are not completing activities of daily living? Why? For a lot of people with schizophrenia, especially if they are, and psychotic disorders, especially if they're on antipsychotics, their motivation for doing these things that you and I think are important is done. You know, it's just not there. They will get to it in a minute. But they process social interactions much differently and find it much. Find social interactions to not be all that rewarding. So doing something that is, you know, taking care of yourself, bathing activities of daily living to please somebody else. So people want to spend time with you. That may not be motivating. We need to understand it from their perspective. Why aren't you doing this? Are you forgetting? And forgetting is very common as well. Use lists and schedules. There was one person that I worked with who they. They never really did get his symptoms a hundred percent under control. And we used a whiteboard that I had a list of his daily chores on that was written in permanent marker. And then he would check them off. There were. I made a grid on the whiteboard. He would check them off as he did them and it reminded him what he needed to do. And everything on there was swiffering the house, taking a bath, eating breakfast. Everything that he needed to do was on there and that was helpful for him. Have go by guides. Sometimes people will forget how to do things and so they stop eating because they. They forgot how to make something or whatever the case may be. If the reason they're not doing it is because they don't know how or they keep forgetting how to do it. Make a go by guide. Pictures can be helpful. Environmental modifications. If they are wearing clothes, for example, that are inappropriate to the season, well put the summer clothes away in the winter. That way the they don't have the option of choosing those and they feel empowered to go into their closet and pick something and people aren't going to criticize them for it. Encourage comparison of their behaviors to other people's behavior, such as wearing a heavy coat in 80 degree weather. That's one thing. I mean, when they're looking around, they're not seeing. My understanding from talking with people with psychotic episodes, they're not seeing things differently. So they can look around and see nobody else is wearing a coat. And that's something that you can talk about. Now they may say, well, guess they're going to get cold. Or they may be able to start recognizing over time how their behavior differs from what everybody else is doing. Disorganized speech is something that you can see and this is going off tangent or answering in a way that doesn't make sense to the other person. The research indicates that some people with psychotic symptoms, with disorders that have psychotic symptoms, have language receptive deficits. So they may not understand what you're saying to them. They may talk a good talk, but they have difficulty taking in information and interpreting it. We need to understand, we need to explore. Maybe they didn't understand what I asked, so I'll ask it in a different way. Or if they went off on, you know, a tangent, you can acknowledge what they're talking about, but then also bring them back and say I'm really interested to know more about this over here. However, right now I need to find out more about and restate your question. So redirecting them to what you need an answer to can be helpful. You may have to break it down into yes and no questions, which is exactly what we're taught not to do in graduate school. But sometimes to prevent going off on a tangent, if you really need information, you may have to ask very close ended questions. Social withdrawal, often due to a lack of interest or pleasure in social activities. Like I mentioned earlier, they found that there is a deficit or a dysfunction in the oxytocin system in people with schizophrenia. And they found that there is an improvement in their interactions with nasally administered oxytocin. So that can be helpful if you're doing something. You know, think about things that you do, that going out with friends, going to a picnic, calling somebody, whatever it is, that social interaction, you get a little boost of oxytocin that makes it rewarding so you want to do it again. The person with schizophrenia, they may do that and it doesn't do anything for Them, so why would they want to do that? Again, they don't have the energy to. To do stuff that's not rewarding. Okay, so the oxytocin can help if it's administered prior to social activities to emphasize or to enhance the rewarding benefits. You can also figure out how to make it rewarding for the person. Maybe they're not getting a reward or a benefit or reinforcement from interacting with people, but if they do go to the community picnic and they do shower and, and take care of themselves, their hygiene, every day this week, they get a token, and they can use those tokens to purchase privileges. Obviously, this is for somebody who is having more difficulty functioning on their own. But a token economy is wonderful because instead of saying, well, you need to do this because interacting with people will make you happy. Well, no, it really won't. You're saying, interact with people and you will get something. You will get to choose something that will make you happy. We also see affective flattening and anhedonia, or difficulty feeling much of anything, which is experienced as a reduction in the range and intensity of emotional expression. It's no fun to feel flat all the time. It just isn't. If you've been depressed before, you know what this feels like. But having this affective flattening is not conducive for most people to what they would consider a rich and meaningful life. How can we help the person, well, increase pleasurable activities that are pleasurable for the person, whatever that is. I worked with one person who. He literally was a nuclear scientist and he had had a psychotic break. But, I mean, he was brilliant. The things that he found amusing and he enjoyed doing, not stuff that would be my favorite, but he enjoyed it. So encouraging people to explore what it is that actually does trigger a little surge of dopamine and decrease