Relapse prevention

Relapse prevention protocol

Early warning signs

Relapse Prevention

A number of studies hove found that changes in thoughts, feelings and behaviours precede the onset of frank psychotic relapse. When low-level psychotic symptoms are combined with dysphoric or ‘neurotic symptoms’, the onset of psychotic relapse can be predicted with acceptable sensitivity and specificity. There is, however, considerable inter-individual variation in the nature of these early warning signs of relapse which is embodied in the concept of a ‘relapse signature’ (i.e. the set of individualised symptoms, occurring in a specific order, over a particular time period). See Birchwood, Spencer and McGovern, (2000) for a review of the area.

A structured approach to the identification and management of individual relapse signatures, known as the ‘Back in the Saddle’ (BITS) approach to relapse prevention has been developed (available from the authors on request).

This approach involves five stages:

1. Engagement and Education

The identification of the relapse signature and drill forms an ideal medium through which to establish common ground with the client and to acknowledge his/her point of view.

Initial sessions focus on understanding the individual’s attitude towards their illness, especially his or her perception of the risk and controllability of relapse. Beliefs that may exacerbate the relapse process, for example, poor perceived control over the illness causing the individual to panic or fail to act on the occurrence of early signs are identified.

It is suggested to the client and their family that fear of relapse may be coped with through skill learning and the analogy of a ‘safety net’ is used to describe these skills. Such o discussion draws upon the positive steps already being taken by the individual to remain well, and occurs in the context of general psychoeducation concerning preventable risk factors of psychotic relapse (e.g. discontinuation of medication and illicit drug use). An example of a completed relapse prevention sheet (See figure 1) is shown.

2.  The Identification of the relapse signature

The aim of the next part of the process is to construct an hypothesis about the individualised relapse signature: that is a set of general and idiosyncratic symptoms, occurring in a specific order, over a particular time period, that serve as early warning signs of impending psychotic relapse.

Clients are first introduced to examples of early warning signs of psychotic relapse. They are then encouraged to review, either alone or with the support of their key worker or family, any noticeable changes in their thoughts, perceptions, feelings and behaviours leading up to their most recent episode of illness, as well as any events which they think may have triggered these.

Two structured exercises are then used to expand and order this set of early warning signs:

a.  The time line exercise

The individual is supported in constructing a time line of significant external events, proceeding backwards in time from the date of referral to mental health services. Early warning signs that the client identified in the previous part of the process are ‘pegged’ to these external events.

b.  The card sort exercise

Similarly, 55 cards describing non-specific and psychotic symptoms, constituting early warning signs of psychotic relapse drown from the empirical literature are presented to the client. (See Figure 2)

The client selects any cards describing early signs that they have experienced in the process of becoming unwell, and places them in order of onset.

The early signs are thus retrieved and arranged in order of onset form the basis of the individual’s relapse signature. Clients are then encouraged to personalise their signatures through the use of any idiosyncratic early warning signs not already mentioned and through personalised descriptions of symptoms identified from the card sort. Discussion of these exercises is then used to clarify possible triggers such as periods of stress and underlying difficulties preceding illness. Additional information, for example, at what point the individual feels that they lose insight, is also gained. Emphasis is placed on supporting the individual in understanding the meaning of these experiences within his or her own life context.

3.  The Development of a relapse drill

Following the identification of the relapse signature, clients are supported in constructing a three-stage action plan known as a ‘relapse drill’.

Staging is an essential feature of the relapse drill. It follows directly from the early warning signs, which are stratified into three levels, from those occurring earliest in the relapse signature, to those occurring immediately prior to the psychotic relapse. In general, the earliest early warning signs in the relapse signature tend to be non-specific symptoms, with low power to predict psychotic relapse. Interventions with potential risks (e.g. increases in antipsychotic medication) are generally used after the relapse signature has clearly progressed towards potential psychotic relapse.

The drill is developed collaboratively and focuses on client strengths, their carers and the service resources. Post coping strategies and therapeutic interventions that have been found to be helpful in preventing relapse are reviewed collaboratively with the individual and incorporated into the drill. Specific early warning signs may suggest new approaches to offer further protection against relapse. For example, anxiety, dysphoria and other affective changes may respond to techniques incorporating stress management. Similarly, clients suffering from low-level psychotic phenomena may benefit from techniques designed to challenge delusional and dysfunctional thinking drawn from the cognitive therapy literature.

At each stage, the relapse drill considers three areas for intervention:

a.  Pathway to support: Clients and carers are provided with details of how to contact the mental health services 24 hours a day, including weekends.

b.  Service interventions: These may include increased contact with the keyworker, anxiety/stress management, negotiated temporary increase in medication, respite care, counselling, cognitive therapy and home treatment.

c.  Personal coping strategies: These consist of successful coping strategies that have been applied in the past by the individual or new ones that have been suggested in the recall of the relapse signature.

4. Rehearsal and Monitoring

Having identified an individual’s relapse signature and drill, the client and relevant involved carers are provided with their own copies of the relapse prevention sheet and monitoring is outlined as a shared responsibility between the individual, carers and mental health services. To enhance effective use, the relapse drill is rehearsed using personalised scenarios and role-plays concerning the client’s response if they should detect early warning signs. Hypothetical situations are used to discuss any difficulties that might arise (for example, denial or panic responses) and how to deal with these.

5.    Clarification of the relapse signature and relapse drill

Clarifying the relapse signature and refining the relapse drill are other important areas of monitoring. Individuals are encouraged to replace existing coping strategies, forms of support and service interventions with more effective ones learned from ongoing therapy or experience. In this way, impending or actual relapse is used as a positive opportunity to refine the relapse signature and improve the relapse drill, thus increasing control over the illness.