Responding to Schizophrenia Symptoms - Mental Illness Policy Org
Responding to Schizophrenia Symptoms2018-08-22T17:38:47+00:00

Understanding and responding to symptoms of schizophrenia

(This is not medical advice. Do not rely on it Discuss with your doctor. This page contains several articles including advice on handling someone who is experiencing paranoia, denial, stigma, hallucinations, delusions, demoralization, negative symptoms etc )

Schizophrenia is a (biological) disease (of the brain) that ebbs and flows. Acute periods are called “relapses” when patients experience sensations that are an addition to their usual repertoire of feelings. Because they are additions, they are referred to as “positive symptoms” but they are far from positive in the sense of being wanted. They are the hallucinations, delusions and thought confusions which return periodically, triggered, probably, by a variety of stresses. They respond, in general, to decreased stimuli, calm interactions, and antipsychotic medicine.

Interspersed between the acute periods are various stages of convalescence during which patients frequently experience “negative symptoms”. These are subtractions from the normal repertoire of feelings such as loss of interest, loss of energy, loss of warmth, loss of humor. In general, these do not respond to medical interventions but require more difficult psychological assistance. (Note: Since this note was written, clozapine, resperidone and other drugs have been introduced which may help with negative symptoms.)

Hallucinations

Hallucinations are false perceptions, inaccuracies that affect our senses and cause us to hear, see, taste, touch or smell what others do not. In the acute phases of schizophrenia, patients are likely to insist they are hearing voices that no one else can hear. Sometimes they hear noises, clicks or non-word sounds. On occasion they are disturbed by seeing, smelling or feeling things that others do not.

Descriptions of these perceptions differ. Sometimes they are experienced as very forceful and apparently important thoughts. Frequently they seem to come from outside the self and are heard as conversations between other people, or commands, or compliments (or insults) addressed to the person. Sometimes the voices are reassuring, at other times menacing. Often the remarks heard are not addressed to the person but seem to be concerned with them in an unclear (but perhaps derogatory) way. Individuals who experience this describe it “like a tape playing in my head”.

The experience is so real that many people with schizophrenia are convinced someone has implanted a broadcasting device in their bodies. Or they come to believe in a supernatural explanation for the strange sensation. It is so real to the person that it cannot be dismissed as imagination. During periods of convalescence, patients are in control of their “voices”; they can often summon and dismiss them at will. Or they may learn to ignore them, or treat them as benign accompaniments of everyday living. But during acute periods, the hallucinations, usually the same ones over and over, take control and the patient feels victimized, powerless, at the mercy of a “foreign presence”.

Patients themselves, and those close to them, must recognize hallucinations as symptoms of illness.

Discussions about their objective truth or plausibility are not valuable. The experience is true and very vivid and has to be accepted as such. Attempts to “set the person straight” result in resistance, tension, and bad feelings. It is, however, helpful to clarify that others do not hear, see, smell, or feel what the patient is experiencing. This helps to identify it as a special experience of the patient whether he can or cannot accept it as a symptom of the illness. At least everyone can agree that something is happening.

Hallucinations respond to a lessening of stress and an increase of antipsychotic medication. Keeping busy is important as it provides helpful distraction. Competing stimuli can sometimes “drown out” the voices. Encourage the patient to discuss when the hallucinations occur and what they say with his therapist. This can clarify the nature of the stress that tends to bring them on.

Another useful strategy is to point out to the patient that he has some control over the hallucinations. Often, unconsciously, the patient has developed the habit of listening for his voices, as if he were a passive recipient. Directing his mind to other interests, and helping him recognize he need not wait for incoming voices, can be surprisingly effective. These are techniques that the patient develops for himself over time and that require a fair amount of trial and error. Encouragement to persevere, not to give up, to discuss things with the therapist and reassurance that the family and close friends understand, are important.

Constant talking about hallucinations can be exasperating but it is understandable that the patient is preoccupied with such extraordinary events. Chronic hallucinations must be accepted as part of everyday life and are not usually sufficient reason to excuse participation in activities or household chores.

