The First Break
While many neuropsychiatric spells and syndromes can be scary to patients, none is more frightening and confusing than the First Break. That is a term used for the first time a patient develops psychosis. It is mostly used in primary thought disorders like schizophrenia, but at the beginning there is no way of knowing what will come. Importantly, the same symptoms can occur in severe depression, mania, and many different medical conditions.
Interestingly, the First Break is rarely the first symptom. The typical first psychotic episode in someone who will go on to develop schizophrenia is one of the most well documented and consistent processes in all of medicine. Few conditions have such a predictable course, and understanding a normal psychotic episode can help doctors and patients understand what to do when the episode is atypical.
Prodrome is the word that we use for the symptoms that often occur before the First Break in disorders like schizophrenia, and it typically develops over the course of 6 months or more. Progressive isolation is common, often leading to questions of exactly what was happening. Slightly disorganized or bizarre conversations occur, where the patient seems different. Their reasoning seems off, and the topics are often centered around threats that become less and less connected to reality. While the government may be out to get all of us, these patients begin to think that they are being uniquely targeted by someone or something that has never been a concern before. There are features of depression laced with paranoia and fear. They often stop attending to basic hygiene like showers or dental care. Eventually they will have bizarre behaviors that make others uncomfortable. However, because of their drive to isolate themselves, families often only see small parts of the larger picture.
Suddenly all of these symptoms seem to unravel, often because of some stressful situation like tests at school or family gatherings over the holidays. Maybe the bizarre behaviors and thoughts lead to an argument with a friend, or break up with a boyfriend or girlfriend. Families realize that something is terribly wrong and confronting the person having their first break almost inevitably leads to major conflict. This in turn results in a request for an urgent visit to the doctor, or even a visit to the emergency department. That is where the right questions are asked and the whole picture becomes clear.
What is the typical symptom profile? Late adolescence through someone’s mid-20s is the classic age for the First Break with a primary thought disorder like schizophrenia. Delusions are usually focused on something special about the person. Something about them justifies persecution. They can understand brain waves, or even push thoughts into the minds of others. The television is speaking to them, or the government needs to contact them. Often they begin to think they are connecting dots that others just cannot see. Hallucinations are almost always auditory, first with low whispers in the background and eventually voices they can hear. First those voices may be simple, just narrating their thoughts, but as the patient becomes more paranoid the voices become more threatening. They may tell the patient to walk into the street, take off their clothes, or even hurt themselves. In this state, the emergency room may be necessary, but it can be extremely frightening.
The other common First Break syndrome is with mania. These first manic episodes often occur in someone’s 20s or 30s. Typically there will have been a few episodes of depression at some point in the past, but often they are mild and ignored or easily treated. Then something happens. Maybe it is a problem at school or in a relationship, or the stress of some work project. Typically the manic prodrome occurs over a week or two with an increase in energy, and faster thinking and talking. The patient begins to think they are special or great at something, and they start getting a lot of great ideas. These ideas may be about god and religion, or work and projects, or maybe they’ve figured out the solution to the government’s dysfunction. Then they can’t sleep, but they don’t need sleep because they feel so awake without any rest. A few days later, they are thinking and talking so fast and so much that it is hard to get in a word. Finally someone confronts them, and this leads to a disastrous conflict resulting in a visit to the ER.
While many doctors and patients will know about these classic stories, they may not be aware that atypical symptoms may point toward medical causes that can be life threatening if missed. Because of how our emergency medical system works, the very first person who sees the patient will usually put them on a track to admission on a general medical ward or admission into a psychiatric unit. There may be conflict over where a patient goes or which medical tests are run, and usually the patient and family aren’t aware of this. The psychiatrist and the ER doc often have a lot of political conflicts between what evaluations are necessary and which department is responsible for them. These decisions are often made before a full evaluation, and after someone has started on one path it is very difficult to change course.
It would take too long to describe all of the many medical causes for a first break, or even the reasons to run which tests, but there are a few key rules that may help patients’ families advocate for them as best as possible.
Be sure of the Last Known Well. When was the patient last seen to be completely normal in their thoughts, perceptions, and behaviors.
Identify any other medical symptoms like insomnia, stomach problems, or recent symptoms of infection.
What is the family history with psychosis or mania? While these events can happen without a family history, usually there is a story about an aunt or uncle experiencing something similar.
Who all can give information about the progression? If they’ve been isolating, what have their friends noticed. If they’ve been at school, what roommates or teachers have seen them recently?
Have they been responding to voices? What about seeing things that don’t exist? Maybe they’ve complained about bugs in the house or animals or people outside. Could these be real or are they hallucinations?
Beyond that, most of the work is done by the doctors, and it all hinges on atypical features. Young kids and people over 40 would very rarely have their first manic or psychotic episode. While hearing voices is common, visual hallucinations are very strange. Did someone have psychosis that developed within a few weeks, or mania that happened overnight? Are there abnormal movements, or is there weakness or difficulty with balancing? Is there any seizure-like activity? While any one of these can be an atypical feature of a normal First Break, when someone has two or more atypical features, they should be emphasized to the doctors so they can consider if a more extensive medical workup should be done before going to a psychiatric stabilization unit.
However, focusing too much on medical causes can be just as dangerous as neglecting them. If someone goes to a psychiatric ward and has a seizure, they will go right back to the emergency department, but once they are admitted to a medical floor, many different threats are present. They may be over sedated or even tied down for safety, since the medical ward doesn’t have the appropriate staff to manage psychotic patients. Hospital patients are more likely to get infections, bed sores, or develop nutritional deficiencies than psychiatric ward patients. Finally, delaying proper psychiatric treatment can lead to worsening psychosis or mania which can make it much harder to treat.
Unfortunately, some of the biggest problems occur when families decide they can take the patient home. Home is often where the stressful triggers are most prevalent. Home delays medical and therapeutic treatment. Home has knives. Home has the highway that the voice told them to walk into. However dangerous the medical facility is, and however frightening the idea of a psychiatric ward may be, they are designed to put safety above all else and the staff are trained to deal with emergencies better than families ever could be.
Are you or a family member experiencing these symptoms, or trying to process a recent hospitalization for a first break? Are you still worried that medical causes were neglected, or worried that the treatment plan isn’t working? Contact us for a consultation to discuss these and any other related issues surrounding a First Break episode.