stress. When stress is high, it's going to be difficult for them to feel happy. Just like for you when you have chronic stress and you're not getting good sleep, it's hard to have a lot of positive feelings. Now, you may dysregulate where you have, you know, you're kind of flat and then furious or frantic. The person with schizophrenia, there's. They actually process stress differently. And they may not have that dysregulation, but it prevents them from experiencing the happiness. Alia is speaking less or a lack of meaningful content in speech. And I really didn't find a lot of interventions to address this. Generally, people speak when they feel motivated to speak and when they have something that they want to talk about and potentially working on that. If you feel that it's important for the person to talk, if they're talking in word salad or if there's a lack of meaningful content, that's probably something that need needs to be addressed because that's going to significantly impact impact their functioning. Abolition is the decrease in the initiation of and persistence in your goal directed behavior. And this goes back to what I was talking about a minute ago. Why did I say yours? A lot of times we look at what a person is doing and they're not doing what we want them to do, what we think they should want to do, what we think would be rewarding. So it's your goal directed behavior. We need to step back and say what kinds of behaviors do they want to initiate and what would help them persist in the face of, you know, needing to use concentration, etc oxytocin. Oxytocin and dopamine are both involved in motivation and persistence and stress management. So a person who has a dysfunctional oxytocin and dopaminergic system gonna have a difficulty with motivation and we're going to need to help them. Motivational enhancement or motivational interviewing help them figure out all of the reasons that they may be motivated to do something. And like I said, your motivations for doing it may be very different from theirs. Which is why token economies can be super helpful in even in functional adults that have psychotic disorders or other issues. Token economies can be helpful because it allows them a way to access things that they find rewarding and can give them a little bit of a nudge to do things that maybe they don't really want to do, but they're going to do it in order to get the reward. We want to evaluate their self talk. Are they telling themselves things that I can't do it, you'll never be able to do it. What's going on? And if they're having that negative self talk, then we need to address that. We want to recognize again, behaviors, communication. If somebody is being resistant or giving up too easy, well, what's that telling us? It's telling us they're not motivated for some reason. Do they not have the skills? Are, do they fear failure? Do they not see the point in doing it? Are they too overwhelmed and stressed out about everything else to really give a crap about it? What, what is their behavior communicating? I've mentioned token economies multiple times and scaffolding. Scaffolding is great for people who, especially ones that have difficulty with persistence scaffolding. I'VE explained in other videos. Think about when you taught your kid how to or a kid to how to tie their shoes. And you start out with teaching them how to cross one lace under, under or over the other and pull it tight. That's the first step. And then they have to make the bow. That's the second step. And there are multiple steps to it. And most children don't do it one time. And, you know, they're great with it. Most children will remember the first step, maybe the first two steps, and then they're like, what do I do now? Scaffolding is when you let the person do as much as they can do until they reach that point where they don't know what to do next and they're starting to get a little frustrated. Then you step in and you assist them, you prompt them, you encourage them. Whatever you need to do to help them finish the task the next time, they're probably going to go a little bit further because we're preventing that stress response from kicking off, which means they're still going to be more able to learn. When we're stressed, when we're in fight or flight, we're not learning. So help. Scaffolding helps people feel safe and prevents them from exiting the prefrontal cortex, if you will. Cognitive impairment in people with psychotic symptoms is common. There may be difficulty in with memory. So have them write things down, lists, charts, sticky notes, whatever it is they need to do in whatever form that is most useful to them. Push notifications and alarms on their phone. I have a alarm on my phone that reminds me to take my medication and give the dogs their medications so I don't forget. And then I also don't go back going, did I do that? I can't remember. In the app, you have to actually acknowledge that you did it and clear the app, which is super helpful for people. And you don't have to use it just for medication. You can use it for. Did you shower? Did you Swiffer? Did you? Whatever it is that you want them to do. Concentration and attention deficits are very common. Well, just like anybody who has concentration and attention deficits, we want to minimize distractions, make sure that they are not trying to do whatever it is in a busy, chaotic environment. If they are functional enough that they're still working outside of the home, it's important to address their work environment to minimize distractions and make it as comfortable as possible for them and minimize as much unnecessary stress as possible. And chunk it. This is great for anybody. Break it down into smaller components, figure out how long they can focus on, and then break it down into components that can be completed in that amount of time. Ten minutes is usually a good place to start. Some people can do 20 or 30, but 10 minutes is a place to start. Problem solving is also a problem for people with psychotic disorders. So we want to role play problems that may come up and help them break. Go through the steps of solving a problem. You're driving and you get a flat tire. What do you do? You are at home and you realize that