Delusions

Delusions are false beliefs or misinterpretations of events and their significance. For instance, a person may get accidentally bumped in the subway and may conclude that this is a Government plot to harass him. He may be awakened by noise from his neighbors apartment and may decide this is a deliberate attempt to interrupt his sleep. Everyone tends to personalize and misinterpret events, especially during times of stress or fatigue. What is characteristic of people with schizophrenia however, especially during an acute period, is that the conviction is fixed and alternate explanations for the events experienced are not even considered.

Usually attempts at reasoning or discussion about possible other meanings of the bumping or the noise in the night can only lead to the further conviction that the reasoner must be in on the plot, too. Arguing with a delusion only leads to further mistrust or anger. The beliefs are tenaciously held, against all reason, and they are characteristically not shared beliefs. They are held only by the person himself and by no one else.

Families and friends must first realize that delusions are a result of illness and not stubbornness or stupidity. Although fixed delusions can be irritating, emotional reactions should be avoided, as should taunts or threats. There is almost always something about the delusional belief that can be empathized with.

For instance: “Getting bumped in subways is very annoying. It must make you feel as if no on cares, no one pays attention, that you’re not important enough to get an apology or an ‘excuse me’.”
(Presumably the belief that one is at the center of a government plot must derive, at least in part, from the fear that one is really very unimportant or worthless.)

Or: “Getting awakened at night is terrible. It’s so hard to get back to sleep later. It saps you of all your strength. If you feel your neighbor is not your friend, it is important to be strong and healthy.” (This kind of reasoning may persuade a person to seek medical attention and/or an increase in his medicine in order to be strong and fend off annoyances by others. It works better than saying, “You’re deluded, and you had better see the psychiatrist.”

Another approach is to help cut down the stimuli that lead to delusion formation.

If crowded subways bring on experiences that lead to persecutory ideas, avoid them. An emergence of delusional ideas, whether persecutory or grandiose (thinking one is special) usually means there is too much activity or emotion, perhaps too many people around.

Example: “I think I am Jesus.” Unhelpful response: “That’s totally irrational. You’re crazy.”
Helpful Response: “I guess you feel really special and different today. Maybe it’s all the excitement around here. Let’s try a very low key routine for the next few days.”

When well on medication, if the person persists in talking about left over delusions, a helpful response would be, “That’s how you see things. I have explained that I don’t agree–we will have to agree to disagree.” (This acknowledges his view yet stops pointless discussion.)

Talking Nonsense

This generally occurs when a person is in the active phase of his illness. It can re-emerge sometimes when medications are too low or stress is too high. What the patient says becomes incomprehensible to those around him either because sentences are unconnected to each other, or else because there seems to be no point to the stories told, or else because topics seem to switch with great frequency.

Words may take on special meanings in schizophrenia either because they trigger private associations or because attention is paid to individual sounds rather than hole words. For instance “psychiatry” may sound like “sigh Kaya tree” and the topic may switch suddenly from a discussion of psychiatry to a discussion about mystical trees. Certain words may be avoided because they sound harsh or evil.

Sometimes intonations are changed for similar reasons. Sometimes language is used as an incantation to ward off threats. Difficulty making sense to others is a symptom of the acute phase of the illness. It is almost impossible to communicate with patients when they are in this phase and it is very frustrating to family.

Try to communicate non-verbally.

Sometimes communication through writing works, as thoughts tend to be more organized in writing.
Do not force yourself to listen and understand; it will usually lead to headache and irritation.

When talking to others, however, do not speak as if the patient were absent. Do not tease or mimic him.

Most people use one side of their brain for language and the other side for art or music or movement. If the language side is disturbed, it might be a good idea to concentrate on the other side and encourage patients to draw, sing, or play an instrument, to exercise or dance. These are other ways of communicating which might prove to be effective.

Like other positive symptoms, thought disturbances respond to a reduction of stress and an increase in antipsychotic medication.

