1. Developing skills in Relapse Prevention
Steve Wood
Lecturer/Practitioner

2. Aims of the workshop After the workshop, you should be able to and
explain the importance of preventing relapse in psychosis
outline the stages of the relapse prevention intervention
explain the reasons for the manner in which the intervention is carried out
suggest solutions to problems that may arise when carrying out the intervention
Knowledge
Aims of the workshop
and
demonstrate the specific skills of
using client as expert in education about relapse
using card sort & time line to identify early warning signs
collaboratively planning & rehearsing an action plan
Skills

3. Why use the term “Psychosis”?
majority of first episode cases do represent schizophrenia or related disorder (Power et al 1998)
but, at time of first episode, course of illness as yet unknown
psychosis demands immediate treatment
definitive diagnosis
conceptually premature
clinically unnecessary
‘psychosis’ most accurate description & avoids fear & stigma of schizophrenia diagnosis (McGorry et al 1997)
Why use the term “Psychosis”?
(rather than a term such as “schizophrenia”)

4. Psychosis mental disorder characterised by – characteristic pattern
disturbances in sensory perceptions (e.g. hearing, smell, taste, touch)
disturbances in thinking & thought processes (e.g. delusional beliefs, hearing thoughts spoken aloud)
associated emotional & behavioural changes
characteristic pattern
episodes of illness interspersed with periods of recovery
phases
prodrome – dysphoria, non-specific signs, psychotic symptoms
acute – frank symptoms, impaired functioning, often hospitalisation
early recovery- 6 mth period after acute treatment
late recovery – another 6-18 mths after early recovery

5. Vulnerability threshold
Stress vulnerability 
Life events
Vulnerability threshold
P.s.i.
Medication
Natural
Day to day stress
Time

6. Early warning signs
Herz & Melville 1980
Birchwood et al 1989
Irritable/quick tempered 62
Sleep problems 69 67
Tense, afraid, anxious 83
Quiet, withdrawn 50 60
Depressed, low 76 57
Poor appetite 53 48
Aggression 79
Restless 40 55
Stubborn 36
Behaves as if hallucinated
Being laughed at or talked about 14
“Odd behaviour”
clients & carers asked about changes observed prior to episode of illness
% of carers reporting shown in table

7. Relapse signatures evidence shows
subtle changes in thought,mood,behaviour precede frank psychosis
commonest are dysphoric - depressed mood, withdrawal, problems with sleep & appetite
less common are psychotic-like symptoms
definite sequence - dysphoric followed by increasing emotional disturbance, then frank psychotic symptoms
usually over period of less than 4 weeks
Herz & Melville 1980, Birchwood et al 1989, Jorgensen 1998
large proportion of people aware of signs
(eg Herz & Melville 1980, Birchwood et al 1989)
63% retained insight until day of relapse
(Heinrichs et al 1985)

8. Relapse signatures people actively use coping strategies to intervene
(McCandless-Glimcher et al 1986)
attempts to predict onset from dysphoric symptoms alone poor sensitivity and/or specificity better if low-level psychotic symptoms included
(eg Jolley et al 1990)
considerable individual variability, prediction more accurate if changes in scores measured against client’s own baseline
therefore, attention focused on identifying & managing individual “relapse signature”
(Birchwood 1995)
self-reports almost as good as psychiatrists’
(Jorgensen 1998)

9. Why do relapse prevention in psychosis?
relapse not entirely eliminated by best combination of medication & psychosocial interventions (Linszen et al 1998)
each relapse associated with increased
residual symptoms (Shepherd et al 1989)
social disablement (Hogarty et al 1991)
feeling of entrapment within illness linked with depression (Birchwood et al 1993)
clients express strong interest in recognising & preventing relapse

10. Aims of relapse prevention
“The ‘early warning signs’ approach to relapse prevention seeks to
identify the earliest signs of impending psychotic relapse
and to
offer timely and effective intervention to arrest their progression towards frank psychosis” (Birchwood et al 2000, p93)

11. Early Intervention What is meant by “Early Intervention”?
What does Early Intervention aim to do?
“Early intervention in psychosis amounts to deciding if a psychotic disorder has commenced and then offering effective treatment at the earliest possible point and secondly, ensuring that intervention constitutes best practice for this phase of the illness, and is not just the translation of standard treatments developed for later stages.”
McGorry et al, 1996, pg 305
To improve outcomes by promoting as full a recovery as possible, thereby reducing long-term disability and human and economic costs.
To achieve this by limiting the duration of psychosis, both before and during treatment, and by preventing relapse.

12. Relapse prevention 5 stage approach
1. Engagement & education 2. Identifying the relapse signature 3. Developing the action plan 4. Rehearsal and monitoring 5. Clarifying the relapse signature & plan

13. Engagement and education
Stage 1.
opportunity to establish common ground with client
initial focus on client’s attitude to & beliefs about illness
identify beliefs likely to exacerbate
suggest to client & family fear may be coped with through skill learning
draw on +ve steps already being used & combine with general education about preventable factors
Engagement and education

14. Identifying the relapse signature
Stage 2.
introduce client to idea of links between thoughts, actions, feelings and examples of ews
asked to review (with family, keyworker if wished) changes prior to most recent episode, & any triggering events
2 structured exercises used to form basis of discussion of period preceding illness, point at which insight lost
time line - significant events working from an identifiable point, pegged to ews previously identified
card sort - 55 symptoms presented, client selects & places in order of onset, forms basis of individual’s relapse signature, then personalised
Identifying the relapse signature

