When one patient expresses pain very emotionally and another patient refuses to admit she has any pain but is grimacing This may illustrate?

Treatment for psychosis involves a combination of antipsychotic medicines, psychological therapies, and social support.

Your care team

Your treatment is likely to be co-ordinated by a team of mental health professionals working together. If this is your first psychotic episode, you may be referred to an early intervention team.

Early intervention teams

An early intervention team is a team of healthcare professionals set up specifically to work with people who have experienced their first episode of psychosis.

Some early intervention teams only focus on a certain age range, such as people who are 14 to 35 years old.

Depending on your care needs, early intervention teams aim to provide:

• a full assessment of your symptoms
• prescriptions for medications
• psychological services
• social, occupational, and educational interventions

Treatment for psychosis will vary, depending on the underlying cause. You'll receive specific treatment if you've been diagnosed with an underlying mental health condition as well.

For example, treatment for bipolar disorder uses a variety of medications, which could include antipsychotics to treat symptoms of mania, lithium and anticonvulsants to help stabilise mood, as well as psychological therapy, such as cognitive behavioural therapy (CBT).

Treatment for schizophrenia usually involves a combination of antipsychotic medication and social support. CBT or another type of psychotherapy called family therapy are also often used. 

Psychosis related to drug or alcohol intoxication or withdrawal may only require a short course of antipsychotics or tranquillisers, which have a calming effect. Referral to an addiction counsellor may then be recommended.

Antipsychotics

Antipsychotic medicines, also known as neuroleptics, are usually recommended as the first treatment for psychosis. They work by blocking the effect of dopamine, a chemical that transmits messages in the brain.

However, they're not suitable or effective for everyone, as side effects can affect people differently. In particular, antipsychotics will be monitored closely in people who also have epilepsy, a condition that causes seizures or fits.

People who have cardiovascular disease – conditions that affect the heart, blood vessels, or circulation, such as heart disease – will also be closely monitored.

Antipsychotics can usually reduce feelings of anxiety or aggression within a few hours of use, but they may take several days or weeks to reduce other psychotic symptoms, such as hallucinations or delusional thoughts.

Antipsychotics can be taken by mouth (orally) or given as an injection. There are several slow-release antipsychotics, where you only need one injection every two to six weeks.

Depending on the underlying cause of your psychosis, you may only need to take antipsychotics until your psychosis subsides.

However, if you have a condition like schizophrenia or bipolar disorder, you may need to take antipsychotics on a long-term basis to prevent further episodes of psychosis.

Side effects

Antipsychotics can have side effects, although not everyone will experience them and their severity will differ from person to person.

Side effects can include:

• drowsiness – this may affect your ability to drive 
• shaking and trembling
• restlessness
• muscle twitches and spasms – where your muscles shorten tightly and painfully
• blurred vision
• dizziness 
• constipation
• loss of sex drive (libido)
• dry mouth 

See the patient information leaflet that comes with your medicine for a full list of possible side effects. In addition, long-term use of antipsychotics can lead to complications like weight gain and diabetes.

Read more about the complications of psychosis.

Tell your GP if you have side effects that are becoming particularly troublesome. There may be an alternative antipsychotic medicine you can take.

Never stop taking medication prescribed for you unless advised to do so by a qualified healthcare professional responsible for your care.

Suddenly stopping prescription medication could trigger a return of your symptoms (relapse). When it's time for you to stop taking your medication, it will be done gradually and under close observation. 

Psychological treatment

Psychological treatment can help reduce the intensity and anxiety caused by psychosis. Some possible psychological treatments are discussed below.

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) for psychosis is based on an understanding of how people make sense of their experiences and why some people become distressed by them.

The aim of CBT is to identify unhelpful thinking patterns and emotions that may be causing your unwanted feelings and behaviours. It's then possible to learn to replace this thinking with more realistic and balanced thoughts.

A CBT therapist may encourage you to consider different ways of understanding what's happening to you. The aim is to help you achieve goals that are meaningful and important to you, such as reducing your distress, returning to work or university, or regaining a sense of control.

Family therapy

Family therapy is known to be an effective form of treatment for people with psychosis. It's a way of helping both you and your family cope with your condition.

After having an episode of psychosis, you may rely on your family members for care and support. While most family members are happy to help, the stress of caring for somebody can place a strain on any family.

