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The 42st National Conference of Child and Adolescent Neurology and Psychiatry and Allied Professions with international participation


PSYCHOTHERAPY IN ADOLESCENT PSYCHOSIS

Autor: Constantin Oancea Bogdan Budişteanu
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Objective

In practice, psychotherapy is a valuable help in the treatment of psychoses. The psychotherapeutic types of interventions should be phased in relation to the evolutionary stage of psychosis: acute, remission and recovery stage. In the acute stage of psychosis, there is a degree of psychotic tension and other threatening manifestations of psychopathology, felt anxiously by that part of the adolescent’s ego that remained integer (i.e. a complete entity). The patient lives confusedly the surrounding reality, too, more pronounced so, if the new, restrictive hospital environment represents this reality.

The psychotherapy conduct will be protective, providing encouragement to the frightened or depressed subject, with short sentences, smiles, without contradictions and with discreet travel restrictions. The entire stafii participates in this conduct, if possible care should be given by stable nursing personnel, allowing for the establishment of affective ties. Only in the early period of remission, when a conversation can be instituted, the therapy may proceed to a phase of explanations on the part of the doctor on the disease, without details to traumatize, underlining the transient nature of the remission, too, on condition that the patient accepts the medication.

In the recovery stage, a program will be formulated matching the current, clearly reduced, resources, which will be checked periodically, with medication adjustment and return to the family. It is important that, in the phase of returning home, the psychotic adolescent should be engaged in activities of all kinds in relation to his/her current capabilities. In parallel, the therapists will work with tutors to reduce the resonance of their anxiety with that of the adolescent’s. We insist on assigning responsibilities in relation to the patient’s mood, in personal care, in taking medicines. Current non-invasive medical treatments contribute substantially to creating an acceptable atmosphere around the psychotic adolescent.

Introduction

Psychoses are neurodevelopmental disorders characterized by: personality disruption, important alteration of the capacity to test the reality, formal thought disorders, impaired perception, affective flattening, apathy and aboulia. Their prevalence in children and adolescents is estimated at 2 per 100,000 inhabitants (Boeing, Cohen) [1,2]. They are an important health issue, both as clinical picture and prognosis.

At first glance, psychotherapy seems to be reserved for neurosis but, in practice, it is a valuable adjunct in the treatment of psychoses. Psychotherapeutic intervention is done in stages, in relation to the evolutionary stage of psychosis, distinguishing the acute stage from the remission stage and the period between episodes. Theoretically, supportive psychotherapy is used with different variants.

The communication style is gentle, encouraging, empathic listening to the adolescent is useful, without unnecessary disagreements, travel restrictions should be communicated by calm people, in a smiling manner. Supportive psychotherapy aims to strengthen and support the defence forces, the protective mechanisms in the economy of the human psyche, to help restore psychic balance by strengthening the Ego and to develop behavioural alternatives in order to ensure self-control and satisfactory adaptation to the living conditions.

Principles of supportive psychotherapy (Oancea, Peter Buckley) [3,4] include the following: unconditional and without reserve acceptance of the patient as a human being, distinct and equal in rights; elucidating the patient’s vision of the world and on his/her experiences from the perspective of his/her disabilities; the use this bridge to enable the patient to make possible changes in personality and accept wisely what has happened in the world around him/ her; ensure self-control and satisfactory adaptation to current conditions.

Supportive psychotherapy reduces anxiety and symptoms. In this context, Gill (1951) [5] developed short psychotherapies, that do not alter the patients’ defences with weak Ego. He claimed that one should never attack the defences that are necessary for the patient to continue to operate because unskilful therapy could do more harm emphasizing mental anxiety and disorganization.

Psychological defences must be preserved, even though they have become pathological (e.g. paranoid ideas) [3], it is not for the patients to be contradicted brutally during the florid psychotic episode, they must be encouraged to express themselves graphically and use their imagination (Nussbaum and Nussbaum, 2012) [6] which contributes to their clarification.

In dealing with the patients, unconditional support comes first, the subjects will be protected with calm and sympathy, will be encouraged and helped to go through this difficult period of their life, in the initial stage they will not learn about their problems and deficits.

The acute stage of psychoses

In the acute stage of psychoses, there is a degree of psychotic tension which is felt as threatening and painful by that part of the adolescent’s ego remained integer. The patient lives the surrounding reality in a confusing mood, there is an estrangement in the relationship between the psychotic patient and the rest of the world, from where he/she receives threatening messages (Marcelli and Braconier) [7]. The unfamiliar, restrictive environment of the hospital may exacerbate the confusion (Eggers) [8].

