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"Pre-psychotic Signals"
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"Pre-psychotic Signals"

Hello,

I came across this in the Journal of Nervous And Mental Disease.  I hadn't heard of their being early warning signs of psychosis coming on.  I hope people find this helpful.



"The discovery of a mechanism of early identification of prepsychotic signals was replicated in additional studies (Dittmann and Schuttler, 1990), and its importance was described in a first-person account by Leete (1989). A woman in her 50s diagnosed with schizoaffective disorder who was interviewed for our study described how she calls a Crisis Hotline when she perceives that a relapse might be impending.

“I depend on [calling the Crisis Hotline]. I’m trying to keep from going in [the acute hospital unit]. I don’t want to go back there . . . usually when I call crisis and reach out for help and tell them how I am feeling they will either tell me to come to the emergency room or to get my medicine, take my medicine as prescribed, take me a cup of tea or drink a glass of milk and lie down for a while. If that doesn’t work, get up and see if you can go around, be around somebody.”

The principles of monitoring warning signs have been used to develop relapse prevention programs (Herz et al., 2000; Lam et al., 2000; Perry et al., 1999; Scott et al., 2001) that teach a form of anticipatory coping skills in that they focus on helping people prepare for the possible but not yet occurring threat of relapse, and take steps directed to minimizing its negative effect. These programs usually include identifying events and situations that had triggered episodes in the past and making a conscious effort to build a routine that would help the person avoid such events and situations in the future. In addition, one can choose a support person whom they would like to help him or her in case he or she felt that things were not going well, as well as generate a crisis plan to implement in case early warning signs are detected.

The relationship between anticipatory coping and a reduced likelihood of relapse has not been well-studied; however, positive findings for the impact of relapse prevention treatment suggest that learning to use anticipatory coping can reduce the likelihood of having a psychiatric hospitalization and associated consequences (Herz et al., 2000).

Preventive coping refers to the process by which a person builds up resources and resistance “just in case” possible stressors occur in the distant future (Schwarzer, 2001). Unlike reactive coping where the stressor has occurred, and anticipatory coping where there are more specific stressors within a shorter timeline which one is preparing for coping with, preventive coping reflects more general preparatory activities to cope with more unknown possible stressors within a more fluid timeline. Others (Aspinwall and Taylor, 1997) have referred to these types of strategies as proactive coping, but Schwarzer has drawn a distinction between preventive and proactive coping, which we follow in our adaptation of his model.

One example of preventive coping is developing “wellness management skills” (Copeland, 1997; Mueser et al., 2002). These are coping strategies that are used on a regular basis whether or not one is experiencing symptoms. The value and purpose of developing such strategies is that they can help reduce one’s vulnerability to future stress and improve resources for dealing more effectively with stressors that might occur. Typical wellness management strategies reported by people with SMI include routinely accessing social support, following a routine for taking medication, exercising, reducing substance use, and adopting a healthy and balanced lifestyle (Yanos, 2001). The man in his 40s diagnosed with schizophrenia who was interviewed for our study described his use of several preventive coping strategies as follows."


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1790964/

---------------------------------


Early Warning Signs

Early warning signs of a psychosis can be defined as subjective
experiences, thoughts, and behaviours of the patient that occur in the phase
preceding a psychotic relapse (Heinrichs & Carpenter 1985; Herz & Melville
1980). The question is now which experiences, thoughts, and behaviours are
characteristic for this phase.

Heinrichs and Carpenter (1985) conducted a prospective study of the
early warning signs of a psychosis in 47 ambulatory patients with
schizophrenia (n=38) or a schizoaffective disorder (n=9). During weekly
appointments with the client, clinicians noted whether or not warning signs
were present that indicated an impending psychotic relapse. On the basis of
this, 32 early warning signs were identified. The ten most common are:
hallucinations (53%),
suspiciousness (43%),
change in sleep (43%),
anxiety (38%),
cognitive inefficiency (26%),
anger/hostility (23%),
somatic symptoms or delusions (21%),
thought disorder (17%)
disruptive inappropriate behaviour (17%),
and depression (17%).

