“how are you doing?”. - The Association for Young People`s Health

Untangling the terrors of
teenage turmoil
Untangling the
Terrors of
Teenage Turmoil
Dick Churchill,
Chair, RCGP Adolescent Health Group
Maryanne Freer,
Charlie Waller Memorial Trust Associate
David Shiers,
GP Advisor to the National Mental Health Development Unit
Quick Quiz
How many young people have a mental
health problem?
How often do young people consult a GP?
What proportion of young people who
consult their GP have a mental health
What proportion of young people with a
mental health problem are identified by their
What proportion of adult mental health
problems start in childhood / adolescence?
Quick Quiz
How many young people have a mental
health problem?
10 - 20%
Quick Quiz
How often do young people consult a GP?
2-3 times a year
Quick Quiz
What proportion of young people who
consult their GP have a mental health
About 1 in 3
Quick Quiz
What proportion of young people with a
mental health problem are identified by their
About 1 in 3
Quick Quiz
What proportion of adult mental health
problems start in childhood / adolescence?
More than 50%
Lots of young people have mental health
Many go unrecognised until they cause
problems in adulthood.
Young people who visit their GP are more
likely to have mental health problems.
Zoe’s Story
Zoe Craddock is 15 and lives with her
mother, step-father and step-brother.
Zoe isn’t very happy at home; she
seems to get ill very often, and has to
have time off school.
Her mum isn’t very sympathetic… she
brings her to the GP with yet another
sore throat and talks about how
frustrated she is. Zoe remains silent!!
What’s going
What would
you do next?
Presentations in General Practice
 Physical symptoms – headaches,
abdominal pain, unexplained pain, sleep
 Frequent attendance with varying
 Parental concerns – behaviour / conflict,
educational issues
 Emotional – mood swings, tearfulness,
 Self-harm – overdose, cutting.
Causes of under-detection in Primary
 Key symptoms not presented or apparent
 Lack of training, experience or confidence – fear of
opening ‘Pandora’s box’
 Belief that problems will be transient
 Treatments and / or services are not readily
available should a diagnosis be made
 Avoidance of potential stigmatisation as a result of a
mental health ‘label’
 Perceived parental resistance to a mental health
 Problems incorrectly identified as being part of
normal development.
Zoe’s Story continues…
A week later Mrs Craddock comes to see you – she is very, very concerned.
She has left her husband at home to look after Zoe; She says ‘“WE’RE
Mum tells you how its been a bad week – Zoe is refusing school - won’t see
her best friend – and she’s pacing her room into the early hours. She has
spoken to Zoe’s teacher - Zoe won’t go out at break - sits by herself,
remote, and won’t open up. There seems no obvious reason - no ‘friend’
The night before, prompted by Zoe muttering loudly, mum entered her room
to find Zoe under the bedclothes, trembling with fear. Zoe had screamed
“leave me alone!”. It was 2am – they then stayed awake all night. Zoe
couldn’t be consoled.
“There’s no problem at home – it’s just Zoe.. We all got on so well before –
it now feels like we’re the most unhappy family I have ever known?” “What
have I done? I must be an awful mum”
You decide to visit Zoe at home later that day. Mum takes you up to her
bedroom where she is sitting on the bed. She is dishevelled, restless and
pre-occupied, avoids eye contact, takes several seconds to reply “I’m OK”
to your “how are you doing?”.
You check if she wants mum to stay - you sit down facing Zoe and gradually
she comes round a little. She admits she can’t sleep. She can’t explain why
she feels so bad. No obvious fall-out with her two best friends - but she
feels wary of them and thinks they are talking about her behind her back.
What are your
Are there more
questions to ask?
What would you do
What explanations
should I consider?
Adolescence and emerging adulthood: a
high risk time for mental disorders
“Roughly half of all lifetime mental disorders in most studies start
by the mid-teens and three quarters by the mid-20s. Later onsets
are mostly secondary conditions. Severe disorders are typically
preceded by less severe disorders that are seldom brought to
clinical attention”
Kessler et al, Current Opinion Psychiatry, 2007
Contrast with other disabling conditions
A first episode
of psychosis?
