The main objective of this online workshop was to raise awareness about symptoms of psychosis and how to support individuals and families experiencing prodrome, early and acute psychosis in different settings ranging from primary care, community mental health and acute hospital

1. Identifying and Treating Early and
Acute Psychosis
Online Workshop for South East NHS England, CCGs,
Primary & Acute Care and Partner Mental Health Teams
Friday 11th December 2020 | MS Live
#EpicMinds #LiaisonPsych

2. Welcome &
Housekeeping
• This is a live workshop which will be recorded and cover:
• Prodrome, Early and Acute Psychosis
• Case Examples
• Treatment Options and Top Tips
• Q & A
• To have a good virtual workshop please:
• Try to be present and participate as fully as you can
• Feel free to ask questions and comment via chat and the Q&A
function (there is no such thing as a stupid question! )
• Use the thumbs up button to vote for questions you want answered
• Be respectful and do not share any patient identifiable information

3. Dr Alex Thomson
Consultant Liaison Psychiatrist, Central and North West
London NHS Foundation Trust
Member, RCPsych Psychiatric Liaison Accreditation
Committee (PLAN) Advisory Group
Welcome

4. 1 Welcome, housekeeping and introduction
2 Identifying and Treating Prodrome and Early Psychosis
3 Identifying and Treating Acute Psychosis
Agenda
4 Questions and Answers
5 Closing Remarks & Next Steps

5. My Family’s Journey:
Noticing Changes, Seeking and Accessing Help
for Psychosis
Dawn Hyde

6. Dawn Hyde
South East EIP Families & Carers
Participation Lead
Image used with permission

7. Berkshire EIP Service Manager & Senior Pharmacist
Joanna May & Camilla Sowerby

8. Identifying and Treating Individuals
with Early and Acute Psychosis -
Prodrome and first episode psychosis
Camilla Sowerby and Jo May, Berkshire EIP

9. What we will touch upon.....
 General principles of EIP and care pathway
 Spotting signs of prodrome and early psychosis
 Care Pathway and Treatment
 Top tips on working with someone with first episode psychosis in the
community

10. AIM
The EIP pathway advocates that people
with suspected or first episode psychosis
should receive timely and evidenced
based interventions during the critical
stage prior and following onset.
Withholding treatment until severe and
less reversible symptomatic and functional
impairment have become entrenched is
costly to the individual, their family and
wider society.
Clinical staging models define the course
of illness as a continuum with a guide on
choice and timing of interventions,
enabling the use of practical strategies
routinely embraced in other types of
mainstream healthcare e.g., breast cancer
care.
STAGE SHORT DESCRIPTION
Premorbid First degree relative of person with psychosis or
schizophrenia. Increased risk of psychosis but no symptoms
currently
Prodrome Characterised by a period of mild or nonspecific psychotic
symptoms, and a period of increased symptom activity
which still does not meet criteria for a psychotic episode.
At Risk Mental
States (ARMS)
Mild or non-specific symptoms of psychosis, including
neurocognitive deficits. Moderate but subthreshold
symptoms, with moderate neurocognitive changes and
functional decline (≥ 30% drop in SOFAS or GAF score in
previous 12 months)
First Episode
Psychosis
(FEP)
Full threshold disorder with moderate–severe symptoms,
neurocognitive deficits and functional decline (GAF 30–50)
Incomplete
remission
Multiple relapses, with worsening in clinical presentation
and impact of illness on social functioning
General Principles of EIP Pathway

12. Spotting signs of a prodrome and
early psychosis
- At risk mental states are indicative of a higher but not inevitable risk of developing
a psychotic disorder.
- Studies have shown that people who present with ARMS and go on to develop a
psychotic episode is 18% after six months, 22% after one year, 29% after two years
and 36% after three years (Fusar-Poli et al 2012).
- Many young people who meet the ARMs threshold will struggle with anxiety and/or
mood – psychotic phenomena could be more usefully considered as an indication of
severity of illness rather than imminent full-threshold psychotic illness

13. Spotting signs of prodrome and
early psychosis - what is ARMS?
A cluster of symptoms and signs that is associated with a high risk of onset
of a full threshold psychotic disorder in the near future
Ultra High Risk (UHR) criteria are the operationalised criteria used to detect
ARMS
CAARMS is a ratified assessment tool although also relies heavy on
formulation.

14. For each experience on a subscale,
the elements scored are:
• Global (intensity) – score of 0 – 6
• Frequency/duration - score of 0 –
6
• Onset and offset dates of the
symptom
• Relation to substance use –
Never, sometimes, only
• Distress – 0-100
Four subscales make up the positive
section.
**These subscales are needed to
detect UHR status.
•Unusual Thought Content (UTC)
•Non-Bizarre Ideas (NBI)
•Perceptual Abnormalities (PA)
•Disorganised Speech (DS)
CAARMS looks at 4 areas and
scores each experience

16. Vulnerability
Group
Attenuated Psychosis
Group
Subthreshold
intensity
Subthreshold
frequency
BLIPS Psychosis threshold
Increasing severity of symptoms
30% drop in SOFAS score over the 12 months, maintained for longer than 1
month OR SOFAS score of 50 or less for past 12 months or longer
CAARMS inclusion criteria
Age between 14 and 30 years

17. First Episode Psychosis
Client has experienced a period of frank psychotic symptoms for at least one
week.
Use of PANSS to identify whether threshold for psychosis is met.
Positive Subscale: 7 positive items
Negative Subscale: 7 negative items
General Psychopathology Subscale: 16 general psychopathology items
Threshold of 4 needs to be met for clinical threshold. (3 for attenuated
symptoms)
This always involves an effect on the severity of impairment on their social role.

