Understanding Psychosis:

1. Understanding Psychosis: An Introduction to the Issues and the Early Intervention Service for Carers.

2. 2 Starting Point� EXERCISE A post-it note On the other, write down three words you associate with psychosis. Place on the whiteboard MATERIALS STICKY NOTES WHITE BOARD WHITEBOARD PEN FLIP CHART AND MARKER ALLOW 5 MINUTES REVIEW Common themes Write up objectives on the flip chart MATERIALS STICKY NOTES WHITE BOARD WHITEBOARD PEN FLIP CHART AND MARKER ALLOW 5 MINUTES REVIEW Common themes Write up objectives on the flip chart

3. 3 Today�s Session Session plan Our service - Why, What and How Psychosis � A better understanding? Fire alarms � follow procedure for college � we will follow you! Toilets/refreshments Breaks Finish TimeFire alarms � follow procedure for college � we will follow you! Toilets/refreshments Breaks Finish Time

4. 4 What is GRIP? Gloucestershire Recovery In Psychosis The GRIP Team is an Early Intervention in Psychosis service. Countywide � 3 �patch� teams. Stroud, Gloucester, Cheltenham Office base: Albion Chambers, Eastgate St, Gloucester Multi-disciplinary team Community and hospital interventions. May hear us referred to as the EI team � shorthand jargon for Early Intervention Name designed to appeal more to young service users � some misgivings about grammar etc, but recent poll chose to keep name The GRIP Team is an Early Intervention in Psychosis service. RATIONALE Government directives (NSF) Early treatment=better outcomes Young people�s limited experience of health services + Denial & fear of stigma & slow onset = Difficulties & delay in accessing specialist services Onset frequently occurs at critical developmental stage in young persons life Multi-disciplinary team Psychiatrists, nurses, psychologists, support workers, occupational therapist, sports therapist, social workers, admin� staff Mostly see people in their homes or in the community (cafes, etc). Try to avoid people needing to go into hospital � but will visit and assess client in hospital as necessary.May hear us referred to as the EI team � shorthand jargon for Early Intervention Name designed to appeal more to young service users � some misgivings about grammar etc, but recent poll chose to keep name The GRIP Team is an Early Intervention in Psychosis service. RATIONALE Government directives (NSF) Early treatment=better outcomes Young people�s limited experience of health services + Denial & fear of stigma & slow onset = Difficulties & delay in accessing specialist services Onset frequently occurs at critical developmental stage in young persons life Multi-disciplinary team Psychiatrists, nurses, psychologists, support workers, occupational therapist, sports therapist, social workers, admin� staff Mostly see people in their homes or in the community (cafes, etc). Try to avoid people needing to go into hospital � but will visit and assess client in hospital as necessary.

5. 3/22/2012 10:04:57 PM 5 Who uses our service? Adults and young people aged 14-35 years. From any referral source including self or family member referral. Currently living in Gloucestershire First presentation of psychosis within 18 months of positive signs. Within the first 18 months of first presentation or within the first 12 months of being treated for a first presentation of psychosis.Within the first 18 months of first presentation or within the first 12 months of being treated for a first presentation of psychosis.

6. 6 Early Intervention: Service provision Psychological Interventions Family Interventions Pharmacological Interventions Social Interventions Relapse Prevention Early Detection (Nice 2002)

7. 7 How is GRIP different from other mental health services? Short time from referral to assessment Greater frequency of visits Holistic approach Specialist knowledge Youth friendly/ flexible approach Involvement of carers/family work Youth friendly- informal style and setting. Assertive engagement- bordering on stalking Extended assessment Youth friendly- informal style and setting. Assertive engagement- bordering on stalking Extended assessment

8. Understanding Psychosis EXERCISE Confidence line

9. Diagnosing a First Episode of Psychosis. Psychosis doesn�t present in neat packages. Teenagers: Can they lack motivation? Be withdrawn? Lose interest in things? Become moody for no reason? Have fluctuating sleep patterns? Feel anxious about social situations? Get irritable? Behave in odd ways? Teenagers: Can they lack motivation? Be withdrawn? Lose interest in things? Become moody for no reason? Have fluctuating sleep patterns? Feel anxious about social situations? Get irritable? Behave in odd ways?