In the initial stage, pain, weakness, delirium, depression, regression, infantilisation, phobias should be accepted as such. Although suffering is visible, it will not be communicated to the patient because such remarks could be treated as criticism, emphasizing weaknesses and discouragement.

Organisational measures with psychotherapeutic component

As organizational measures, minimal information ought to be provided on the current state, stressing that it is a transient condition that requires treatment like any other disease, the support that the patient will receive from staff is highlighted. In remission stage, it is mandatory to have a clarifying discussion with the patient on what has happened to him/her, about the disease and its significance, symptoms and effects (Remschimdt) [9]. In relation to the mood, it should be insisted on volunteering for responsibilities in attendance, taking medicines and communication with outsiders. Non-invasive medical treatments contribute substantially to their acceptance by the adolescent and to creating an acceptable atmosphere around the psychotic adolescent.

The remission stage

In the remission stage, the ego’s strength and its capacity of assessing the reality will be tested and, in case they are found satisfactory, the moment of passing to the second stage will be established, the teenager will be considered not as a patient but as a person who can engage in solving his/her own problems. It will be claimed that he/she should assume responsibility and he/she will be stimulated to travel the long road of rehabilitation, with therapeutic support in solving his/her problems. It takes into account The current form of defect will be taken into account, as well as the cognitive deficit, and the difficulties with social relationships. In the teenager, an important role will be given to mediating the relationships with family, through the age specific conflict resolution. The youth has to be taught again to resume regular life skills and daily routines.

When confrontation is used with the patient in remission stage [3], it has the role of developing motivation to work with the passivity of the patient, in order to overcome it. It is an apparent therapeutic change, that lies within the concept of sustaining- supporting (eng. To support = to help, to stimulate, to keep something going).

Psychotherapy sessions after discharge

In conjunction with counselling sessions, W. Brautigam [10] supports the need for meetings after discharge with the aim of giving support, encouragement, reassurance, defining issues in connection to the chronic disease. An initial frequency from once a week, with gradual spacing leading to one session every 4-6 weeks is required. The art of that kind of therapy is maintaining the balance between the subject’s needs for infantile dependence, emotional contact and the preservation of a distance from the therapist. Expectations should not be too high; the patient who does not advance towards recovery will feel frustrated if pressed from the outside, feeling everything like an aggression. The therapist should assist in understanding and solving current situations, inclusively by the use of medication. Through these measures, the patient may remain in the normal life, avoiding hospitalization.

During long-term support, which can be maintained for years, a leading relationship (directive) is created. The customer needs transcend to the foreground and the current situation is analysed, clarified from the perspective of the disease, of its consequences and of certain future therapeutic interventions. Relationship with the therapist is a support pivot in the labyrinth of a twisted, unsatisfactory, often conflicting existence [3].

The subject is regularly reinforced through contact with the reference person (doctor, psychologist, psychiatric nurse) who is able to integrate complex information provided by the customer to provide solutions. The therapist will learn to listen, to understand what is happening outside of symptoms. The attitude should be more directive, persuasive, and encouraging.

The relationship with the patient’s family

In parallel, we will work with tutors to reduce the resonance of their anxiety feelings with those of the adolescent. Through information and emotional support, they become adjunctive instruments in the psychotherapeutic assistance of the patient. Informing relatives requires meticulosity, being reserved for person who has the higher grade, using few words at first, without unnecessary scientific terms, without worrying prognosis and statements.

Family psycho-education is very important, family thus becoming more compliant and more involved in the therapeutic process [3]. The contact with the family will be maintained, at least in the adolescent, concomitantly with the latter, but support sessions can take place in his absence, too, in case of difficulties in relationships with the family. After Remschmidt, therapy could take the form of guidance or family therapy is required [9].

The follow-up study, which was spread over five years (Rosenbaum et al.) [11], showed a better evolution of patients who , in addition to therapy, benefited from supportive psychotherapy. Programma 2000 (Italy) [12] – multimodal protocol of early intervention in psychosis – includes also, besides treatment, supportive psychotherapy, psycho- education and psycho-social interventions. Better results have been achieved in social skills, emotions control and negative symptoms.

Case presentations

In the following, we will present two clinical cases in support of the importance of the psychotherapeutic approach in psychotic disorder.

