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Psychosis

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  • 1. EarlyPsychosisA GUIDEFOR MENTAL HEALTHCLINICIANSTHE UNIVERSITY OF BRITISH COLUMBIAMental Health Evaluation &Community Consultation UnitDepartment of Psychiatry2250 Wesbrook MallVancouver British ColumbiaCanada V6T 1W6Printed In CanadaDESIGN: MIND’S EYE STUDIO“SCORNED AS TIMBER, BELOVED OF THE SKY”-EmilyCarr“SCORNED AS TIMBER, BELOVED OF THE SKY”-EmilyCarr
  • 2. EarlyPsychosisMental Health Evaluation& Community Consultation UnitYEAR 2000A GUIDE FORMENTAL HEALTHCLINICIANS
  • 3. Early Psychosis: A Guide for Mental Health CliniciansTableofContentsPractical Guidelines for First-Episode Psychosis. . . . . . . . . . . . . . . . . 4 - 5Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9First-Episode Psychosis........................................................................11Psychosis and Early Intervention ....................................................11Why is Early Intervention Needed? ................................................12Stress-Vulnerability Model of Onset................................................14Figure 1: Stress-Vulnerability Model...............................................15Course of First-Episode Psychosis......................................................16Prodrome......................................................................................16 - 17Acute Phase..................................................................................18 - 19Recovery Phase ................................................................................20Summary of First-Episode Psychosis ..............................................21 - 22Role of the Clinician ............................................................................23ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Typical Presentations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25An Assessment Framework . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Table 1 - Components of a Mental Status Exam . . . . . . . . . . . . 26 - 27Interview Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 - 31Family Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Investigations in First-Episode Psychosis . . . . . . . . . . . . . . . . . . . . 33Referral Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Hospitalization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
  • 4. Early Psychosis: A Guide for Mental Health CliniciansTREATMENT................................................................37Guidelines .............................................................................................37Initiating Treatment..............................................................................37Pharmacological Interventions ............................................................38Antipsychotic Medication Free Period ............................................38Pharmacotherapy Options............................................................38 - 39Non-Pharmacological Interventions....................................................40Resources.........................................................................................40Coordinating Care ...........................................................................40Psychoeducation ..............................................................................41Cognitive Therapy ...........................................................................42Coping Skills and Stress Management Approaches ........................42Family Therapy................................................................................43Group Programs...............................................................................43Other Therapies...............................................................................43Summary of Strategies for Early Intervention ...............................44 - 45Source Materials ................................................................................46Other Resources .........................................................................................47Cover Credits .............................................................................................48TableofContents
  • 5. Early Psychosis: A Guide for Mental Health CliniciansPractical GuidelinesFOR FIRST-EPISODE PSYCHOSISea ly detectionProdromal symptomsRefer client for psychiatric assessmentMonitor client’s progressSupport and counsel client and familyEmerging psychotic symptomsAsk direct but gentle questions about psychotic symptomsRefer promptly for thorough psychiatric assessmentdiagnosisRemain prepared to revise the provisional diagnosisConsider specialist reassessmentWor ing relationshipStrive to maintain continuity of careDevelop a trusting relationship with the clientTreat the individual as an autonomous adultFoster collaboration with the client in managing the illnessp actice issuesMaintain a client registerDevelop management protocols for problems such as missedappointments, adherence to treatmentEnsure multidisciplinary comprehensive assistance to clientand family4
  • 6. Early Psychosis: A Guide for Mental Health CliniciansLiaison with mental health agenciesMaintain communication with the client’s psychiatrist,physician, school counselor, etc.Involunta y admissionsWork with the psychiatrist and/or physicianFirst ensure safety of self and others (involve policeonly if necessary)Use a non-threatening, non-confrontational approachDetermine whether criteria for involuntary admission arepresentClearly explain and inform the client of his or her legal statusEnsure supervised transport to hospitalPha macological Inte ventionsUtilize specialists with expertise using antipsychotics withfirst-episode clientsBe patient with the “start low - go slow” approachMonitor symptomsExplore reasons for non-complianceEncourage client’s role as collaboratorNon-Pha macological Inte ventionsDevelop a supportive therapeutic relationshipSet realistic goalsProvide reassurance and an opportunity to air emotionsEducate the client and familyEncourage symptom self-monitoring and coping skillsEnsure provision of multiple evidence-based interventions5
