introduction to the easa model early assessment and support alliance (easa) ryan melton phd lpc acs...
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Introduction to the EASA Model
EARLY ASSESSMENT AND EARLY ASSESSMENT AND SUPPORT ALLIANCE (EASA)SUPPORT ALLIANCE (EASA)
Ryan Melton PhD LPC ACSRyan Melton PhD LPC ACS
EASA Clinical CoordinatorEASA Clinical Coordinator
The Next Generation!
Who is Here?
Mission of the Early Assessment and Support Alliance Keep young people with the early signs
of psychosis (schizophrenia) on their normal life paths, by: Building community awareness and Offering easily accessible, effective
treatment and support (2 years) Network of educated community members
& highly skilled clinicians Most current evidence-based practices
General Criteria
Resides in your catchment area. Age range from 15-25 (minimum- can go
older or younger). IQ greater than 70 No tx or dx for severe psychotic that has
lasted over 6 months (minimum- can go longer).
The psychosis is not known to be caused by substance or medical condition.
History and intent of EAST/EASA
Where we’ve been
Where we are
Where we’re going
History and Intent of EASA
International Early Psychosis Association
http://www.iepa.org.au/
Early Psychosis Programs
First programs began around 1990
Early psychosis intervention “standard of practice” in Australia, Great Britain, Canada, Scandinavia
Early psychosis intervention came to Oregon in 2001, with Mid-Valley Behavioral Care Network’s Early Assessment and Support Team (EAST)
2007 Oregon legislature allocated $4.3 million to disseminate EAST; the Early Assessment and Support Alliance was created in 2008
Our History 2001- Part-timers from (10 hrs/wk) around a table; Australians come 2002- First sustainability committee 2003- Vocational services added, Foundation funding; RWJF funding; first multi-
family group 2004- First poster by EAST at IEPA 2005-Added a little bit of occupational therapy; Addictions and Mental Health
provides Block Grant funds 2006- RWJF decides to create national early psychosis program office 2007-Legislative allocation; increased intensity, EDIPPP research study, added
nursing; McGorry returned 2008- EASA created; 11 new counties; National RAISE study 2009- Legislature maintains same level of funding 2010-First EASA conference; focus on peer supports and self efficacy; first
agreement with state VR including EAST grads; new programs in California 2011- First cost offset study (Western Interstate Consortium on Higher
Education) 2012- IEPA in San Francisco; continued expansion
Why We Do It: Oregonian, 8/10/2010 (front page article on EASA) “Josh is now going to college part-time and
plans to be a firefighter…
“Now, he's doing fantastic," his father says. "He's on break from college, where he's got a 4.0 (GPA). He's got a job all summer. He's got his personality back. He's just a great guy."
Way to go Josh and LifeWorks!
Early Assessment and Support Alliance counties, 2008
RAISE
New program
Evolution of EASA’s Model
Practice Guidelines/Fidelity Tool Adapted from
Australian/WHO guidelines Integrated SAMHSA toolkits
-Multi-family psychoeducation-Individualized Placement and Support (supported employment)-Illness Management and Recovery-RPP-Dual diagnosis (TTM)-Elements of Assertive Community Treatment
Culture of feedback
Ongoing adaptations Systemic elements to
practice guidelines Cultural modifications Peer support/ Hart’s Ladder Clinical supervision Clarification of roles: ot,
nursing Following/integrating current
research: social cognition approaches, nutrition/ Omega 3, 10X10 Wellness
Our Intent: Change This Too-Common Reality Delays in getting help Loss of friends & family School/life drop-out Drug use Legal involvement Escalating crisis, Involuntary commitment Disability
Cure sometimes worse than the illness (metabolic disorder, pushed onto disability, etc.)
Why has EASA been Successful?
Leadership commitment
Relevance to policy makers
Unappealing alternatives
Data
International research
Participant voice in legislative process
Training, collaboration & accountability
Training and Technical Assistance
Ongoing consultation Site visits/ fidelity review process Collaboration with experts/ research
State-level oversight being convened Data collection Training: introductory, multi-family group,
Clinical practices, Differential DX; annual conference with topics generated from local experience
EASA Practice Guidelines
Iterative process
Based on current evidence & experience
Collborative
Core Concepts
Ownership and self efficacy Evidence-Based Practice Recovery concepts Psychosis as a common health condition Public health vs. clinic-based approach Stress vulnerability High Risk and 1st Episode Cyclical condition Partnership and self efficacy Shared explanatory model
Public Health Approach
Universal access based on condition
Effort to educate and change behaviors of community
Psychosis is Far More Common than Insulin-Dependent Diabetes (5x more
common for Schizophrenia alone)
Stress Vulnerability
Decrease Vulnerability
Increase Vulnerability
•Genetics•Drugs
•Medical Conditions•Lack of Sleep
•Stress•Isolation
•Healthy Lifestyle:
•Sleep
•Nutrition•Exercise•Social
support
•Using antipsychotic medicines
•Avoiding alcohol & street drugs
•Brain development age 16-30
Shared Explanatory Model
• Acceptance of a diagnosis is not a goal– Internalized stigma
• Build on the person’s language and motivation
• Offer new information and different ways of looking at it
Policy Considerations
Crosses child and adult systems All funding sources/insurances Connection to larger mental health system
Consistency of practices/ context Screening/transitions
Goal: Prepare people to act as effective self-advocates, partners and owners.