Preoccupations

These are fixed ideas, not necessarily false (like delusions) but overvalued. They take on extraordinary importance and take up an inordinate amount of thought time. One idea often returns and returns. Frequently it is a worry about doing the right thing or doing it well or in time. Characteristically, the worry grows and becomes unrealistic. A common sequence of events is for the worry to take up so much of a person’s time that the “right thing” does not get done and its not being done is then attributed to the bad motives of others. Or it may be rationalized as God’s wish. OR, frequently, the person may decide he’s physically unable to carry out the task.

Example of unrealistic explanation: “I can’t get up because I’m paralyzed.” “I’m supposed to stay in bed today because it’s the Lord’s Day.” “If I get up, I’ll get hurt.”

These kinds of explanations sound odd to others but to the person with schizophrenia they seem warranted. They do not understand why others see them merely as “excuses”. To them they explain the facts better than any other explanation. Sometimes these preoccupations have a mystifying character to them. They seem to require puzzling over and decoding.

The person with schizophrenia spends much time in this kind of puzzling activity and that is why he thinks he has solved mysteries that others haven’t, since they spent no time at it. When lost in thought, people with schizophrenia do not want to be distracted. They feel they have important work to do to try and come to the bottom of the puzzle and they do not appreciate offers of conversation or shared activities at those times.

Preoccupations are usually seen in the active phase of the illness but may continue into the convalescent stage. They may take the form of daydreaming.

They must not be allowed to control the life of the patient or the life of those around him. Distraction is helpful as is a structure or daily routine that does not permit too much time for sitting and thinking. The necessities of life: sleep, good food, exercise, fresh air, cleanliness, health and social interactions must be maintained. Preoccupations must not be allowed to interfere. Increased meds may be required.

Violent or Aggressive Behavior.

This is not really a symptom of schizophrenia but when it does occur, it tends to occur in conjunction with hallucinations, delusions, preoccupations and jumbled thoughts. It, too, is triggered by stress and abates when antipsychotic medication is taken in appropriate amounts. Violent behavior is much more frequent in mental disorders that have nothing in common with schizophrenia. It is described here mainly because patients and families are so frightened of it and it leads to so much dread and worry.

It is most common in young men. It can be precipitated by psychological or chemical stimulants.
Violence against others is often a result of misinterpretation of their intent and a resultant feeling of being cornered. A person in the acute stage of schizophrenia may exaggerate other’s irritation and misread it as fury. He may see ridicule in what is meant as jest. He senses himself in danger when he is not and may strike out under those circumstances.

Violence against the self is more common and is discussed under depression. In an attempt to prevent violence, try to avoid blame, ridicule, confrontation, teasing, or insult.

Allow your person with schizophrenia relative privacy and psychological distance. Should violence erupt, however, do not allow yourself to be intimidated by it. Take whatever measures are necessary for the safety of everyone concerned. This may require firmness or help from friends and neighbors. It may require summoning the police. Let the patient’s therapist know if violence erupts at home. Ask the therapist for pointers on how to help the patient develop self-control. In addition, always maintain an up-to-date list of helpful community resources

Although violence is not common is schizophrenia, it may become a pattern with some people with schizophrenia. If so, discuss appropriate living arrangements and appropriate anticipatory and preventive measures with the therapist.

Restlessness

Restlessness, anxiety, tension and agitation are words describing similar states. None of these are positive symptoms of schizophrenia but, like aggressive behavior, they tend to occur in conjunction with the positive symptoms. They may result from fear and apprehension, as a response to the frightening aspects of hallucinations and delusions. If this is so, they require quiet, calm reassurance. Patients who are so anxious about what is happening to them need to have someone near to provide explanation and stability. The reduction of stress and the introduction of medicines will reduce anxiety as well.

Restlessness that begins after the patient is started on medication may be a secondary effect of the drugs. This kind of restlessness usually appears as a shaking of the legs and a need to pace the floor. Patients may be seen to move from one foot to the other or, when sitting, shake their legs up and down on the ball of the foot. At the dinner table, this constant motion may cause the whole table to shake.