  • 7. Early Psychosis: A Guide for Mental Health CliniciansPrefaceThis booklet was produced by Mheccu as a supporting document for the Early PsychosisInitiative (EPI) of British Columbia. A major goal of EPI is to enhance recognition ofearly signs and symptoms of psychosis so that effective treatment can be started promptly.In the 1999/2000 fiscal year, the Ministry of Health (Province of British Columbia)undertook an initiative with bridge funding to further the goal of developing preventionand early intervention services for young persons at risk for severe mental illness asidentified in the Mental Health Plan. In March 2000, the Ministry for Children andFamilies announced additional one-time funds to further inter-ministry goals in this area.Partners with the Ministry of Health and the Ministry for Children and Families includeregional representatives of the Ministry for Children and Families and regional healthauthorities, Ministry of Education and regional counseling and special servicesrepresentatives, the BC Schizophrenia Society and the Canadian Mental HealthAssociation. All health regions in the province are participating in EPI strategies aimed atimproving services to young persons in the early stages of psychosis.Mheccu (Mental Health Evaluation & Community Consultation Unit), the contractor forEPI, is a unit of the Division of Community Psychiatry, University of British Columbia.For further information on EPI or how to obtain copies of this booklet contact:THE EARLY PSYCHOSIS INITIATIVEMheccu, UBC2250 Wesbrook MallVancouver, BC, CanadaV6T 1W6or via the website:www.mheccu.ubc.ca/projects/EPI7
  • 8. IntroductionEarly Psychosis: A Guide for Mental Health Clinicians 9Approximately 3% of people will experience apsychotic episode at some stage in their life. Usually a firstepisode occurs in adolescence or early adult life, an importanttime for the development of identity, relationships andlong-term vocational plans.The initial episode of psychotic disorders is typically aconfusing and disturbing process for the person and theirfamily. Lack of understanding of psychosis often leads todelays in seeking help. As a result, these disorders are leftunrecognized and untreated. Even when appropriate helpseeking does occur, further delays in diagnosis and treatmentmay result from skill and knowledge gaps among professionals.Suspiciousness, fear and lack of insight also hinder contactwith professionals.Increasingly, attention is being paid to strategies that reducethe personal, social and economic strain of these conditionson affected individuals, their families and the community.Early intervention in first-episode psychosis is aimed atshortening the course and decreasing the severity of the initialpsychotic episode, thereby minimizing the many complicationsthat can arise from untreated psychosis. Appropriate earlyintervention can provide significant long-term benefits.This booklet provides mental health clinicians with a briefoverview of first-episode psychosis guidelines in order topromote early and appropriate intervention.
  • 9. Early Psychosis: A Guide for Mental Health CliniciansIntroduction11FIRST EPISODE PSYCHOSISPsychosis and Early InterventionPsychosis describes a mental state characterized by distortion or lossof contact with reality, without clouding of consciousness. Positivesymptoms of psychosis include delusions, hallucinations andthought disorder.Negative symptoms of psychosis such as affective blunting, povertyof thought or speech and loss of motivation can also occur. Thereare usually a number of other secondary features, such as sleepdisturbance, agitation, behaviour changes, social withdrawal andimpaired role functioning. These secondary features often provideclues to the presence of psychosis.Psychosis can be caused by certain medical conditions, drug andalcohol abuse, and a variety of psychiatric disorders such asschizophrenia, bipolar disorder, schizophreniform psychosis andschizoaffective disorder.Early intervention involves investigating psychotic disorders at theearliest possible time and ensuring that appropriate treatment isinitiated. Treatment should begin at the first sign of positive psychoticsymptoms, but it may also be possible to intervene during theprepsychotic, prodromal phase. To date, antipsychotic medicationhas not been validated for use in the prodrome. Psychosocial inter-ventions are indicated.Achieving early intervention requires increasing communityunderstanding of early signs and decreasing the stigma which cansometimes delay people from seeking help. It also requires improvingskills and knowledge among health professionals positioned todetect and treat these disorders.
  • 10. Early Psychosis: A Guide for Mental Health CliniciansWhy is Early Intervention Needed?Numerous studies have shown there is often a significant delay ininitiating treatment for people affected by a psychotic disorder.These delays vary widely but the interval between onset of psychoticsymptoms and commencement of appropriate treatment is oftenmore than one year.As a consequence of these delays, significant disruption can occur ata critical developmental stage along with the formation of alarmingsecondary problems. The longer the period of untreated illness, thegreater the risk for psychosocial disruption and secondary morbidityfor the person and their family.A psychotic episode commonly isolates the person from others andimpairs family and social relationships. Difficulties in school andwork performance arise and problems such as unemployment,substance abuse, depression, self harm or suicide and illegalbehaviour can occur or intensify.Some evidence shows that long delays in treatment may causepsychotic symptoms to become less responsive to treatment. Delaysin receiving treatment are associated with slower and less completerecovery. Longer duration of psychotic symptoms before startingtreatment appears to contribute to poorer prognosis and a greaterchance of early relapse. It is hypothesized that untreated psychosiscauses increased pathophysiological changes in the brain and thatrepeated episodes further erode long term functioning.12Introduction
  • 11. Delayed TreatmentCan Result In...Slower and less complete recoveryInterference with psychological andsocial developmentStrain on relationships, loss of family andsocial supportsDisruption of parenting role in youngmothers/fathers with psychosisDisruption of study or employmentIncreased family strainPoorer prognosisDepression and suicideSubstance abuseUnnecessary hospitalizationIncreased economic cost to the communityEarly Psychosis: A Guide for Mental Health Clinicians 13IntroductionDelayed TreatmentCan Result In...
