Post-Psychotic Adjustment State

New York — A psychotic episode is a traumatic event, and what appears to be a subsequent psychotic decompensation may actually be an understandable part of the emergence from a life-shattering psychotic experience, Ms. Mary D. Moller said at a meeting of the World Association for Psychosocial Rehabilitation.

In some cases the patient may be suffering from post-psychotic adjustment state, or PPAS, said Ms. Moller, clinical director of Suncrest Wellness Center, an outpatient psychiatric clinic in Nine Mile Falls, Wash, who has been collaborating with Carol S. North, MD , professor of psychiatry at Washington University School of Medicine in St. Louis, Missouri in the development of these concepts.

An accurate differential diagnosis is essential for appropriate treatment. Not all patients who report hearing voices or seeing things are necessarily suffering from psychotic illnesses such as schizophrenia or bipolar disorder. People with trauma-related and personality disorders are known to report these kinds of experiences also commonly leading to misdiagnosis of psychotic disorders. Inappropriate treatments applied to these patients can dramatically alter the course of their lives.

She outlined four symptom presentations to consider before making a definitive diagnosis: primary psychosis and related symptoms, primary trauma and related symptoms, co-existing post-traumatic stress disorder and a primary psychotic disorder, and PPAS, which is not to be confused with psychosis or PTSD. Unfortunately there is a popular trend in the literature to classify the postpsychotic state as PTSD. Careful application of the DSMIV TR criteria for PTSD to descriptions of patients in postpsychotic states clearly demonstrates that the presentation is quite different and does not meet diagnostic criteria for PTSD.

PPAS is a phenomenon that is as old as schizophrenia but has been neglected, having never been formally described or studied before. It is a changing state and will never be a diagnosis.

Too often, PPAS has been treated as relapse or an exacerbation of schizophrenic symptoms. This has serious implications for treatment because exacerbations and relapse in psychosis are typically managed with an increase or change in medications. Whereas PPAS is best treated with therapy and social services. Ms. Moller said.

PPAS describes the sadly neglected aftermath of psychosis. PPAS is characterized by intense interpersonal feelings such as fear, failure, humiliation, shame, anxiety, and anger associated with the psychotic episode. The fear – particularly of symptom return, medical treatments, and inability to regain or maintain control – can be the most debilitating aspect of the state.

The onset of PPAS is variable however, there are some common patterns. In the first few months, PPAS patients who remain in treatment, may slowly lose interest in trying to recover. They may undergo a number of medication changes only to find that things aren’t working, and they often appear clinically depressed.

Toward the end of the first year patients may get so caught up in trying to manage symptoms they are unable to successfully plan and carry out normal activities of daily living such as going to school or work. One patient described this as only being able to "think in the now" . Treatment fails to engage the patient in any discussion of their emotional state in the aftermath of the psychosis, Ms. Moller explained.

In the second year if PPAS continues it enters the persistent phase characterized by loss of interest in established life goals or repeated failure in obtaining those goals. These symptoms often appear to be apathy, but actually represent loss of personal courage to persist in the face of what feels to be repeated failure. After repeated treatment failures it is easy to understand why patients with PPPAS may have difficulty trusting treatment recommendations, Ms. Moller said.

Patients vary in their presentation, but the reluctance to move forward with life, profound sadness, and hopelessness are common.

The chronic fear associated with PPAS can be immobilizing. Many of these patients complain they sleep poorly. These conditions impair the ability to perform normal activities of daily living. Many patients relapse in these circumstances. They may also have an impaired ability to understand treatment recommendations and difficulty adhering to treatment Ms. Moller noted.

PPAS may be further complicated by drug abuse, alcohol misuse, financial problems, interpersonal difficulties, lack of social support, and victimization. Treatment essentials include 1) establishing an empathetic, trusting relationship, 2) establishing an effective medication and therapy regimen, 3) opening a gentle discussion of the emotional aftermath of the psychotic episode,4) constructing a hopeful future through encouragement and reinforcement that the emotions experienced are understandable, 5) determining the meaning of the psychotic event to the person’s life, and 6) focusing on the future once the patient becomes comfortable with the "facts of the present," Ms. Moller said.