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Establish an accurate diagnosis, considering other psychotic
disorders in the differential diagnosis because of the major implications
for short- and long-term treatment planning. If a definitive diagnosis
cannot be made but the patient appears prodromally symptomatic and
at risk for psychosis, reevaluate the patient frequently.
Reevaluate the patient's diagnosis and update the
treatment plan as new information about the patient and his or her
symptoms becomes available.
Identify the targets of each treatment, use outcome measures
that gauge the effect of treatment, and have realistic expectations
about the degrees of improvement that constitute successful treatment.
Consider the use of objective, quantitative rating scales
to monitor clinical status (e.g., Abnormal Involuntary Movement
Scale [AIMS], Structured Clinical Interview for
DSM-IV Axis I Disorders [SCID], Brief Psychiatric
Rating Scale [BPRS], Positive and Negative Syndrome
Select specific type(s) of treatment and the treatment setting.
(This process is iterative and should evolve over the course of
the patient's association with the clinician.)
Identify the patient's
goals and aspirations and relate these to treatment outcomes to
increase treatment adherence.
Assess factors contributing to incomplete treatment
adherence and implement clinical interventions (e.g., motivational
interviewing) to address them. Factors contributing to incomplete
treatment adherence include
lack of insight about presence of illness or need to take medication,
patient's perceptions about lack
of treatment benefits (e.g., inadequate symptom relief) and risks (e.g.,
unpleasant side effects, discrimination associated with being in
breakdown of the therapeutic alliance,
practical barriers such as financial concerns
or lack of transportation,
cultural beliefs, and
lack of family or other social support.
Consider assertive outreach (including telephone calls
and home visits) for patients who consistently do not appear for
appointments or are nonadherent in other ways.
Work with patients to recognize early symptoms of relapse
in order to prevent full-blown illness exacerbations.
Educate the family about the nature of the illness and coping
strategies to diminish relapses and improve quality of life for
Work with team members, the patient, and the family to ensure
that services are coordinated and that referrals for additional
services are made when appropriate.