  • 12. Stress-VulnerabilityModel of OnsetThe onset and course of psychosis can beviewed in terms of a "stress-vulnerability"model (see Figure 1). Interactions betweena biological predisposition (genetic andneurodevelopmental factors) andenvironmental stress can trigger activepsychotic symptoms.A positive family history of psychosis andparticular personality disorders (i.e., schizotypal,schizoid, and paranoid personality disorders)are associated with an increased risk of vulnera-bility to psychosis. For example, the risk ofdeveloping psychosis associated with schizo-phrenia is 1% for the general population vs.13% for the children of those with schizophrenia.An estimated 80% of clients affected by a psy-chotic disorder experience their first episodebetween the ages of 16-30.The median age of first onset of schizophreniais 19 years, with females experiencing a firstepisode two to three years later than males.Early Psychosis: A Guide for Mental Health Clinicians14Introduction
  • 13. Early Psychosis: A Guide for Mental Health CliniciansFigure 1STRESS-VULNERABILITY MODELNO SYMPTOMSPSYCHOTIC SYMPTOMSLow HighVulnerability✶ family history of psychotic disorders✶ obstetric complicationsStress✶adverse acute &chronic life events✶ developmentalchallengesHighLowlesssymptomsprodromalorsymptomspsychotic-likesevere15Introduction
  • 14. Early Psychosis: A Guide for Mental Health Clinicians16COURSE OFFIRST-EPISODE PSYCHOSISThe typical course of the initial psychotic episode can be conceptualizedas occurring in three phases: prodromal, acute and recovery.P odromeThe prodromal phase occurs when the individual experienceschanges in feelings, thought, perceptions and behaviour althoughthey have not yet started experiencing clear psychotic symptomssuch as hallucinations, delusions or thought disorder.Prodromal symptoms vary from person to person and some peoplemay not experience a prodrome. The duration is quite variable,although it usually spans several months. In general, the prodromeis fluctuating and fluid, with symptoms gradually appearing andshifting over time. Some areas where prodromal signs and symptomsoccur include:EmotionDepression, anxiety, tension, irritability, anger or mood swings.CognitionDifficulty in concentration and memory, thoughts feel sloweddown or speeded up, odd ideas, vague speech, overvalued ideas.Sense of Self, Others or the WorldFeeling somehow different from others, that things in theenvironment seem changed, suspiciousness.Introduction
  • 15. PhysicalSleep disturbances, appetite changes, somatic complaints, lossof energy or motivation and perceptual aberrations.BehaviouralDeterioration in role functioning, social withdrawal or isolation,loss of normal interests, preoccupations such as increasedconcern with spiritual/philosophical issues, uncharacteristicrebelliousness.Clearly, these changes are non-specific and can result from a numberof psychosocial difficulties, physical disorders and psychiatric disorders.The key for early intervention in psychotic disorders is to keep thepossibility of psychosis in mind when seeing a young personexhibiting these symptoms. It is especially important to determineif the changes in personality and behaviour are persistent orworsening. These changes should not immediately be dismissed asjust being part of adolescence. Various explanations may exist, butprodromal psychosis is one of them and close review and regularmonitoring of the person is advisable.Early Psychosis: A Guide for Mental Health Clinicians 17Introduction
  • 16. Acute PhaseDuring the acute phase, typical psychotic symptoms emerge.Positive symptoms such as thought disorder, delusions and halluci-nations may become predominant. This phase usually continuesuntil appropriate treatment is initiated.Hallucinations are sensory perceptions in the absence of an externalstimulus. The most common types are auditory hallucinations.Other types of hallucinations include visual, tactile, gustatory andolfactory. These are less common and other medical/drug causesmay be contributory.Delusions are fixed, false beliefs out of keeping with the personscultural environment. These beliefs are often idiosyncratic, verysignificant to the client but hard for other people to understand.Delusions often gradually build in intensity, being more open tochallenge in the initial stages, before becoming more entrenched.COMMON TYPES OF DELUSIONS INCLUDE:persecutory delusionsreligious delusionsgrandiose delusionsdelusions of referencesomatic delusions andpassivity experiences such as thought insertion/broadcasting/withdrawal.Early Psychosis: A Guide for Mental Health Clinicians18Introduction
  • 17. Thought disorder refers to a pattern of vague or disorganized thinking.Speech seems disjointed and hard to follow. Thought disorder mayalso refer to ideas of reference (special meanings that are found inwords and events and are communicated to the person), "thoughtblocking" (an abrupt interruption to the flow of thought that can beinterpreted as stolen thoughts), and "thought insertion" (sense thatideas seem alien and are often interpreted as the thoughts of othersplaced in the client’s mind).While delusions, hallucinations & thought disorder are definitive ofpsychosis, disturbances of mood, behaviour, sleep and activity mayco-occur.Many clients with an underlying psychological/psychiatric disorderinitially present with tiredness, repeated headaches, insomnia orvague physical symptoms.The person’s initial presentation is variable. The common presentationof positive symptoms and disturbed behaviour should not lull oneinto overlooking the quietly deteriorating “odd” individual whosepsychosis leads to a predominantly negative presentation.Negative symptoms such as decreased motivation, energy and interest,blunted affect and a decrease in the richness of inner mental life arecommon in the acute phase. These symptoms, along with vaguesomatic symptoms, may be misinterpreted as depression therebyincreasing the duration of improperly treated psychosis.Early Psychosis: A Guide for Mental Health Clinicians 19Introduction