10. PSYCHOSIS � SYMPTOMS 1 Positive symptoms are active, noticeable behaviours that are NOT normally present in a person without psychosis. Examples include hallucinations or hearing voices. Negative symptoms refer to the absence or lessening of behaviours that are normally present in a person. Examples include lack of motivation and social withdrawal. Depressive or anxiety symptoms may also be present e.g. lowering of mood, worrying and loss of interest or pleasure.

11. PSYCHOSIS-SYMPTOMS 2 Positive symptoms are easier to spot and more likely to bring someone to attention of the mental health services quickly. Negative symptoms and depressive symptoms may be difficult to distinguish from each other. Negative symptoms can be very difficult to cope with for the person and their carers they may predominate over time, interfering with normal social life.

12. DIAGNOSTIC CRITERIA SYSTEMS Physicians use diagnostic criteria systems to categorise a users symptoms and arrive at a diagnosis. However, the assessment of the presence or absence of these criteria remains a process of �subjective interpretation�. The commonly used systems are: those developed by the American Psychiatric Association and called DSM-III-R and DSM-IV. those developed by the World Health Organisation, such as ICD-10.

13. ICD-10 CRITERIA FOR PSYCHOSIS 1. Symptom(s) are clearly present for most of the time during a period of 1 month or more. One (if the symptom is very clear) or two or more of the following symptoms: delusions of control of thought (e.g. thought echo) delusions of being controlled hallucinatory voices persistent delusions of other kinds (e.g. the person believes they possess superhuman powers and abilities)

14. ICD-10 CRITERIA FOR PSYCHOSIS 2. Or: At least two of the following clearly present for most of the time during a period of 1 month or more: persistent hallucinations breaks in chain of thought (leading to incoherence) catatonic behaviour negative symptoms (apathy, loss of concentration) significant and persistent change in personal behaviour, social and/or occupational functioning

15. PHASES OF PSYCHOSIS Fortunately, around 20% of people diagnosed as having psychosis only experience one episode. Studies have shown that the course of psychosis is variable. Researchers have described three phases of psychosis: prodromal active residual

16. PRODROMAL PHASE / EARLY SIGNS Characterised by the slow and insidious development of a number of signs and symptoms. Early recognition and management of psychosis leads to a better long-term prognosis. Common signs and symptoms include: Behaviour- social withdrawal, decrease in school or work performance, deterioration in hygiene and grooming. Mood swings- uncharacteristic suspiciousness, depression, anxiety, anger. Thoughts- odd ideas, vagueness, poor concentration. Physical- sleep disturbances, loss of energy, motivation or appetite.

17. ACTIVE PHASE Usually positive psychotic symptoms, such as hallucinations, delusions and confused thoughts. The hallucinations and delusions in the active phase are usually alarming enough for family members and friends to seek professional intervention. Possibly aggression. Sufferers may move into the active phase as they relapse.

18. RESIDUAL PHASE usually follows the active phase of psychosis as symptoms become more controlled. may experience psychotic episodes of lesser intensity than those in their most recent active phase or no symptoms at all. may appear to need less care since they may be perceived as being stable. Negative symptoms are common during residual phases. These symptoms contribute to social withdrawal.

19. Break Check people OK/ debriefed on return from break, any Q�sCheck people OK/ debriefed on return from break, any Q�s

