PSYCHOSIS
This is what to do about it…
If someone has a mental illness the first people to recognise what is happening are most often family and friends, though it may be that primary care services or addiction services are the first contact. The point is, it will probably not be mental health services who are first to help with the problem. The exact nature of the mental illness does not matter, what is important is making the right response at the right time. There are several possible situations to be considered…
The person has florid symptoms such as hallucinations, delusions and confused or incoherent talk and they can be seen as a danger to themselves or others, or there may be drowsiness and disorientation. It is likely that this person will need to be in hospital. This requires immediate action: i) the police have powers to take people in this state to a place of safety ii) there may be an emergency psychiatric service or psychiatrist on the staff of the addiction service.
The person is clearly unwell but not a danger. There may be hallucinations or delusions but they are not too troublesome and the person has adequate support. This requires urgent action: i) try to find out if the person is known to mental health services and, if not, make an urgent referral ii) make an immediate care plan and revise after consultation with mental health services.
The person has a history of serious mental illness but seems currently to be well or at least symptom free. This requires timely action: i) find out if the person is known to mental health services and, if not, make an urgent referral ii) review the care plan accordingly.
For all heavy drinkers, whenever seen, check out if there has been a neglect of diet and, therefore, a risk of vitamin B1 deficiency. If ‘yes’ then there is a need for timely action to give oral vitamin supplements. If there are symptoms or signs of deficiency such as drowsiness, disorientation or double vision then this requires immediate action: i) give parenteral vitamin B1 or, if not available ii) take to A&E.
How to manage psychosis
In this video there are some more explanations of what it is like to experience an episode of psychosis. For practitioners Jessica Bird describes in some detail the research evidence for how to approach helping someone going through a psychotic episode. The guidance she gives is practical and can be implemented by all professional groups. Naturally the general guidance needs to be applied carefully to suit each individual. (15 minute video)
Dr Jessica Bird is a Research Clinical Psychologist & NIHR Research Fellow
ANXIETY
There is very little evidence from controlled trials on the best way to help people with comorbidity and in particular anxiety and substance use. One approach is to determine a person’s readiness to change for anxiety and substance use and then treat each problem with the standard treatments. The difficulty is that the two problems become so intertwined and fuel each other and so the ideal way forward is to secure a period of abstinence which will give time to treat the anxiety and simultaneously take stock of the addiction problem. Psychological treatments are the most effective but medication can help reduce very high levels of anxiety…
❶ Generalised anxiety :: For most people making lifestyle changes, meaning taking regular exercise, a balanced diet and avoidance of stimulant drugs, including caffeine, will be effective. There are plenty of self-help books and support groups to facilitate a healthy lifestyle.
❷ Phobias and specific anxiety :: For simple phobias some form of exposure and desensitisation to the object or situation that causes the anxiety is the standard treatment. For more complex phobias, agoraphobia for example, then deeper psychotherapy may be needed. These interventions are best delivered by an experienced and suitably qualified practitioner such as a clinical psychologist.
❸ Alcohol and drug induced anxiety :: Logically, abstinence from psychoactive drugs is the best intervention here. The evidence supports the effectiveness of long term abstinence. Withdrawal syndrome anxiety will respond to sedative medications.
❹ Panic attacks :: Panic attacks can happen anywhere. They are not life threatening or hazardous, just very scary. This video is an excellent guide for anyone who experiences panics and equally practitioners helping with a panic attack…
10 Minute Guided Mindfulness Meditation - Relaxation
❝I've listened to this meditation well over a dozen times now and I find it to be one of the best to listen and meditate to before bedtime or any time.❞
There are more videos on Julie’s YouTube Channel
Dr Julie Smith is a Clinical Psychologist
Coping with a panic attack
❝My teeth would chatter uncontrollably and my whole body would tremble, I'd hyperventilate and cry with panic as the feeling that I was going to fall unconscious was so convincing.❞
❝I turned my mental health crisis into a mental health triumph.❞
MIND is a UK mental health charity
DEPRESSION
his is what to do about it…
Family, friends and colleagues at work are more likely than helping agencies to have regular contact with people who experience depression. Everybody needs to be able to respond, effectively and within their competences, to someone saying that they are depressed. Deciding what to do can be difficult even for experienced mental health practitioners. Ask yourself these four questions…
Assessing severity of depression
① For practitioners making a clinical judgement, the presenting symptoms are most important. It is common for people who are not depressed to express sadness, anxiety, worry, tiredness, low self esteem, frustration, and anger. It is more likely to indicate depression if they talk of a persistent low mood, hopelessness, tearfulness, guilt, loss of interest in activities, indecisive and poor concentration, lack of enjoyment, seeing no future, suicidal thoughts, no point to life, weight loss, early waking, bleakness.
② Rating scales are useful and objective albeit less reliable for people who are drinking or taking drugs, especially if they are intoxicated. A score >=15 on the PHQ9 or >=15 on CORE-10 is suggestive, but not diagnostic, of depression or a mental health problem. A suitably qualified practitioner is needed to make a diagnosis.