  • 18. Recovery PhaseWith available treatments, the great majority of people recover wellfrom their initial episode of psychosis.The recovery process is affected by the treatment environment,medication and psychological therapies, personality style and factorswithin the persons family and social environment. The recoveryprocess will vary in duration and degree of functional improvement.Specific issues to be dealt with in the recovery phase include helpingthe person and family make sense of the illness experience, restoringself-confidence and facilitating a return to premorbid levels of function-ing. Problems such as post-psychotic depression, anxiety disorders,decreased self-esteem and social withdrawal need to be addressed.Assistance with housing, finances, employment and study may alsobe required.To achieve maximal recovery, a supportive and collaborativeapproach utilizing specialist treatments and a comprehensivebiopsychosocial approach is essential.Medication is usually continued for at least twelve months afterrecovery from a first episode and then slowly discontinued whilethe individual continues to be monitored. Unfortunately, manypeople fail to continue with medication and relapse as a result.Following recovery from a first episode, a significant number ofpeople will never experience a recurrence of psychosis.Early Psychosis: A Guide for Mental Health Clinicians20Introduction
  • 19. Early Psychosis: A Guide for Mental Health CliniciansOthers will develop recurring episodes of psychosis, but lead produc-tive lives between episodes. During the recovery phase, a discussionof these possibilities should occur with the person and their family.Guidelines for recognizing and seeking treatment for relapses at theearliest possible stage should be established as part of the generalfocus on client and family psychoeducation. Definitive prognosis isnot possible.Summary of First-Episode PsychosisA first episode typically occurs in adolescence or earlyadult life.It is confusing, distressing and disruptive for the personand their family.Symptomatic clients often remain undiagnosed anduntreated for long periods. Failures to initiate treatmentresults from multiple factors (e.g., lack of insight andstigma), with delays in recognition representing a criticalpart of the problem.Increasing public and professional awareness of thesymptoms and course of first-episode psychosis assistsearly case detection.The first episode usually occurs in three phases-prodromal, acute and recovery.Early intervention means intervention at the earliestsign of positive symptoms.Treatment should proceed in the least restrictiveenvironment possible.21Introduction
  • 20. Treatment requires a comprehensive biopsychosocialapproach and a range of specialist treatments aimedat treating the persons primary psychotic symptomsand assisting them in overcoming the secondarypersonal and social difficulties that the illness oftencreates.Full symptomatic recovery from the first episode isthe norm.EARLY APPROPRIATE TREATMENT CAN:reduce the degree of disruption created by thepsychotic illnessreduce secondary morbidityresult in more rapid recoveryimprove outcomesEarly Psychosis: A Guide for Mental Health Clinicians22Introduction
  • 21. Role of the ClinicianMENTAL HEALTH CLINICIANS ARE WELL-SITUATED TO:1. identify the early warning signs of psychosis,2. provide a range of appropriate and timelyinterventions3. coordinate the clients care.It is important you be aware of the usual presentations of psychoticdisorders and proficient in performing a preliminary psychiatricassessment. You also need to be aware of the specialist psychiatricservices available to assist your clients.The key to early recognition of these disorders is maintaining a highindex of suspicion, particularly when dealing with an adolescent oryoung adult with persistent psychological difficulties or deteriorationin personality or behaviour.If a psychotic disorder is suspected, a “wait and see” approach toassessment and treatment may not be in the person’s best interest.Not infrequently, a diagnosis of depression is given (followed bytreatment for depression) because of the pessimism and stigmaattached to diagnoses such as schizophrenia.Early Psychosis: A Guide for Mental Health Clinicians 23Introduction
  • 22. Typical PresentationsThere are numerous ways in which a person experiencing their firstepisode of psychosis may come to your attention.Psychotic illnesses rarely present “out of the blue”. They are typicallypreceded by a gradual change in psychosocial functioning. The familyusually senses that something is not quite right and may initiateseeking help.Even when the person does visit a clinician, the predominantpresentation may consist of depression, anxiety-related problems,and cognitive or somatic complaints.In the acute phase, psychotic symptoms may be evident but the clientmay be suspicious or attempt to conceal difficulties. Reassuranceand gentle persistence may be necessary. Focussing on the concernsraised by the persons family and asking the individual for theirpoint of view are usually fruitful approaches.An Assessment FrameworkWhen interviewing, it is helpful to have some sort of framework toassist you in exploring potential problem areas.One commonly used framework is the mental status examination(MSE). The major domains assessed by the MSE are represented bythe letters of the mnemonic "ABC STAMP LICKER" (see Table 1).Early Psychosis: A Guide for Mental Health Clinicians 25Assessment