20. 3/22/2012 10:04:57 PM 20 Hallucinations Usually the most distressing aspect of psychosis. Experienced by over 60% of people diagnosed with schizophrenia Most likely to be auditory- but not everyone that hears voices is in touch with mental health services. They are very real to people- pervasive and compelling. Paranoia Content of the voice- if distressing, derogatory or disruptive= service involvement. Other situations- bereavement, PTSD (often visual), sensory deprivation, physical illness. Movie examples: A beautiful mind, the fischer king (not one flew over cuckoos nest) Lack of insight common but not absolute. Study indicated that the parts of the brain indicated showing internally generated. Auditory hallucinations and spoken word- same areas. Functional brain scans have revealed that the areas of the brain that react to sensory perceptions are active during psychosis. For example, a PET or MRI scan of a person who claims to be hearing voices may show activation in the auditory cortex, or parts of the brain involved in the perception and understanding of speech*. ( *Copolov DL, Seal ML, Maruff P, Ulusoy R, Wong MT, Tochon-Danguy HJ, Egan GF. (2003) Cortical activation associated with the experience of auditory hallucinations and perception of human speech in schizophrenia: a PET correlation study. Psychiatry Res, 122 (3), 139-52. PMID 12694889.) Own internal voice vrs voice heard apparently from outside Some theories regard many psychotic symptoms to be a problem with the perception of ownership of internally generated thoughts and experiences* For example, the experience of hearing voices may arise from internally generated speech that is mislabeled by the psychotic person as coming from an external source. *Blakemore, SJ; Smith J, Steel R, Johnstone CE, Frith CD (2000). "The perception of self-produced sensory stimuli in patients with auditory hallucinations and passivity experiences: evidence for a breakdown in self-monitoring.". Psychological Medicine 30 (5): 1131-9. PubMed. PMID 12027049.Content of the voice- if distressing, derogatory or disruptive= service involvement. Other situations- bereavement, PTSD (often visual), sensory deprivation, physical illness. Movie examples: A beautiful mind, the fischer king (not one flew over cuckoos nest) Lack of insight common but not absolute. Study indicated that the parts of the brain indicated showing internally generated. Auditory hallucinations and spoken word- same areas. Functional brain scans have revealed that the areas of the brain that react to sensory perceptions are active during psychosis. For example, a PET or MRI scan of a person who claims to be hearing voices may show activation in the auditory cortex, or parts of the brain involved in the perception and understanding of speech*. ( *Copolov DL, Seal ML, Maruff P, Ulusoy R, Wong MT, Tochon-Danguy HJ, Egan GF. (2003) Cortical activation associated with the experience of auditory hallucinations and perception of human speech in schizophrenia: a PET correlation study. Psychiatry Res, 122 (3), 139-52. PMID 12694889.) Own internal voice vrs voice heard apparently from outside Some theories regard many psychotic symptoms to be a problem with the perception of ownership of internally generated thoughts and experiences* For example, the experience of hearing voices may arise from internally generated speech that is mislabeled by the psychotic person as coming from an external source. *Blakemore, SJ; Smith J, Steel R, Johnstone CE, Frith CD (2000). "The perception of self-produced sensory stimuli in patients with auditory hallucinations and passivity experiences: evidence for a breakdown in self-monitoring.". Psychological Medicine 30 (5): 1131-9. PubMed. PMID 12027049.

21. 21 Delusions A strongly held belief that is also culturally inappropriate, but a �nugget of truth� A huge proportion of delusions relate to an idea which predated the delusion. (egs) Nugget of truth egs: GCHQ, CCTV, (Trueman Show, Big Brother), 9/11= behaviour- tin foil, shutting curtainsA huge proportion of delusions relate to an idea which predated the delusion. (egs) Nugget of truth egs: GCHQ, CCTV, (Trueman Show, Big Brother), 9/11= behaviour- tin foil, shutting curtains

22. 3/22/2012 10:04:57 PM 22 So what is it like? EXERCISE: Hearing voices. Groups of 3 One person volunteer to be the subject: Other person talk to the subject on a normal topic of conversation, e.g., last holiday Voice � whisper into ear of subject whilst they are conversing to other person: nothing too nasty Do this for 3 minutes each / swop around ? Feedback LOOK AFTER YOURSELF AND EACH OTHER If you are feeling fragile or vulnerable suggest you are not a �subject� Some people find this exercise difficult � unplug and de-brief if you are finding it distressing Voice commentary nothing too upsetting/nasty May comment on the other person what they are wearing, whether you can trust them NB � not all people have derogatory voices ALLOW AT LEAST 20-25 MINUTES.LOOK AFTER YOURSELF AND EACH OTHER If you are feeling fragile or vulnerable suggest you are not a �subject� Some people find this exercise difficult � unplug and de-brief if you are finding it distressing Voice commentary nothing too upsetting/nasty May comment on the other person what they are wearing, whether you can trust them NB � not all people have derogatory voices ALLOW AT LEAST 20-25 MINUTES.

