Assessment
Comprehensive assessment and early detection of psychosis in young people is a fundamental component of an early intervention service. However, assessing young people presents particular challenges and subsequently requires a specialised approach.
Most young people experiencing a first episode of psychosis have not previously had contact with mental health services. They are therefore likely to have little knowledge of how health services operate or of their condition, and may be fearful at the prospect of illness and treatment. Therefore, it is crucial that assessing clinicians incorporate skilled, evidenced-based engagement strategies of the young person and their family into their approach.
For more information on engagement click here.
With any new contact with a young person, it is important to address confidentiality issues in a reassuring way whilst explaining its limits. Limits to confidentiality include instances where there are serious concerns about abuse, concerns about the young person self-harming or committing suicide, or concerns about their potential to harm others. It is important that this is discussed with the young person in order to avoid future difficulties should confidentiality have to be breached.
Obtaining collateral history from a variety of sources is vital if available. This will predominantly be sourced from family members but may also include school welfare officers, teachers, employers or any other health professionals involved. When a young person attends appointments with his or her parents it may be helpful to greet the young person with their family, but see the young person alone initially and then with the family. Family members may also need to be seen on their own in order to ascertain an uninhibited collateral history. However, again it is important to reassure the young person regarding confidentiality and explain reasons for seeing them and their parents separately.
In a first episode psychosis service, assessment should include not only establishing the presence (or absence) of psychotic symptoms but also understanding the personal context of these symptoms. Establishing the presence of psychosis may initially be difficult due a number of factors such as the slow evolvement of symptoms, the symptoms themselves mimicking other behavioural issues related to normal (developmental) or pathological (non-psychotic disorders) changes, the nature of psychosis presenting as a constellation of symptoms, and the presence of co-morbid presentations such as Borderline Personality Disorder, anxiety, mood difficulties, and substance use. Subsequently, assessment should be longitudinal over several sessions rather than simply seeing the young person at one point in time.
A bio-psychosocial approach to assessment should be taken with a view to developing a formulation on which to base ongoing treatment. The assessment should include a full psychiatric history including the phenomenology as well as a development history, social and occupational functioning, family history, substance and alcohol use, risk assessment, and physical assessment. It can also be important for engagement to enquire about strengths, interests, and resources in the young person rather than simply focusing on pathology.
In a first episode population further factors which require assessment due to their impact on recovery, risk and treatment response are:
- The length and nature of the prodromal period
- The duration of untreated psychosis (DUP)
- The duration of unresolved psychosis (DUP plus treatment time)
- Cognitive deficits (which can be predictive of functional recovery)
For more detailed information on assessment see:
Lambert, M (2009) ‘Assessment and pharmacology of the acute phase’ in Jackson H.J. & McGorry P.D. (Eds) The recognition and Management of Early Psychosis: A Preventative Approach (Second Edition). Cambridge: Cambridge University Press.
Marshall , M, Harrigan, S, Lewis, S (2009) Duration of Untreated Psychosis: definition, measurement and association with outcome in Jackson H.J. & McGorry P.D. (Eds) The Recognition and Management of Early Psychosis: A Preventative Approach (Second Edition). Cambridge: Cambridge University Press.
Edwards, J. & McGorry P (2002) Implementing Early Intervention in Psychosis. London; Martin Dunitz.
For assessment of ‘at-risk’ mental state see:
Yung, A., Addington, J., & Morrison, A.P. (2009) ‘At-Risk Mental State and Prediction’ in Jackson H.J. & McGorry P.D. (Eds) The Recognition and Management of Early Psychosis: A Preventative Approach (Second Edition). Cambridge: Cambridge University Press.