  • 23. Table 1COMPONENTS OF A MENTAL STATUS EXAMINATIONThe Mental Status Examination is a review of psychiatric symptoms. The following mnemonic may aidin remembering all of the areas to review.A B C S t a m p L i c k e rAppearance Note anything unusual in the person’s self-care, dress,make-up or belongings.Behaviour Look for abnormal motor activities, level of activity, eyecontact, mannerisms and posture.Cooperation Note the persons attitude toward the interview.Speech Look for any abnormalities in rate, tone and ability to expressand comprehend language.Thought Assess both form and content. Note whether thoughts areconnected and logical. Ask about delusions and unusual ideas.Affect Note untimely or excessive affect, lack of affective responses toemotionally-laden topics. Determine whether affect matchesthought content.Mood Ask about depressive, anxiety and manic symptoms.Determine the intensity and stability of any mood symptoms.Perception Ask about hallucinations and perceptual disturbances in allsensory modalities.Level of Note how alert the person is during the interview and if theconsciousness level of consciousness fluctuates.Early Psychosis: A Guide for Mental Health Clinicians26
  • 24. Insight and Determine judgement through questions on specific,judgement practical issues. Determine the client’s insight intosymptoms and need for treatment. Ask about theirunderstanding and attitude towards treatments.Cognitive Consider using a Mini-Mental Status Exam as a screeningfunctioning tool for any cognitive deficits.Orientation - ask about date, place and person.Memory - ask about memory problems. Note whether theperson seems to have difficulty recalling either recent orremote events. Give the person a three to five word list andask them to repeat it five minutes later.Attention and concentration - note whether the person attendsto your questions; ask about capacity to attend to a TV show.Reading and writing - ask about reading ability. Ask the personto read several sentences aloud and to write a sentence.Knowledge base Note whether the person seems to have significant gaps in commonknowledge. Ask about significant dates, names of current politicalfigures, or recent newsworthy events.Endings Inquire about both suicidal and homicidal ideation. If any ideation,do a thorough risk assessment. Ask about plans, intent and lethalityof method. Consider factors that increase the risk such as previousviolence to self or others, drug and alcohol abuse, a recent triggeringevent, impulsiveness, severe personality disorders, organic andneurological conditions, mood and psychotic symptoms (especiallycommand hallucinations).Reliability Note whether the information gathered from the interview andobservations seems reliable.Early Psychosis: A Guide for Mental Health Clinicians 27
  • 25. The MSE is just one component of a psychiatric interview. For aninterview to be comprehensive, it is essential to gather informationin numerous other domains.PSYCHIATRIC ASSESSMENT:MSEpresenting problempersonal historypsychiatric historyphysical health (including head injury)developmental historyfamily history (including family psychiatric history)interpersonal relationships (both social and family)role functioning (work, school, parenting, etc.)daily functioningdrug and alcohol usesexualityEarly Psychosis: A Guide for Mental Health Clinicians28Assessment
  • 26. Early Psychosis: A Guide for Mental Health CliniciansIt is important to explore the hints and cues given by the client. What underlies theanxiety? Why has the client been having so many headaches? Why is he always sotired? Why has she stopped seeing her friends?Ask specific questions to assess for the presence of particular syndromes such asdepression, anxiety disorders and psychosis. Inquire about possible substance abuse.Assess the risk of suicide and whether the person poses a risk to others.Clinicians should inquire, matter-of-factly and without embarrassment, about thepresence of psychotic phenomena. The following are sample queries to assesspsychotic thinking:Sometimes people hear noises or voices when no-one is speaking and there isnothing to explain what they are hearing? Do you ever have something likethat happening? If yes, what do they say? How many are there? Do they seemto be having a conversation among themselves about you? Do they commenton what you are doing?Sometimes people have experiences that other people can’t really understand.For example, sometimes people feel like they are under the control of someperson or force that they can’t explain, …that the radio or TV are referringto you, …that others can read your mind?Is someone trying to hurt you or plot against you?Is anything interfering with your thinking? Some people feel as if thoughts arebeing put into their heads that are not their own. Do you ever feel that yourthoughts are broadcast out loud so that other people can hear what you arethinking,…feeling that thoughts are being taken out of your head against your will?If the person is clearly psychotic or quite disturbed, the assessment will be morefocussed, but will always include an assessment of present problems, a mental statusexamination and a risk assessment.29Assessment
  • 27. Interview ConsiderationsThe interview starts the therapeutic process betweenyourself and the person. Therefore, a balance mustbe sought between assessment, assistance and rapport.Failure to develop good rapport is a major cause oftreatment dropout, which itself predicts poorer long-term outcome.It is better to ask specific questions about psychosisthan to let it go undetected.Obtain collateral information about the person fromtheir family or others. Explain that you want to findout further information in order to provide better help.You are trying to obtain information from others, nottell them about the client. Try to get the person tobring along a family member to an appointment.The termination of the interview involves discussingyour assessment and management plan and negotiatingproposed treatment, review or referral. Fostering acollaborative partnership helps to counter the lowself-esteem and demoralization that usually followsthe experience of psychosis.Early Psychosis: A Guide for Mental Health Clinicians30Assessment
