Section X: Brief Reactive Psychotic Episode

Staying in Touch with Reality

Goals of the Exercise

1. Obtain a complete history, including the type and severity of psychotic symptoms.

2. Strengthen treatment alliance so that psychotropic medication is taken as prescribed.

3. Report decrease or elimination of positive psychotic symptoms (i.e., hallucinations and delusions).

4. Eliminate or adequately control positive and negative psychotic symptoms so that independent functioning can resume.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Staying in Touch with Reality” activity is designed for use with veterans/service members who are newly experiencing psychotic symptoms in the immediate aftermath of a severely traumatic or shocking experience and are trying to understand what is happening to them. The rapid onset of psychotic symptoms is extremely disturbing, especially to individuals who have never experienced them before. Questions such as “Am I crazy?” “Will I be like this the rest of my life?” or “Will I be able to stay in the military?” should be expected. This exercise will help the veteran/service member gain some perspective on his/her illness and engage in reality testing to regain more sense of control in his/her life. It will also help the therapist identify any precipitating factor(s) leading up to the psychotic break and assist the therapist with mitigating risk factors that may exacerbate current symptoms. Follow-up for this activity can include bibliotherapy using books suggested in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE X.A Staying in Touch with Reality

Symptoms such as hearing voices others don't hear, seeing things others don't see, and believing that people are plotting against you can be very distressing, especially if you've never experienced them before. These symptoms can seem very real even when they aren't. If they become long-lasting or permanent, they are considered evidence of a disorder called psychosis (also known as schizophrenia), which means that a person sees, hears, smells, feels, or tastes things that aren't really there, or that he or she has strong beliefs about situations when the available evidence doesn't support those beliefs.

However, sometimes after experiencing a traumatic or shocking event, a person can experience something called a brief reactive psychotic episode, in which these symptoms appear suddenly, but fade out within a month or so with medications and do not turn into a long-term problem.

This exercise will help you gain a greater understanding of these symptoms, learn ways to tell when things you experience are not real, and help you and your therapist develop a plan to help you get better.

1. Have you recently begun to have strange sensory experiences that people around you aren't having—hearing voices other people don't hear, seeing people or objects that other people aren't seeing, or having any other kinds of sensory experiences other people around you don't have—smells, tastes, or physical sensations? _____ If you have, briefly describe these experiences, including when they started, any important events that happened before they started, and the following additional information:

a. What kinds of events happened shortly before these experiences started, and when?

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b. If you've heard voices, say whether you recognize them as people you know, what they say to you, and whether they try to get you to do anything:

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c. If you see people or objects, briefly describe them; if they are people, do you know them? What do you see them doing?

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d. If you have other sensory experiences that other people don't—smells, tastes, or physical sensations—briefly describe them:

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e. On a scale of 1 to 10, with 1 being the least and 10 the most, how much do these experiences bother you? _____

f. If there are events, situations, or things that you do that cause them to start, increase, or become more upsetting, what are those events, situations, or actions?

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g. If there are events, situations, or things that you do that cause them to stop, decrease, or become less upsetting, what are those events, situations, or actions?

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2. Have you recently begun having thoughts that people want to hurt you or are secretly planning to hurt you? Yes _____ No _____ . If you have, briefly describe these thoughts, including what they are, when they started, any important events that happened before they started, and whether there are ways you can tell they are or aren't true:

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a. What kinds of events happened shortly before these thoughts started, and when?

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b. On a scale of 1 to 10, how much distress do the thoughts cause you? If you can tell when they aren't really true, does that lower your stress level? _____

c. If there are events, situations, or things that you do that cause these thoughts to start, increase, or become more upsetting, what are those events, situations, or actions?

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d. If there are events, situations, or things that you do that cause them to stop, decrease, or become less upsetting, what are those events, situations, or actions?

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3. Have you noticed anything about any of these sensory experiences or thoughts that enables you to tell whether they are real or not? _____ If so, describe how you can tell:

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4. If you've identified ways to tell when any of these kinds of experiences aren't real, does it make it less stressful to know that you can still tell the difference between things that are real and those that aren't? _____ Does it make these experiences less stressful when you know that when they suddenly start the way they did in your situation, they usually go away within a month after the trauma or shock that caused them? _____ Please keep working with your therapist on ways to cope with these experiences.

Be sure to bring this handout back to your next session with your therapist, and be prepared to discuss your thoughts and feelings about the exercise.