18. First Episode Psychosis
Positive Subscale Items
P1: Delusions
P2: Conceptual disorganisation
P3: Hallucinatory behaviour
P4: Excitement
P5: Grandiosity
P6: Suspiciousness/persecution
P7: Hostility
Negative Subscale Items
N1: Blunted affect
N2: Emotional withdrawal
N3: Poor rapport
N4: Passive/apathetic social withdrawal
N5: Difficulty in abstract thinking
N6: Lack of spontaneity/flow of
conversation
N7: Stereotyped thinking

19. First Episode Psychosis

20. Family or Self Referral Primary Care Schools/Colleges/Uni Social Care Single Point Access CAMHS/CMHT CRHT/MH Ward Justice System
EIP Assessment
First Care Planning Meeting with Key Supporters
Assertive Outreach, Intensive Case
Management & Relapse Prevention
Social Interventions
Individual
Placemen
t Support
(IPS)
Social
Groups
and F-F +
Online
Peer
Support
Support
with
accessing
housing &
benefits
advice
Medical Interventions
Interventions
for risks e.g.
Diabetes,
according to
NICE
Guidelines
Pharmacology
and Medicines
Management
Comprehensive
Cardio-
Metabolic
Screening
Psychological Interventions
Family
Interventio
ns(FI)
CBT for
Psychosis
(CBTp)
High /Low
Intensity
Individual
and Group
Psycho -
Therapy
Midway Review with Carers and Key Supporters
Pre-Planned Discharge with:
Relapse Prevention Plan developed with receiving team including GP
Future mental health care options
Service user and carer views on experience and outcomes
Signpost to appropriate
Non-NHS service
Onward Referral to Most
Appropriate NHS Service
<2 Weeks
<3 Months
<18 Months
30 -36
Months
<6 Months
Allocate EIP Care Coordinator
Face to Face
and Online

21. Top tips on working with someone with
first episode psychosis in the community
1. Build a positive therapeutic relationship – client and family
2. Focus on symptoms not diagnosis
3. Normalisation of experiences
4. Work collaboratively to identify goals
5. Be curious
6. Informed practice and choice

22. Thank you
questions…

23. Berkshire Psych Liaison Consultant Psychiatrist & Service Manager
Dr Priya Anand & Colin O’brien

24. Acute psychosis
presentations and
management in A&E
Dr S Priya Anand
Consultant Liaison Psychiatrist
Wexham Park Hospital
East Berkshire Psychological Medicine
Berkshire Healthcare Foundation Trust

25. Our caseload during pandemic

26. Covid VS Non- Covid stress

27. Psychotic presentations related to COVID
19 stress
CovidRelatedPresentations
Psychosis 7
ManiawithPsychosis 4
PsychoticDepression 1
AcuteStressReaction 1

28. Usual presentations to A&E
 Police
 Ambulance
 Relatives
 Self
 Other specialties

29. Common
presentations
Agitation/
Aggression
Confusion
Distress
Self neglectStupor
Mutism
Harm to
self/others

30. How we manage psychosis in Liaison
services?
Assess, diagnose and treat Follow up clinic appointments- if
appropriate
Handover to appropriate teams-
CRHTT, inpatient, EIP, GP

31. Case studies  1. Parallel treatment on the acute wards
 2. Follow up by EIP
 3. Follow up clinics and handover to GP
 4. Commencing treatment in A&E
 5. Is this really psychosis?

32. Case study 1  45 year old male
 IT Consultant
 Working from home due to lockdown
 Developed hay fever symptoms and worried about
catching COVID 19
 Sleepless nights for a week
 3 days prior to A&E visit:
- stopped eating and drinking
- Needing prompting for self care
- Became selectively mute
- On review, delusions of guilt, nihilistic delusions,
auditory hallucinations, lacking insight and capacity to
consent

33. Management  Correction of electrolytes and hydration
 Communicating only with wife- hence COVID 19
restrictions relaxed for her visits
 Parallel psychiatric treatment alongside physical
treatment
 When medically fit, transferred to psychiatric unit
 Started showing improvement
 Discharged home within a week
 Whole process of assessment and starting treatment to
discharge took maximum of 2 weeks

34. Case study 2  41 year lady, young Mum of 2 daughters aged 10 and 8
 First presentation to A&E complaining of vomiting and
dizziness due to food poisoning
 Recurrent visits to A&E with similar complaints
 4th time referred to Psychological medicine
 On exploration, very guarded, over valued ideations on
her food being poisoned by her Husband, partial insight
 Stressors: daughter’s 11 plus exam, COVID 19 lock
down, relationship difficulties led to sleeplessness for
few days prior
 On further exploration, misperception of panic attack
symptoms as food poisoning symptoms