No one can do this alone Modeling what we teach Explain how things work and what to expect Provide relevant information Learn from each person Encourage risk taking Normalize setbacks
Practice Guideline Elements Systemic change Individual/family participation in
decision making At-risk focus Community education Accessibility Access and screening Assessment and tx planning Family/support system partnership
Practice Guideline Elements Transdisciplinary team Psychoeducation Counseling Occupational therapy Supported employment/education Medications Nursing Multi-family groups Transition Planning
1. Systemic Infrastructure: System-Level Commitment and Intervention
Principles: Part of broader commitment to recovery-
oriented system change Senior management involvement in removing
policy, funding, procedural, personnel system barriers
Transdisciplinary approach of adequate intensity
1. Systemic Infrastructure
1.1. Adequate staff time set aside for team
-Additional job responsibilities carefully assessed to not interfere
1.2. Staffing based on assertive community treatment standard. 1:10 across team is optimal
1.3. System infrastructure: core treatment elements Psychiatry Nursing Social work/psychology/counseling Occupational therapy Supported employment/education
1. Systemic Infrastructure
1.4. Culturally informed
1.5. All team members trained & supported to serve both under and above age 18 (understanding youth culture and needs)
1.6 Specific screening and engagement process (includes cross-county agreements)
1.7 Job description, duties, work hours, training and supervision specific to EASA
1.8. Systemic Infrastructure:
Substance abuse tx done within team. Treatment done in-vivo and in office. Modifications may need to be made to
standard procedures. Forms may need modification. Ongoing evaluation with feedback from
participants. (1.9) Bill all forms of insurance!
Discussion
2. Individual and Family Decision Making
3. At-Risk Focus: Integrate information about early signs and risk factors in education and treatment. Statewide historically focused on 1st episode but
integrating at-risk individuals.a. Often most disabling stage. Suicide risk, drop-out,
family conflict common.b. Assessment & monitoring may prevent much of
acuityc. Psychosis is cyclical: prodrome predicts relapse
signatured. Symptoms similar but insight retained; easier to
engage & non-pharmaceutical approaches can be effective
e. Public education about gradual onset & common prodromal symptoms may increase speed & effectiveness of early identification.
CognitiveDeficits
Affective Sx: Depression
Social Isolation
School Failure
Biological Vulnerability: CASIS
Brain Abnormalities
StructuralBiochemical Functional
Disability
Social and Environmental Triggers
Incr
easin
g Po
sitiv
e sy
mpt
oms
Early Insults(e.g. Disease Genes, Possibly Viral Infections, Environmental Toxins)
After Cornblatt, et al., 2005
Positive Psychotic Symptoms as a Cyclical Condition
Prodrome
Acute psychosis
Recovery
3. At-risk focus.
Multiple risk factors: assessment and careful monitoring may help reduce disability & prevent acute sxs (examples: attenuated psychotic sxs, or negative symptoms, gross recent decline (30% or more on GAF), family history in first generation)
Psychosocial interventions generally preferred
Medications avoided unless rapid deterioration or risk of harm; low doses
Awareness/education of risk factors and signs/sxs of prodromal phase broadly included in treatment messages.
Discussion (Pros and Cons of prodromal/at risk work?)
4. Community Ed.
4.1. Adequate staff and funding capacity set aside so it is not overshadowed by clinical demands
Target specific groups & tailor messages- no “general public”. Medical, school, parents, others who come in contact with youth
Positive, hopeful message about early recovery; combat negative perceptions
Specific information about observable early symptoms routinely included
Systematic efforts to reach out to smaller communities.
4.3 Proactive and ongoing community education to increase knowledge and reduce attitudinal barriers among those most likely to encounter early psychosis.
Goals: Increase awareness and skill level in identifying signs
and facilitating referrals Increase community awareness of existence and
accessibility of early psychosis services as a DISTINCT ELEMENT of the mental health system of care
Communicating positive understanding of psychosis as a common, highly treatable condition in which positive outcomes are expected with early intervention.
Audiences:There is no “general public”
Priority Audiences
Internal gatekeepers/ referents Crisis system & hospitals Parents (media) Schools Primary care doctors Clergy… Funders/policy makers
UNIQUE
2000 students: Approx. 60 students will develop psychosis
Teacher presentation example
Value: Graduation into adult life Misconception:
Psychosis is not common I wouldn’t recognize it It doesn’t matter whether we identify it early It’s hard to get help
Action: Spread the word Call and consult if in doubt- don’t wait!
Vision: Kids will stay and school, graduation and go on to a good life
Community Education: Success
People know us! Youth identified early
Referred to us! Doing well, our best resource Connected to ongoing support Positive view
Sustainable & infectious
5. Access and screening: Services are appropriate and easily and quickly accessible Principles:
Presentation of suspected psychosis is considered a psychiatric emergency.
Ease access is of particular importance Unfamiliar to person/family, highly distressing
Develop partnership with close family members or others they rely on for support, maintain contact throughout process
Delayed access associated with slower/ less complete recovery, increased relapse
Clearly defined process of entry High risk of hospitalization, re-hospitalization, state
institutions. Hospitalization often traumatizing & disconnects from supports; use of alternatives when possible.
Completed by well trained diagnostician!
5. Access and Screening
Accept referrals form all sources. Rapid Contact (2 days!) Screenings can occur anywhere! Keep family/support system informed and
provide support /psychoeducation even if individual is not engaged yet.
