Download EAST STRATEGIC PARTNERS

EARLY ASSESSMENT AND
SUPPORT ALLIANCE (EASA)
Ryan Melton PhD LPC ACS
EASA Clinical Coordinator
Introduction to the EASA Model
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:
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Building community awareness and
Offering easily accessible, effective
treatment and support (2 years)
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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
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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 multifamily 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
New program
RAISE
Evolution of EASA’s Model
 Practice
Guidelines/Fidelity
Tool
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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
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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 TooCommon Reality
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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
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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
•Healthy
Lifestyle:
•Sleep
•Nutrition
•Exercise
•Social support
•Avoiding alcohol
& street drugs
•Using
antipsychotic
medicines
•Brain
development age
16-30
•Genetics
•Drugs
•Medical Conditions
•Lack of Sleep
•Stress
•Isolation
Increase Vulnerability
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
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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
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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
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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:
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Part of broader commitment to recoveryoriented 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.
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Statewide historically focused on 1st episode but
integrating at-risk individuals.
a.
b.
c.
d.
e.
Often most disabling stage. Suicide risk, drop-out,
family conflict common.
Assessment & monitoring may prevent much of
acuity
Psychosis is cyclical: prodrome predicts relapse
signature
Symptoms similar but insight retained; easier to
engage & non-pharmaceutical approaches can be
effective
Public education about gradual onset & common
prodromal symptoms may increase speed &
effectiveness of early identification.
Social and
Early Insults
Environmental
(e.g. Disease
Triggers
Genes,
Possibly Viral Infections,
Environmental Toxins)
Biological Vulnerability: CASIS
Brain
Abnormalities
Structural
Biochemical
Functional
Cognitive
Deficits
Affective Sx:
Depression
Social
Isolation
Disability
School
Failure
After Cornblatt, et al., 2005
Positive Psychotic Symptoms as a
Cyclical Condition
Acute psychosis
Recovery
Prodrome
3. At-risk focus.
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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
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Medications avoided unless rapid deterioration or risk of harm;
low doses
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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
UNIQUE
 Internal gatekeepers/ referents
 Crisis system & hospitals
 Parents (media)
 Schools
 Primary care doctors
 Clergy…
 Funders/policy makers
2000 students: Approx. 60 students
will develop psychosis
Teacher presentation example
 Value: Graduation into adult life
 Misconception:
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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:
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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
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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:
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Presentation of suspected psychosis is considered a
psychiatric emergency.
Ease access is of particular importance
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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
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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?
Anosognosia
Stigma
Side 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/ind
ex.shtml
7. Family Partnership.
 Transparency and shared decision making
 Principles:
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Family support & involvement important to successful
outcome
Distressing effect on families
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Key components;
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First contact often debriefing session
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
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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
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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
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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 Format
Client MFG/
SFE
Coun SE/Se OT
seling d
Medic Succe Transi PW
al
ss
tion
due
date
Ryan
Family
invited
to WS
Joinin
gs
compl
ete
CBT
with
Ninaanxiet
y
Wants
to
return
to
OSURefer
to
John
Refer
for
Assmfor
school
accom
odatio
n
Abilify
-5mg
some
fatigu
e. RN
to
obtain
labs
Feelin 7/3/13
g
more
motiva
ted
Need
new
copy
of Ins
card.
Tamar She is
a
not
intere
stedjoin
with
family
alone
MI
work
aroun
d THC
use.
Help
with
housin
John
doing
practic
e
intervi
ews.
Compl
eted
Assm.
Rob to
review
.
Not
intere
sted in
taking.
Sees
Rob
next
week.
Family 7/9/12
happy
she
will
meet
with
EASA
team
Worki
ng on
transiti
on
check
list
Avoid getting stuck!
What is the role of your EAST
Counselor (QMHP)? (10)
1)
2)
3)
4)
5)
6)
7)
8)
9)
Coordinate all the services (FACT Model) EAST
offers.
Identify the strengths and goals of the individual
and make a plan.
Connect the individual to resources in the
community (insurance, social support, recreation
etc.)
Identify individual’s triggers for stress and ways to
manage (IMR)
Provide support, advocacy and education.
Co-lead Multi-family Groups.
Provide supportive therapy (CBT)
Obtain feedback (Miller/Duncan)
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
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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
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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
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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
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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)
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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 Sessions
Multifamily groups (MFG) and single-family treatment (SFT)
1. Socializing with families and consumers
MFG
15 m.
SFT
10 m.
2. A Go-around, reviewing--
20 m.
15 m.
5 m.
5 m.
45 m.
25 m.
5 m.
90 m.
5 m.
60 m.
a. The week's events
b. Relevant biosocial information
c. Applicable guidelines
3. Selection of a single problem
4. Formal Problem-solving
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
Total:
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
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Advocate has a copy of plan.
Transition Checklist
2. Appropriately qualified ongoing doctor or nurse is
identified.
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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.
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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.
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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
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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.
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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
EARLY ASSESSMENT AND
SUPPORT ALLIANCE (EASA)
Ryan Melton PhD LPC ACS
EASA Clinical Coordinator
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
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conditions
Schizophrenia
Bipolar disorder
Depression
Anxiety disorder
Bullying
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Steroids
Stimulants
Methamphetamine
Brain tumors
Trauma
Sleep deprivation
Severe stress
Sensory deprivation
And others….
Drugs
Stress
Medical Illness
Trauma
ADHD
PSYCHOSIS
Depression
Autism/Aspergers/
PDD
Schizophrenia
Facticious/Malingering
Personality
Mania
ODD
THE GRAND DSM RAILROAD
Psychosis Risk
Syndrome
Bipolar Risk
Syndrome
Tenacious
Depression
Syndrome
Clinical experience and recent
research has shown 2 things
1
2