35. Management  Started on Clonazepam with initial working diagnosis as
acute stress reaction
 Reviewed in planned follow up clinics on 3rd day and 7th
day
 Presenting with paranoid delusions rather than
overvalued ideations
 Started on antipsychotic
 Referred to EIP and CRHTT

36. Case study 3  44 year old University lecturer
 Father of a 9 year old daughter
 Separated from wife and child with Mother
 Financial strain- unable to support daughter’s expenses
 Stress caused him sleeplessness
 Brought in by the Police in the middle of the night as
was shouting, praying continuously and was throwing
things out of the window
 Thought disordered, auditory hallucinations and
paranoid delusions about black magic being done on
him

37. Management  Diagnosed as ‘stress induced psychosis’
 Treated with Clonazepam and Olanzapine under liaison
 Telephone follow up in 7 days
 Joint follow up with EIP Consultant in 2 weeks
 Remission from psychotic symptoms, regained insight
and willing to start part time job
 Didn’t need EIP support
 Discharged back to GP

38. Case study 4  28 year old male
 1st presentation- self presented
 Guarded
 Not a good historian- Latvian origin
 Scared about ‘sleep walking’ and worried that he might
unconsciously harm others
 It was of delusional intensity
 Collateral information obtained
 E/o paranoid delusions, barricading himself, self
isolating, family h/o psychosis and suicide

39. Management  No beds in the psychiatric unit
 Admitted to acute assessment unit
 Commenced on antipsychotics and benzodiazepines
 Awaiting a transfer

40. Case study 5  32 year old male
 Brought to A&E by his friend
 Auditory and visual hallucinations
 Disoriented
 Thought disordered
 On review, was agitated, pacing up and down, seeing
small animals and people in his room

41. Management  Differential diagnoses considered
 Wait and watch
 Rapid tranquilisation given
 After 48 hours, was able to engage in a conversation
 On exploration, took Quetiapine OD under the influence
of alcohol
 Recovered quickly from intoxicated state
 Discharged home

42. Top tips  Treat them parallel- respond quickly
 Collateral information is very valuable
 Identify early warning signs- prodromal, emerging
psychosis
 Intervene early- treatment can very well start in A&E
 Communicate the care plan clearly
 Support ED staff in risk management
 Referral to EIP sooner - don’t wait for other teams to
refer
 Work in close collaboration with A&E, CRHTT and EIP for
a better outcome
 Rule out toxic states- may take hours - days to recover

43.  Comments and Questions

44. Q & A

45. Surrey Psych Liaison Consultant Psychiatrist & Service Manager
Dr Kit Akass & Belinda Manyumbu

46. FIRST EPISODE
PSYCHOSIS AND LIAISON
PSYCHIATRY
Dr Kit Akass, St Peter’s
Hospital

47. HOW DO
WE GET
INVOLVED?
Acute presentations
Police - ? S136
? Medical causes and investigations
Appropriate referrals
 Delirium
 Pseudo-hallucinations
 Intoxication

48. CASE 1
40 year old lady
3 day change in behaviour
Irritable, minimal sleep
Accused of drug use at work (negative UDS)
Partner brought to A&E
Highly agitated, shouting, threats in A&E
Given rapid tranquilisation

49. CASE 1
Reviewed urgently in A&E
Collateral gained
Investigations – NAD
Slept in A&E following sedation
Insightful, remorseful keen to engage

50. CASE 1
HTT and EIS referral – acute transient episode of psychosis
Paranoia
Leaving home
Escalation with family and police - S135
Admission
Progress with EIS

51. CASE 2
29 year old male, attended A&E – sister concerned
Visual hallucinations of insects
Paranoia – contacting police
Auditory hallucinations –running commentary, persecutory and
command hallucinations
Increasingly intense
“Watch what is going to happen to you. Now I am going to come and
hurt you.”
Passivity

52. CASE 2
Erratic sleep
Anhedonia
History of cannabis misuse – 2 months abstinent
Admission/HTT discussed
Supportive family, good compliance

53. CASE 3
20 year old female
3 day history of reduced sleep
New onset religious belief
Brought to A&E by her mother
Normally well, lives at home relatively isolated
Increasingly distressed – biting self and staff in A&E
No significant past history

54. CASE 3
Given rapid tranquilisation
Physical investigations
Once awake – MHA assessment
Belief of possession 4 days ago, guarded, possible auditory
hallucinations
Section 2 – period of assessment

55. LIAISON PSYCHIATRY AND EIS
Direct communication
Exclude organic causes
Notify early – when acute pathway involved
Information giving – patient and family

56. Q & A

57. Olivia Falgayrac-Jones
Deputy Director of Clinical Delivery and Networks, NHS
England South East
Closing Remarks & Next Steps

58. www.england.nhs.uk
For more information about the South EIP programme,
please visit
www.time4recovery.com
To access EPIC MINDS resources developed with service
users and carers, please visit www.epicminds.co.uk
Commissioned by
Thank You