How to cope with A/H and paranoia

Key points:

Approach treatment with a plan and stick to it long enough to see if it works. Don't confound results by using substances that counteract the effect of medications being tried or lifestyle changes you've made. Agree on how you and the people around you will know whether your plan is working.

There are a number of techniques for coping with symptoms you already have, but they can be hard to incorporate into a normal daily routine that requires you to focus on other things. A combination of medications and lifestyle changes can reduce some symptoms to the point where they can be ignored.

Distraction techniques are the most common way of coping with voices that are too loud to be ignored. They almost always help, but since they require listening to music or other distracting sounds, they limit what you can do while using them.

Vocalization (such as humming a single note or melody) works by disrupting the mental and physical processes that cause A/H. With practice it can be done so quietly that no one notices. It's an option to consider for situations where you can't wear headphones or listen to music.

Monaural occlusion (putting an earplug in one ear) has also been shown to reduce A/H, and may help people distinguish between real sounds and imaginary ones. It's unique among coping skills for managing A/H in that it requires no conscious effort and allows you to focus all your attention on other things.

Nathan

Session 1: Encouraged Nathan to approach treatment with a plan and stick to it long enough to see if it works. Taking his medications at random times, starting and stopping them on his own, and adding other substances to the mix is not the same as a decision to try managing his symptoms without medications. If he wants to try managing his illness with coping skills and lifestyle changes alone, he should develop a plan for doing so that includes being straightforward with his doctor and not allowing her to prescribe medications for him that he may or may not take. Everyone involved in his treatment should be on the same page so they will be assisting him in ways that are supportive of his decision. His plan should include a list specific coping skills and lifestyle changes he will implement as well as a description of things he will measure to determine whether his plan is working. Approaching treatment in a systematic way will help him become an expert on his illness over time and figure out the most effective ways of treating it.

Session 2: Briefly reviewed what we discussed last week, which is the importance of approaching treatment with a plan and sticking to it long enough to see if it works. Educated Nathan on research which shows that when schizophrenia is untreated or undertreated for long periods of time, brain damage can occur that is visible on MRIs. The more often people decompensate and become highly symptomatic, the harder it can be for them to return to former levels of functioning. For this reason, it is important that he pay close attention to the effectiveness of whatever plan he chooses to implement and be open to considering other options if the plan does not appear to be working. Asked Nathan to describe things that both he and the people around him could see or hear that would indicate his plan wasn’t working. He came up with "I go to the hospital", "I get 5150’ed", "The cops have to come out again", and "The voices get so loud I can’t talk to people". We made a list of these things and agreed that if they happened, it would indicate the need to make changes in his plan.

Session 3: In prior sessions we agreed on the importance of approaching treatment with a plan and on specific things Nathan will measure to determine whether the plan is working. In today’s session I introduced lifestyle changes he can implement that may help reduce the severity of his symptoms. These changes can be part of a plan to try managing his symptoms without medications, or they can be used with medications to further reduce his symptoms, but whatever he decides, it should be part of a plan that both he and his doctor agree on. Began by educating Nathan on the effects of stress. Explained that high levels of stress are believed to trigger schizophrenic episodes by increasing the body’s production of the hormone cortisol. Reducing stress is therefore one of the best things he can do to reduce the frequency and intensity of the voices he hears. Explained that in upcoming sessions I would show him different ways of doing this.

Session 4: Encouraged Nathan to think about situations that are stressful to him and consider ways he might be able to avoid them or approach them differently in the future. Explained that regular exercise could help reduce his overall level of stress. In addition to reducing his symptoms, it could also improve his focus and energy, and help him feel calmer. Advised him to aim for 30 minutes of activity on most days, either all at once or broken up into three 10-minute sessions. Suggested he try rhythmic exercises that engage both his arms and legs, such as walking, running, or dancing. Also stressed the importance of getting enough sleep. Explained that lack of sleep can cause hallucinations, paranoia, and delusions even in people who aren’t diagnosed with schizophrenia. To improve sleep, he should exercise in the morning or afternoon so that his body’s internal thermostat will be returning to normal levels around bedtime, triggering feelings of drowsiness.

Session 5: Last week we discussed how getting enough sleep can reduce overall levels of stress, which in turn can help reduce the severity of symptoms such as A/H and paranoia. This week we discussed the effect of commonly used substances on sleep. Caffeine affects people in different ways. Some people are sensitive to it while others are not. Suggested that Nathan try drinking coffee only in the morning, and reducing the total number of cups he drinks, to see if it helps him sleep better. Alcohol, if consumed within 4 hours of bedtime, usually makes it easier to fall asleep but harder to stay asleep. Nicotine does appear to provide short-term relief from some symptoms of schizophrenia, but it also stimulates the release of adrenalin, which constricts blood vessels and increases heart rate. This effect persists for 30-60 minutes after smoking a cigarette. With this in mind, I advised Nathan avoid smoking within 2 hours of bedtime and not to smoke if he wakes up during the night. He can try crunching on carrots, peanuts, or something similar to occupy himself during those times. Reminded Nathan that the goal of these changes is to improve the quality of his sleep, as better sleep often leads to a reduction in stress and an improvement in symptoms.

Session 6: In prior sessions we discussed the ways that exercising and limiting consumption of substances such as caffeine, nicotine, and alcohol can help improve sleep, and how improved sleep can help reduce stress and make symptoms less disruptive. Today we discussed the skill of meditation. I taught the skill in 3 parts, first modeling deep breathing, then progressive muscle relaxation, then finally doing both together while explaining that I was silently repeating a word to myself and trying to put all other thoughts out of my mind. Invited Nathan to do it along with me and provided feedback and praise. Explained to Nathan that the goal of meditation is to help reduce overall levels of stress, as reducing stress is one of the key coping skills for managing symptoms of schizophrenia.

Session 7: In prior sessions we discussed lifestyle changes Nathan can make to help reduce the intensity of his symptoms, especially the voices he hears. Today we talked about ways he can cope with voices he is hearing in the moment, that medication and/or lifestyle changes alone have not eliminated. Introduced Nathan to the skill of vocalization, a technique that involves using the vocal cords to make sounds such as humming, singing, or speaking. Although these sounds can be of any volume, with practice it is possible to make them so quietly that others do not notice or hear. Also suggested Nathan try wearing an earplug in one ear. Although this technique sometimes becomes less effective over time, it can reduce A/H by nearly 50% when first used. Discussed the related coping skill of listening to music, talk radio, or audio books, as these will all shift focus away from A/H. Music can also have the added benefit of reducing stress.

Session 8: In past sessions we focused on things Nathan can do to reduce the intensity of A/H. Today we discussed ways of coping with feelings of paranoia. Suggested that Nathan identify a person or persons whose judgment he trusts, who he can share his concerns with and get honest feedback from. These persons can be used to test the validity of distressing ideas he has and can help him challenge negative things the voices may be saying about him. Discussed the value of joining a support group where he can get assistance from others who are dealing with the same challenges and obstacles.

Session 9: Reiterated the importance of approaching treatment with a plan and sticking to it long enough to see if it works. Taking medications at random times and using substances that mask or counteract their effect make it impossible to figure out what works and what doesn't. Encouraged Nathan to be honest with his doctor about what he hopes to get out of treatment and collaborate with her to find a medication that provides an acceptable balance between symptom relief and side effects. To do this, he needs to take the medication exactly as prescribed and not confound the results by using illicit substances. If the results are unacceptable to him, he has every right to decline the medication and ask to try something different. Explained that knowledge is power and sticking to a game plan is the way he acquires it.