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Schizophrenia: Crises Situations and Management

When caring for Schizophrenics some events can create a crisis situation. Here are some common crises situations that need to be handled with sensititvity. Some of these are

  • Suicidal thoughts or attempting suicide.

  • Recurrence or worsening of symptoms.

  • Poor Compliance: Refusal to take Medication.

  • Violence and aggression.

  • Wandering tendencies

  • Sudden illness or untimely death of care giver.

  • Medical Emergency/Surgery etc
  • Suicidal Thoughts / Attempts

  • Reasons

  • Assessing the Risk

  • Talking Suicide

  • Attempting Suicide

  • Preventing Suicide
  • Why Does The Patient Think Or Attempt Suicide?

    • Patient could feel very depressed and feel the life as worthless.

    • A feeling of persecution leading to contemplation of attempt at suicide.

    • Patient could attempt suicide, acting on auditory hallucinations.

    • Confused thoughts can drive them to seek relief through suicide.

    • Attempt suicide impulsively.

    Is the person contemplating Suicide?

    A schizophrenia patient could be thinking of taking his life if he/she:

    • Often talks / writes about ending life.

    • Expresses a feeling of being worthless constantly.

    • Facing major stresses in life such as failure in exams/marriage/job etc.

    • Attempts suicide during relapse.

    • While remitting from illness if the patient is confronted with major setbacks

    • It is often not possible to anticipate suicide.

    When There Is Persistent Talk Of Suicide:

    • Do not ignore the persistent talk of suicide. Be alert to the patient's conversation, the sleep pattern and changes in behavior.

    • Try to keep the patient calm through reassuring conversations.

    • Inform the psychiatrist about the problem immediately.

    • Contact the nearest GP to deal with the situation.

    • If this is not possible, arrange to admit the patient in a hospital, as advised by your psychiatrist.

    • Keep all medicines out of the patients' reach.

    • Do not leave the patient alone.

    If The Patient Has Attempted Suicide:

    1. Rush the patient to the nearest hospital for first aid medical care.

    2. Be sure to take the psychiatrist's prescription to the hospital along with you.

    3. Inform your consultant psychiatrist and the social worker in charge of the patient.

    Preventive Measures

    • Ensure drug compliance through supervised medication.

    • Maintain contact with the treating Psychiatrist and the social worker as often as possible.

    • Engage the patient in all household activities.

    • Motivate the patient to make him/her feel worthy.

    • Reassure frequently and allow for regular interaction.

    • Discuss with the treating psychiatrist the possible cause and the preventive measures to be adopted in future.

    Relapse

    A relapse occurs either when there is an increase in severity of existing symptoms in the patient or a recurrence of symptoms which have been under control. Previous symptoms may recur or there may be evidence of new problems. It may occur quite suddenly but can be triggered by gradual changes in relationship between the patient and the family.

  • Causes

  • Identification

  • Dealing with Relapse

  • Prevention
  • What Causes a Relapse ?

    • When the patient faces a stressful situation, something he can not cope with, for example: failure in exams, critical remarks from caregivers on the failure.

    • Patient discontinuing medication, refusal to take medication.

    • Care giver altering / discontinuing medication, ignoring the psychiatrist's advice.

    • Patient moving to a stressful environment for eg. he has moved to a new place, which is not to his liking.

    • Sometimes a relapse can occur despite adequate medication and with no precipitating factors.

    How Does One Identify A Relapse ?

    Symptoms under control may reappear, or worsen. New symptoms may occur. Some of these are:

    • Restlessness, fear, complaints of difficulties in concentration.

    • Changes in sleep pattern leading to sleeplessness.

    • Changes in behaviour - patient becomes irritable and quarrelsome.

    • Changes in mood - talks or laughs to himself, more frequently.

    • Refuses to take medicines / food.

    • Becomes quite excited / agitated / disturbed / depressed.

    • Evidence of a change in behaviour: Eg: unusual mannerisms.

    • Deteriorating personal hygiene (refusal to brush teeth, shave, groom the hair, etc.)

    • Remaining in bed for long periods.

    • Refusal to co operate in all matters (household activities / going to work etc.)