Source:
Recognition of early warning signs in patients with schizophrenia:
A review of the literature

B. van Meijel
M. van der Gaag
R.S. Kahn
M.H.F. Grypdonck
Tags: psychotic
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29 Comments Post a Comment
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585414_tn?1288944902
Yes that's worthwhile information. I will bookmark it and read it further. I have experienced some of these trigger points that show concerns before my current recovery and since I still experience mood swings (the psychosis is in "relative remission" with a treatment in Phase 2 FDA study) I know some of those changes in thought patterns can still occur to a certain extent. I keep my psychiatrist updated at any time there are any concerns and always did and its good to have more exact knowledge about what can occur.
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Avatar_m_tn
I'm still at a loss for detecting this stuff in myself before I reach a full blown relapse.  I have to rely on other people to tell me when I'm starting to relapse.
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Avatar_f_tn
I also have a thread on possible nutritional causes of psychosis.
http://www.medhelp.org/posts/Depression/Psychosis-Caused-By-Magnesium-Deficiency/show/1326478


With the poor reliability of testing in some things, such as magnesium, it makes me question how often it is missed as the cause?  Doctors say the loading or tolerance test is the better one for magnesium.
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585414_tn?1288944902
Yes there can be causes of psychosis other than schizophrenia or other psychotic disorders or other factors that would worsen it that are physical. A person at all times should make their psychiatrist aware of any physical disabilities or disorders they have or especially inherited tendencies in the family. Before a person starts medication full blood work is done to rule out other causes of psychosis and generally should be done once a year (I am getting blood work next week) for general health purposes and to check up on long term medication side effects such as liver damage (unless the medication requires monthly tests in which case a person should follow doctor's instructions as regards follow up with blood work). However it should be noted that the standard clinical understanding of schizophrenia and other psychotic disorders is changing and as I've posted there is a whole new generation of antipsychotics in clinical study, the NMDA receptor modulates that are based on increasing glutamate transmission instead of decreasing dopamine transmission. For more information google "Dr. Javitt, glycine".  There is also further research into new mood stabilizers and since they have found fish oil to be effective and as I've posted the medication Lovaza which was derived from fish oil is now in clinical study as a mood stabilizer. As happens I'll be starting it today. I do take a mood stabilizer but it doesn't provide enough coverage and Lovaza has shown some efficacy and some psychiatrists use it. There are many promising arenas of research for present and future treatments.
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Avatar_m_tn
ILADVOCATE is right about the blood work.  Before I was diagnosed with a psychotic disorder, they tested me for all kinds of crap like with MRIs and tests for syphilis and blood deficiencies and such.  The psychiatrist who ordered all this stuff seemed disturbed a little that he found nothing wrong and then prescribed an antipsychotic which I refused to take at the time and talked like he had diagnosed me with schizophrenia which back then I had no clue what he was talking about when he said it would get rid of my delusions and such.  Since then over the years I learned how to describe it properly and described it accordingly and they diagnosed me with that then and I took the medicine this time because I was scared of myself and I had MRIs yet again and all that crap.
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Avatar_f_tn
"I've posted there is a whole new generation of antipsychotics in clinical study, the NMDA receptor modulates that are based on **increasing glutamate transmission** instead of decreasing dopamine transmission."

Very interesting.
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Avatar_f_tn
There are indeed a number of studies indicating that fish oil can be quite beneficial in bipolar disorder, but one teeny word of warning, buried about 3/4 of the way down this article, in the segment headed "Side effects and warnings:

http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-fishoil.html  

"There are rare reports of mania in patients with bipolar disorder or major depression. Restlessness and formication (the sensation of ants crawling on the skin) have also been reported."