If individual is in hospital screening occurs there! Address all barriers (language, transportation
etc.) Written notification of outcome Modified enrollment process.
I’M Sorry but you need to go back through intake!
Why Focus on Engagement?
AnosognosiaStigmaSide effects
6. Assessment & tx planning
Business as usual! Phenomenology Primary and secondary symptoms Course & duration Prodromal symptoms Precipitants Relieving factors Explanatory model
6. Assessment and tx planning
Comprehensive Risk Assessment! Physical examination and medical tests. Tx plan is driven by strength’s assessment. Reviewed on consistent basis with individual
and support system.
6. Risk assessment
Suicide Violence Victimization Disorganization Impulsivity Delusional content Include potential of leaving usual residence Family conflict
6. Strengths Assessment
University of Kansas website: http://www.socwel.ku.edu/strengths/about/index.shtml
7. Family Partnership.
Transparency and shared decision making Principles:
Family support & involvement important to successful outcome
Distressing effect on families First contact often debriefing session
Key components; Collaborative, tailored approach Aim to empower family to cope, adjust to crisis of psychotic
illness Pre-existing problems addressed to degree impact person’s
recovery; referred to outside counseling/tx as appropriate. Clarify person’s wishes around family involvement. If don’t
want involvement, clarify basis for feeling
7. Family partnership
Contact within 48 hours of initial assessment (if have not contacted already)
Initial interview: understand level of knowledge and current needs Family history and observation of behavior is important
part of ongoing diagnosis Part of ongoing review process 7.4. Key foci for intervention: impact on family
system, individual family members (including client), interaction between family and course of psychosis, and what to expect
Transdisciplinary Team: FACT Model (McFarlane, Stanstny & Deakins, 1992) Counselors/social workers Vocational/Educational specialist Occupational therapist Medical: psychiatrist or prescribing nurse;
RN Using components of ACT model
Multidisciplinary
Multiple disciplines with roles defined by profession
Separate goals, assessment and intervention
Regular communication
Transdisciplinary vs. Multidisciplinary (Bruder 1994) Share roles and systematically cross
boundaries Pool and integrate expertise to provide more
efficient and comprehensive assessment & intervention
Continuous give-and-take on regular, planned basis
Professionals teach, learn and work together toward common goals
Usually results in less daily contact with person
8. Transdisciplinary team
Coordinate closely: Frequent meetings, preferably 2x/week Review each person’s situation weekly
Routinely cross disciplines (i.e. co-facilitating groups/no cancelation policy)
Meetings routinely focus on success stories. Lead counselor assigned to each person: establish
relationship, introduce to team, ongoing management of assessment, tx plan, discharge plan, tx coordination. CLINICAL CASE MANAGER. Continuity of care with transfers.
Contact is based on phase of care.
FACT Meeting FormatClient MFG/
SFECounseling
SE/Sed
OT Medical
Success
Transition date
PW due
Ryan Family invited to WS Joinings complete
CBT with Nina-anxiety
Wants to return to OSU-Refer to John
Refer for Assm-for school accomodation
Abilify-5mg some fatigue. RN to obtain labs
Feeling more motivated
7/3/13 Need new copy of Ins card.
Tamara
She is not interested-join with family alone
MI work around THC use. Help with housing
John doing practice interviews.
Completed Assm. Rob to review.
Not interested in taking. Sees Rob next week.
Family happy she will meet with EASA team
7/9/12 Working on transition check list
Avoid getting stuck!
What is the role of your EAST Counselor (QMHP)? (10)1) Coordinate all the services (FACT Model) EAST offers.2) Identify the strengths and goals of the individual and
make a plan.3) Connect the individual to resources in the community
(insurance, social support, recreation etc.)4) Identify individual’s triggers for stress and ways to
manage (IMR)5) Provide support, advocacy and education.6) Co-lead Multi-family Groups.7) Provide supportive therapy (CBT)8) Obtain feedback (Miller/Duncan)9) Assist in the transition from EAST.
11. Occupational Therapy
The OT’s Role: Cognitive and sensory assessment
Assessment and functional support in all life domains with emphasis on sensory modulation.
Training of other staff
12. Supported Employment/Education Role (IPS Model)
When individual is ready!
Job preparation Job search Job development Help staying employed Benefits counseling
Assist/advocate with school for accommodations (IEP/504).
Provide educational support to stay in school.
Transition planning for after high school.
13. Medications
Risk/benefit analysis done by EASA team prescriber.
Rapid appointment offered to individual and or family.
If deemed appropriate start low and go slow with consideration of titration.
No polypharmacy Prescriber integrated team member/shared
appointments. Appointments occur at least monthly and occur
even if individual not interested in meds.
14. Nursing
EASA has taken SAMHSA’s 10x10 challenge! Monitor side effects (BMI, AIMS, BARNES, comorbid
illness, metabolic disorder Takes lead in health education. Assist with medication administration (injections, pill
minders, problem solving etc.) Assists with Patient Assistance Programs Tracks laboratory tests. Monitors OTC and supplement use. Facilitates coordination/referral to PCP.
What it really takes to be a good EASA Clinician.
15. Multi Family Groups
Evidence based practice with international recognition as primary treatment for early psychosis.
All EASA trained team members can lead the group.