Another commonly observed movement is tremor. This is a rhythmic contraction of muscles, usually seen in the extremities. The tremor is usually not particularly bothersome to the patient unless he plays the piano or uses the typewriter. The restlessness, however, is very uncomfortable. The patient has some control over it, can stop it for a few moments at a time but it comes back the instant he lets his attention waiver. It can be quite agonizing for some patients and needs to be reported to the doctor who can change the dose of antipsychotic drugs or add side-effect medicine which will make this restlessness disappear. The same procedures will reduce the tremor that is secondary to the medicine.

After many years of antipsychotic drug use, some patients develop other kinds of movement disorders, usually jerky movements around the mouth and extremities. These are not usually uncomfortable but can be unsightly. The prescribing doctor must be made aware of them and will adjust the dose of the drugs accordingly. These movements are more difficult to control. They may, in fact, become worse for a time after the drug dose is lowered. In most cases the movements gradually wane if the drugs can be discontinued for a prolonged period but that is sometimes risky because the patient may become acutely ill again.

Restlessness and tension, whether psychological or secondary to drugs, is made worse by stimulants (coffee, tea, cola drinks, chocolate, cold tablets). Sedative medication helps but should only be used with the advice of the prescribing doctor. Understanding helps. Do not criticize the patient for pacing. Instead, try accompanying him for a walk, encourage exercise, jogging and bicycle riding. If the pacing becomes unbearable in the house, suggest other areas, outside the home, where the patient might walk about without disturbing others.


How to manage 5 common symptoms of schizophrenia

Abbreviated version of article in  May’95 issue of Hospital and Community Psychiatry. 

Individuals with schizophrenia often develop five symptoms that are difficult for the individual, parents, brothers, sisters, professionals and others to deal with. The symptoms are paranoia, denial of illness, stigma, demoralization, and terror of being psychotic.

The following may be helpful in dealing with these syndromes. These ideas presume the availability of and belief in psychopharmacologic treatment. Medication management should be reviewed regularly


6 steps to handling paranoia

1. Place yourself beside the consumer rather than face-to-face. 

The side-by-side position tends to deflect the paranoid fears away from you. Instead, both you and the consumer are looking out at the (hostile) world together. This positioning technique may improve the chances that you will form a working therapeutic relationship with the consumer early on. Don’t stand directly in front of the individual. That may be considered confrontational.

2. Avoid direct eye contact. 

Direct eye contact often makes a paranoid individual feel even more so. Look elsewhere.

3. Speak Indirectly. 

Avoid speaking directly to the consumer. Substitute pronouns such as “it”, “he”, “she” or “they” for the words “I” and “you”. Like the body positioning, the purpose is to deflect the consumer’s paranoid projections away from one-on-one interactions with the case worker. Instead, paranoid symptoms are directed towards external and more general “real world” issues.

4. Identify with, rather than fight, the consumer. 

Whenever possible, your attitudes and emotional expressions should parallel the consumer’s attitudes and expressions. The goal is to help the consumer feel understood. Meet anger with reciprocal anger, frustration with frustration (i.e., you also express anger and frustration with the difficult circumstances). Your own emotional expressions should be taken up to the point of, and perhaps slightly beyond, the consumer’s own emotional expression to show your on his/her side A paranoid individual is not thinking rationally and your attempts to rationalize will not likely be successful.

5. Don’t rationalize. 

Share mistrust. The intuitive approach with a paranoid person is to try to persuade him or her to be more trusting. It is often better to do the opposite; that is, for you – along with the consumer – to mistrust the world together. No attempt is made to correct or contradict the consumer, or to test reality. Temporarily, the consumer’s account of reality is accepted as reality. The assumption behind this technique is that, in the midst of a paranoid state, the consumer is overburdened and overwhelmed by a mixture of real-life stresses and distress from psychotic symptoms. While carefully avoiding collusion with the psychotic symptoms, you should attempt to find certain believable or credible aspects of the paranoid belief system. This allows you to agree with the consumer on something. You then move on to a symptom area, attempt to substitute a less paranoid, more benign (and general) explanation for the more highly personalized paranoid one. The process of exchanging more malignant to benign paranoid beliefs is best done in a step-wise fashion, where the alternate explanation is only a notch less paranoid than the previous one. The eventual goal is for the consumer to tell the case worker, “Don’t be so paranoid.” Ms. C. blames her last hospitalization on a police conspiracy to terrorize her. Rather than confront her with her own behavior that led to her being arrested, her case manager agrees that the police cannot be trusted and goes on to talk about his own outrage at the Rodney King case. By the end of the conversation, Ms. C. tells the case worker to stop treating the police so unfairly!

