Assessment in First
Episode Psychosis
Manchester Mental Health &
Social Care Trust
1
Aims & Objectives
For participants to gain an understanding of
the process and content of initial
assessments.
To develop an awareness of the
components of a comprehensive multidisciplinary assessment
To provide an overview of additional
assessments which might be conducted
during the assessment process.
2
Why is Early Assessment
Important?
A delay in spotting that a young person might
be developing psychosis also leads to delay
in getting help and treatment
Such problems include less chance of
complete remission of symptoms, an
increased resistance to treatments (including
medication), increased incidence of
compulsory admissions (involving violence),
lack of insight, family problems, poverty,
increased depression and suicide
(Johannessen 2001)
3
Why is Early Assessment
Important?
The cognitive and psychosocial damage
caused by psychosis appears to occur in the
first 5 years. This is often referred to as the
‘critical period’.
If help is not offered in this critical period, a
range of long-term problems may develop the ‘plateau of disability’ (Lieberman 1997)
Treating during the ‘critical period’ can
decrease relapse and social disability, limit
psychological problems and reduce
healthcare costs (McGorry & Jackson 1999)
4
Duration of Untreated
Psychosis (DUP)
The longer the ‘DUP’ the more risk of longterm problems (Johannessen et al 2001)
Early intervention has been shown to reduce
DUP (Perkins et al 2005)
Earlier detection is a core principle of Early
Intervention teams
5
Duration of Untreated
Psychosis (DUP) and National
Guidelines
Reducing DUP is a specific target in national
mental health performance measures (DOH
2003)
MH services are required to reduce service
DUP to 3 months and not exceed 6 months
(DOH 2003)
HOWEVER, these figures relate to ‘genuine’
psychosis, not to ‘pre-psychotic’
presentations
6
Who might notice?
In two large groups, discuss who might
be in a position to notice if a young
person was developing the early signs
of a possible psychotic illness
List these people on a flip chart
Feedback results to the whole group
7
What might they notice?
Behavioural Changes
Losing interest in doing things
Losing interest in the way they look
Changes in sleep - either much less or much more
Seeing less of friends
Having trouble sitting still and relaxing
Eating less (or more)
Arguing more frequently with family and friends
Deterioration in personal appearance
8
What might they notice?
Changes in Thinking
Trouble concentrating and ‘thinking straight’
Thoughts seem more rapid - can’t ‘keep up’ with them
Spending time thinking about new ideas - e.g. religion
Trouble making even simple decisions
Bothered by thoughts they can’t get rid of
Having more trouble remembering things
Thinking that ‘people’ are making fun of them
Thinking that people are checking up on them
Laughing/smiling to themselves, talking when noone’s there
9
Questions to consider
about thinking and beliefs
What are the central beliefs the young person
holds?
What specific situations lead to difficulties ?
How much conviction is there in these beliefs?
How much distress do the beliefs cause?
Can the person be distracted ?
How much time is spent thinking about the
beliefs?
10
What might they notice?
Changes in Mood
Mood gets lower - may feel bad for no reason
Future seems to become more hopeless
Feeling distant from family or friends
Feeling disconnected with surroundings
Feeling guilty, maybe about doing something wrong
Feeling tense and nervous
Feeling worthless and low self esteem
Feeling very frightened for no obvious reason
11
Why do mental health
professionals assess mental
state?
To provide an understanding of the person
To assist in the judgement of the individual’s
level of ability
To provide the foundation for a planned
programme of care
To develop a baseline for observing progress
over time
To plan service provision
For research purposes
12
Why do mental health
professionals assess mental
state?
To provide a history and an outline of the
persons current life circumstances
To identify current difficulties, problem areas
strengths and abilities
It can assist in engagement and provides the
opportunity for the person to be involved in
their care
It can help to provide an alternative but
plausible explanation for the illness
Instils hope as this leads on to active
interventions
13
Where does assessment fit
into the care pathway?
ENGAGEMENT
ASSESSMENT
PROBLEM IDENTIFICATION
FORMULATION
CARE PLAN
INTERVENTION
REVIEW
14
How do professionals
assess?
Hearing the persons story in their own
words & observation
Semi-structured interviews
Standardised assessments and
questionnaires
Self Rating e.g. diaries
Listening to significant others
Genograms and lifelines
15
Listening to the young
persons’ story
 Some people can find it threatening or at
least very difficult to remember their
experiences
 Experiences of failure should be avoided
particularly in the early stages
 Clients will be more likely to be responsive to
the help offered if a partnership is developed
that allows them to have some control.
16
Helping the assessment
process along
Establish mutually agreed boundaries at the
beginning such as the time you want to
spend talking.
Encourage the client to expand on
information by the asking the question: Is
there anything you would like to add?
Keep questions simple, avoid asking multiple
questions and allow the client time to answer
Avoid using complicated terms or jargon
17
Helping the assessment
process along
Re-cap on the information you have
been given to ensure clarity
If you need to write anything down
explain why you are doing this and ask
permission
18
Aims of the
Semi-structured Interview
To acquire the history behind the illness.