In reading messages on forums in which fish oil is discussed, such as the heart rhythm community, I have seen maybe three or four messages (out of hundreds) from people who had felt their anxiety/agitation became worse on fish oil, and one who noted that crawly feeling on the skin, probably without having read anything at the website I just noted.

The only study I could find which notes this effect of Omega 3s appears in an 8/08 study cited further below, within the paragraph titled "Safety Profile of Omega-3 Polyunsaturated Fatty Acids":

"Since ω-3 polyunsaturated fatty acids may have antidepressant effects, another possible adverse effect is drug-induced mania. Until now, there has only been one formal case report to show ω-3 polyunsaturated fatty acid–induced hypomania.[64] Further research is needed to clarify whether treatment with ω-3 polyunsaturated fatty acids increases the risk for mania or hypomania."
(The Use of Omega-3 Fatty Acids in Treatment of Depression, http://www.psychiatrictimes.com/cme/display/article/10168/1171213)
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585414_tn?1288944902
Yes I agree that can be a concern. That's why it should only be taken at the specific amount directed by a psychiatrist and only under psychiatric supervision. However from what my psychopharmocologist informed me he is changing over any patient of his who takes fish oil to Lovaza because it is an FDA approved medication so that it is a known quantity. The other reason besides what you posted is that any product containing concentrates of fish would have a build up of mercury residue because of pollutants in the sea(this I was directly informed).  When I took fish oil or flaxseed oil in the past it was only of benefit as a supplement to known medications. As to whether Lovaza which is an FDA approved medication and can thus be prescribed off label will be beneficial for bipolar as a primary mood stabilizer or just an adjunct will take further controlled studies which are ongoing at this point (those are listed in Clinicaltrials.gov where are all ongoing clinical studies are listed, Pubmed is another good search engine to read for informational purposes). I did experience some extra pyramidal side effects from fish oil which might be clinically rare or it might be what you described. That I would not know. Lovaza may or may not have the same side effect profile but I'll read up on it before I take it and discuss any concerns with my doctor or pharmacist and see what happens. I did read the first post and did note some of the signs of emergent mania so it will be worthwhile to achieve some further stability. I will keep people updated over time.
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Avatar_f_tn
These are fascinating topics.  Please do post updates.
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Avatar_f_tn
Just came across this from the Merck site:

"CNS symptoms include psychosis, encephalopathy (characterized by impaired consciousness), and cognitive decline (dementia). Psychosis is characterized by memory impairment, disorientation, confusion, and confabulation; the predominant symptom may be excitement, depression, mania, delirium, or paranoia."


I've also found on google that psychosis can be caused by deficiencies in: Calcium/Magnesium, B12, Niacin, and Vitamin D.
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Avatar_m_tn
Huh that's weird, I thought depression and mania were symptoms of mood disorder and not also of psychosis itself, if I read that right.
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585414_tn?1288944902
They can be related. The psychosis caused by direct structural damage to the brain can appear similar to that from a psychiatric disability but a full clinical tests can rule out those causes as they are clinically separate. In schizoaffective disorder and bipolar with psychotic features mania and psychosis can overlap and a person needs both a working mood stabilizer and an antipsychotic and the effects overlap so that if an antipsychotic is not working properly a person can become manic and the reverse. The full spectrum from bipolar to bipolar with psychotic features and schizoaffective is not fully understood. Neither is the relation between dementia and bipolar and schizophrenia although dementia can be a part of advanced schizophrenia especially if it is left untreated. As per myself, the Lovaza has worked on standard symptoms of mood stabilization and in augmenting an antipsychotic agent helped on symptoms of psychosis as well. Because it also provided marked help with tardive dyskinesia (which is not a known effect, although fish oil has been used for that purpose) I will be seeing my neurologist to gauge that specific effect and of course my psychiatrist to follow up as well. The beneficial effect of fatty acids on the brain is still being clinically understood through specific research as well.
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Avatar_f_tn
Also interesting, adrenal issues can cause psychosis, paranoia, hallucinations...

http://psy.psychiatryonline.org/cgi/content/full/47/2/175

There are many results on google with "adrenal + psychosis."
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Avatar_f_tn
FEP = First Episode Psychosis

RESULTS: At baseline, no differences were observed in cortisol, DHEAS or the cortisol/DHEAS ratio between patients and controls. . . .

