Helping Patients Navigate the Halloween Season and Sensory Overload: In Conversation With Richard W. Miller, MD

CLINICAL CONVERSATIONS

Halloween can be a uniquely stressful time for patients with mental health disorders. Sensory overload from loud parties, flashing lights, fog machines, and frightening costumes can exacerbate preexisting disorders and sensitivities. Psychiatric Times sat down with Richard W. Miller, MD, to discuss how psychiatric clinicians can best support patients through the spooky season and beyond.

Psychiatric Times: The Halloween season can be a sensory overload, particularly for patients with mental disorders. What challenges does this holiday present? What patients do you believe are most affected by this time of year? Why?

Richard W. Miller, MD: Halloween can be very stressful for individuals living with certain serious mental illnesses, such as schizophrenia. There are costumes, spooky decorations, crowds of people, and for someone working hard to manage symptoms, all of that can be very overstimulating. For individuals who experience hallucinations or delusions as a part of their illness, seeing someone dressed as a frightening character can line up a little too closely with what they are already hearing or seeing.

People living with anxiety can also struggle this time of year. Trick-or-treating, parties, or being in a neighborhood packed with kids and parents can push them out of their comfort zone. And for those with posttraumatic stress disorder (PTSD), the darkness, loud noises, or even a negative memory tied to this time of year can be activating as well.

Unintentionally, Halloween places individuals with psychosis, anxiety, or PTSD in situations that can be full of potential challenges. They may not even see it coming, and suddenly they are overwhelmed or distressed, so sensitivity and awareness during this season are essential.

PT: How can sensory overload intensify symptoms such as anxiety, paranoia, or hallucinations? Can you share any research/evidence?

Miller: Halloween can be like turning the volume up from 1 to 10. If somebody is already hearing what they perceive to be the voice of the devil, as a hypothetical example, and then you expose them to someone dressed as the devil, or wearing red, or whatever it might be, you are potentially making that hallucination feel a lot more real. Same thing with paranoia or anxiety. You are putting them in a situation that is uncomfortable and can lead them to feel symptoms more intensely.

As a specific clinical illustration, individuals living with schizophrenia have a harder time filtering out background noise. In a functional MRI study, researchers exposed participants to everyday city sounds while they completed visual attention tasks.¹ Those living with schizophrenia showed greater neural activation in brain regions that should remain quiet during focused attention, which made it harder for them to complete even easy tasks. They also responded more slowly and performed worse overall when the distracting noises were present.

On days like Halloween when they are flooded with an overwhelming amount of background noise, symptoms of psychosis, such as hallucinations and delusions, could subsequently worsen.

I usually explain it like this: someone who is in recovery from alcohol use disorder can go to a bar, but it may not be a good idea for them. They may say no to the drink, but they are still in a setting that can generate negative associations and stress, and could even challenge their recovery. So, the more overstimulating the environment is, the more we risk someone decompensating.

PT: How can patients best enjoy the ‘spooky season’ and the subsequent holidays without becoming overwhelmed? What routines, coping strategies, etc, do you share with patients?

Miller: I think the most important thing is trying to stay on a routine. If something feels uncomfortable for a patient, they should make that known, whether that is to a care partner, case manager, or family member. And if there is a medication question, it is critical that they keep taking their medication as prescribed and have any needed conversations with their health care provider.

There is a guiding clinical principle someone taught me: do not make medication changes from Halloween until New Year’s. It is a festive time, the days are getting darker, there can be travel or increases in socialization, as well as schedule changes, making staying consistent with daily medication more of a challenge. Long-acting injectables (LAIs), like aripiprazole lauroxil (Aristada), can be helpful as part of an overall therapeutic strategy. With an LAI, medication is already accounted for, so that is one less thing for the patient or the family to worry about while they are out trying to navigate this busy season.

PT: A lot of Halloween and horror movies build upon stereotypes of mental illness (“Psycho,” “Split,” etc). Do you think this perpetuates stigma against mental disorders? How can clinicians help combat this phenomenon?

Miller: A lot of the characters in horror movies are portrayed as having mental illness, as being psychotic or dangerous, and the whole reason they are doing what they are doing in the movie is because of that illness. It is concerning because these depictions are distorted for dramatic effect and perpetuate an inaccurate conclusion that people with mental illness are dangerous. That is just not true for the overwhelming majority of people living with these conditions. And, in fact, people living with a mental illness are more likely to be the victims of crime than the perpetrators of it.

One way clinicians can help is by helping patients separate fiction from reality. We can remind them that these are fictional characters, exaggerated to scare people, and not an accurate representation of someone living with schizophrenia, bipolar disorder, or any other condition.

Reassurance is a big part of this. We must tell our patients, repeatedly, “You are not that character,” to help them feel comfortable and confident in who they are. It also can open a door to conversation about what life with these conditions can look like with treatment and support.

PT: In general, how can clinicians best support these patients during this time of year? Are there any tips you can share?

Miller: It all goes back to communication and meeting patients where they are. If there are certain prompts or stressors that usually make things worse, we want to avoid those. Maybe that means celebrating during the day instead of late at night. Maybe it means avoiding parties where there are extra creepy decorations. Environment matters so we must help them feel empowered and aware to choose the safer option when possible.

Having a support network in place is also key. Patients should know who they can call when they need help, whether that is a family member or an emergency number.

From a clinical standpoint, medication planning can be a proactive strategy. If adherence tends to drop during the holidays, that might be a good time to consider an LAI option so stability is not disrupted.

Halloween and the broader holiday season should be enjoyable. A little preparation and communication can go a long way in making sure patients stay well while still being part of the celebrations.

PT: Thank you!

Dr Miller is a staff psychiatrist at Elwyn Adult Behavioral Health in Cranston, Rhode Island. He has over 16 years of experience in the medical field and specializes in treating serious mental illnesses such as schizophrenia. His work centers on a family-oriented, holistic treatment approach.

Reference

1. Smucny J, Rojas DC, Eichman LC, Tregellas JR. Neural effects of auditory distraction on visual attention in schizophrenia. PLoS One. 2013;8(4):e60606.