EASA programs offer quarterly workshops as part of the EBP
Specific training offered to all staff.
What should Families know!The Family Guidelines!
Believe in your ability to change outcomes
One step at a time Consider the idea that
medication can protect your future
Reduce stresses and expectations for a moment
Keep it calm Give each other space Set a few simple limits Ignore what you can’t change
(Pick the right mountain to die on)
Keep it simple Carry on business as usual Solve problems step by step Avoid alcohol and street
drugs Explain your circumstances
to your closest friends and relatives and ask them for help and to stand by you.
Don’t move away (to a new school)
Attend the multi-family groups
Follow the recovery plan KEEP HOPE ALIVE!
The 1st and 2nd Groups
“Getting to know you” co-facilitators model
behavior share personal
information culturally normative
introductions begin to develop trust
and understanding
“Impact of situation” co-facilitators model
behavior personal stories of
impact of M.I. are shared
continue to build relationships
Copyright
William R. McFarlane, MD
Structure of SessionsMultifamily groups (MFG) and single-family treatment (SFT)
MFG SFT1. Socializing with families and consumers 15 m. 10 m.
2. A Go-around, reviewing-- 20 m. 15 m.
a. The week's events b. Relevant biosocial information c. Applicable guidelines
3. Selection of a single problem 5 m. 5 m.
4. Formal Problem-solving 45 m. 25 m.
a. Problem definition b. Generation of possible solutions c. Weighing pros and cons of each d. Selection of preferred solution e. Delineation of tasks and implementation
5. Socializing with families and consumers 5 m. 5 m. Total: 90 m. 60 m.
16. Transition Planning
Successful treatment is not defined by what a person does in EASA, but after they leave.
Services conceptualized in phases with ultimate goal of successful, prepared transition.
16. Transition Planning
This starts at engagement! Extensive psychoeducation of individual and
family has occurred “On track” developmentally OR in need of long-
term intensive services Transition in place and has occurred
successfully. (You can do a slow handoff if necessary)
Celebrate the individual’s “Graduation” Offer “safety net” services.
Transition Checklist
1. Person has written transition/relapse plan/advanced directive.
Plan in place to meet unmet goals (educational, vocational, social etc.)
Plan identifies early, intermediate and late warning signs.
Plan specifies actions to be taken by the individual and others when these signs occur.
Plan includes history of effective and ineffective interventions, and preferences about medications/ strategies
Plan is realistic and has been tested. The person has identified one or more key individuals
to advocate in case of relapse Advocate has a copy of plan.
Transition Checklist
2. Appropriately qualified ongoing doctor or nurse is identified.
The person has met and accepted the medical person. It is clear how the individual is going to pay for the medical
care. A copy of the person’s most recent assessment,
medication history and relapse plan has been sent to prescriber.
3. Ongoing counselor is identified. A determination has been made of whether the person
needs/ wants an ongoing counselor. Counselor is identified and person has met, accepted
counselor. Counselor has treatment and medication history,
assessments, relapse plan. It is clear how the person is going to pay for services.
Transition Checklist, Cont.
4. Access to medications has been established. Person has access to medications through
insurance or other means. Medications have been established through
pharmaceutical assistance or other means for the next 3 months.
Person knows how to secure future medications.
5. Person has completed treatment goals and has clear path going forward
Resources in place for ongoing goals
Transition Checklist
6. Family members and/or other key support system members have been consulted and are in agreement that the person is ready for transition.
Meeting has occurred & transition plan in place that all have agreed to
Family members and other key supporters have a copy of the relapse plan.
7. Person has completed discharge survey and permission to follow up established.
Resource/Contact Information
www.eastcommunity.org www.oregon.gov/HDS/mentalhealth/
services/easa/main.shtml http://www.mvbcn.org/home/mv1/east_login_
main.html Password: Oregon
Ryan Melton PhD LPC ACS
503-361-2667
Differential Diagnosis for conditions with Psychosis.
EARLY ASSESSMENT AND EARLY ASSESSMENT AND SUPPORT ALLIANCE (EASA)SUPPORT ALLIANCE (EASA)
Ryan Melton PhD LPC ACSRyan Melton PhD LPC ACS
EASA Clinical CoordinatorEASA Clinical Coordinator
• Mental illness and substance use disorders account for 60% of the non-fatal burden of disease amongst young people aged 15-34 (Public Health Group 2005)
• 75% of mental health problems occur before the age of 25 (Kessler et al 2005)
• 14% of young people aged 12-17, and 27% of young people aged 18-24 experience a mental health problem in any 12
month period (Sawyer et al 2000, Andrews et al 1999)
Why does EASA focus on Schizophreniform and Bipolar conditions?
Available research on early intervention and prodrome
Psychotic mania difficult to differentiate and course is variable.
Level of associated trauma & disability
Research base to build from
Disproportionate impact on public system
What Can Cause Psychosis?
Vulnerability Frontal lobe epilepsy LOTS of medical
conditions Schizophrenia Bipolar disorder Depression Anxiety disorder Bullying
Steroids Stimulants Methamphetamine Brain tumors Trauma Sleep deprivation Severe stress Sensory deprivation And others….