Within FEP patients, decreases in cortisol and the cortisol/DHEAS ratio over time were directly related to the improvement in depression . . . negative . . . and psychotic symptoms . . . .

Perceived stress significantly correlated with DHEAS . . . and the cortisol/DHEAS ratio . . . in controls, but not patients, possibly reflecting an impaired hormonal response to stress in FEP patients.

http://www.ncbi.nlm.nih.gov/pubmed/20619421
________________________________

What does that last paragraph mean?  "Impaired hormonal response?"  No correlation with cortisol/DHEA?  Why?

Any thoughts?
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585414_tn?1288944902
Well adrenaline and other neurotransmitters when increased artificially (such as by steroids as described in the article) can clearly worsen psychosis in a person with a pre-existing psychiatric disability or cause psychosis of their own. It should also be noted that another cause of psychosis which is substance induced is PCP induced psychosis has lead to promising research to treat it and understand the nature of psychosis from schizophrenia and other related psychiatric disabilities. That was how the NMDA receptor modulates were discovered (google "A New Class of Antipsychotics"). In treating PCP induced psychosis, they were then used to see if they were of efficacy in treating schizophrenia which was found to be the case. As well Thyroxine is in clinical study for use on bipolar depression:
http://www.psycheducation.org/thyroid/introduction.htm
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Avatar_f_tn
Hello,

I was talking on an Addison's forum and they got me talking about some other bloodwork.


What might these mean?

And interestingly, just five months AFTER the bloodwork (below), I ended up in the hospital with my first psychosis episode; and I've read that iron anemia, and folate/B12 deficiencies can cause psychosis. My doctor didn't say a word about the above issues, only my estradiol and physical complaints I had, as well as low mood and anxiety, all associated with life issues.



____________________________________
I'm soon to be 28, and my Ferritin in 2008 was 15.3 [ref 6.2-137.0 ng/mL]


Also:



RBC COUNT 3.49 LOW [REF 4.2-5.4]


Hemoglobin 11.8 LOW [REF 12.0-16.0]


HEMATOCRIT 34.7 LOW [REF 37-47%]


MCV 99.3 HIGH [REF 81-99]


MCH 33.9 HIGH [REF 27-31]
____________________________________



I'm wondering if I've got an iron, B12 and/or Folate deficiency. Years of fatigue and poor attention/concentration/retention/memory here.



Is it possible for that kind of anemia to go back to normal?





Preceding all of that, I had been on lots of meat/poultry/fish eating, along with lots of vegetables, seaweed, supplements, sea salt, olive oil, etc. and cutting back on carbs and sugars, all to see if it would help my energy and concentration. Also, there was a very stressful, dysfunctional environment; friend moving out of state; beloved pets dying painfully, etc.


Thank you.

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Avatar_f_tn
Another interesting note:

Antipsychotics work on dopamine and glutamate

Folate and/or B12 has to do with glutamate, and monoamine neurotransmitters.
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585414_tn?1288944902
    Yes that's true. Adrenal or thyroid conditions can of course cause changes that might otherwise appear mental. That would not mean that a person might not have anxiety disorder as well (which doesn't always require medication, talk therapy and cognitive behavioral therapy can be helpful as well) and talk therapy can be helpful for anyone even if they have no disability. If a person has any concerns about any over riding physical concern that hasn't been sufficiently answered then they should seek a second opinion or see an appropriate specialist. If psychosis or any other changes started with the onset of a specific physical disability then the appropriate doctor would need to follow up, diagnose and treat that. Once those concerns have been addressed with the appropriate physical treatment then they could then decide with their doctor whether a further referral is appropriate and the doctor could be in touch with whom they are referred to. I do have some over riding concerns that are neurological and under clinical study that cause mental changes of their own but I also have a psychiatric disability. One is followed up by a neurologist and the other by my psychiatrist and they both consult regularly which is crucial.
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585414_tn?1288944902
  Yes although medications work in specific manners exactly how neurotransmitters function and how medications effect them is still advancing as regards research. The dopamine hypothesis as regards schizophrenia is well known. The glutamate hypothesis is still under research but clearly effects the specific parts of the brain and their functioning that can be shown to be the origin of the cluster of symptoms of schizophrenia that also would be noted in a Pet scan. Monoamine neurotransmitters are also involved in how MAO inhibitors work a class of anti-depressents that would be used more if it were not for enzyme interactions. However now that Ensam is available in patch form (that is one MAO inhibitor) they are using that more as they are one specific class of anti-depressents that other than that specific side effect is effective and has less of some other side effects than other classes of anti-depressents.
    Understanding how treatment works is essential and the appropriate follow up tests can also determine any specific causes that might not otherwise be evident. Blood tests can be very specific. For example as part of a whole series of tests after being ruled out for epilepsy (with an EEG) I was then ruled out for Willson's Disease which required a specific test for daily copper metabolism. Once test results are determined then proper follow up can be as well.
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Avatar_f_tn
Doctors just haven't said anything about looking for a cause to my episodes.  Other than the thyroid check that I pushed, and there was an abnormality with that which they are periodically checking.  I'm having to dig up my files, internet research, and encourage them myself.  The psychosis has always been with my poor ability to handle stress, my system is fragile, and my gut says something is deficient.

Is there some kind of doctor that can thoroughly evaluate ALL minerals, vitamins, aminos, blood contents, etc.?  Upon asking for some tests, just some, from one of my doctors, she said "we can't do everything; we can't just do whatever you want."  Oy vey.

It's strange how hormones and bodily things can affect us mentally.  I had PMS recently, and for just that one week prior, just-7-days, there was awful irritability (I practiced a LOT of virtue not to be reactive to anyone), and some awful blues and teariness for no reason.  Then PMS ends, and voila, that all passed!  Crazy it is!
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585414_tn?1288944902
  Obtaining any blood test for specific conditions can be difficult because any blood test has to be authorized by a doctor. There is no blood test that would at one time comprehensively cover all the potential concerns you are looking for at one time but there are individual blood tests as per the different concerns. A standard blood test can test for a wide variety of deficiencies at once but there are specific blood tests for certain concerns. There are doctors within standard medical practice that have a better understanding of nutritional and other concerns. Its a matter of finding a referral to the appropriate specialist which does take time. I myself had to call a referral hotline to find a psychopharmocologist and it took me years to find a neurologist who was truly of help. Best to look through referral agencies as regards who could help in this regard. Seems like you are doing the right thing. Best of luck.
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Avatar_f_tn
Very interesting...

This is five months before I had my first psychotic episode...

Bloodwork also shows anemia (iron, folate, and/or B12)


1/08:


Vitamin D, 25-OH, Total: 7ng/ml LOW [ref 20-100]


Vitamin D, 25-OH, D3: 7ng/ml


Vitamin D, 25-OH, D2: <4ng/ml

_____________________________

I read that 7ng/ml is the severe range of deficiency for Vitamin D.

See article:
Vitamin D Deficiency Linked to Psychotic Symptoms in Adolescents
By: MITCHEL L. ZOLER, Internal Medicine News Digital Network

It discusses vitamin D deficiency being common in those with psychosis.  Interesting...