6. Postpone Psychoeducation.

A consumer in the midst of a paranoid state often cannot tolerate psychoeducation, as he or she is unable to acknowledge to others the existence of a psychotic illness. Rather, the consumer will deny the illness and blame others for his or her difficulties. Until the consumer is strengthened, and the paranoia lessened, no attempt should be made to identify, correct, or argue with the consumer about paranoid or delusional symptoms. Until a sound alliance is formed, you should avoid the more traditional psychoeducational approach that teaches about illness and benefits of medication.


How to help with denial of illness

If psychotic, treat the individual:

If the denial represents a symptom of an acute psychotic episode, the consumer should be managed as an acute relapse with hospitalization and/or increased medication. If they are denying that they are sick, they will also most probably deny treatment. The only way to treat someone over objection is to get them involuntarily commited to an inpatient unit (NYS does not offer involuntary outpatient treatment). The only way to have someone committed to an inpatient unit is to have them declared a “danger to self or others”. This is not easy to do. AMI/FAMI is working on changing the laws to make it easier to get treatment to those who need it before they become a danger to self or others. Your help is appreciated.

Avoid Overzealous Attack on Denial

When the denial of illness is chronic and seems unrelated to relapse, the first step is to determine whether the denial should be addressed at all. Denial of illness may not be harmful as long as the consumer is otherwise doing well and is compliant with treatment. Indeed, several studies have shown that consumers who deny their illness see themselves as having more purpose in life, are more optimistic and have fewer affective symptoms. This is a difficult concept for families to accept. But denial of illness often only needs to be addressed if it is causing a problem.

Provide Alternative Explanations.

If denial has to be addressed, it should be addressed indirectly. Enlarge the consumer’s perspective by helping the consumer acknowledge the existence (or at least the possibility of) different points of view. There are 4 steps to accomplish this.

Step 1. Recognize the consumer’s point of view. Assume the consumer’s point of view is believed in, even cherished, highly learned, or overdetermined. For example, if the consumer says “I’m not sick, its others who are sick and making up these stories about me” , hold off from disagreeing. Instead, you should think (but not say to the consumer) ‘let me assume this statement is true. Now, in what way can this be true?’ This kind of thinking can assist you with the task of assuming that the denial is a reasonable response from the consumer’s point of view. In this context, you can acknowledge the consumer’s beliefs as being one “point of view” – even if delusional – without having to collude with them.

Step 2. Establish that the consumer’s view is only one point of view. After you have comprehended the consumers rationalization of the denial, the goal here is to establish with the consumer that people can have legitimate differences in viewpoints and opinions, and that people can “agree to disagree” without taking personal affront at the disagreements. Discuss nonthreatening issues (e.g., recent political events, sports, music) and come to an understanding that different opinions are acceptable and a part of life. Then, you can bring up that it is acceptable to hold different points of view about the consumer’s own situation or need for treatment.

Step 3. Supply an alternative. This step marks the first time denial is directly addressed. You suggest alternative explanations in a way that leaves the consumer a way to disagree without getting into a power struggle with you. Be respectful: Feel why it is necessary for the consumer to take the position of denying the symptoms. For example, you may broach a new topic with something like “Other people have found that … is it possible that this is true for you.”