Case 1

The 13-year-old patient comes to clinic for: refusing food and fluids, auditory hallucinations, negativism, refusal to communicate, agitation, unmotivated screaming (feels like someone enters his body) with the onset of about 2 weeks.

From the anamnesis, we retain pre-morbid personality: shy character, tendency to isolation, poor social skills and emotional immaturity.

On admission, the patient was pale, had hollow eyes, psychic contact was difficult to establish, avoided eye contact, oppositionist, monosyllabic answers, the mother is very anxious, given the general state of the child.

He was placed in a side room, the specialist discussed more with the mother, to abate her anxiety and to involve her in the therapeutic process.

The mother was advised to avoid the anxious attitude, not to force him anymore to communicate, to try to comply with his need for privacy. She was also informed that it was a transient state, which would improve gradually. Under treatment with Olanzapine 7.5 mg, Depakine 300 mg, Zoloft 50 mg, with gradual resumption of food and fluids intake, with the disappearance of hallucinations and restlessness and the favourable evolution of the patient.

Towards the patient, the attitude was open, calm, positive, all his requests were fulfilled, as far as possible, (he was allowed to visit home after 7 days), potentially stressful situations or excessive strain were avoided, the only thing he was asked, was to take medication and accept the fluid intake (to avoid invasive treatments).

Given the pre morbid personality, scarce social skills and poor adjustment to school difficulties, he was recommended to start psychotherapy. He was assessed monthly. Currently, his evolution is favourable and the patient was reinstated in the class group.

Case 2

Patient aged 15 years, comes to clinic for: thoughts of being chased, suspiciousness, marked psychomotor agitation, potentially dangerous to others, undue aggressive reactions, anxiety, insomnia, affective inversion towards parents, impaired perception (rare auditory and visual hallucinations).

Pre morbid personality traits: shy, introverted character, perfectionist, poor social skills, the desire to assert himself in front of others.

On admission, the parents were very anxious and claimed that their life was in danger. Many times during the assessments, the patient asked for reassurance that he was not watched or listened to while his discourse was extremely critical of parents (coprolalia).

The following medication was instituted: Risperdal 3mg, Clopixol 15 drops, Romaprkin 3 capsules, Depakine Chrono 1000 mg, Levomepromazine 3 capsules, and, a few months later, Serlift was introduced.

At first, we discussed especially with the teenager who was nervous, anxious, and confused. In the early days, the patient’s compulsion to discharge himself and to express his discontent was observed; no criticisms of his discourse was expressed.

The patient stayed in the clinic for about 5 days; after that, at his and his parents’ request he had ambulatory assessment daily. When he asked to be assessed as outpatient, certain limits were set (he was to take the treatment, physical violence was prohibited, he was to return to the clinic in case he did not feel well).

The evolution was favourable, with the gradual reduction of vehemence and anxiety, relationships with parents improved, the patient gradually began to accept other points of view. He was discharged with almost complete remission of symptoms, and was to return every two months or whenever he felt the need for support.

He was subsequently seen at varying intervals (from 1 to 3 months) according to his evolution; sometimes he also suffered conditions that required a temporary increase in dosage, while the therapist’s discourse had always been positive, encouraging. For 2 years now, the patient has been psychiatrically balanced. Medication has been discontinued gradually for 1 year, in agreement with the attending physician.

Conclusions

There is consistent evidence showing the effectiveness of psychotherapy, family counselling and multidimensional intervention. A supportive attitude of both patient and family is very important. The therapist’s approach ought to be positive, gentle, tactful and showing understanding to the needs of patients. Clear information is to be provided, as synthetic as possible, overly pessimistic approaches should be avoided. In the first stage, the therapist will point out that it is a transitory situation. Later on, in the remission stage, more information will be provided, in a more accessible language. After the acute stage, confrontation can also be used to stimulate the patient and avoid his/her refuge in the disease and in an in­fantile attitude. Confrontation will be used only after obtaining therapeutic cooperation and depending on the adolescent’s residual capabilities. When remission is obtained, a long-term psychotherapeutic relationship will be initiated, where the position of the physician should be, most often, a directional one. Patient and family should be informed of the possibility of relapses but it will always be emphasized that these are transient. In conclusion, psychotherapy is an adjunct and a valuable tool in the treatment of psychosis and therapeutic approaches ought to be optimistic and to respect human dignity.

REFERENCES

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Correspondence to:
bbudisteanu@yahoo.com