Family therapy involves a series of informal meetings that take place over a period of six months. Meetings may include:

• discussing your condition and how it might progress, plus the available treatments  
• exploring ways of supporting someone with psychosis 
• deciding how to solve practical problems caused by psychosis, such as planning how to manage future psychotic episodes 

Self-help groups

If you're experiencing episodes of psychosis, you may benefit from being around other people who've had similar experiences.

Although illness behavior is best conceptualized as a process, it is important to note that it usually does not proceed in a straight path from one well-defined stage to another. Rather, there are likely to be bidirectional interactions between four elements—symptom perception, symptom interpretation, symptom expression, and coping behaviors.

The process of illness behavior usually begins when a noticeable change in bodily function is interpreted as a symptom of ill health. Symptoms are necessarily experienced against the background of a particular individual's ordinary functioning. All of us know how our bodies behave in the multitude of circumstances that make up our daily lives. If we choose to focus on our bodies for a few minutes we become aware of sensations associated with breathing and moving that we normally do not notice. At other times, changes in functioning may be readily apparent but their proximate cause is so obviously not an illness that we do not call these altered sensations symptoms. After physical exertion, for example, our increased respiratory rates, difficulty breathing, muscle fatigue, and the like may be experienced as discomfort or even as pain, but they are unlikely to be perceived as "symptoms." Consciously or unconsciously we "cognitively packaged" the changes in functioning and attributed them to our recent exertion. In the course of our daily lives we constantly interpret bodily sensations and assign meaning to them, often without being aware of it (Pennebaker, 1982).

For a change in functioning to be interpreted as a symptom it must have evoked concern that the alteration is somehow not normal and is not readily accounted for except in the framework of illness. The perception of a sensation as a symptom of ill health involves categorizing the experience and assigning meaning to it. Our past repertoire of experience with our own and others' illnesses provides the basis for making such interpretations. These interpretations then affect our perceptions such that the processes of perceiving and assigning meaning to symptoms become intertwined with values and beliefs and influence each other (Cassell, 1985).

Attention (selecting and integrating sensory input from the external and internal environments) plays a major role in the experience of pain. A cardinal characteristic of pain is that it has a unique ability to captivate and hold one's attention. The patient who has suffered a significant injury or disease and fears a recurrence of the pathology may be constantly on the alert for any physical signs or pains associated with the feared disorder. Another curious property of pain is that attention directed to it typically exaggerates its aversiveness (Pennebaker and Epstein, 1983). As individuals think about their pain, it tends to become more intense and disabling, whereas distraction and meaningful activity are likely to reduce the salience of pain experiences. Thus, some people believe that as activities (including work) become more rewarding and stimulating, people will be less likely to focus attention on themselves and their incapacities. On the other hand, because pain is distracting, it may make work and other activities seem less rewarding and stimulating. The degree of awareness of one's own pain may vary from a near denial of its presence to an almost total preoccupation with it, and the reasons for attending to pain may vary. Pain itself may become the focus of the self and self-identity, or may, however uncomfortable, be viewed as tangential to personhood. One of the most powerful influences on the way in which symptoms are perceived and the amount of attention paid to them is the meaning attributed to those symptoms.

Meaning attribution about the cause and likely outcome of symptoms is influenced by a host of psychosocial and cultural factors as well as by a person's prior experience with illness. Assigning meaning to symptoms can be a conscious process that helps people structure the experience, or it may occur outside of awareness. A person's report of symptoms inevitably reflects not only the nature of the experience but also its significance to that person. A person's assessment of meaning may be as important to symptom formation as the disturbances in functioning for which the meaning is invoked (Cassell, 1985).

The meanings given by a patient to an accident, sickness, personal suffering, or the relentless presence of pain affect subsequent illness behavior and help to order experience in several ways (Engel, 1959; Taylor, 1983). First, meaning is associated with a sense of coherence or purpose for life events. Patients seek to comprehend why an accident or sickness has occurred and what impact it has had and will have in the future. Causal attributions are formed by patients to account for current unfortunate circumstances. These formulations shape the meaning of the situation and can open or close options for actively dealing with it or the feelings it evokes.

Second, the ability to assign meaning to an illness or to symptoms has been found to enhance some patients' sense of self-mastery over a problem or crisis (Lewis, 1982). For example, the limitations imposed on a patient's lifestyle by chronic pain may be significantly attenuated if the patient believes that he or she can control the pain or can, despite the pain, undertake activities without harm (Averill, 1973). In contrast, it has been observed that patients who believe that they have little or no control over their health and well-being work less effectively with health care providers to achieve rehabilitation (Pilowsky, 1984).

