.Psychosis involves one or both of the following:

• Hallucinations. Hallucinations occur when you hear, see, or otherwise sense something that is not actually present. Auditory hallucinations occur when something is repeatedly heard that others do not hear, most commonly voices. Voices can be loud or quiet, aggressive or gentle, sudden or predictable.  Visual hallucinations involve seeing something that others do not see. These experiences may include seeing shadows, people, animals, or other figures. Less frequently, other types of hallucinations occur. These include tactile (feeling something on the skin or inside the body that isn't there), gustatory (tasting something foreign or inexplicable), or olfactory (smelling something with no known cause). 
• Delusions. Delusions are fixed, false beliefs to which you hold strongly and which interfere with your normal cognitive functioning. Examples could be believing that you are being followed, or that your phone is tapped. These are examples of persecutory delusions. They can be accompanied by hallucations, such as seeing someone following you or hearing someone tampering with your phone. Other types of delusions also exist. Delusions of grandeur involve believing you are special and different from others, have been chosen to perform special tasks, or are being given special sorts of information. Delusions of guilt or sin involve beliefs that you are unforgivable and/or should be punished.  Erotomanic delusions involve beliefs about others being in love with you. Delusions of reference involve placing unusual significance on specific objects, people, or events in your environment. 

Psychosis is not a mental health diagnosis, but rather a set of symptoms that accompany a diagnosis. Schizophrenia, schizophreniform disorder, and brief psychotic disorder are three diagnoses distinguished only by the duration of time symptoms have been present. They each include either hallucinations or delusions, may include disorganized speech and/or behavior, and may include what's called "negative symptoms" which manifest as lack of emotional or behavioral expression. Negative symptoms include decreased interest in activities, decreased speech, decreased social interaction, or decreased ability to experience pleasure.  Schizoaffective disorder involves the symptoms of schizophrenia listed above, with an accompanying mood disruption like depression or mania.  Delusional disorder involves delusional thinking without the symptoms listed above that indicate schizophrenia-related disorder. Depression and bipolar disorder in their most severe forms can include psychosis as well. 

Psychosis can be induced by substance use, and usually pass once intoxication passes. Most notably, methamphetamine, hallucinogens (particularly synthetics like K-2), and stimulants like cocaine can induce symptoms that look like psychosis. Acute alcohol withdrawal can also produce psychotic-like symptoms, and should be treated immediately.  

Some medical conditions may also induce psychosis. The most notable conditions in which this may occur are endocrine and metabolic disorders, autoimmune disorders like lupus, and temporal lobe epilepsy. 

Stay tuned for another post on treatments available for disorders that include psychosis. In the meantime, here is a helpful page from the National Institute of Mental Health on schizophrenia.

Sleep is so important that almost every single diagnosis in the Diagnostic and Statistical Manual for Mental Health Disorders (or DSM) has a disrupted sleep component to it. That's why I ask every client about sleep on the initial paperwork when entering counseling. I have conversations about sleep so frequently in counseling sessions, I decided I needed to gain more information and new ways to explain what happens while we are sleeping. There happened to be a great article about this topic in the November issue Counseling Today, a periodical published by the American Counseling Association. 

It turns out there are two critical periods to your sleep cycle. The Stage 3 NREM phase is crucial for physical health. Your immune system and cells regenerate. It's called recovery sleep. The system in the brain which creates the stress response (the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system) is powered down. We spend the most time in this kind of sleep and it seems to be akin to recharging our batteries. 

The Stage 4 REM sleep phase enhances our emotional health, allowing us to keep our feelings in check so that we can function in our day. Emotional memories are encoded during this phase and are separated from the actual emotional response, allowing us to retrieve these memories from a distance and not get so overwhelmed in them again, as if they were happening all over. People with trauma histories have a particularly disrupted Stages 3 NREM and 4 REM cycles, resulting in the inability to process memories and deactivate the stress response. 

See the below graphic for more details about all the stages of sleep.

For more on sleep hygiene and an excellent sleep diary, visit the National Sleep Foundation. You can improve your sleep by avoiding caffeine, alcohol, and heavy meals in 2-3 hours leading up to bedtime. It also helps to have a bedtime ritual at the same time every day, engaging in an activity like reading, relaxation exercises, gentle stretches or drinking herbal tea in the hour before bedtime. And exercise in the early afternoon seems to have a positive effect on sleep quality. 

Here's to a restful night's sleep!  

In order from most restrictive to least:

1.      Medically Managed Inpatient

• Supervised detoxification and stabilization under the care of 24/7 medical staff
  
• Provides safety when detoxing from substances like alcohol, benzodiazepines, opioids
• Helpful when clients have complicated medical conditions and co-occurring substance abuse and mental health conditions

2.       Inpatient or Residential (IP)

• May or may not include 24/7 medical care
• Involves a stay at the facility or hospital while receiving treatment.
• Can last from overnight, a few days, weeks, or in rare cases a month or more.
• Usually receive medical care, individual counseling, group counseling, family counseling, recreation, all meals
  

3.       Partial Hospitalization (PHP)

• Involves spending most all of the day at the facility or hospital, but evenings and nights are spent at home
• Usually receive medical care, individual counseling, group counseling, family counseling, some meals
• Removes you from your everyday environment without the added cost and time of spending nights
• Must have a stable and healthy home environment
  

4.       Intensive Outpatient (IOP)

• Involves 3-6 hours per day at the facility or hospital
• Involves group, family, and individual counseling, might share a meal
• Appropriate for those who need a high level of care to support a change in everyday living but need to maintain their work or school schedule
• Must have a stable and healthy home environment
  

5.       Outpatient (this is what Flourish provides)

• Weekly counseling sessions for family, individual, or group
• May or may not involve collaboration with physicians for medication management
• Focus may be on abstaining from substance use or problematic behaviors, and preventing relapse 
• Focus may be on “harm reduction”, or decreasing the amount or frequency of substance used
  

6.       Prevention and Early Intervention

• Information is provided to the general public about mental health and substance abuse
• May be used with  individuals experiencing life stress that may lead to substance abuse or mental health diagnosis

Health care professionals can help you make the best decision for what level of care is most appropriate. The first step is reaching out and letting us know what you're going through. We are here to help.

