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       Ask The Doctor

Early Intervention Models for Psychosis

NAMI partnered with the National Council for Behavioral Health to deliver a webinar about implementing early intervention models for psychosis. Leaders from around the country shared how different models work and their experiences running clinics. NAMIís Darcy Gruttadaro shared the role that family organizations play in early intervention and Dr. Ken Duckworth shared his experience of working in a first episode clinic.  Here is a link to the webinar recording

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QUESTION:

 

My son is 33 years old; he was diagnosed with the severest from of Bipolar Disorder in 2004. He's been hospitalized 6 times since. Each time upon discharge, he complies with medications for up to 2 years, until there are a pile up of negative stressors (bad news from his ex, death of a family member, too many hours working, not enough sleep, etc).

 

Recent research that indicates that the reason why persons diagnosed with Bipolar tend to self-medicate with alcohol, illegal drugs, simultaneously taking themselves off of prescribed medications for their brain disorder; isn't because of stubbornness, giving up on themselves, or the weight gain associated with these medications.

 

Instead, it has been suggested that parts of a  person's brain has been impaired or damaged, i.e. amagdala and hippocampus. These areas help regulate our emotions and good decision-making. Neuroscientists have concluded that the neurons in these areas of the brain have been impaired. And, new neurons may not be able to be rejuvenated quickly. What are your thoughts on this?

 

Also is the impairment due to the organic brain disorder, substance abuse, a combination of both, and make poor decisions as a result? Or, is it that persons diagnosed with this disorder as a result of neuron impairment make poor choices and decisions?

 

My son has been off of medication for 8 months, and is now in the penal system. He is not receiving psychological care or medications. He has been cycling from mania to extreme mania to psychosis, and has yet entered the depressive stage. Is it true that even though he's manic; he may very well be depressed? How long can a person remain in a manic state without further damage to the brain? Will a person ever come down from a manic state without medications? And, doesn't a person risk other serious health issues, if they don't?

 

It is my belief, that when a person with this disorder articulates too themselves or others that they're getting off of medication; that they're not thinking rationally.

 

Unfortunately, many therapists, counselors, etc, don't agree, saying it is a conscious choice.  And, the person hasn't hit rock bottom yet.  Really?

 

 

ANSWER: There is a lot behind these questions which warrant further exploration and discussion, but to go to the heart of at least one of the issues raised here: how can we help someone who continues to make poor decisions, even after they have presumably hit bottom and are sitting in the penal system?  Why does he continue to make poor decisions when overwhelmed with the predictable, albeit major, stresses that most us have to periodically deal with?  The question of what causes these problems (e.g. brain damage due to drugs, the illness, temperament) is really secondary in my mind since we do not really know the answer, though it is an interesting issue.

 The answer to the first two questions, many of us believe, is to help the person to develop better coping skills when under stress. These can include an array of options from briefly increasing medications, requesting a short hospital stay or brief stay at home, learning relaxation skills or methods from cognitive or dialectic behavioral therapy (commonly known as CBT and DBT), having and following a WRAP plan, or maintaining a support group.  Each of these steps requires some degree of ownership of the illness by the consumer, as well as the associated belief that he has the ability to manage his life when under stress.  In most cases, adjustment to the illness may require the person to markedly alter or even give up some of their dreams which can be incredibly painful for anyone to face, especially if they have already had to handle so many disappointments. Consumers stop their medications, become manic and use substances because these provide an escape, and also indirectly express their frustration with the world.  In the moment, they may think substance use is the rationale thing to do. And if the person has no ability to deal with stress or think others are responsible to protect them from relapses, it perhaps makes sense to them.

 It is important for each family to work together and with care providers to try to assess what they can do to support and encourage the person to move forward, and where to draw the line to avoid unnecessary frustration and grief.  In particular, it is important to recognize that many consumers (and normal young adults) want to hold their families responsible for not giving them the life they think they deserve, long after the family has lost the ability (if they ever had it) to do so. It is important to express love and concern, and perhaps to intervene in certain emergencies, while at the same time trying to empower the person to develop confidence around handling situations that only they are in a position to address.

 

QUESTION: Is it possible for a 21 year old to have most dementia symptoms without memory loss? My son was diagnosed with type 1 diabetes at age 14, rapid cycling bipolar at 17, and had a infarct lunar thalamus stroke at age 19.  A year later he began losing his cognitive skills, gets very confused when he tries using his brain, and has many of the symptoms of dementia besides memory loss.  Can this be the start of dementia? 

 

ANSWER: I'm sorry to hear about your son's struggles.  "Dementia" is a word that indicates the loss of cognitive functioning.  The most common cause of dementia is Alzheimer's Disease, which develops in late adulthood and is always associated with memory loss.  Strokes can cause cognitive disturbances too, including memory loss, language problems, attention problems, and confusion.  Neuropsychological testing can help determine what cognitive changes your son might have, and a neurologist can help with diagnosis and treatment.  Since strokes can cause cognitive changes, it would be important to learn what caused the stroke.  Best of luck.

 

QUESTION: Does the cognitive deficit in persons with schizophrenia make them more at risk to develop Alzheimers disease?


ANSWER: There is no established additional risk for individuals with schizophrenia to develop Alzheimer's disease.

 

QUESTION: What is being done to correct the cognitive deficit in persons with schizophrenia?


ANSWER: Cognitive symptoms are now recognized as critical targets for treatment by researchers, clinicians, the National Institute of Mental Health, and the pharmaceutical industry as we know that cognitive deficits account for much of the disability in schizophrenia.  Several initiatives are underway to evaluate the effectiveness of new medications and cognitive training programs on the cognitive deficits experienced by individuals with schizophrenia and other psychotic disorders.  These studies are being conducted at research centers across the country, including Northwestern University. 

 

Several studies have established that the cognitive deficit observed in schizophrenia is present at the time of onset of the illness and tends to remain relatively stable over time, including into later life.  Further studies that follow elderly patients with schizophrenia over time are needed to establish whether the age related changes in cognition are more pronounced in schizophrenia.    

 

Questions may be submitted to namiil@sbcglobal.net.