you don't have anything to eat. What do you do? Making sure that they can solve the problems that they're going to be occasionally faced with. When they do encounter a problem they don't have an answer to and they struggle with it, that's going to often feel very frustrating for them. But then in the next session, you can role play that problem so they feel comfortable that the next time it happens, they're going to get it. Impaired executive functioning. That's somebody's ability to plan, to organize, to think ahead. If you will have go by guides. If executive functioning is important in cooking, for example, what do you do first? What do you do next? Go by guides can be super helpful. If somebody's having difficulty with something like that. Review and repetition. Just doing it with them several times can be helpful. If you're having a session with somebody and maybe they were trying to make macaroni and cheese or spaghetti or something the other day, they couldn't remember how to do it and they started getting frustrated. Okay, so let's talk about how to do that. Maybe you did it together once or twice, and then the third time you're going to review. Now you want to make macaroni tonight. What are the steps you need to take in order to make your macaroni and have them talk through it so they're integrating the knowledge. As I mentioned, cognitive behavioral therapy for psychosis is generally not effective during an acute episode. Trying to argue with somebody about their reality versus yours not only is ineffective and will put them on the defensive most of the time, but it is invalidating and sometimes demoralizing. We don't want that. We want people to feel safe in our presence. We want people to feel safe telling us about their psychotic symptoms. CBTP may primarily be used in patients with chronic schizophrenia with residual symptoms as an augmentation strategy. If they are able to manage most of their symptoms with medication, but you have occasional breakthrough symptoms or their hallucinations and delusions, they're still having them but they're not egosyntonic anymore. They recognize, yeah, this is not actually what I want to do. That's great. And CBTP can be really helpful for that. It can also be considered in the prodromal phase and in patients at high risk of developing psychosis. Even if someone's not prodromal, there are a lot of risk factors, genetics being one of them, that can put somebody at high risk. So cognitive behavioral therapy is not harmful to anyone that I know of if it's done correctly and compassionately. So they do advise it as a preemptive or a prevention strategy. The goal of CBTP is to reduce the occurrence of symptoms, the distress associated with them, and or the degree to which the symptoms interfere with their quality of life. In terms of interventions with cbtp, don't argue or try to reason with a delusional or hallucinatory experience. It's invalidating. Reinforce positive behaviors and improvements if somebody recognizes that their symptoms are their. Their hallucination is commanding them to do something that they really don't want to do. Acknowledge that. Commend that. We had several patients in residential treatment in substance abuse. A lot of times they started using in order to silence those voices or get rid of the hallucinations, whatever they were seeing or hearing. So when they got clean, guess what? Those hallucinations came back. And they weren't always able to get their medication right the first time through, and sometimes not able to completely eliminate the symptoms. Now, remember, this was 15 years ago when I was working in treatment. Hopefully they've come a little further. But I digress. I had one patient, I remember telling me that he was having this particular command hallucination that was very violent, and I'm not going to get into it. But he said, I, I don't want to do that, and I need to do something because I need to do something to silence the voice. And we would go. We would talk, we would go on a walk, and if he was talking, he wasn't hearing that voice. The other thing that worked for him and several other people we had that had auditory hallucinations, we was listening to music, and it was particularly helpful at bedtime. Remember, people with psychotic disorders often hear the voices more when they are drifting off to sleep. So for people who had auditory hallucinations, allowing them to listen to music with headphones as they were going to sleep was extremely helpful at improving their sleep quality. We just, we want to talk with the person. We want to try different things. We want to identify and monitor their thoughts and assumptions. In specific situations and to evaluate and correct these thoughts and assumptions against objective external evidence and actual circumstances. Remember, this is not in an acute episode and we don't want to push the issue. If we encourage them to look around and say, hey, you know, everybody else is wearing a coat and you're in shorts and a T shirt. You know, is that working for you? Are you comfortable? Or vice versa. If they're wearing a coat, nobody else's have them look at the objective external evidence and then draw a conclusion about what needs to happen. Especially if they're wearing a coat and, and they're just pouring down sweat. You want to say, is that really helping you feel comfortable? You also want to explore why are you wearing the coat? Tell me about that behavior as communication. Did their hallucination tell them to wear the coat? Do they believe, do they have the delusion that if they don't wear the coat they're going to be in danger? What's the meaning of the coat? Why are they wearing a winter coat in 90 degree weather? And then you can start to address it from that perspective. Remember, that perspective is their reality and it's not our right to invalidate their reality. We just, we can be there to pro provide alternative explanations. The behavioral components of the therapy aim to increase coping skills and reduce problematic behaviors. Relaxation training, graded exposure, scaffolding, activity scheduling, distraction techniques, problem solving with a token economy. All of these can be really helpful interventions to reduce