23. So what was it like? Feedback and debrief.

24. Who gets Psychosis, and Why?

25. 3/22/2012 10:04:57 PM 25 Who gets psychosis? 3% of the population will be diagnosed with some form of psychosis. Onset age range is from 18-24 yrs Psychosis seems to affect men and women equally. Psychosis is more prevalent in urban areas than rural areas. The average treatment lag from onset of symptoms to onset of treatment is one year. Evidence suggests that the longer the treatment lag, the worse the prognosis. Around 20% have only one �episode� Majority of our service users are young men in their late teens/ early 20s Women tend to have a 4 year later onset � mid 20s, then 2nd onset around menopause, more benign course. 20% - one �episode� no changes/damage to longer term functioning or personality 35%- 45% - several episodes but static or OK in between 35% - multiple episodes with increasing levels of impairment Majority of our service users are young men in their late teens/ early 20s Women tend to have a 4 year later onset � mid 20s, then 2nd onset around menopause, more benign course. 20% - one �episode� no changes/damage to longer term functioning or personality 35%- 45% - several episodes but static or OK in between 35% - multiple episodes with increasing levels of impairment

26. 26 Vulnerability factors for psychotic experiences Social, biological and psychological causes of psychotic experiences are all important and interact with one another. Life circumstances: e.g. research now demonstrates that a trauma history actually predicts psychosis. Disadvantaged backgrounds- increased stress life events, trauma, escape into drugs Afro-Caribbean- more likely to receive diagnosis, more heavy handed approach- previously, maybe presently. Trauma- sexual abuse particularly Disadvantaged backgrounds- increased stress life events, trauma, escape into drugs Afro-Caribbean- more likely to receive diagnosis, more heavy handed approach- previously, maybe presently. Trauma- sexual abuse particularly

27. 27 Social & psychological explanations �Labels� leads to or perpetuate oppression, social exclusion and stigma Stress vulnerability. (eg. Bereavement, academic pressure, trauma, isolation). Cognitive understanding of delusions Jumping to conclusions Thinking bias/ selective attention. Making sense of their world. The �illness� or experience is almost insignificant, but the social reaction is what is disabling. Ignorance, fear and prejudice is most damaging Loss of social role= more disadvantaged, dropping down social ladder- increasing vulnerabilities. The �illness� or experience is almost insignificant, but the social reaction is what is disabling. Ignorance, fear and prejudice is most damaging Loss of social role= more disadvantaged, dropping down social ladder- increasing vulnerabilities.