  • 28. DISCUSSING CONFIDENTIALITYWith any new client, it is useful to provide reassurance about theconfidentiality of your discussions but also explain the limits ofconfidentiality.REDUCING THE TENSIONAcknowledge that the person may be nervous or wary and findsome common ground for discussion, gradually building uptowards more specific questions about their psychotic experiences.If the client attends with her/his parents, it usually works best to seethe person alone before meeting with the family.TAKING TIMEIt may not be possible to develop rapport and perform a completeassessment in one session. Repeat visits over days or a couple ofweeks often clarifies the picture.The length of each session is also important. The person withpsychosis can often hold it together in brief or superficial conversa-tion but the psychosis often becomes apparent in more lengthy orchallenging conversations.Do not hesitate to contact a person if they fail to turn up for theirappointment. This is usually perceived as expressing concern ratherthan intrusiveness.Dont let the client drop out of sight as there is a significant risk ofsuicide. This may require making some sort of agreement with theclient at the end of the first appointment enabling you to makecontact if they fail to attend.Early Psychosis: A Guide for Mental Health Clinicians 31Assessment
  • 29. Family ConcernsThe family’s distress, confusion or denial need to be acknowledged.Dismissing presenting problems invalidates the familys experienceand may foster denial thereby delaying reassessment and eventualdiagnosis and treatment.Ask the family to describe specific examples of behaviour.Assess the degree of change and its duration.Gather information about the person’s premorbidpersonality and functioning.Clarify the family history including family history ofpsychotic disorders.Ask specifically about the behavioural manifestations of psy-chosis, such as laughing or talking to themselves, poor self-care,increased or decreased motor activity, posturing, etc.If the family is present without the person, determine the urgencyof the situation. If things can wait, encourage the young person tocome in and see you. If the situation seems serious and urgent thenan outreach assessment should be arranged.If a home assessment is contemplated, the family has to be consulted.If there are indications of risk for violence to self or others, enlistthe support of experienced community psychiatric workers.Early Psychosis: A Guide for Mental Health Clinicians32Assessment
  • 30. Investigations inFirst-Episode PsychosisA referral should be made to a physician for athorough medical exam. The physical examina-tion and investigations are important to excludepossible medical and neurological conditionsthat may present with symptoms of psychosis.However, only about 3% of psychoses in theyoung are attributable to such medical condi-tions.Brain imaging and neurocognitive testing forintelligence, memory, attention, executivefunction, language, visuospatial and motor skillsare helpful if they can be arranged. A good MSEat least provides some indication of cognitivefunctioning.Early Psychosis: A Guide for Mental Health Clinicians 33Assessment
  • 31. Referral IssuesReferral for specialist psychiatric assessment isusually appropriate in suspected or confirmedcases of psychosis.Even though an assessment in the prodromalphase may be inconclusive, it is useful."Prodromal" symptoms may not actuallysignal psychosis but do suggest a mentalhealth problem that needs to be addressed.The clinician is able to provide continuedsupport while diagnostic uncertainty remains byacknowledging problems and helping the clientand family cope.Depending on the persons difficulties, availablesocial supports and the assessment of possible risksto the person or others, outpatient treatment orhome based treatment may be a viable option. Atother times, close monitoring of the client by thefamily may be an option.Early Psychosis: A Guide for Mental Health Clinicians34Assessment
  • 32. HospitalizationSome people will require hospital admission for treatment or assessment. Hospitalization may beindicated if there are insufficient social supports for home treatment, or a period of observationmay be needed for adequate assessment. It is important to ensure that transport to hospital andthe admission itself, is also handled with care. Clients often experience a considerable degree ofshame and distress if their hospitalization is violent and coercive. Frequently the person willaccept the recommendation to be hospitalized.A person who refuses hospitalization may be admitted involuntarily because of risks to the personshealth and safety or for the protection of members of the public. The person does not have tobe assaultive to self or others.According to the Mental Health Act in British Columbia (1999), there are three methods ofarranging for involuntary admission:1. through a physicians Medical Certificate (preferred method)2. through police intervention3. through an order by a judgeIn order to fill out a Medical Certificate, the physician must have examined the person and beof the opinion that ALL four criteria are met:1. is suffering from a mental disorder that seriously impairs the persons abilityto react appropriately to his or her environment or to associate with others;2. requires psychiatric treatment in or through a designated facility;3. requires care, supervision and control in or through a designated facility toprevent the persons substantial mental or physical deterioration or for thepersons own protection or the protection of others; and4. is not suitable as a voluntary patient.35Early Psychosis: A Guide for Mental Health CliniciansAssessment