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585414_tn?1288944902
Yes well I am aware there are some universities that do standard clinical research in this area and might be able to of help. I believe one is in Ann Arbor. If your doctor is unable to help you and an appropriate specialist is not you could seek a referral. I have seen a research neurologist who then consulted with my neurologist who then discussed the findings with my psychiatrist. That is separate from that kind of treatment but the consult worked in the same manner as a referral had to be given first. There is some continuing research into the area of orthomolecular treatments and its essential to find a practitioner who has knowledge in this area and background.
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Avatar_f_tn
I find orthomolecular psychiatry fascinating. I am currently vamping up my nutrients.The problem is you have to take a lot of pills. At least I got a powered mega B complex. It tastes like bitter lemon candies. Not bad but not tasty either. Better than a big honkin pill though. Unfortunately there is not a lot of research out there and it is really hard to know how much to take of what.

The only one I really notice a difference with is the omega oils. Its kind of funny. I bought the really expensive pills with a promise of 'no fishy after taste' and they gave me the worst fish burps. I bought the stuff at the local Grocery store, no coatings at all, and I get very mild fishy burps. And I get the same mental effects. Goes to show that more expensive isn't always better. If you get really bad fish burps it may be a sign that the fish oil has gone rancid. I keep mine in the fridge now. The other risk with omega oils is they do act as mild blood thinners so if you have any condition that causes bleeding best to avoid it.
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Avatar_f_tn
Hello again.

I'm finding great information by searching google with "Prodromal psychosis" (aka early symptom).

Some great studies about omega 3 (EPA/DHA about 700mg/500mg) cutting psychosis risk in a great number!

See:

Omega-3 may slash psychotic disorder risk: study
By Stephen Daniells

Omega-3s for prodromal psychosis
http://psychiatry.jwatch.org/cgi/content/full/2010/308/2

I'm very hopeful from all of this information!  :)
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Avatar_f_tn
Another interesting thing I read from a paper from "Textbook of Integrative Mental Health Care" by James Lake.  "Assessment approaches that may yield specific diagnostic information about the cause of psychosis."

"It says that FOLATE supplementation may ameliorate psychotic symptoms (i.e., by indirectly affecting brain GLUTAMATE levels.)"  Awesome!

That's the new class of antipsychotics!
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Avatar_f_tn
This is from a great article on psychosis:

"Early warning signs

The following symptoms often appear in the early stage of an emerging psychosis.

•disturbances of receptive language: not getting the conversation
•visual anomalies or distortions : things look or sound strange, unreal
•thought interference : stopping in the middle of a sentence, voices interrupting one's thoughts

The time frame in which symptoms progress is called the prodrome or prodromal phase.A prolonged prodromal phase appears to cause damage to neuron pathways and structures in the brain. It seems the longer it takes to get treatment the more difficult it is to recover. "

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585414_tn?1288944902
  Yes that's true and for that reason there were some studies where people who showed potential signs of schizophrenia or other psychotic disorders that require the use of antipsychotics were started on them earlier to see if that could prevent the onset of schizophrenia. However because a direct need was not shown at that time and the specific side effect profile of current antipsychotics there were some concerns over that. However as research into new treatment modalities advances this should be helpful and genetic studies to determine the cause of schizophrenia and other psychotic disorders is advancing as well. It is also of course true that specific imbalances that can be triggered by a variety of causes can cause disruptions in brain functioning. Folic acid of course is essential to prevent birth defects. The connection between folate and the NMDA receptor modulates is still being researched and I am trying to read up on those studies. Glycine of course is still a compound that they are trying to determine the exact function of as to how to specifically target those receptors in order to be effective and developing treatments from there. However medications such as Namenda which lower glutamate transmission have shown potential efficacy as mood stabilizers in clinical studies so the clinical understanding of how they work is still in its early stages. The idea of an integrative approach to psychiatry is an interesting one and I would be interested in reading up more on what you posted on. Its always good to keep updated as to new treatments in development and new approaches to therapeutic help.
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Avatar_f_tn
I found an EXCELLENT guide for psychosis - early prevention and treatment.

http://www.preventmentalillness.org/images/brand/EDIPPP_booklet.pdf
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