    • Withdrawal from the company of friends and relatives, starts brooding.

    • Wanders away from home.

    • Expresses suicidal thoughts and ideas.

    How To Deal With A Relapse?

    • Learn to identify early symptoms of relapse. Usually, symptoms which were present in earlier episodes recur. At times new symptoms may occur.

    • Ensure that the patient has not missed his/her dosage of medicines.

    • If found that he/she is not taking medicines properly, begin supervising closely.

    • Increase the dosage by immediately seeking psychiatric advice.

    • If you are able to identify any stressful situations, make changes to defuse the crisis as soon as possible.

    • If you have problems handling the patient, admit him/her in the nearest hospital. Keep the consultant psychiatrist/social worker informed.

    How To Prevent The Occurrence Of A Relapse In Future

    • Do not neglect the medication. Maintain the dosage and timing systematically. Discuss the need to review medications as or when the need is felt.

    • Help the patient discuss freely and frankly about his/her discomforts in dealing with people/situations.

    • Be kind but firm with the patient.

    • Encourage the patient to undertake regular activities during the day; praise and motivate.

    • Ensure a regular follow up with the psychiatrist and case manager.

    Poor Compliance: Refusal to take Medication

    Medicines are essential to control signs and symptoms of schizophrenia and may be required to be taken over long periods.

    Realising that medicines have to be taken all through the life, a person suffering from schizophrenia could sometimes give up taking medicines. At times, he may adjust medication according to his convenience against medical advice. Sometimes, he may be very irregular with doses.

  • Reasons

  • Assessment

  • Dealing with the Situation
  • What Are The Reasons For This?

    • Patient may feel better and decide that he does not need drugs any more.

    • The patient becomes distressed by the side effects of the medicines.

    • The patient tends to believe that medicines are in no way helpful.

    • The patient may be forgetful and tends to skip the prescribed dosage.

    • The patient cannot afford medicines.

    • The patient feels that because of medicines his activities have slowed down.

    • Lack of supervision by carer. Refills not timely.

    How Would You Know That Patient Is Not Taking Drugs Or Is Irregular?

    • Patient adamantly refuses drugs.

    • Early signs and symptoms of relapse are seen.

    • The patient may be throwing away drugs / spitting them out, without the carer’s knowledge.

    • A surprise check on medicines may reveal the patient is not taking dosage as advised.

    How Can You Deal With This Situation?

  • When you suspect the patient is showing early signs and symptoms of relapses, supervise the medication immediately and ensure compliance under compulsion.

  • Contact the local psychiatrist for further action. If the patient continues to refuse taking medicines and you already have a prescription for injections, your nearest general practitioner can administer the same till you can see the psychiatrist. Ensure drug compliance by either injectable form of medicine or by liquid medication until the situation improves.

  • If patient refuses drugs because of side effects, a change in drugs may be tried. Discuss this with the psychiatrist.

  • Later, upon recovery, the patient may require education on the need for medicines.

    Aggressive or Violent Behavior

    Aggression or violence is a display of unpleasant behavior by the patient This includes being irritable, angry, abusive, reacting physically by beating, breaking objects etc.

  • Reasons

  • Assessing the Situation

  • Dealing with the situation

  • Dealing with the Agression
  • What Are The Causes Of Such Actions?

    • Patient gets provoked by family members who are critical or instructive and are viewed as critical/ irritating in nature.

    • Patient is faced with a stressful situation which he finds difficult to manage.

    • The patient could have stopped medicines and relapsed.

    • Voice that the patient has been hearing may be urging him to behave in a violent manner.

    • The patient could be acting out on his delusions or false beliefs that of being persecuted, harmed or controlled.

    • Even ordinary day to day life situations can provoke / irritate him.

    How Can One Recognise That The Patient Has Become Violent / Aggressive?

    The patient could be increasingly

    • Restless.
    • Irritable.
    • Demanding
    • Use abusive language.
    • Show a tendency to be physically violent.
    These may occur just before the patient turns violent / aggressive.

    How To Deal With Such A Situation?

    In the event of a violent or aggressive behavior.

    • First ensure that medication is being taken properly.