Consider what, when, how, where and
why.
To ascertain any current risk factors
Elicit any current concerns and the
implications or consequences of these.
19
Semi-structured
Interviews
To become aware of the presenting
symptoms and coping skills
To evaluate physical health status
To gain an insight into social needs and
functioning
To ascertain the persons’ past and current
quality of life and its effects on others
To consider any issues concerning the client
in relation to accommodation or financial
needs
20
Exercise
In groups of three - one person to role play
Monica, one the support teacher and the
other to act as an observer
Read the case study provided
You are meeting Monica to ask her some
questions about what has been going on for
her recently
Consider how you are going to introduce the
process and manage her suspiciousness
Practice this in role play. Following feedback
from the observer, change roles
21
Standardised Assessments
and Questionnaires
A standardised assessment accurately
measures either a population or problem area
accurately as it has been proven to be both
reliable and valid
There are many standardised assessments so
it is important to choose the most appropriate
ones.
Standardised assessments might be
completed by the client or the professional
22
Standardised Assessments to
Assess Mental State
Areas that warrant a formal assessment
might focus on particular areas:
 Psychotic symptoms: KGV; Positive & Negative
Syndrome Scales (PANSS); Brief Psychiatric Rating
Scale (BPRS).Psychiatric Rating Scale (PSYRATS);
Belief About Voices Questionnaire (BAVQ)
 Mood: Calgary Depression Inventory(CDI); Beck’s
Depression Inventory (BDI); Hospital Anxiety &
Depression Scale (HADS).
 Risk: Sainsbury’s Assessment and Management of
Risk; Manchester Assessment of Self Harm (MASH)
23
Standardised Screening Tools,
Assessments & Questionnaires
Substance Misuse: Michigan Alcohol Screening
Tool (MAST);Drug Abuse Screening Tool (DAST)
Substance Abuse Treatment Scale (SATS);Clinical
Drug Use Scale (CDUS);Clinical Alcohol Use Scale
(CAUS);
Activities of Daily Living & Function; Social Function
Scale (SFS); Canadian Occupational Performance
Measure (COPM);Model of Human Occupation
Screening Tool (MOHOST)
Family Assessments:Family Questionnaire (FQ);
General Health Questionnaire (GHQ);Relatives
Assessment Interview (RAI);Knowledge about
Schizophrenia Questionnaire (KASI)
24
Assessment
 Other areas to assess include:
 Relationships and sexual functioning
 Physical health,
 Interests and activities,
 Education,training and employment
 Benefits and finances
 Accommodation
25
Diaries & Self Reporting
Useful for self monitoring
Can identify the things that help (e.g. “being
with a trusted person reduces the distress”)
Gives an idiosyncratic account of the clients’
experiences
Provides more detail which often leads to
new ideas about dealing with the problem
Can be used to record psychotic experiences,
substance misuse, sleep pattern & activity
levels
26
Diaries & Self Reporting
Include dates and times
Consider triggers to changes in mood,
incidents, social situation or
environmental changes
List any coping strategies that were
effective or ineffective
May include associated physical
sensations, thoughts or beliefs
27
Gaining Information
from Collateral Sources
All kinds of people MAY be in a position to
recognise potential psychosis in young people:
Families, friends and carers
Teachers and others involved in education
GPs, practice nurses and others in primary
care
Police, probation officers, prison officers etc
Youth workers, either professional or voluntary
Neighbours, hostel staff, wardens, domestic
staff
28
Genograms
Assists in the understanding of family support
system
Helps to understand the relationships
between family members
Indicates who would benefit from being
included in family interventions
Aids engagement
Can clarify history of mental and physical
health
29
Lifelines
Aids engagement
Can be used as an aid to describe stress
vulnerability
Assists in the development of Early Warning
Signs and Relapse Prevention
Can be used in the process of medication
management
Helps to ascertain use of alcohol & drugs
Helps to gain insight into future aspirations
30
Problems in the use of
Genograms & Lifelines
They might highlight difficult past memories
They might trigger strong feelings of past
relationships & experiences
They may reinforce low self esteem and
feelings of inadequacy and loss
They may introduce confidentiality dilemmas
They may increase the development of
paranoid ideas
31
Group Exercise
Use the case study from earlier in the session
In small groups list all those areas you might
want more information
List the types of assessment you might use
to do this
Consider the advantages and disadvantages
of each type of assessment
Compare your answers with the larger group
as you feedback.
32
Conclusions
Evidence suggests the importance of early
assessment for those who have the potential
to develop a psychotic illness
Changes in behaviour, thoughts and mood
may be recognised by anyone involved with
the young person
Assessment should follow the engagement
process. Making sense of information
discovered during assessment precedes
treatment
There are many forms of assessment, from
informal observation to formal and
standardised styles.
33