PSYCHOSIS
Drugs
Depression
Stress
Mania
Schizophrenia
Medical Illness
Personality
ADHD
ODD
Facticious/Malingering
Trauma
Autism/Aspergers/PDD
Psychosis Risk Syndrome
Bipolar Risk Syndrome
TenaciousDepressionSyndrome
THE GRAND DSM RAILROAD
Clinical experience and recent research has shown 2 things1 There are many people with something resembling the
clinical phenotype of psychosis who apparently do not have a need for care (van Os et al 2001) Some subthreshold, some full threshold, some just false positives
2 Most people who develop a sustained psychotic disorder experience a significant period of subthreshold symptoms, distress and serious functional decline long before they become frankly psychotic and ultimately access treatment (Sullivan 1927; Meares 1959, Häfner et al 1989)
So while we may wish to “protect” one group from care/intervention or at least not seek them out, we must try to find ways to offer it to another
We therefore need to decide who needs care, how early and where it should be offered, and what should be the range and sequence of interventions
Potential Obstacles to Prepsychotic Intervention
FALSE POSITIVESA. Can we define subthreshold “caseness”? B. Iatrogenic harm esp drug therapies, stigmaC. Enhanced by fear of “schizophrenia” and the reality of “standard care”D. Poor context for this approach in most settings - Needs to be developed
in generic/primary care/youth environmentsE. Can decrease false positives to 10 - 20% but also decrease sensitivity _
the “prevention paradox”
“INACCESSIBLE” POSITIVES (unaware, reluctant or unrecognised) 90%!A. Can we find them anyway? Do they want or need help - are they really
“cases”? (van Os et al 2001)B. Increasing access may reduce the “true” positive rateC. An ounce of prevention is better than a pound of cure but is 15 ounces of
prevention worth the effort? (Eaton & Harrison 1996)
adolescenceadolescence
Puberty Sexuality Peer group
identification Cognitive development
Abstraction Empathy
Educational goals Vocational goals Personality development Intimacy Drug use Family issues
Differential Diagnosis of Psychotic Disorders
Psychosis vs. “psychosis” Challenging dynamic Qualities of Psychosis include:
Egosyntonic and yet role functioning impairment Bizarre Frequent (daily for hours) Described as outside of self (hallucinations) Objective findings (mental status changes: thought processes, emotional
expression) Qualities of “psychosis” include:
Egodystonic and less role impairment Nonbizarre Episodic (once a day), brief Described as “inside” of self Visual hallucinations Lack of objective findings on MSE
Symptoms of Acute Psychosis
HallucinationsDelusionsSpeech & movement
problemsCognitive & sensory
problemsInability to tell what
is real from what is not real
Differential Diagnosis of Psychotic Disorders
Prevalence in clinical populations: Adolescence 8% Children 4%
Children and adolescents with psychosis had the following conditions: Major Depressive Disorder 41% Bipolar Disorder 24% Depression NOS 21% Schizophreniform 14%
“…the basic defect in schizophrenia consists of a low threshold for (mental) disorganization under increasing stimulus input.”
Epstein and Coleman, 1970
Stages of Schizophrenia
Positive symptoms Negative symptoms
Prodromal phase1 week-1 year
Acute psychosi
s1 week-1
month
Recovery phase6-36 months
Risk for relapse
The Schizophrenia “Prodrome" ~90% of patients with schizophrenia
experienced a “prodromal stage” ~35% of persons who experience prodromal
symptoms will develop a psychotic disorder Characteristic symptoms: at least one of
the following in attenuated form with intact reality testing, but of sufficient severity and/or frequency so as to be beyond normal variation:(i) delusions(ii) hallucinations(iii) disorganized speech
Perkins and Lieberman Prodrome and First Episode e in Essentials of Schizophrenia APA Press, Washington DC 2011
Thought Content
Attenuated delusionA 15 year old high school student starts to sit in the back of the class because if she sits in the front she has an uncomfortable feeling that other students are whispering about and laughing at her. She knows this is “silly”, but feels better in the back.
DelusionA 15 year old high school student believes that other people are talking about her, read her mind, and making fun of her where ever she goes. She is sure this is happening, and she is isolating herself at home because she is uncomfortable in public.
Perception
Attenuated hallucinationAbout 2 or 3 times a week a 22 year old cashier sees colors on the wall seeming to be distorted, textures and waves on the wall. He has started hearing beeping sounds that can last for minutes, and last week he heard a momentary (a second or two), faint, unintelligible voice. He is not sure, but thinks it is most likely his mind playing tricks on him.
HallucinationOn an almost daily basis a 22 year old cashier hears voices speaking to him. They speak to him outside of his head. They refer to him in the third-person. and sometimes criticize him or tell him to do something silly, like “pat the cat”. He believes these voices are real and he is very frightened of them.
CognitiveDeficits
Affective Sx: Depression
Social Isolation
School Failure
Vulnerability: CASIS
Brain Abnormalities
StructuralBiochemical Functional
Disability
Social and Environmental Triggers
Incr
easi
ng Pos
itive
sym
ptom
s
Early Insults
After Cornblatt, et al., 2005
e.g. Disease Genes, Possibly Viral Infections, Environmental Toxins
Psychosis with schizophrenia Hallucinations
74% auditory hallucinations Delusions
22% delusions Thought Disorder Negative symptoms Cognitive and Behavioral Changes Distressing!