stress, to help them cope when they start feeling anxious or when they start hearing voices or having hallucinations or delusions. That can all be super helpful. In a typical CBTP session, the person describes their psychotic experiences. The therapist focuses on a specific psychotic symptom by directing or creating a link between the predominant mood during this psychotic experience, thoughts, feelings, and behaviors. So the therapist is going to hone in on that anxiety, for example, and you started feeling like people were reading your mind when you got anxious. So let's, let's start drawing a connection between your mood state and the types of schema that it triggers. Underlying beliefs are explored by Socratic questioning in an empathetic manner. If the person believes the neighbors are dangerous, or people look at me every time I step out of my house, or people can read my mind, okay, what's your evidence? You know, tell me how you know this to be true. These beliefs are then analyzed and linked with the patient's past and present difficulties. We start helping them see how their beliefs may be causing them problems. But we also start seeing how their beliefs may have occurred or developed as a result of prior learning, prior trauma that they tried to figure out how to stay safe from. They're hearing these program tapes, if you will. In some cases, the patient is asked to analyze the alternative possible explanation for their beliefs. If the patient doesn't come up with an explanation, guided non judgmental explanations are provided. And if they disagree. Okay. Techniques for persistent delusions in CBTP include in the assessment phase, these initial sessions, not just the single session, but the initial five, six sessions, try to understand the patient's life as a whole, including past life events and patients reactions to them. A lot of times, not always, but a lot of times, the initial psychotic episode is preceded by a significant stressor and how the person encodes that stressor and the associated environment and people and themselves in that particular situation may contribute to or inform, if you will, their future hallucinations or delusions. We want to explore their pre delusional beliefs by asking about daydreams, fantasies and their usual perceptions about themselves, others and society. Prior to the psychotic episode. When you were a kid, what did you think about? What did you fantasize about? What did you daydream about? Children who? People, not necessarily children, people who spend a whole lot of time on active role playing games may actually integrate some of that and some of that may come out in some of their hallucinations and delusions. I am not saying that video games and role playing games are going to cause hallucinations and delusions. Don't get me wrong, I'm not saying that. But for someone who has a psychotic break, some of that stuff may get misconstrued and integrated into their hallucinations or delusions. We want to inquire about the antecedents and triggers to the onset of the delusions and or hallucinations. What was going on right before you started having this thought, right before you started being anxious about this. And discuss physical, interpersonal and emotional consequences of the delusions and their behavioral responses. This is where we're bringing it back to the cognitive behavioral and we're saying, all right, you're having this delusion. How? How's that working for you? And this is how you respond to having these delusions? How is that working for you? Is it helping you move towards your rich and meaningful life or is it alienating you or moving you away from the things that are important? Ask about evidence for the delusions. Okay, tell me about what makes you believe this particular thing and what is the evidence that you've got? What are the facts in this context? Can you elaborate. Help me understand. We want to be careful how we ask these questions. We don't want it to feel like an interrogation. We. We want it to feel like what it should be. And that's curiosity. Help me understand where this is coming from. Ask if there are any alternate explanations other than the ones that they're holding. If they're having a. A delusion that everybody is out to get them, you know, paranoid delusions. Are there any. Al. Al. Alternate explanations for. For why someone might be walking behind you on the street for three blocks? Ask about their level of shity. For previous beliefs and alternate explanations. How confident are you that this. This belief is accurate? And if you have other explanations, how confident are you that this belief is inaccurate? Or divide them up. You have three different alternatives. What percentage of your sureness is on this one? What percentage is on this one? And what percentage is on this one? Educate them about cognitive distortions. In psychotic disorders. A lot of the psychoses and delusional beliefs revolve or involve. Involve cognitive distortions. All or nothing thinking, catastrophic thinking, mind reading. Give explanations about the falsity of their assumptions and allow the person to agree or disagree with your explanation. We want to empower them. This is what I see or this is what I think might be happening. What do you think? Put it out there. They are living in their own skin. We're not to take away their power. We want to empower them. Similar practice sessions are carried out until the patient understands the link between their thoughts, beliefs, and behaviors, helping them practice and think about. You got anxious. You started thinking that people were staring at you. Then you went back into your house and wouldn't come out because you were afraid that they were judging you or criticizing you. Okay, so let's understand how a feeling triggered thoughts which triggered behaviors, or how thoughts trigger feelings that triggered behaviors. Homework assignments are given to identify and analyze similar experiences. Think about other times this week that you have felt anxious and you've had a hallucination or you've had a delusion. What was the connection? How did those work together? And how did it work for you? As the certainty of the patient about their beliefs begins to break down and