    • Make sure to prevent the patient being provoked in any manner.

    • Make sure to remove dangerous objects such as knives, sticks etc. from the scene.

    • Get in touch with the psychiatrist or case manager for appropriate advice.

    • If advised injections, the nearest GP could be requested to give injections.

    • Hospitalise if necessary.

    Dealing with Agression

  • Ensure that every one moves away from the scene till he calms down.

  • Try to have a control over the situation by remaining calm.

  • Do not argue or quarrel with him.

  • Try to get the neighbours to control and overpower the patient if such a need may arise.

  • Try to administer liquid medication in some fluids.

  • If all the measures fail, get a GP to administer injections. Contact your psychiatrist immediately if hospitalization is required.

    Wandering Tendencies

    At time the patient may wander away from home, without intimating the caregiver. There may be no information about his whereabouts.

  • Reasons

  • Dealing with the Situation

  • Preventive Measures

  • Why Does A Patient Wander Away ?

    • He could be responding to the voices that he has been hearing.

    • The patient could feel threatened and presecuted and my prefer to get away.

    • There may be no identifiable reason.

    • The patient may have relapsed.

    • He may be confused.

    • May want to get away from a stressful situation.

    How To Deal With This Situation?

    • If the patient has wandered away in the past, you should be alerts, for it may be repeated.

    • If he is found missing, call up places where he usually frequents for e.g. the homes of relatives / friends.

    • Ensure that somebody keeps a constant watch on him,

    • Consult the doctor if prescription needs to be revised.

    • If the patient is not traceable, you may lodge a complaint with the police.

    To Prevent Wandering In The Future:

    • Keep a constant watch on the patient.

    • Inform relatives and friends familiar to the patient about his wandering tendencies. Request them to inform the family if he arrives at their place.

    • Make sure that an identity card is present on the patient's person.

    Sudden Illness Or Death Of The Care Giver

  • Illness of the Primary Caregiver

  • Death of a Primary Care Giver

  • Such a situation, occurring suddenly, can cause a severe stress in the patient which may manifest in the form of either a relapse / aggressive or violent outbursts / depression and grief/ withdrawal from day to day activities / decrease in social interactions etc. At times, the patient may just not show any response at all due to blunting of emotions.

    How Can Other Care Givers Deal With Such A Situation?

    In the event of sudden illness in the primay care giver:

    • New care giver can go along with the patient to the treating physician, reassure the patient. The secondary care giver and other family members must be tolerant of the patient.

    • Inform the treating facility (Especially the patient’s psychiatrist and case manager) regarding the problem. A change in medication may be needed. A short term hospitalization or admission to a residential facility may be required.

    • If the patient cannot be admitted, efforts must be taken to see that some other family member supervises the client's medication.

    • If the patient is stable, he can be involved in the care of the primary care giver in an appropriate manner.

    • If the patent is admitted to a hospital/residential facility, he must be periodically visited and informed about the care giver.

    In The Event Of Care Givers Death:

  • Patient's grief should be acknowledged and he /she must be provided emotional support.

  • The psychiatrist and case manager should be informed.

  • Efforts must be taken to see that someone supervises the patient's medication regularly.

  • Long term responsibilities of the family with regard to the patient must be discussed. Legal formalities like transfer of pension, change in trust deed etc. can be initiated with the help of the case manager.

  • Follow ups with his doctor must not be missed.

  • If a crisis situation arises, it should be handled ably, without panic. The following must be done:

    • Contact the patient’s doctor

    • If the doctor/counsellor are not within reach, contact a General Practitioner.

    • Admit the patient in a hospital or a treatment facility.

  • Medical Emergencies

    Mentally ill patients can also suffer from other medical problems. Emergencies like appendicitis may warrant hospitalization and even surgery.

    Should such a crisis arise, the caregiver must

    • Inform the specialist about the mental illness and the medicines that the patient has been taking.

    • Inform the psychiatrist and seek their opinion with reference to change in dosage.

    • Ensure that psychiatric medicines are at no point of time discontinued but adjust the dosage as is convenient to facilitate continuation of treatment by seeking appropriate guidance from both the specialists.

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