Hallucinations with schizophrenia
Most commonly a voice Heard in a grammatical form that is
different from how we experience our own thoughts
Sex of the voice is nearly always identified, but the identity is not
Hallucinations with schizophrenia Voices diminish if meaningful
conversation is going on Experienced outside the head (or poorly
localized) Voices are speaking thoughts aloud,
arguing in the third person, commenting on the persons actions
Delusions with schizophrenia False fixed beliefs Persecutory, reference, grandiose
Most common/ nonspecific Being controlled, thought broadcasting,
thought insertion Very specific for schizophrenia
Psychosis with schizophrenia The most common negative symptoms
seen in children: Affective flattening Poverty of speech Inability to experience pleasure No interest in relating to people Lack of initiative Inattentiveness
Psychosis with schizophrenia Most common neurocognitive
impairments: Working memory Verbal processing Executive functions Sensory deficits Social cognition
Symptoms of 1st episode Schizophrenia related conditions
Thought Disorganization Obtained by family, friends and/or teachers. Direct observation and interview:
“Do people ever tell you they can’t understand you or seem to have difficultly understanding you?”
Symptoms of 1st episode Schizophrenia related conditions
Auditory Hallucinations (cont) Ask questions that get at
locality: “where do you think it is coming from?” frequency: content: time of day more likely to hear: what helps? what makes them worse? mood at time of hallucination:
This will help differentiate between mood disorders and PTSD
Symptoms of 1st episode Schizophrenia related conditions
Bizarre and uncharacteristic behavior, beliefs or speech. FYI: Kids are bizarre in general, must compare with other
friends and social group. Obtained via family report, direct observation, interview. Look
for overvalued ideas, magical thinking and ideas of reference. “Do you have feelings or beliefs (religion, philosophy, politics)
that are important to you?” Do your friends and family tell you
that they are unusual, or weird.” “Have you felt that things around you have a special meaning
for just you”. Specifically explore musicians, websites and TV.
Symptoms of 1st episode Schizophrenia related conditions Auditory Hallucinations “Do you ever hear a voice that others don’t seem to hear”, “Does it sound
clearly like my voice speaking to you now?” Localized outside of the head usually in 3rd person with
running commentary or multiple voices talking to each other.
They are egodystonic initially although can become egosyntonic. Also tend to be incongruent to mood.
Individual usually is able to identify gender but is unsure who it is.
Usually they are diminished with other sounds and do not wake individual while sleeping.
Symptoms of 1st episode Schizophrenia related conditions
Thought Insertion, Withdrawal, & Broadcasting: These are the first rank symptoms!
“Have you felt that you are not in control of your thoughts?”
“Do you ever feel people somehow can puts thoughts in your head or take them away?”
“Do you feel your thoughts are being said out loud so that others or you can hear them?”
“Do you think that people can read your mind?” “Do you ever change your thoughts so people cannot read them?”
Other symptoms that need exploration…..
Depersonalization/derealization: “Do you ever get a sense that you are not real or that
your life is all a dream?”. Heightened sensitivities or visual distortions:
“Do you ever feel that your mind, eyes or ears are playing tricks on you?”
Anomalous experiences more common in kids. Increased fear, anxiety or paranoia:
“Do you ever feel that you have to play close attention to what’s going on around you in order to feel safe?”
You must rule out if this is a real fear or more consistent with paranoia.
Other symptoms that need exploration…..
Functional Decline In Schizophrenia related disorders this happens
prior to onset of perceptual symptoms. Obtain good history from family and client to get
at this. Ask specifically about school/work changes and
declines. Ask about changes in time spent with friends. Ask about self care Explore for premorbid depression and anxiety. Explore previous drug use.
Family History
Monozygotic twins: 48-50% increase likelihood.
Parents and Siblings: 10% increase Grandparents, Aunts & Uncles: 4%
Clinical Summary/Treatment
“Subclinical” (Prodromal) Symptoms: Emerging evidence base
Psychotherapy Omega-3 Fatty acids Family Psychoeducation
Alternative interventions (need evidence base)
Stress management, (exercise, meditation, yoga, etc.)
Persons at elevated risk for psychosis, and persons with psychosis have altered cardiovascular, endocrine, and immune indices of stress
Antipsychotic risk outweigh benefits
Clinical Summary/Treatment
First Episode: Early intervention with antipsychotics improve
likelihood of sustained recovery Low doses of antipsychotics and counseling may
be very effective to prevent relapse Family Psychoeducation/Supported
employment/ED A sub-group of good prognosis individuals (~15-
20%) may not need maintenance antipsychotics, but there are no clinical features that can reliably identify these individuals.