28. 3/22/2012 10:04:57 PM 28 Biological/ Medical explanations Neurological damage (head injury/ birth complications) Dopamine Hypothesis (chemical imbalances in the brain). Substance misuse Genetic Factors EEGs, MRIs, blood tests sometimes used to explore possible organic (pathological/illness) reasons for psychosis � neurological disorders such as alzheimers -electrolyte disturbances (glucose, potassium etc) - infections (flu�) -diseases (malaria) Sleep deprivation � temporary hallucinations, esp. On waking/falling asleep � not psychosis Psychosis has been traditionally linked to the neurotransmitter dopamine. In particular, the dopamine hypothesis of psychosis has been influential and states that psychosis results from an overactivity of dopamine function in the brain, particularly in the mesolimbic pathway. The two major sources of evidence given to support this theory are that dopamine-blocking drugs (i.e. antipsychotics) tend to reduce the intensity of psychotic symptoms, and that drugs which boost dopamine activity (such as amphetamine and cocaine) can trigger psychosis in some people. However, probably over-simplifies and phamaceutical companies have a vested interest in promoting chemical causes of mental illness whilst ignoring social and developmental factors. NB Medication for psychosis: common side effects weight gain, sedation, (sexual/fertility dysfunction) withdrawal from barbiturates and alcohol can be particularly dangerous, leading to psychosis or delirium Some studies indicate that cannabis use may lower the threshold for psychosis, and thus help to trigger full-blown psychosis in some people. It is not clear whether this is a causal link, and it is possible that cannabis use only increases the chance of psychosis in people already predisposed to it; or that people with developing psychosis use cannabis to provide temporary relief of their mental discomfort. The fact that cannabis use has increased over the past few decades, whereas the rate of psychosis has not, suggests that a direct causal link is unlikely for all users. Confounding issues � e.g. maybe those who use cannabis are less concordant with medication Genetics � children of parents with sz have a 10 fold increased risk of developing sz themselves (so say 10% rather than 1% in gen� population) EEGs, MRIs, blood tests sometimes used to explore possible organic (pathological/illness) reasons for psychosis � neurological disorders such as alzheimers -electrolyte disturbances (glucose, potassium etc) - infections (flu�) -diseases (malaria) Sleep deprivation � temporary hallucinations, esp. On waking/falling asleep � not psychosis Psychosis has been traditionally linked to the neurotransmitter dopamine. In particular, the dopamine hypothesis of psychosis has been influential and states that psychosis results from an overactivity of dopamine function in the brain, particularly in the mesolimbic pathway. The two major sources of evidence given to support this theory are that dopamine-blocking drugs (i.e. antipsychotics) tend to reduce the intensity of psychotic symptoms, and that drugs which boost dopamine activity (such as amphetamine and cocaine) can trigger psychosis in some people. However, probably over-simplifies and phamaceutical companies have a vested interest in promoting chemical causes of mental illness whilst ignoring social and developmental factors. NB Medication for psychosis: common side effects weight gain, sedation, (sexual/fertility dysfunction) withdrawal from barbiturates and alcohol can be particularly dangerous, leading to psychosis or delirium Some studies indicate that cannabis use may lower the threshold for psychosis, and thus help to trigger full-blown psychosis in some people. It is not clear whether this is a causal link, and it is possible that cannabis use only increases the chance of psychosis in people already predisposed to it; or that people with developing psychosis use cannabis to provide temporary relief of their mental discomfort. The fact that cannabis use has increased over the past few decades, whereas the rate of psychosis has not, suggests that a direct causal link is unlikely for all users. Confounding issues � e.g. maybe those who use cannabis are less concordant with medication Genetics � children of parents with sz have a 10 fold increased risk of developing sz themselves (so say 10% rather than 1% in gen� population)

29. EFFECTS ON FAMILIES & CARERS Day-to-day care of a person with psychosis can be demanding. Lack of understanding and information can leave carers feeling anxious, depressed, physically ill, guilty or confused. Caring for a user with psychosis can also add to the financial burden felt by carers. Carers are an important contact point for checking a users progress. The carer�s personal health may also suffer.

30. Main Points GRIP is a specialist service for psychosis in Gloucestershire Psychosis doesn�t present in �neat packages� Psychosis early signs are difficult to spot 20% only have one episode Psychosis can go in �phases� Some people are more vulnerable than others Various explanations for psychosis, but often a combination Carers often cope with a considerable amount of distress. Hallucinations- hearing, seeing, feeling, smelling, tasting things that others don�t. Delusions- firmly held beliefs that are widely believed to be false and/or lack factual basis. Paranoia- about specific people or events. Disordered or muddled thinking. Explain positive and negative symptoms Prodromal softer signs explained laterHallucinations- hearing, seeing, feeling, smelling, tasting things that others don�t. Delusions- firmly held beliefs that are widely believed to be false and/or lack factual basis. Paranoia- about specific people or events. Disordered or muddled thinking. Explain positive and negative symptoms Prodromal softer signs explained later

31. Anything else? Unanswered questions Concerns Evaluation thingy Confidence line revisited 31