Aging can be a difficult process. Between aches and pains, forgetfulness, diminished independence, and career and retirement worries, getting older can be complicated and scary. Roles are often reversed between parents and children, as elders become less able to take care of themselves and adult children take on increasing responsibility as caregivers. Sometimes, though not always, dementia and other cognitive diseases accompany the aging process and the end of life. Through working in hospice with families managing these illnesses with their loved ones at the end of life, I've compiled some helpful information. Let's go over the basics.

First, according to Alzheimer's Association at Alz.org, dementia and related disease affects more than 5 million people in the US, and disproportionately affects women over men. There are many different types types of diseases that involve dementia and cognitive decline, and lots of medical terminology describing the different symptoms you may see. 

Dementia is a general term referring to a decline in mental ability accompanied by memory loss, difficulty communicating, and disorientation to people, places, or things that were once familiar. The distinct types of dementia result from the different areas of the brain that are affected. 

Alzheimer's disease is a form of dementia caused by abnormal proteins around brain cells, beginning in the hippocampus which is responsible for memory. The disease has distinct stages with a progressive decline in mental functioning, with the hallmark first symptoms being the inability to learn and retain new information. Someone in the initial stages of Alzheimer's may experience mild forgetfulness or difficulty choosing the right word in conversation. Over time, organizing and managing daily tasks becomes harder, remembering things that happened a short or long time is harder, and communication with spoken and written words becomes more difficult. Difficulty using language is called dysphasia or aphasia. 

The middle stages of Alzheimer's disease can involve wandering behavior and increased disorientation. The individual may have lapses in memory of details of their lives, like their name or address. They may need to be reminded how to dress properly for the weather, or prompted to initiate daily tasks like eating, bathing, or going to appointments. They may become unable to cook independently, leaving pots over lit burners, or leaving the gas on the stove. Risk of becoming lost and being unable to return home increases during this stage.

In the final stages, the loved one loses recognition of family members and caregivers by name, though they may recognize familiar vs. unfamiliar faces and have flashes of intact memory. Their personality may change dramatically. They may become verbally and physically aggressive. They may become incontinent, needing assistance with toileting and feeding. The ability to use and control muscles is diminished and they are unable to move about on their own. They may have difficulty swallowing, and their immune system is compromised. If you want to learn more about the signs, symptoms, and stages, click here for a 10 sign of Alzheimer's checklist. I will describe other forms of dementia in later posts, including vascular dementia and dementia with lewy bodies.  You can learn more now about these conditions by visiting the Alzheimer's Association Dementia page here. 

Now let's turn to caregiver grief. Grief is an important concern for family members witnessing the mental decline of a loved one, especially for those responsible for helping with day to day tasks.  Depending on the severity of the illness, family members may choose to care for the patient at home or move them to an assisted living or nursing facility. There are many different levels of retirement and nursing facilities. Let's go over some of the terms used to describe them.

Many retirement communities offer services on a continuum based on need. Independent living is at the least restrictive end of the continuum. The patient has their own apartment within a retirement community, is responsible for their own meals and daily schedules, but have access to amenities like transportation, social events, activities, and common social areas. Assisted living is a next step when patients' needs become higher, and involves helpers in the home to assist with tasks like cleaning, meal preparation, medication adherence, and assistance with bills. Some facilities provide all meals in a dining hall type environment for those needing this level of care. Skilled nursing is an added service in some facilities when patients' medical conditions require daily health monitoring.  Memory care is an even more intensive nursing environment for dementia, where patients are typically confined to one area of the facility to prevent wandering, and are monitored 24/7 for medical need. Hospice care is offered in addition to any of these levels of care when patients are diagnosed with a terminal illness and expected to live less than 6 months.

Some families decide to keep patients at home throughout the course of illness, with family members primarily responsible for looking after the patient's day to day needs. Home health and hospice care can provide additional support to family in the home. Some families hire private health aides in addition to home health or hospice to give family members a break or allow them to continue working. Many primary caregivers become exhausted with the round-the-clock care that dementia patients require in the late stages of their illness. Because caregiver burnout is common, the importance of self-care can't be over-stated. I will dedicate future posts to this topic.

As patients with dementia are unable to do things independently, become combative, and sometimes dramatically change personality, caregivers and especially their adult children, must adjust to the loss of the person/mother/father they used to know.  Because the loss of the relationship happens gradually through the mental decline but before death actually occurs, the grief process is unique and starts early. I will write future posts on this topic, but in the meantime for more information, visit the grief section of AARP's caregiving website.

Look for future posts on other types of dementia, caregiver self care, and caregiver grief. And as always, if you or someone you know if suffering from grief of any kind, please call a counselor.