Step 4. Anticipate setbacks after successfully addressing denial. When denial of illness abates, be prepared for trouble ahead. Demoralization, sense of failure, or despair often follow. The most striking example is development of suicidal despair during the period when the recently-psychotic consumer is regaining insight. This is often triggered by setbacks, such as repeated rejections in finding a romantic partner. Denial may have been protective, shielding the consumer from attributing the setbacks to his or her symptoms. When the consumer becomes aware of his real-life defeats, show how apparent defeat sometimes represents real progress. Success and progress frequently go unnoticed; even the most striking success can be viewed (by the consumer or you) as a failure. Often, the hidden success is the willingness and courage to make an attempt.


How to help overcome stigma

Many consumers will not admit to stigma because an admission is equated to acknowledging that they suffer from a “mental” illness. Therefore, stigma’s presentation is often indirect: A refusal to participate in treatment or programs. (Note: refusal to participate may also come about because the program is inappropriate, ineffective, or otherwise substandard-ed.). Stigma may also lead to substance abuse, where having psychotic symptoms in the setting of “getting high” is seen as “normal”. Stigma may also be the underlying cause of unrealistic expectations such as an seemingly foolish attempt to overreach vocational goals (for example, a very poorly functioning and symptomatic consumer signed up for pre-law exams). Stigma can explain the commonly seen paradoxical situation of when the consumer seems to deny illness but voluntarily takes antipsychotic medication.

Stigma may be greatest in consumers who had good pre-sickness functioning, who come from higher socioeconomic backgrounds, and among consumers whose families have trouble accepting the person’s diagnosis. Acknowledge the stigma, normalize the consumer’s experiences, support self-esteem, and help save face. Help the consumer recognize how normal he/she is. Stigmatized consumers tend to attribute all of their struggles to being ill, an attitude that fosters greater stigma and isolation. Normalizing the consumer’s experience, as much as possible, can be very helpful. Many consumers idealize the lives of “normal” people. These consumers do much better if they know that many of the “trials and tribulations” of life are experienced by so-called “normals”.

Talk about yourself.

Talking about yourself is a way of normalizing the consumer’s experience. It allows the consumer to compare his or her frustrations with yours. Use concrete examples taken from your own life (e.g., trouble with authority, experiencing failure) to assure the consumer that not all of his or her difficulties come from illness. You should not patronize or trivialize the consumer’s real-life difficulties (for example, getting a mediocre grade in a course is not a comparable setback to dropping out of school because of mental illness). Avoid disclosing socially taboo or overstimulating topics (for example, sexual issues).

Use Performative Speech.

One technique that works very well is the use of performative statements. Performative speech refers to statements that derive their power simply from being made, providing that they are made by the right person under the right circumstances. Should the consumer not acknowledge the authority of you, then the performative statement can be given by someone else with credentials that are acknowledged by the consumer. Help consumer ‘save face’. Blunt or direct use of emotionally-laden psychiatric terms may backfire when used on stigmatized consumers. Often, the consumer is confronted with “psychoeducation” before he or she is ready. Be tactful. Use descriptors rather than medical terms. Ex. “psychotic symptoms” instead of “schizophrenia,” and “suspiciousness” or “sensitivity” instead of “paranoia”. Find a face-saving way to explain humiliating events. For example, someone brought in in handcuffs after walking naked in the streets may accept an explanation like “you know, being naked is upsetting to many people” rather than “you know, you were exhibiting bizarre psychotic symptoms”.


What to do about demoralization

Often, demoralization occurs after the psychotic phase. This paper will assume that the consumer does not have a depression or neuroleptic-induced akinesia which is causing it. Demoralization often is a function of failing to meet societal or familial expectations (e.g., shame over not achieving higher education goals). Not achieving these expected goals then affects all other aspects of the consumer’s self-esteem. For example, a consumer who has to drop out of college because of schizophrenia may go on to depreciate all of his or her remaining intellectual gifts. Depression is common. Self-deprecating trends can be recognized by a tendency to comment negatively on one’s performances. There is an accompanying tendency not to blame others. A central difficulty of this assessment is consumer’s frequent reluctance to disclose any feeling of stigma, low self-esteem, or self-deprecation.

Maintain a Positive Attitude

A hopeless attitude is a major problem for many family members and people with severe neurobiological disorders. It is very important to maintain morale and hope; otherwise, the consumer’s attitude will be a reflection of your’s, leading to a vicious circle of demoralization.