15. Developing the relapse prevention plan
Stage 3.
3 stage action plan
developed collaboratively, based on strengths, past coping strategies, carers, service resources
specific ews may suggest approaches to increase protection
3 areas considered for intervention at each stage
personal coping strategies
pathway to support
service interventions
interventions with potential risks generally used after progression to clear potential relapse
Developing the relapse prevention plan

16. Evidence about interventions after ews
Medication
intermittent medication only, given at detection of ews inferior to continuous, not recommended (Carpenter et al 1990, Gaebel et al 1993)
intermittent medication on detection of ews plus maintenance medication reduces relapse to 12-23% over 2 years and allows maintenance medication to be decreased (Jolley et al 1990, Gaebel et al 1993)

17. Evidence about interventions after ews
Cognitive behavioural
even after ews, stress management skills may be useful (McCandless-Glimcher et al 1986)
individual, graded approach, focusing on identification & management of affective symptoms significantly delayed adverse events (Hogarty et al 1997)
focus on meanings of symptoms in frank psychosis good results in ameliorating psychotic symptoms (Garety et al 1994, Drury et al 1996a), reducing recovery time (Drury et al 1996b)
psychological responses such as denial or excessive fear may increase probability of relapse, cognitive techniques challenging these beliefs may prevent escalation of ews to frank psychosis (Birchwood 1995)

18. Rehearsal and monitoring
Stage 4.
copies of relapse prevention plan to client, carers and appropriate others
monitoring is a shared responsibility
rehearsed using personalised scenarios and role plays
hypothetical situations discussed
Rehearsal and monitoring

19. Clarification of the relapse signature and plan
Stage 5.
individuals encouraged to replace existing strategies with new, learned from experience/therapy
impending relapse viewed as +ve opportunity to refine & therefore increase control
Clarification of the relapse signature and plan

20. Common problems lack of “insight” “sealing over”
may still be possible to develop relapse signature without client conceding a belief delusional
psychotic experiences may be attributed to other factors, but may still accept increased support or medication
“past insight” present, but “present insight” lost - may use family, also standardised measures used fortnightly
“sealing over”
if recovery style characterised by isolating the psychotic experiences, attempting to encapsulate, ews may provoke anxiety by focusing on the illness
lack of syndrome stability
may be exacerbated by co-morbid substance misuse, ews may be unstable & relapses have to be used to clarify

21. Aims of the workshop You should now be able to Knowledge
explain the importance of preventing relapse in psychosis
outline the stages of the relapse prevention intervention
explain the reasons for the manner in which the intervention is carried out
suggest solutions to problems that may arise when carrying out the intervention
Knowledge
Aims of the workshop

22. Test yourself to check that you can!
1. “Early warning signs” of relapse in schizophrenia . . .
. . . often begin with dysphoric symptoms T
. . . usually develop over many months F
. . . are more likely to predict actual relapse if both neuroleptic and low-level psychotic symptoms are included as signs
. . . are rarely identified by patients themselves
. . . show considerable variability between individuals
. . . often begin with dysphoric symptoms
. . . usually develop over many months
. . . are more likely to predict actual relapse if both neuroleptic and low-level psychotic symptoms are included as signs
. . . are rarely identified by patients themselves
. . . show considerable variability between individuals

23. 2. Relapse in schizophrenia . . .
. . . can never be prevented by stress management techniques after the onset of “early warning signs”
. . . can be successfully treated by 5-times-a-week “personal therapy” concentrating on early life experiences
. . . may be accelerated by the patient’s reactions to the early symptoms
. . . can generally be prevented by the use of intermittent medication alone targeted at early warning signs
. . . increases the risk of residual symptoms and social disability after each episode
. . . can never be prevented by stress management techniques after the onset of “early warning signs” F
. . . can be successfully treated by 5-times-a-week “personal therapy” concentrating on early life experiences
. . . may be accelerated by the patient’s reactions to the early symptoms T
. . . can generally be prevented by the use of intermittent medication alone targeted at early warning signs
. . . increases the risk of residual symptoms and social disability after each episode

24. 3. A relapse signature . . .
. . . is a type of psychotic writing disorder F
. . . can be completed without the patient if a relative takes part
. . . requires attendance at out-patients
. . . involves a card sort exercise to select suitable patients
. . . should be preceded by attempts to understand the patient’s attitude to his or her illness T
. . . is a type of psychotic writing disorder
. . . can be completed without the patient if a relative takes part
. . . requires attendance at out-patients
. . . involves a card sort exercise to select suitable patients
. . . should be preceded by attempts to understand the patient’s attitude to his or her illness

25. 4. Problems with relapse prevention are associated with . . .
. . . poor insight T
. . . a recovery style characterised by “sealing over”
. . . older age F
. . . single marital status
. . . variation in the presentation of early signs in different episodes
. . . poor insight
. . . a recovery style characterised by “sealing over”
. . . older age
. . . single marital status
. . . variation in the presentation of early signs in different episodes

26. 5. A relapse drill . . .
. . . involves therapeutic intervention appropriate to different stages of early warning signs T
. . . requires rehearsal using role-playing
. . . incorporates the patient’s own coping strategies
. . . usually uses increased medication as the earliest intervention F
. . . needs to be memorised by the patient
. . . involves therapeutic intervention appropriate to different stages of early warning signs
. . . requires rehearsal using role-playing
. . . incorporates the patient’s own coping strategies
. . . usually uses increased medication as the earliest intervention
. . . needs to be memorised by the patient