Alternative treatments may increase proportion of individuals who do well without maintenance antipsychotic treatment
Stress management (meditation, yoga, etc.) Persons at elevated risk for psychosis, and persons
with psychosis have altered cardiovascular, endocrine, and immune indices of stress
Symptoms of psychosis do not imply diagnosis of schizophrenia
Psychosis can occur in: Medical Conditions Drug-induced PTSD Asperger’s/Autism Bipolar disorder Major Depression
Differential Diagnosis of Psychotic Disorders Benign Psychosis
Sleep and stress Psychosis associated with a medical
condition Migraines Delirium Seizures
Differential Diagnosis of Psychotic Disorders Psychosis associated with psychotropic
medication Stimulants (RARE) Steriods
Substance Use Methamphetamine Cannabis
Cannabis
Very popular with adolescents
Steady increase over the years
Binds to specific parts of the brain
Cannabis
Increases the risk of schizophrenia by six times
Exacerbates the symptoms Earlier age of onset More psychotic symptoms Poorer response to medications Poorer outcome
Cannabis
Cannabis psychosis odd and bizarre behavior violence and panic less thought disorder better insight
People who use cannabis on a daily basis were 2.4 times more likely to report psychotic symptoms then non-users
The best manner to rule this in or out is through natural course
Methamphetamine
Methamphetamine is an addictive stimulant drug
releases high levels of dopamine
damages brain cells that contain dopamine and serotonin
Sensitization and cross-sensitization
Psychotic sxs. Occur in about 40% of meth depend. Persons
Psychotic sxs. Can occur in response to stress
Methamphetamine
Methamphetamine psychosis: Can look similar to schizophrenia or
bipolar Extreme irritability Visual hallucinations Aggressive behavior Paranoia Post-episode depression and withdraw
Psychosis in drugs
CAN YOU TELL THE DIFFERENCE? 1st episode differentials (premorbid):
Family HX of substance abuse/dependence
DX of substance abuse/dependence Anti-Social personality traits or DX More likely to have friends Age
Clinical Summary/Treatment Substance misuse/abuse is common
amoungst adolescents. Challenging to treat Trans-theortical stage of change model
has the best evidence (e.g. harm reduction with precontemplative individuals.
ADHD
Poor concentration
Hyperactivity Impulsive Disorganized Loses stuff Always has to go
first Bossy Interrupts
Doesn’t turn in homework
Fails to do chores well
Disrupted sleep (Can be) defiant Poor insight into
symptoms Intelligent 1 out of 25
Oppositional Defiant Disorder (ODD) Loses temper Argumentative Refuses to follow
rules Deliberately
annoying Blames others for
mistakes Anger Revengeful
Starts by age 8 Can lead to
Conduct disorder 1 in 5 Medication usually
ineffective Therapy/
behavioral modification
School suspensions
Autism and Asperger’s Developmental
delays in speech and motor skills
Poor eye contact Poor breast feeding Poor sleepers Poor social skills Challenged in team
sports Expressive and
receptive language problems
Do not invite others into their experiences
Narrow interests Poor emotional
response Function better
with rigid routine Hand flapping
when excited
Post Traumatic Stress Disorder (PTSD) Trauma Nightmares Flashbacks Hypervigilance Intrusive
memories Psychosis Avoidance Mood changes
Anxious/ helplessness
6 in 100 for boys, 15 in 100 for girls
Therapy/ medication
PTSD
Post-Traumatic Stress Disorder Hallucinations in 75-95% of clients Psychosis is “trauma” related Impulsive, aggressive, and self-abusive
behaviors are present Intact social relatedness
Clinical Summary/Treatment
Often misdiagnosed as psychosis or schizophrenia
Truama itself is not suffiencent for diagnosis
Less response to medications Improved with sensitive psychosocial
interventions-DBT Awareness of countertransference
“In my opinion melancholia is without any doubt the beginning or even part of the disorder called mania. The melancholic cases tend towards depression and… if, however respite from this condition… occurs gaiety and hilarity in the majority of cases follows, and this finally ends in mania. ….. The patient who previously was gay, euphoric, and hyperactive suddenly has a tendency to melancholia; he becomes, at the end of the attack, languid, sad, taciturn, he complains… about his future, he feels ashamed. When the depressive phase is over, such patients go back to being gay, they laugh, they joke, they sing, they show off in public with crowned heads as if they were returning victorious from the games; sometimes they laugh and dance all day and all night.”
Aretaeus of Cappadociaca. 150 CE
Mood Disorders
Affective psychosis: Most common psychotic conditions of
childhood Higher rate of psychosis then their adult
counterparts Psychosis often related to the mood
disorder Hallucinations are more common in children
Observed in one-third to one-half of depressed children
Delusions are more common in adolescents
Unipolar Affective Disorder (MDD) Sad, irritable Disrupted sleep
cycles Lack of interest Statements of
hopelessness, helplessness
Thoughts of death Social isolation Poor school work Defiant behavior
Two weeks of symptoms
10-15% symptoms 1 in 12 will have
MDE 1 in 14 suicide Alcohol and Drug
use Psychosis related
to mood.
Bipolar Affective Disorder (manic-depression) CHANGE in mood
Grandiose Irritable (EXTREME)
Sleeplessness Increased energy Hypersexual Giddiness Psychosis related
to mood “This is NOT my
child”
Poor judgment Spending money 1 in a 100 Rapid mood changes
for several days
Clinical Summary/Treatment
Bipolar disorder over diagnosed in children and adolescents.
Medications: Psychotherapy: CBT most evidence
based for depression but does not imply most effective form of treatment.
Excercise
BAD vs. Borderline Personality Disorder
ImpulsivityMood instabilityInterpersonal difficultyPsychosisSubstance use
Abuse historySelf-injurious behaviorUnstable/malignant relationshipsPervasive, disturbed self-image
GrandiositySleep difficultiesRacing thoughtsPressured speech
BAD vs. Schizophrenia
PsychosisDisorganized speechDisorganized behavior
Negative symptomsSocial declineCognitive decline
InsomniaExcessive energyRacing thoughtsgrandiosity
Diagnosis Philosophy
“Psychosis” and Schizophrenia-spectrum disorders are heterogeneous Symptom characteristics Etiology Course
People who develop “psychosis” and schizophrenia-spectrum disorders are heterogeneous Experience (especially with the illness) Personality Culture Resources
Diagnosis Philosophy
At the early stages of a psychotic illness prognosis: is variable generally and uncertain for the
individual patient may be influenced by treatment (both
postively and negatively) The goals of treatment are:
symptom remission social and vocational functional recovery development of an illness management
strategy that maintains recovery
CASE PRESENTATIONS AND QUESTIONS?