③ If there is a history of depression or self-harm then this is a good guide both to the nature of the current problem and its likely course. For people who self-harm watch out for a pattern of escalation in drinking or drug use, number of drugs taken in an overdose and the seriousness of the self-harm. For people who have completed a detoxification, stay vigilant: low mood and suicide attempts are common for months afterwards, perhaps to do with facing up to the reality of their circumstances or perhaps some biological readjustment.
➊ How severe is the low mood?
“Tell me about your mood right now?” - get an overview :: “Have you been thinking about harming yourself?” - check out the worst thing that could happen :: “What are you doing for the rest of the week?” - check out if the person sees a future. You can go on to explore other signs of the severity of the depression if needs be.
Getting an accurate picture of the severity of low mood is essential to making the right response. People with moderate or severe symptoms need to be assessed by a qualified mental health professional.
➋ Is there a clear cause for the low mood?
“Tell me when did you start to feel depressed?” - understand the duration and possible cause :: “Do you think that there is something in particular causing you to feel like this?” - a direct attempt at finding the cause.
If a cause can be identified then it makes sense to try to address it. Often there are multiple reasons associated with a poor quality of life, and a psychosocial intervention will be the most helpful. Antidepressants are not indicated unless the depression is particularly severe.
➌ Is the person intoxicated?
“What have you taken/drunk today?” - make it clear you know the person is intoxicated and find out what they have taken.
People do reckless things when intoxicated. It is not possible to assess the severity or even presence of depression and the question is whether or not the person needs to be in a place of safety or with someone who can ensure their safety.
➍ Is this a life threatening situation?
Low mood can be overcome. It is up to the practitioner to keep an individual alive so that they have the chance to recover. A good way to assess a situation is the Four Ps…
Have there been previous suicide/self-harm attempts?
Has a plan to commit suicide been made?
Adding up the risk factors, what is the probability of doing it?
What protective factors are there?
A supportive psychosocial intervention such as Social Behaviour and Network Treatment will be effective for most people attending addiction services with mild to moderate depression. Additional antidepressant treatment may be helpful but only for people with a moderate to severe depression. The evidence for prescribing antidepressants is weak and any benefits may derive from the sedative effect of medication. People with pre-existing mental illness or newly diagnosed severe depression are best cared for by mental health practitioners.
Use the CORE10 Questionnaire for a preliminary test of psychological wellbeing
EMOTIONAL REG
This is what can be done about it…
Aberrant emotional regulation is a recurring theme with personality problems. People who are emotionally over expressive often misuse alcohol or drugs and commonly seek help from addiction services. To help with emotional regulation Dialectical Behaviour Therapy, DBT, delivered by a suitably qualified practitioner is the treatment of choice, but all practitioners with an awareness of the general principles outlined below will be able to improve their interventions.
Family, friends and colleagues at work are more likely than helping agencies to have regular contact with people who have difficulty with emotional regulation. It can be very demanding of these individuals. So, it is a good idea for everybody to be familiar with what can be done to help. DBT is a very specialist mental health treatment but it can be useful for anybody trying to help to be aware of the principles involved.
Four key areas aimed at enhancing life skills are addressed:
Distress tolerance: Feeling intense emotions like anger without reacting impulsively or using self-injury or substance abuse to dampen distress.
Emotional regulation: Recognising, labelling, and adjusting emotions.
Mindfulness: Becoming more aware of self and others and attentive to the present moment.
Interpersonal effectiveness: Navigating conflict and interacting assertively.
The treatment is delivered in a rolling programme with four stages:
Stage 1: Treats the most self-destructive behaviour, such as suicide attempts or self-injury.
Stage 2: Begins to address quality-of-life skills, such as emotional regulation, distress tolerance, and interpersonal effectiveness.
Stage 3: Focuses on improved relationships and self-esteem.
Stage 4: Promotes more joy and relationship connection.
The mode of delivery can be face-to-face or on-line and use a flexible structure agreed locally and varied to suit individual needs:
Weekly DBT skills training group
Individual therapy
Phone coaching, if needed for crises between sessions (usually within office hours)
Weekly Consultation group for the DBT team, to stay motivated and discuss patient care
In this video Dani Brown talks about…
The conceptual basis of DBT
The component parts
The core practices
Methods of treatment delivery
Dani Brown is a Mental Health Nurse, Specialist in Addiction and DBT Practitioner
Dani Brown demonstrates a simple skill that can be applied in any situation to dissipate anger
Dani Brown’s team achieved these outcomes for people with addiction problems…
Leeds Dependence Questionnaire
Scores lower than 11 indicate low dependence, 11 to 22 indicates medium dependence and scores over 22 high dependence, up to a maximum of 30.
Clinical Outcomes in Routine Evaluation (CORE)
85+ indicates severe distress, 68-84 indicates moderate to severe distress, 51-67 indicates moderate distress, 34-50 indicates mild distress, 21-33 indicates low level distress, 1-20 indicates psychological health.
The Borderline Symptom List 23 (BSL 23)
A cut-off score of 1.5 is able to distinguish people with Borderline Personality Disorder from those with other mental health problems such as anxiety disorders, major depressive disorders or schizophrenia. Note that the Difficulties in Emotion Regulation Scale is now used in preference to the BSL.