more balanced and less distressing interpretations are developed, their stress is going to be reduced as they start to think, hey, all right. I still think this might be true, but I'm starting to see your point of view. Okay, great. We're not breaking them down. We're not forcing them over to our point of view. We're saying, just consider. And as they Start to consider the alternatives. That's where we can help them develop less distressing interpretations. What might be a compromise? Somebody's walking behind you for three blocks. Well, it could be that they're following you, or it could be that they're going in the same direction that you are. So what interpretations feel safest to you and how can you test this? For example, go into a store. If you're walking three city blocks, go into a store. If they go into the store after you, you know, then that's a whole different issue. But most of the time they're not going to do that. If they do, you know, maybe you went into a coffee shop and they went in right after you. Well, it's nine o' clock in the morning and the line for the coffee shop is seven people deep. Not surprising that that person might have also wanted to get coffee. So we need to help them be able to evalu how accurate based on the facts in context their beliefs are. And then behavioral experiments are carried out toward the end of the therapy experience, not a single session, but toward the end of therapy, three, six, nine months in, to test the accuracy of new interpretations and invoke cognitive change to the delusional beliefs. So we start having experiences where we have them go out and test their beliefs for persistent hallucinations and to a certain extent, delusions. Have them maintain a diary to monitor the triggers, mood states and the voices being experienced throughout the day. Help them develop distraction techniques, make them aware of the situations where and when the voices start and how they diminish. Help them start tracking the ebb and flow, if you will, of the hallucinations and delusions. And help the person recognize that the hallucinations or delusions may be a reflection of their attitudes about themselves or what they imagine others might be thinking about them. Recap. Physically, we need to reduce stress by making sure they're getting adequate quality sleep, they are getting adequate nutrition and managing their hydration, they're not getting too much caffeine. We want to make sure we evaluate any medication changes. We're not doctors, we're not going to change their meds. But if the doctor changes their meds and they start having symptoms, that's a clue. Interpersonally, we want to help them develop support as they feel they need it. Remember, they don't have the same oxytocin response. We want to help them develop assertiveness so they can communicate their need to other people. We need to address receptive language deficits, helping them assertively say, I don't understand what you asked or if they don't realize when they're not understanding, then we need to work with others around them to be more cognizant when this person is not understanding. We also need to address deficits in differentiating self from other. There's a lot of Piaget would say egocentrism in people with psychotic disorders and who are having hallucinations and delusions where they have difficulty differentiating what you're thinking or feeling or wanting to do versus what they're feeling, thinking or wanting to do. So if they're feeling attacked, then they may think that you're wanting to attack them emotionally. Stress and anxiety management and increase opportunities for positive emotions cognitively. We talked about a lot of interventions to help them when they're having difficulty with attention. We're not going to increase their attention. We need to provide reasonable accommodations to support deficits in attention. We need to provide them help with understanding cognitive distortions and fact based reasoning. We need to provide them supportive tools to help them deal with poor memory and poor executive functioning. The inability to plan and anticipate things environmentally reduce stressors people with psychotic disorders, particularly schizophrenia. But it's also prevalent in people with a variety of other disorders where they have sensory gating difficulties and it's difficult to shut out certain stimuli. They also may be hyper or hyposensitive to stimuli. So what you think is a really bright light might not bother them or what you think is a really dim light may be too bright for them. Any of that, any of those environmental stressors are stressors and they can be addressed. Add prompts in the environment to remind them to do things they need to and add opportunities for voluntary sensory distraction. What I mean by that is headphones if they're hearing voices, if they are having tactile sensations, something else that they can do, something else that they can feel so they're not focusing on that something else they can look at if they're having hallucinations, if that helps them feel safer. There are many causes for psychosis relapse as well as symptom breakthrough which need to be assessed and addressed. Stress exacerbates psychotic symptoms. Even in a psychotic state, people's behavior is goal, directive and communicative for them based on their reality. We need to motivate behaviors based on what is most rewarding for the individual. Most studies indicate that cognitive behavioral therapy for psychosis may not be effective during an acute episode but can be very helpful for the prodromal symptoms during remission periods and maybe even prior to the first psychotic episode. Thank you everybody for bearing with me and being here today. I hope you got something out of this that you didn't already know. Are there any questions? Foreign. Everybody, have a wonderful day. And if you want more information on this, I'm actually going to be converting it to a an on demand class that is I believe it's four hours that has the PDF of the journal article that has all of the steps in cognitive behavioral therapy with for psychosis. So if you're interested in that, keep an eye out for that on demand class that should be available early next week. Take care.