Introduction to the EASA Model EARLY ASSESSMENT AND SUPPORT ALLIANCE (EASA) Ryan Melton PhD LPC ACS EASA Clinical Coordinator.

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.


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


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

[email protected]

503-361-2667

Differential Diagnosis for conditions with Psychosis.




• 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….

Tamara Sale

Goal here is to emphasize anyone can develop psychosis, many causes

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

Tamara Sale

Describe what each of these things mean; give examples

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?”


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


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.


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


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


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


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?






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Integration of the Strength’s Based Model into Clinical Practice




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






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Introduction to the EASA Model EARLY ASSESSMENT AND SUPPORT ALLIANCE (EASA) Ryan Melton PhD LPC ACS EASA Clinical Coordinator.

Documents

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