A 22-year-old man is brought to the emergency department by the police due to agitated behavior and hearing voices. The patient's mother called the police after he locked himself in his bedroom while shouting, "The voices won't leave me alone. They have taken over my brain." The patient had a previous psychotic episode a year ago while attending college out-of-state and was treated in a psychiatric hospital. After being discharged, he moved in with his parents and younger sister but did not take any medications or attend follow-up appointments. His mother says the patient is unemployed, and she must frequently remind him to tend to personal hygiene. She has also noticed him laughing to himself on several occasions. A comprehensive medical evaluation is within normal limits. The patient is treated with quetiapine in the hospital and is discharged 5 days later. At his 1-week outpatient follow-up, the patient feels "okay" and notes that the voices are quieter since starting medication. His mother says, "He is much calmer, but I'm worried because he just stays in his room and seems unmotivated to do anything." In addition to continuing pharmacotherapy, which of the following would be most effective in reducing this patient's risk of relapse?

Question

A 22-year-old man is brought to the emergency department by the police due to agitated behavior and hearing voices.  The patient's mother called the police after he locked himself in his bedroom while shouting, "The voices won't leave me alone.  They have taken over my brain."  The patient had a previous psychotic episode a year ago while attending college out-of-state and was treated in a psychiatric hospital.  After being discharged, he moved in with his parents and younger sister but did not take any medications or attend follow-up appointments.  His mother says the patient is unemployed, and she must frequently remind him to tend to personal hygiene.  She has also noticed him laughing to himself on several occasions.  A comprehensive medical evaluation is within normal limits.  The patient is treated with quetiapine in the hospital and is discharged 5 days later.  At his 1-week outpatient follow-up, the patient feels "okay" and notes that the voices are quieter since starting medication.  His mother says, "He is much calmer, but I'm worried because he just stays in his room and seems unmotivated to do anything."  In addition to continuing pharmacotherapy, which of the following would be most effective in reducing this patient's risk of relapse?

Quizplus · Accepted Answer

This patient's ≥1 year history of illness, characterized by episodes of acute psychosis (auditory hallucinations; delusions; disorganized and agitated behavior) and negative symptoms (lack of motivation, poor personal hygiene), is consistent with schizophrenia, a psychotic disorder with onset typically in young adulthood. In addition to pharmacotherapy with antipsychotic medication, family therapy involving psychoeducation is an important treatment intervention that has demonstrated efficacy in reducing the risk of relapse. Family intervention is particularly helpful for patients who have had a recent psychotic relapse and who live with or have frequent contact with family members. In family therapy, the patient and family are educated about the symptoms, course, and treatment of schizophrenia. Topics addressed include the importance of adhering to medication, developing realistic expectations for improvement, and recognizing early signs of relapse. Explaining that the patient's lack of motivation, social withdrawal, and difficulty maintaining personal hygiene are negative symptoms rather than willful laziness can promote family support and help minimize critical comments that result in a stressful environment, which increases the patient's risk of relapse. Other psychosocial interventions that are beneficial include cognitive-behavioral therapy, social skills training, assertive community treatment, and supported employment. (Choice A) Dialectical behavior therapy is a type of psychotherapy that specifically targets severe emotional dysregulation. It is most commonly used in the treatment of borderline personality disorder. (Choice B) Exposure therapy is a type of behavioral psychotherapy whose goal is to decrease the patient's reactivity through repetitive exposures to a stimulus. It typically requires a highly motivated patient and is commonly used in the treatment of phobic and other anxiety disorders. (Choice D) Motivational enhancement therapy is a structured type of motivational interviewing that is primarily used in the treatment of substance use disorders to encourage patients to change maladaptive behaviors. (Choice E) Psychodynamic psychotherapy involves developing insight into unconscious conflicts originating in childhood experiences. It is not recommended in schizophrenia because individuals must be able to tolerate an initial increase in anxiety, which can be overly stressful and destabilizing for patients with psychotic illness. Educational objective: Family therapy is an effective adjunct to antipsychotic medication in patients with schizophrenia and has been shown to reduce the risk of relapse. It focuses on educating the family about the symptoms, course, and treatment of the disorder, and it helps to promote a supportive family environment. References: Key elements of a family intervention for schizophrenia: a qualitative analysis of an RCT. (http://www.ncbi.nlm.nih.gov/pubmed/27896805) Family interventions for schizophrenia and the psychoses: a review. (http://www.ncbi.nlm.nih.gov/pubmed/27411376)

A 22-Year-Old Man Is Brought to the Emergency Department by the Police