Finally, the personal meaning of an illness or symptom may affect self-esteem either positively or negatively. Becoming an invalid, even briefly, can be a blow to a person's self-esteem. Similarly, being unemployable or forced to accept employment at a lower wage or job status because of pain can be demeaning. However, for some patients embracing the sick role is seen as an elevation in status. These people value the nurturance and special consideration of friends, family, and neighbors that follow injury and the development of chronic pain. Personal meanings are likely to be influenced by the shared meanings of the group to which the individual belongs. Studies of various socioeconomic, cultural, and religious groups reveal that the meanings associated with pain tend to vary by group membership (McKinlay, 1975; Zborowski, 1952; Zola, 1966) and by the structural characteristics of ethnic and cultural groups (Suchman, 1965, 1966).

The meaning attributed to pain influences whether or not suffering occurs. Although suffering and pain are often associated with one another, they are distinct phenomena. First, the degree of suffering is not necessarily related to the degree of pain. People may tolerate severe pain without suffering if they understand (1) the source of the pain, (2) that it is not dire, (3) that it will end, and (4) if means exist to control it. Second, suffering commonly occurs in the absence of any physical distress, for example, in someone who is anticipating the return of a terrible pain even though the pain is not currently present, or when one is unable to help a loved one in pain. For some people, pain and suffering have religious and moral significance. The Judeo-Christian tradition has attempted to interpret the moral significance of suffering in numerous texts. Some people view pain and suffering as tests or trials of their moral worth. Others view them as conditions that may purify or "cleanse" the character or soul. Health care providers need to be sensitive to the possible clinical significance such interpretations can have both for patients and providers in the treatment of chronic pain (Cassell. 1982).

The interpretation of symptoms and the meaning assigned to them may have a profound influence on coping responses. Whether or not people who perceive a change in their physical functioning attribute the alteration to sickness will obviously influence their help-seeking behaviors. Particular meanings may result in more or less productive responses that may affect patients' rehabilitation potential. The expression and communication of pain in the family and other social settings is also influenced by the meaning attributed to the symptom.

Although pain is subjective, it is the outward expression—the observable illness behaviors—of the patient in pain (rather than any subjective state or physiological indicator) that defines the severity of the problem for others. Particular words chosen by the person to describe his or her pain let others know about the experience. Movements and body postures, as well as nonverbal vocalizations (sighing, groaning) are also powerful indicators of pain states. Body language expressive of pain may include posturing, bracing, grimacing, rubbing, gasping, or withdrawal from normal activity. Facial expression is a principal cue for caregivers' perception of patient distress, which influences the level of concern expressed for the patient (Le Resche and Dworkin, 1984; von Baeyer et al., 1984). The method of pain expression influences how the individual is judged by others. While those who appear more stoical and less histrionic may have their pain taken more seriously by caregivers, it is also possible that they may be taken less seriously and receive less attention from caregivers than patients who express pain more vocally or dramatically. As discussed later in this chapter, because pain expression is influenced by familial and cultural norms, it may not be a good indicator of severity.

Like all the other aspects of illness behavior, how people cope with their pain or other symptoms is determined in many ways and varies from person to person. Coping responses may be more or less adaptive and more or less consciously motivated. Although some people may deny their symptoms and diseases, others may exaggerate them.

The abnormal functioning that occurs in chronic illness leads inevitably to compensatory behavior that may have positive or negative effects on subsequent symptoms and functional levels. One group of compensatory mechanisms serves to avoid unpleasant symptoms. For example, guarding a painful joint reduces its activity, which leads to increasing involuntary immobility (the origin of the common condition called "frozen shoulder"). Similarly, reduced physical activity will eventually decrease the effective muscle mass, which makes physical activity more difficult. On another level, the sick person may develop reclusive behaviors that further exaggerate the social loss of being ill.

Another group of compensatory mechanisms assists in attempts to maintain normality. So-called "overuse syndromes," for example, refer to the damage done to alternate muscle groups or joints that were used to restore lost function (e.g., walking) and have sustained too much activity. Symptom avoidance and compensatory mechanisms may aggravate the illness and produce further losses, but they may also, if used properly, facilitate coping and continued effective functioning. Thus, compensatory behaviors, initiated in response to symptoms and altered functioning, also affect subsequent functioning. As such, these compensatory mechanisms may contribute to the self-sustaining nature of chronic illness.