Use Admiring and Approving Statements

Statements of admiration have special power when used sincerely. While this may seem obvious, in practice it is common to see problems stressed at the expense of strengths. One way to assist in sincerity of admiration is to consider, and reflect to the consumer, the inner strengths needed to keep on going with life despite having disabilities. The use of admiring or approving statements can backfire. There are two common traps: the first is insincerity and making patronizing remarks. Choose only admiring statements that are genuine and sincere; allegedly “admiring” statements are frequently said in a degrading or sarcastic tone, especially by professionals who are accustomed to focusing on psychopathology, not strengths. The second trap is to be discouraged by the subsequent rejection of the admiring statement. Expect initial rejection; in fact, the consumer’s disowning of approval suggests that you are “on target”.

Give/Get Education about Negative Symptoms

Negative Symptoms of schizophrenia (apathy, inertia, etc.) can mimic or cause demoralization. When a consumer understands that these are symptoms of the disorder, they may feel better. Use medical language in this case. Laziness becomes avolition, tiredness becomes apathy, and lack of appreciation becomes anhedonia. How to help someone overcome the terror of being psychotic Many consumers are terrified that they can no longer find or maintain coherent mental functioning. What often follows is a desperate search for normal mental functioning combined with an attempt to hide this struggle from other people. Be aware of how bad the terror can be and how common it is. Recognizing terror depends upon a number of familiar signs. Because consumers often can’t or won’t verbalize their terror; it is all too easy to ignore this problem, or become indifferent to it. You need to look for indirect evidence of terror. Thoughts are scattered or dissociated; feelings are volatile, inappropriate or absent, and behavior unpredictable or contradictory. Management of Terror: The goal is to decrease the sense of terror and despair that comes with awareness of being psychotic. Treating the reaction to loss of normal mental functions requires an intervention that, in some respects, is not easily described. Ask the consumer about being frightened, and state that you would be frightened under the same circumstances. The knowledge that someone else can recognize the sense of terror without it having to be explained can be tremendously reassuring. Perhaps the greatest difficulty facing you is to understand the extent of the consumer’s desperation while, at the same time, not to become overwhelmed by it.Reassure

While obvious, this simple measure is often overlooked. Help reassure the consumer that the fear is normal, and that the psychotic experience – although terrible – will improve. Avoid false cheerfulness, which will be picked up as feigned.

Provide Companionship.

Even when verbal communication cannot be reciprocated, companionship can be very helpful in reassuring the consumer that he or she is not completely alone. While in the presence of the terrified consumer, proper physical positioning is important. You should remain slightly to one side and avoid staring; one aims for an easy accompanying. An air of quiet confidence is also needed because anxiety is contagious. Little should be said except occasional reflections about what must be experienced by the consumer’s presumed state of mind. Words like “wandering”, “aimless”, “frightened”, “bewildered”, or “vulnerable” might be tried to see if the consumer can acknowledge any of these states. These attempts to make contact with the withdrawn and frightened consumer are best rendered by combining these descriptions with short empathic statements such as; “How awful.” or “It must by frightening.”

Leave the Consumer Alone.

Paradoxically, at the same time as offering companionship, you need to be able to leave the consumer alone. The skill here is to know how to be able to sit with the consumer and, at the same time, give the consumer enough emotional space. It is important to avoid being intrusive. Some emotional distance should be maintained because anxiety over excessive verbal interventions or interpersonal closeness can exacerbate psychotic symptoms. Too much activity, emotional reaching toward the consumer, or inquiring about symptoms can backfire by overstimulating the psychosis. Many mental health professionals and family members have trouble with the notion of being alone with a consumer, feeling that being quiet together means that they are experienced as indifferent or hostile. Actually, being alone with the consumer doesn’t feel like that at all, and the consumer is able to sense the difference. Everyone is an individual No two individuals, consumers or otherwise are identical. Knowing the consumer is the first step towards helping.

Posted at Mental Illness Policy Org. https://mentalillnesspolicy.org/