GP guidance
A first episode of psychosis?
 Rarely presents in ‘neat parcels’
 Be prepared to keep a watching brief
 Take family concerns seriously
 Think about risk
 Diagnostic uncertainty
“Would I be surprised if this turned
out to be psychosis within the next
6 months”
What should I do?
 GPs are key pathway players for people like Zoe
and her family
 Zoe’s frank delusional symptoms = RED ALERT
- Don’t assume ‘adolescence’ or ‘drug misuse’
- Don’t just wait and see if it will go away
Early detection of psychosis and
appropriate treatment are highly effective.
In England this specialised approach (14-35 yr olds)
is usually provided by Early Intervention services.
Make sure you know how to access them.
So what is the essence of Early
Intervention in Psychosis?
A mum’s view...
“The shock of my second son
developing psychosis at the age of
15, as his elder brother had fifteen
years earlier, pushed me into a deep
depression. Our eldest son is still
unable to work because of his health
and …has never been well enough yet
to achieve his potential…”
So how did we get to today, three years on, where
hope is back?
Michelle Gladden (2008)
A focus on broader outcomes /
supporting ordinary lives …
Early detection / working across
transitions and agencies…
“…our GP made a very quick referral to
CAMHS and L. was referred to EIS. We
had support from CAMHS and EIS
EIS helped us to work with other
agencies to put in place much needed
additional support. ”
A family centred approach / hope
and optimism about potential for
“EIS involved the whole family in L’s
recovery… EIS gave us an individual
map to help us find the way out of the
hopeless place we were in”
His hopes for the future are back …”
“L. is about to start University after
managing to achieve A grades in his
GCSEs and A Levels despite his
illness, long absences from school and
side effects of medication”
Evidence based interventions /
cost effectiveness...
“Earning a place on a Masters Degree in
Physics with Particle Physics and
Cosmology at the University of
Birmingham is pretty hard evidence
that EI and family therapy has been
worth any extra initial cost to the NHS”
Zoe’s Story continues…
Zoe returns to see you by herself you as arranged. She tells you how she
thinks her sore throats are something very serious, like cancer, because
they won’t go away. She knows that the sore throats stress her mum out
because she takes time off work to look after her.
You look through the notes of Zoe’s previous consultations and see that
there has never been very convincing physical signs of infection. She has
had negative throat swabs and normal blood counts and glandular fever
tests on a couple of occasions too.
Now Zoe seems happy to talk to you, you ask some more questions. Zoe
bursts out saying how stressed she is. Her boy friend left her a few weeks
ago. She didn’t tell her mother, but reacted by going out with her friends &
drinking. This led to problems at school which have meant her mother was
‘on her case’ continually.
Previously close, the two of them fell out. For the last month, for three or
four nights a week now Zoe cries herself to sleep listening to her mother &
step-father argue about her. Every few days she feels so unhappy that she
struggles to get up & out of bed.
Zoe says she used to go to dance classes but stopped 2 weeks ago as
she can’t be bothered. Zoe goes on to admit that she has started to miss
meals. She wants to get thinner. Zoe finishes by saying very hesitantly how
she thinks she is useless and just cant seem to please anyone. She feels
very lonely.
What could
you do now?
What could
you do now?
Some Management Issues
 Somatisation
 ? Teenage turmoil
 If I “don’t” ......
 Non stigmatising – watchful waiting
 Risk – life long mental health admissions,
 If I “do”.....
 Prescribing
 Family practice & self care
 Referral
The Contact
Initial consultation
Second consultation
 Mental Health
 Confidentiality
 Formulation
 Rapport building
 Diagnosis
 Dealing with parents  Risk
 Problem Solving
 Opportunistic
screening question
 MH Promotion check
 Resource List
Tool 1:
Mental health consultation framework
Life Situation/Practical Problem etc.
Altered thinking
Altered physical
Altered mood
Altered behaviour
Tool 2
Primary Care Mental Health Checklist
Tool 3:
What will you
do now?
An Overview
Don’t panic!
Be alert for warning signs
Use ‘tools’ to help
Get help early if indicated
Be patient