Malingering is an extreme example of a consciously motivated coping response. We all engage in malingering to some extent when, for example, we take a day off from work because we are not feeling entirely well but, in fact, are probably not too sick to continue our usual routines. Malingering in the sense of deliberately feigning sickness solely for the purpose of gain over a long period of time is probably uncommon, and experienced clinicians believe they can identify such behavior. There is no evidence that malingering is common in the SSA disability context.

Most people who experience symptoms and fear they are sick visit doctors. For the chronic pain patient and for health professionals, such encounters can be frustrating because the symptom is often so very difficult to diagnose and treat. The absence of a diagnosable disease does not mean the absence of abnormalities, disturbances, or alterations in bodily functions. Thus, severe illness, illness behavior, and suffering can exist in the absence of a diagnosable disease. Effective treatment of patients with chronic pain requires that health care professionals view illness broadly and not only in terms of a narrow disease model (see Chapter 10).

Some proportion of people with chronic pain use alternative care systems either in lieu of or as adjuncts to the traditional medical care system. Although it is known that musculoskeletal complaints, including pain, are a common reason for choosing alternative therapies, particularly chiropractic care, it is not known what proportion of patients with these complaints use alternative practitioners.

Some alternative practices have developed as a reaction to what a number of people perceive to be shortcomings in traditional medical care. The holistic health care and self-care movements are examples of such alternative approaches, and both of them receive considerable support from some physicians for much of their work and for their basic philosophies. The holistic health care movement emphasizes mind-body unity and positive health enhancement (Inglis and West, 1983) and integrates traditional practices of Eastern mysticism into medical programs for pain and stress relief (Benson, 1975). Holistic health care practitioners believe that analgesics should be used only minimally (Mattson, 1982), but little is known about how pain is treated in holistic health care centers. The self-care movement emphasizes the individual's role in risk avoidance and decision making, self-monitoring and diagnosis, self-treatment, and medication. Little is known about the effectiveness of the self-care approach in ameliorating chronic pain. As discussed previously, however, feeling in control of one's symptoms and illness is likely to promote better coping skills and may therefore be beneficial.

Numerous folk and religious healing traditions exist in the United States. A survey of a metropolitan suburb located 130 types of alternative healers (McGuire, 1983). In the past, scholars attributed whatever effectiveness these forms of healing may have to suggestion, catharsis, or a placebo effect. More recent research suggests that religious and folk practices may be effective insofar as they take into account essential psychosocial factors, such as patients' explanatory models of illness, that are often neglected by conventional medicine (Kleinman and Sung, 1979). In addition, these modes may help alter the meaning of illness in such a way as to allow a different and more healthy response (Csordas, 1983; Bourguignon, 1976; Frank, 1973). These observations suggest the need for research on how the transformation of the meaning of illness may contribute to the amelioration of pain and impairment, not only in religious and folk healing but also in conventional medical care.

Two specific alternative treatment modalities deserve mention. Acupuncture, a specific technique of Chinese traditional medicine, has acquired notable publicity in the last decade, although the extent of its use is not known. Findings from clinical and experimental studies of acupuncture analgesia are inconclusive (Hu, 1974). Comparison of actual and simulated (placebo) acupuncture in patients with shoulder pain (bursitis or tendonitis) demonstrated that a positive or negative therapeutic milieu determined the therapeutic response rather than the actual or simulated treatment itself (Berk et al., 1977). Several authors have discussed possible neurophysiological and psychological mechanisms (Lewith and Kenyon, 1984) and the merits of acupuncture for chronic pain (Lee, 1975; Kepes et al., 1976), but, in general, this explanatory literature leans heavily on notions of suggestibility. Good outcome studies are lacking.

Finally, chiropractors, who are licensed in all 50 states and are covered by Medicare, Medicaid, and most private insurers, treat over 7.5 million patients each year (Caplan, 1984), most of whom have musculoskeletal complaints, including pain. Those who seek care from chiropractors are more likely than other people to seek care from physicians too—they tend to be frequent users of health care services of various types, perhaps partly because of the nature of their symptoms (Cleary, 1982). Some observers report that chiropractic treatment is effective for short-term relief of back, neck, and other musculoskeletal problems, as well as for headaches (Coulehan, 1985b; Klein and Sobel, 1985). The therapeutic milieu and the chiropractor-patient relationship are believed to be significant determinants of treatment effectiveness (Coulehan, 1985a; Cowie and Roebuck, 1975; Skipper, 1978). More research on the effectiveness of chiropractic is warranted in view of the fact that so many patients use it (National Institutes of Health, 1975).