Resource/Contact Information
www.eastcommunity.org www.oregon.gov/HDS/mentalhealth/
services/easa/main.shtml http://www.mvbcn.org/home/mv1/east_login_
main.html Password: Oregon
Ryan Melton PhD LPC ACS
503-361-2667
Integration of the Strength’s Based Model into Clinical Practice
EARLY ASSESSMENT AND EARLY ASSESSMENT AND SUPPORT ALLIANCE (EASA)SUPPORT ALLIANCE (EASA)
Ryan Melton PhD LPC ACSRyan Melton PhD LPC ACS
EASA Clinical CoordinatorEASA Clinical Coordinator
Typical Mental Health Assumptions
You must be 100% compliant and 100% abstinent from illicit drugs.
You must accept your illness and make the effort to attend your appointments.
You must never work harder then your client. Close clients that do not show for appointments. A clear exit from the system is never a goal. Stability is the goal. Therapists should not do service coordination. Maintain strict boundaries with your client. Some people just can’t be helped. Adults and Children should be in different systems. Families are a barrier to treatment.
Engagement Strategies:(Xavier Amador: LEAP)
Listen Empathize Agree Partner
InsteadEngage! Put person at ease. Meet in a location that is comfortable for the client. Try side-by-side. Non-threatening body posture despite what is said Acknowledge viewpoint/collaborative language Be flexible, active and helpful. Spend time socializing, focus on interests, especially those
you have in common. Identify common ground or create it. Explain procedures & write things down with clear
instructions. Worry about assessment at later time, it is recommended to
gather information gradually and in the form of story telling (aids in memory and identifying negative cognitions and stigma.)
Try to stay up on the times.
Do you know…
The relevance of Fruit Ninja When you have been “De-Faced”? Team Edward vs. Team Jacob The Districts of Hunger Games? How to interpret…
BRB PHAT PAW/P911 <2/831 ADIEM
Why Focus on Engagement?
AnosognosiaStigmaSide effects
Stigma in Media and Culture
“Real” People with Mental Illness
Can you name any well-known people who have a mental illness? Artist President Author Actor Nobel Prize Winner Musician
Stigma and Discrimination
Less access to health care & education. More likely to be singled out based on stigma that under estimate their abilities.
Cannot ask for help without others assuming they will need help with everything.
Can expect to pay more for cars, homes and furniture due to increased risk of being exploited or mislead.
Less likely to be taken seriously and more likely to be treated like children or considered violent.
More likely to segregated into living, education, work and sport programs, less likely to have access to accommodations necessary.
Now that we know all this…what really promotes change in individuals?
15% can be attributed to your use of a therapy model.
15% can be attributed to your ability to provide hope and empathy.
30% is the relationship you build 40% is what the individual already has
(attributes and resources!)
Given that how to we get the most bang for our buck? Focus on what individuals already have by
following the Strength’s principles! Individuals have the capacity to learn, grow
and change. Focus on strength’s as opposed to pathology. The individual directs the relationship. The relationship is primary and essential. Working in an individual’s environment. The community is an oasis of resources!
Demonstration of strength’s based planning!
Clinicians Rock!
The effect size of therapy is .80! (the average treated individual is better off than 80% of untreated individuals)
Couples/Adolescents = .75-.80 Family Psychotherapy = .58-.70 This equates to the point that therapy is cost
effective when compared to psychological and medical interventions
Reference: (Minami, et al., 2008. Journal of Consulting and Clinical Psychology).
Clinicians Suck!
Make claims of effectiveness but only 3% of therapists count outcomes (Akins & Christensen, 2001).
Despite all innovations (400 tx models) no improvement in 30 years! 47-50% of individuals drop out. Despite individuals feeling less stigmatized a lack of confidence in therapists exists. Continued emphasis on medical model despite better outcomes for most MH
conditions. Ongoing claims of superiority amongst models without evidence.
Model v. model= ES of .20 Disorders Tx ingredients Individual demographics & dx (<1%) Therapist’s degree and demographics (0%)
From The great psychotherapy debate by Wampold, B.E. (2001)
Outcome Rating Scale (ORS)
40 pt measure with 4 subscales Adult and child versions Higher scores=lower level of distress. Lower
scores=higher level of distress Clinical cutoffs: 25 (>19), 28 (13-19), 32 (<12) 5 pt change is considerable reliable change. Complete at start of session. It takes 1 min.
Session Rating Scale (SRS)
40 pt measure with 4 subscales Adult and child version Scores below 36 should be discussed with
client or any subscale below 9 Lower scores early could mean anything-
discuss. Low scores later 4x likely to drop out.
Done at end of session, takes 1 min. Can plot ORS & SRS on Excel. All materials free at www.scottdmiller.com
Resource/Contact Information
www.eastcommunity.org www.oregon.gov/HDS/mentalhealth/
services/easa/main.shtml http://www.mvbcn.org/home/mv1/east_login_
main.html Password: Oregon
Ryan Melton PhD LPC ACS
503-361-2667