  • 33. GuidelinesMedication and other treatment strategies are outlined in severalpublications including the Canadian Guidelines for the Treatmentof Schizophrenia and the Australian Guidelines for Early Psychosis.Initiating TreatmentOnce it is decided that further assessment or treatment is required,all options should be presented to the person and their family.Because the diagnosis of most psychotic disorders requires a certainduration, it is best to avoid the early use of specific diagnoses.Focus on assisting with the presenting problems. Clients are morelikely to be receptive to obtaining assistance for concrete problems(e.g., confusion or sleep difficulties) while you check things outfurther. By using this approach, clients can be encouraged to accepthelp in the early stages of psychosis. Additional education is ethicallyand therapeutically indicated before a substantial period of timehas elapsed.There is a growing recognition that the treatment approach requiredfor a person with a newly diagnosed psychotic illness is different tothe approach suitable for long-standing illness. One clear exampleof this difference can be seen in the area of psychopharmacologicaltreatment.Early Psychosis: A Guide for Mental Health Clinicians 37Treatment
  • 34. Early Psychosis: A Guide for Mental Health Clinicians38PHARMACOLOGICALINTERVENTIONSAntipsychotic Free PeriodIt is becoming common practice in first-episode psychosis, to providean antipsychotic free period of several days. Any agitation, irritabilityor insomnia can be managed by the use of a long acting benzodiazepine.This period gives clinicians a chance to assess the person more closelyto exclude more transient psychoses (such as a drug-inducedpsychosis). It also allows an opportunity to build up trust and rapport.Pharmacotherapy OptionsA referral should be made to a specialist that is familiar withantipsychotic use in early psychosis.A person experiencing a first-psychotic episode is typically verysensitive to the pharmacological effects of these drugs and susceptibleto side effects.The prescribing physician will chose an antipsychotic medicationafter considering their relative side effects. In general, low potencydrugs are more likely to produce sedation, postural hypotensionand anticholinergic side effects while high potency drugs producemore extra pyramidal side effects.Treatment
  • 35. For first-episode cases, it is essential to start anyantipsychotic medication at very low doses tominimize side effects. Side effects contribute topoor compliance. It is important to be patient withthe "start low – go slow" approach to treatmentwith antipsychotics. Full remission takes time, butwill occur in the majority of cases. Overall, around60% of persons will respond by 12 weeks andanother 25% will respond more slowly. Low dosesare generally effective in treating psychotic symptomsin this population.The adjunctive use of a long acting benzodiazepineover the first few weeks allows for sedation andcontrol of agitation, until the antipsychotic startshaving its full effect. In addition, the prophylacticuse of anticholinergic drugs, such as benztropine,to protect against possible extrapyramidal sideeffects is also common. These are then graduallydiscontinued over the following weeks, unlessextrapyramidal side effects remain a problem.The advent of atypical medications is especiallypertinent to first-episode cases because of their lowpropensity to generate extrapyramidal side effects.This decreases the need for anticholinergic drugs,which themselves produce adverse physical andcognitive side effects. The newer atypical antipsy-chotics are frequently used as front line medicationsbecause of their favourable side effect profiles.Early Psychosis: A Guide for Mental Health Clinicians 39treatment
  • 36. EVIDENCE-BASEDNON-PHARMACOLOGICALINTERVENTIONSMental health clinicians may provide a range of these non-pharmacologicaltreatments and/or refer for more specialized interventions as appropriate.Although clinicians may be familiar with most of these interventions,training is encouraged because these approaches are modified in bothcontent and technique for use in early psychosis.ResourcesThe Early Psychosis Prevention and Intervention Centre (EPPIC)based in Melbourne, Australia (http://www.eppic.org.au/)has developed both best practice guidelines and a variety of trainingmaterials on the use of non-pharmacological interventions.Coordinating CareActing as a case manager, the mental health clinician plays a crucialrole by coordinating care among a variety of treating professionalsand creating links to other community services as needed. The casemanager also helps ensure continuity of care. Development of anindividualized treatment plan should be coordinated by the casemanager with input from the client, family, and other involvedprofessionals.TreatmentEarly Psychosis: A Guide for Mental Health Clinicians40
  • 37. PsychoeducationPsychoeducation for first episodes involves teachingpeople (including families) about mental illness whilemaintaining an ongoing, interactive psychotherapeuticrelationship. In the case of psychosis it is importantto impart a message of hope without downplayingthe seriousness of the disease. Three inter-relatedissues that should be addressed are "meaning","mastery" and "self-esteem". All clients and theirfamilies should receive psychoeducation.Meaning refers to addressing the confusion surround-ing the experience and introducing the concept ofpsychosis. Discovering the persons own explanatorymodel and resolving discrepancies between it andmedical definitions is a key task.Mastery involves instilling hope for recovery, buildingstress management and coping skills, learning torecognize possible signs of relapse and learninghow to access needed resources in the future.Self-esteem enhancement includes helping the personto distinguish "between the person and the illness"and to counter stigmatized views they may haveinternalized (e.g. that they are incompetent).treatmentEarly Psychosis: A Guide for Mental Health Clinicians 41
