Family and Caregiver Schizophrenia Discussion Forum

Discussion of APA Schizophrenia Practice Guideline Statement 1: Assessment of Possible Schizophrenia

See the document here

Thanks, @caregiver1, for starting this discussion group. In Statement 1 I particularly appreciated the acknowledgement of the patient’s views and goals:

“Throughout the assessment process, it is important to gain an understanding of the patient’s goals, their view of the illness, and preferences for treatment.”

I’m thankful my son has insight and the ability to express himself. I try to remind him to make the best use of his psych appointments. The APA Guideline Statements might make for interesting conversations with him. Shine on, son, we’re both stars in the family constellation.

@amysfo, I’ve been looking at the book Working with Voices II . Before they even get into how a person works on their voices they ask the person to think about their short term and long term goals. I think not just for mentally ill people, but for everyone, believing in something or some purpose greater than yourself is important.

My son has been having a very hard time with voices the past couple of months and yesterday I said to him that God is a higher power than the voices. Unfortunately he said that the voices were gods, which I then had to say something like they are lesser gods compared to the one loving God, which Jesus is an incarnation of.

Neither he or I are Christians, but I’ll try anything that works at this this point.

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Read through Statement 1 twice and I am planning on going through one more time and making a list of all of the information that they judge should be gathered when doing an evaluation. I am then going to address each one of these in a document so that the next time he is hospitalized, I will be able to provide the information about my son that they should be collecting. My son has been hospitalized three times and I don’t think they have ever done a blood draw. I would love to have his blood tested for absolutely everything, but he will not agree to a blood draw. I think this document is really important to become familiar with as it definitely gives backbone to holding psychiatric care to a high standard.

I recently acquired the book Working with Voices II. I have started to make a list of things that my son has indicated that he is attracted to in view of helping him to set some goals that are meaningful to him. I have noticed that on the rare occasions that he initiates a conversation that it often contains a kernel of something he is interested in. For example the other night he said he had seen some off road motorcyclists in our area and I asked him if that looked like something he would like to do. Yes, was the answer, so I added it to my list.

I’ll try anything that works too caregiver1. I am open to it all.

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"Throughout the assessment process, it is important to gain an understanding of the patient’s goals, their view of the illness, and preferences for treatment. This information will serve as a starting point for person-centered care and shared decision-making with the patient, family, and other persons of support "

By coincidence, I selected the same phrase to bring forward - while my son doesn’t have insight like @amysfo and continues to be unmedicated for his scz, understanding and working with my son’s goals has been quite key to the progress he has made in building a satisfying life for himself. His second psychiatrist did speak openly to me about my son, possibly she learned she could trust me as I never revealed anything that I learned from her as she spoke more openly as his work with her progressed. She was able to guide me to support him working part time on a very limited basis. She felt some sort of work was key to how he felt about himself.

I sent her updates about things that happened at home and eventually as things worsened with his delusions, she did let us know that she felt my husband was not safe. Because we had isolated the two of them from any contact as my husband (his dad) had become a trigger for psychosis, his doctor didn’t have anything she could work with in a positive sense in their sessions. My son did start having delusions that I was trying to hurt him, she could counter those with your mom takes care of your pets, helps get your meds, deals with paperwork, etc.

When my son and I were conversing with texts (phone calls are still bad for his psychosis- the voices say all kinds of things and he thinks its whoever he is talking to that is saying those things) I was responding using LEAP and he would show her our text conversations in their sessions.

After reading all of APA SPGS 1, now I understand why diagnosing takes so long and why his initial psychiatrist said he needed a year of sessions to be able to work with my son properly.
There is a lot to discover and especially when working with those who lack insight and suffer from paranoia, its going to be a slow process of discovery.

Mentions the need for goal-setting:

Consequently, discussions of goals should be focused beyond symptom relief and may include goals related to schooling, employment, living situation, relationships, leisure activities, and other aspects of functioning and quality of life. (page 9)

and psychosocial history:

The psychosocial history reviews the stages of the patient’s life and may include attention to perinatal events, delays in developmental milestones, academic history and performance (including learning difficulties, special education interventions, or disciplinary actions), relationship and sexual history, interpersonal functioning (including in social and family roles, such as parenting), occupational history (including military history), legal history, and identification of major life events (e.g., parental loss, divorce, traumatic experiences, migration history) and psychosocial stressors (e.g., financial, housing, legal, school/occupational, or interpersonal/relationship problems; lack of social support; painful, disfiguring, or terminal medical illness) (pages 11 and 15)

Wondering how this information is used. I suppose they could use this information to see if the meds are making any improvements. My experience is that medication adjustment is simply based on if it is decreasing delusions and voices.

A psychologist is needed to help manage ongoing setting and attaining goals and psychosocial improvements.

Table 2 has useful information about intervals for follow-up blood work: 4 months after initiating a new medication and at least annually thereafter. I think it’s important that this gets done regularly to check for diabetes, hyperlipidemia and metabolic syndrome.

Toxicology is mentioned. That might mean something like checking for illicit drugs and/or lithium levels if the person is taking lithium.

BMI every visit for 6 months and at least every 3 months thereafter. If a person is living at home, the family might help the person keep a log of their weight changes.

Posted this in the announcement for this group - but will repeat here:

Oh - and by the way - if you want to get some ideas from what they do in other countries - I recommend you review the Practice Guidelines for Treatment of Schizophrenia in the UK , Scotland and Canada. I’ll try to find and post the links to these documents and info here:

https://www.nice.org.uk/guidance/cg178

Full UK Guideline PDF:
https://www.nice.org.uk/guidance/cg178/evidence/full-guideline-490503565

Scotland Guideline:

Canada:
https://journals.sagepub.com/doi/10.1177/0706743717720448

More info on Canada Guidelines:

And here is Australia’s:

https://www.ranzcp.org/files/resources/college_statements/clinician/cpg/schizophrenia-disorders-cpg.aspx

Thanks @SzAdmin. It will be interesting to compare and contrast the different guidelines. I saw somewhere in the APA guideline that they made use of guidelines from other countries. I imagine the other countries do the same.

A main takeaway from Statement 1, IMO, are the physiological testing recommendations. These are all the regular medical tests the family member needs to have done, usually at 4 months and annually thereafter, upon initiating or changing drugs. I think the affected family member, and if they have caregivers, need to be on top of this.

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