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
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 POSITIVES
A. Can we define subthreshold “caseness”?
B. Iatrogenic harm esp drug therapies, stigma
C. 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 environments
E.
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 rate
C. An ounce of prevention is better than a pound of cure but is 15 ounces of
prevention worth the effort? (Eaton & Harrison 1996)
adolescence
 Puberty
 Educational goals
 Sexuality
 Vocational goals
 Peer group identification
 Personality development
 Cognitive development
 Abstraction
 Empathy
 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
Hallucinations
Delusions
Speech & movement
problems
Cognitive & sensory
problems
Inability 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
Risk for
relapse
Prodroma
l phase
Acute
psychosis
Recovery
phase
1 week-1 year
1 week-1 month
6-36 months
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 delusion
A 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.
Delusion
A 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 hallucination
About 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.
Hallucination
On 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.
e.g. Disease Genes,
Possibly Viral
Infections,
Environmental
Toxins
Early Insults
Social and
Environmental
Triggers
Disability
Vulnerability: CASIS
Brain
Abnormalities
Cognitive
Deficits
Affective Sx:
Depression
Social
Isolation
School
Failure
Structural
Biochemical
Functional
After Cornblatt, et al., 2005
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
 Do not invite others








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


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 Cappadocia
ca. 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
Grandiosity
Sleep difficulties
Racing thoughts
Pressured speech
Impulsivity
Mood instability
Interpersonal difficulty
Psychosis
Substance use
Abuse history
Self-injurious behavior
Unstable/malignant relationships
Pervasive, disturbed self-image
BAD vs. Schizophrenia
Insomnia
Excessive energy
Racing thoughts
grandiosity
Psychosis
Disorganized speech
Disorganized behavior
Negative symptoms
Social decline
Cognitive decline
Diagnosis Philosophy
 “Psychosis” and Schizophrenia-spectrum disorders
are heterogeneous
 Symptom characteristics
 Etiology
 Course
 People who develop “psychosis” and schizophreniaspectrum 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
[email protected]
503-361-2667
EARLY ASSESSMENT AND
SUPPORT ALLIANCE (EASA)
Ryan Melton PhD LPC ACS
EASA Clinical Coordinator
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
Instead
Engage!







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?
Anosognosia
Stigma
Side 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 anythingdiscuss. 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_
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Password: Oregon
 Ryan Melton PhD LPC ACS
[email protected]
503-361-2667