  • 38. Cognitive TherapyCognitive therapy is a structured psychotherapy directed towardsolving current problems by modifying distorted thinking andbehaviour. It assumes that thoughts, beliefs, attitudes and perceptualbiases influence emotions and behaviour. Realistic evaluation andmodification of thinking produces improvement in mood andbehaviour.Cognitive therapy may be used to treat non-psychotic symptomsand adjustment issues (e.g., depression, anxiety, substance abuse)in clients with early psychosis. It is increasingly recognized to be ofbenefit in treating the positive symptoms of psychosis. It can beparticularly useful for young people, as it offers a way of examiningalternative explanations for delusions or fixed ideas before theybecome entrenched.Coping Skills and StressManagement ApproachesStress management approaches help people develop coping strategiesand reduce vulnerability to stress-induced relapse.Stress management also teaches people to monitor stress, recognizepotential warning symptoms and modify the stressor by adjustingtheir environment or behavior.Early Psychosis: A Guide for Mental Health Clinicians42Treatment
  • 39. Family TherapyFirst episode psychosis is very disruptive and distressing to families.Before proceeding with family therapy, it is important to considerthe clients wishes with regard to the extent of family involvementin recovery. Family work may be useful to help the family copebetter with the psychotic illness and should be tailored to the needsof each individual family.Group ProgramsIf possible, group programs specific to the needs of people withearly psychosis should be made available. These group programscan provide peer support, education, problem-solving opportunities,and learning through discussion and observation. Group work alsoprovides the young person with an opportunity to take on an activesocial role during a time when psychosocial functioning may be at a low.Other TherapiesOther therapies should be arranged on an individual basis as needed.The clinician should be alert for signs of substance misuse as thereis a high incidence of drug and alcohol abuse among first episodeclients. Arrangements for substance misuse counseling should beconsidered when appropriate. Other therapies that may be usefulfor certain first-episode clients include social skills training, psycho-social rehabilitation and cognitive rehabilitation. Education and workreadiness must be addressed.Early Psychosis: A Guide for Mental Health Clinicians 43treatment
  • 40. Summary of Strategiesfor Early Intervention1 Mental health clinicians can play a pivotal role inensuring early detection and intervention forpsychotic disorders. The key is to maintain anindex of suspicion.2 Develop rapport, discuss confidentiality, reducetension and take time. Family concerns shouldbe addressed.3 Use a framework to assist the assessment.Describe specific symptoms and behaviours inyour documentation.4 Inquire systematically about psychiatricsyndromes and ask specifically for prodromalchanges and psychotic symptoms.5 Assess for potential to harm self or others.Early Psychosis: A Guide for Mental Health Clinicians44Treatment
  • 41. 6 Obtain collateral information, particularly fromthe persons family or living companions.7 Refer for a physical examination andappropriate investigations.8 Seek specialist psychiatric assistance ifpsychosis is overt or suspected.9 Work with the clients physician and/orpsychiatrist when hospitalization is indicated.10 Pharmacological treatments are best handledby specialists in early psychosis.11 Non-pharmacological treatments are beneficialand should not be neglected.Early Psychosis: A Guide for Mental Health Clinicians 45treatment
  • 42. Source MaterialsEarly Psychosis Prevention and Intervention Centre (EPPIC)for Psychiatric Services Branch, Victorian Government Departmentof Health and Community Services. (1994). A Stitch in Time:Psychosis… Get Help Early. Melbourne, Australia. H&CSPromotions Unit.Early Psychosis Prevention and Intervention Centre(EPPIC). (1999). Early Diagnosis and Management of Psychosis.http://www.eppic.org.auJeffries, J. J. (1996). Is my patient schizophrenic?The Canadian Journal of Diagnosis, 79 – 90.Macnaughton, E. & Wilkinson, P. (1999). New and emergingpsychological approaches. Visions: The Journal of BC’s MentalHealth, 1, 9-10.McGorry, P.D., & Jackson, H.J. (Eds.; 1999). Recognitionand management of early psychosis: A preventive approach.New York: Cambridge University Press.National Program of Education and Consultation inPsychiatry. (1996). Managing the Patient with Symptoms ofPsychosis: A Practical Guide. Mississauga, Ontario: CA.The Medicine Group (Canada) Ltd.Robinson, D.J. (1997). Brain calipers: A guide to a successfulmental status exam. London, Ontario: Canada. Rapid Psychler Press.Some information contained in this booklet was adapted from the above publications.Early Psychosis: A Guide for Mental Health Clinicians46
  • 43. Additional material written by Mheccu staff. Priya Bains, B.Sc.,Tom Ehmann, Ph.D., Laura Hanson, Ph.D.Other ResourcesCanadian clinical practice guidelines for the treatment of schizophrenia.Canadian Journal of Psychiatry, 1998, 43 (supplement 2).The Early Psychosis Prevention and Intervention Centrehttp://www.eppic.org.au/British Columbia Schizophrenia Societyhttp://www.bcss.org/Internet Mental Healthhttp://www.mentalhealth.com/Mental Health Evaluation & Community Consultation Unithttp://www.mheccu.ubc.ca/projects/EPIB.C. Ministry of Health site pertaining to mental health(including guide to Mental Health Act)http://www.hlth.gov.bc.ca/mhd/index.htmlEarly Psychosis: A Guide for Mental Health Clinicians 47
  • 44. Cover CreditsCover Photo Courtesy Of:Emily Carr, SCORNED AS TIMBER, BELOVED OF THE SKYoil on canvas, 1935Vancouver Art Gallery, Emily Carr Trust VAG 42.3.15(Photo: Trevor Mills)Early Psychosis: A Guide for Mental Health Clinicians48

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