Reality Checks

Goals of the Exercise

1. Report decrease or elimination of positive psychotic symptoms (i.e., hallucinations and/or delusions).

2. Take psychotropic medications as prescribed.

3. Eliminate or adequately control positive and negative psychotic symptoms so that independent functioning can resume.

Additional Problems for which this Exercise may be Useful

Suggestions for Processing this Exercise with Veterans/Service Members

The “Reality Checks” activity provides the veteran/service member with information about the formation of hallucinations and delusional beliefs in both transient and chronic thought disorders; this exercise is primarily aimed at veterans/service members experiencing brief reactive psychotic episodes, and thus is aimed at a fairly well-organized and high-functioning person whose sensory and cognitive processes are mostly normal and are expected to fully return to normal in a short time. Follow-up for this activity can include bibliotherapy using books suggested in Appendix A of The Veterans and Active Duty Military Psychotherapy Treatment Planner.

EXERCISE X.B Reality Checks

Most of us go through life, most of the time, taking it for granted that our physical senses and our thought processes are working properly. If you're in traffic and see a blue station wagon in front of you, it probably never crosses your mind to wonder whether it's really there, or whether it's really blue. We also trust our logic and ability to tell fact from fantasy. However, you may be finding that as a result of a recent traumatic experience your senses and thinking have become less dependable. You can assume pretty safely that this is a short-term result of that recent trauma, because if this was a more serious and chronic problem, you wouldn't have ever gotten into the military in the first place, or would have failed to complete basic training or OCS. Still, even knowing it won't last, it's nerve-wracking, like living in a minefield, to have to constantly wonder about the reality of what we see, hear, think, or remember.

However, there are tools you can use to handle this while your brain is recovering from its recent shock. This exercise will show you some of those tools.

1. The title of this exercise, “Reality Checks,” is often used to describe a situation in which someone finds out that something he or she believed isn't true, often in some way that is costly, embarrassing, or painful. Here we mean it literally, though, as in checking the reality of things, to avoid those situations. Another phrase used more seriously for the same kind of thing is “reality testing,” and it applies to both sensory experiences and the thoughts that interpret them. What do you think would be some effective ways to test the reality of things you see and hear?

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If you saw the film A Beautiful Mind, you may remember a scene in which John Nash, the mathematician whose story the film tells, is teaching at a university after decades of struggling with a mental illness that caused him to hallucinate (in his case, he sometimes saw people who weren't actually there) and suffer from delusions (beliefs that are not based on fact and are often bizarre). A man stops him in the hallway at the school and tells him that he, John Nash, has just been awarded the Nobel Prize for his work. Nash stops a passing student, points to the man from the Nobel committee, and asks the student, “Can you see him?” When the student says he can, Nash accepts that this is real, but his first thought is that he might be hallucinating—so he gets a second opinion. Obviously, he couldn't do this with everything he saw or heard. So he would first ask himself if what he perceived was consistent with the way the world and his life normally operated. The more out of the ordinary something was, the more likely it wasn't real. Having a stranger walk up and tell him, out of the blue, that he had won a prize that would make him rich and world-famous was definitely not part of his average day, so the first thing he did was get an independent check. We all do this at times: Can you remember a situation where you saw something strange or unusual enough that you said to whoever was with you, “Did you see that?” or something similar, or had someone say it to you? What was the situation?

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2. The point of presenting this example is to show you that you already have a lot of practice at reality testing when it comes to your senses. Since you experienced your recent trauma, have you seen, heard, smelled, tasted, or felt things that turned out not to be real? What were they, and how did you find out that your senses were playing tricks on you?

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3. Beyond asking someone nearby whether he or she can see or hear the thing you're wondering about, another option for testing might be to take a picture of it, maybe with a camera built into your cellular phone, then show the picture to other people later and ask them to tell you what they see. Would this work for you? _____

4. What sensory illusions or hallucinations have you experienced recently, if any, and did they have characteristics you could watch for that would make it possible to tell them from things that are real? If so, describe the hallucinations and the qualities that let you know they weren't real:

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5. Are there people who could help you with this kind of reality testing, like the student in the hallway in the film? Who are they, and how can you ask for that help?

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6. The other positive symptom of a psychotic episode—positive means that something's happening that shouldn't (a negative symptom is the absence of something that should be present)—is delusional thinking. As we said above, this means a belief in something that contradicts obvious facts. Again, it's impossible to go through life checking the validity of every thought that drifts through your mind, so the best strategy is to test thoughts that seem weird based on our knowledge of the world in general. What delusional thoughts have you had, if any, since your recent shocking experience?

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Is there a pattern in those thoughts you could use to check the reality of future thoughts? If you see a pattern, what is it?

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7. Finally, can the people who could help you check for hallucinations also help you check for delusions, or can someone else? Again, who are they and how can you ask for that help?

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Be sure to bring this handout with you to your next therapy session, and be prepared to discuss your thoughts and feelings about this exercise.