Schizophrenia — Dealing with a Crisis

From the the World Fellowship for Schizophrenia and Allied Disorders (WFSAD):

Sooner or later, when a family member has schizophrenia or a major affective disorder, a serious crisis [may] occur. When this happens there are some actions you can take to reduce or avoid the potential for disaster. Ideally, you need to reverse any worsening of the psychotic symptoms (psychotic means out of touch with reality) and provide immediate protection and support to the ill person.

Seldom, if ever, will a person suddenly lose total control of thoughts, feelings and behaviour. Family members or close friends will generally become aware of a variety of behaviour which gives rise to mounting concern: sleeplessness, ritualistic preoccupation with certain activities, being suspicious, unpredictable outbursts, etc.

During these early stages a full blown crisis can sometimes be averted. Often the person has ceased taking medication. If you suspect this, try to encourage a visit to the physician. If this is not successful (and the more psychotic the person the less likely it is to be so) you should contact the physician by telephone or by a note dropped off at his office [or by email] in order to get advice. [And call the Mental Health Mobile Crisis Team at (902) 429-8167 or 1-888-429-8167 (toll free in Nova Scotia.]

You must also learn to trust your intuitive feelings. If you are truly frightened, the situation calls for immediate action. Remember, your primary task is to help the patient regain control. Do nothing to further agitate the scene.

It may help you to know that the person is probably terrified by his/her own feelings of loss of control over thoughts and feelings. Further, the "voices" may be giving life-threatening commands. In the person's mind messages may be coming from light fixtures; the room may be filled with poisonous fumes; snakes may be crawling on the window.

Accept the fact that the person is in an "altered reality state". In extreme situations the person may "act out" the hallucinations, e.g. shatter the window to destroy the snakes. It is imperative that you remain calm. It is also imperative that your relative get medical treatment. While waiting for medical help to arrive (or before attempting to take your relative to the hospital) the following suggestions may prove helpful:

• Remember that you cannot reason with acute psychosis.
• Do not express irritation or anger.
• Don't threaten. This may be interpreted as a power play and increase assaultive behaviour by the person.
• Don't shout. If the psychotic person seems not to be listening, it isn't because he or she is hard of hearing. "Voices" or deluded thoughts are interfering.
• Don't criticize. It will only make matters worse; it cannot possibly make things better.
• Don't squabble with other family members over "best strategies" or allocations of blame. This is no time to prove a point.
• Don't bait the person into acting out wild threats; the consequences could be tragic.
• Don't stand over the person if he/she is seated. Instead, seat yourself.
• Avoid direct, continuous eye contact or touching the person.
• Comply with requests that are neither endangering nor beyond reason. This provides the person with an opportunity to feel somewhat "in control".
• Don't block the doorway. However, do try to keep yourself between your relative and an exit.
• Decrease other distractions immediately — turn off the TV, radio.
• Express understanding for what your relative is experiencing.
• Speak quietly, firmly and simply.
  

Should the psychotic episode involve violence, there may be no time for all the above strategies. Do not be hesitant to call the police [dial 911]. Tell them that your relative has schizophrenia. Explain what you are experiencing and that you need the help of the police to obtain medical treatment and to control the violent behaviour. Instruct the police not to brandish any weapon. If you are alone, be sure to contact someone to come and stay with you until the police arrive. The doctor who has been involved with the care of your relative should be advised of the situation as soon as possible.

Because a crisis often comes without warning, a plan should be made before it happens. Call you local police station and advise them that your relative has schizophrenia and can act in bizarre ways at times. Let close friends or neighbours know that you may call upon them for help if things get difficult. Then keep a list of the names, addresses and telephone numbers of these special people handy. If a crisis arises, you will be prepared. (You will not have to worry about your pets, the other children, etc.)

When you have weathered one crisis, your family may try to find the reasons it happened. It is normal for people to want explanations. It is important that the family does not blame itself or anyone else for the ill person's behaviour. Very little is understood about why crises occur and why violence can be so unpredictable. One factor is important: continuous taking of medication considerably reduces the risk of relapse and possible crisis.

Recognizing a common genetic syndrome: 22q11.2 deletion syndrome

An article in published in the February 12th edition of the Canadian Medical Association Journal. To download the entire article (PDF) click here.

Below is a quote from the article authored by Ronak K. Kapadia, BSc,* and Anne S. Bassett, MD.**

*Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia.
**Clinical Genetics Research Program, Centre for Addiction and Mental Health, Department of Psychiatry, University of Toronto, Toronto, Ontario.

22q11.2 deletion syndrome, previously known as DiGeorge syndrome or velocardiofacial syndrome, is the most common microdeletion syndrome known (estimated prevalence of 1 in 4000 live births), yet it remains underrecognized, especially in adults (1,2). Clinical variability, multisystem disease, subtle features, lack of medical genetics services, the recent availability of molecular cytogenetic testing in 1994 and, most importantly, the unfamiliarity of clinicians with this syndrome all contribute to delayed and missed diagnoses. Clinic visits and admissions to hospital present opportunities to diagnose 22q11.2 deletion syndrome, but without knowledge of this syndrome and its features, patients will not receive the correct diagnosis.

The deletion is hemizygous (affecting only 1 chromosome) and involves the 22q11.2 region of the long arm of chromosome 22. In most newly diagnosed cases (> 90%), and in our case, the parents are unaffected because this is a de novo mutation. Both parents of patients with 22q11.2 deletion syndrome should be tested for the deletion because expression may be mild (1). Fertility is generally unaffected in individuals with 22q11.2 deletion syndrome. Patients with a confirmed diagnosis require genetic counselling about the 50% chance of transmitting the deletion with each pregnancy and about the wide range of congenital and later-onset conditions associated with this syndrome (1). Common later-onset conditions include endocrine disorders, such as hypothyroidism and hypoparathyroidism (1), and schizophrenia or schizoaffective disorder (about 25% of cases) (1,2).

Bold emphasis is mine.

References

1. Bassett AS, Chow EWC, Husted J, et al. Clinical features of 78 adults with 22q11 deletion syndrome. Am J Med Genet A 2005;138:307-13. [Medline]
2. Bassett AS, Chow EWC. 22q11 deletion syndrome: a genetic subtype of schizophrenia. Biol Psychiatry 1999;46:882-91. [Medline]
   

Changing the Name Schizophrenia

From the World Fellowship for Schizophrenia and Allied Disorders:

The World Fellowship for Schizophrenia and Allied Disorders is conducting a survey: Changing the Name Schizophrenia. The issue has been talked about for years and continues to crop up. It is an important time to ask this question, as the DSM is being reviewed (it will be published in 2012) and changing the name of schizophrenia is one of the items being considered. While it is a diagnostic and treatment-based decision, the impact is much broader than just diagnosis and treatment.

We need to add our voices to the debate, letting the reviewers know how family, people with the illness and other mental health professionals feel. We want to gather a broader range of opinions than is typically gathered when this question is posed - around the world and to all of the stakeholders, and also give people a chance to say 'this is important' or 'this is a waste of time'.

It will take just a few minutes to complete the survey. Simply click here.

Useful References

Renaming schizophrenia (2007)

Schizophrenia can and should be renamed (2007)

Change is required; but name or attitude? (2007)

Renaming schizophrenia: a Japanese perspective (2006)