star - south west healthcare · · 2013-11-26the system to aid recovery (star) provided by mental...

STAR

Guide Number 9

Early Warning Signs Mental Health Services

January 2012

Early Warning Signs

System To Aid Recovery 2

ACKNOWLEDGEMENTS

These Guides are derived from the contributions of many health

professionals, primarily the late Professor Ian Falloon.

This Guide Belongs To:____________________________________________

Clinical Therapist Name:

_________________________________________________________________

Contact Number:________________________________________________

Date Received:__________________________________________________

Date Completed:________________________________________________

Key Support Person:______________________________________________

Doctor/Psychiatrist:______________________________________________

Early Warning Signs


INSTRUCTIONS FOR USE

The System To Aid Recovery (STAR) provided by Mental Health Services is

made up of a series of Guides. These Guides are designed to strengthen

your skills and knowledge and to support your treatment plan. They will be

of most benefit when you participate as fully as you can in the process. The

Guides are designed for you and your family and provide information about

how to manage mental disorders and their impact.

Reflective Questions

Questions designed to help you think about the information and begin

applying it.

Summary

A small review of what was covered in the Guide.

Worksheets

Activities designed to help with your recovery.

Education

Information on mental disorders and strategies for recovery.

Notes

These pages are designed for you to write down any questions and to write

notes that you find interesting or helpful.

The Goal of this Guide

To assist in the development of early warning signs.

Early Warning Signs

INTRODUCTION

This Guide on Early Warning Signs (EWS) is designed to provide an overview

of how to recognise early warning signs that may lead to a relapse of

mental disorder. It will assist you to develop a plan for action and to work

toward preventing major relapses.

There are three sections in this Guide. The first section

discusses the concept of early warning signs. The second

looks at stress management and its part in preventing

relapse. In section three you can start to develop a plan

for what to do when you see these early warning signs

emerging.

Remember: This Guide will match a form that your Clinical Therapist will

keep on your file that records your Early Warning Signs and

Management Plan. This Guide is designed to support you and your

Clinical Therapist to develop this plan together. The plan you develop

together can be recorded in the plan in the back of this Guide

(Worksheet 9A) which will match the Clinical Therapist’s form.

This Guide is also designed to be used in conjunction with other Guides

related to Medication, Side Effects and Education about your diagnosis.

These Guides may take some time to work through. It is a good idea to take

your time and work with your Clinical Therapist and support people.

Caution: Having to think about times when you are

unwell can be distressing for some people and it is

understandable that you may be reluctant to

undertake this work. However there is significant

research that demonstrates that by developing an

early warning signs management plan, you will be able

to reduce or avoid relapse altogether. It is important to use the supports

available to you while doing this work and to talk about these feelings

rather than bottling them up. It may take a while to identify the early

warning signs and develop the plan.

1. WHAT ARE EARLY WARNING SIGNS?

Early warning signs are the very first changes that occur when a mental

disorder may be returning. They usually happen quite slowly and can be

noticed weeks or in some cases, months before relapse. Early signs typically

include changes in the way you may be thinking, feeling or behaving. Early

warning signs are important because they can help you to recognise signs

of relapse at the earliest possible stage. This allows you to take action early

to prevent relapse taking place or at least, to reduce its severity.

This Guide helps you to learn more about your early warning signs and what

you can do to intervene. The aim is to come up with a management plan

that will identify potential triggers for becoming unwell, what your unique

early warning signs are, what you and your support people will do if early

warning signs emerge.


Early Warning Signs


Identifying Your Early Warning Signs

Different mental disorders have different early warning signs and individual

warning signs will usually differ from person to person. Below are a few

examples of early warning sign.

Less enthusiasm for your work, hobbies or friends.

Not caring for your children or partner in the usual way.

Taking less care of your appearance.

Forgetfulness.

Not able to concentrate.

Missing meals.

Having special unusual worries.

Not being able to relax.

Particular problems with sleep.

Becoming less talkative.

Things looking different.

Your feelings seem to have changed.

Feeling tense and irritable.

Various aches or pains.

You will find that you have two or three special signs that you notice before

you have a major relapse. Sometimes your friends, family members,

teachers, workmates, or even your family doctors may notice that

something is not quite right even earlier. These unique changes are what

are called your Early Warning Signs (EWS).

What Do My Early Warning Signs Look Like? In order to start identifying your Early Warning Signs take some time to

answer the following questions. Use the list above as well as changes your

family can identify before you get unwell.

Q. What changes have you noticed before a major relapse?

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

_____________________________________________________

Early Warning Signs


Q. Do these changes follow any particular order? Put them in the order

you think.

_______________________________________________________

_______________________________________________________

________________________________________________________

_______________________________________________________

________________________________________________________

________________________________________________________

Q. How long would the gap be between noticing the first changes and

becoming unwell?

Same Day

Days How Many _______________

Weeks How Many _______________

Unsure

There is no easy way to identify your Early Warning Signs as it can be difficult

to remember everything that was happening around the time you were

unwell. With the help of people that you trust and know you well, you will

be able to build a very good picture of your Early Warning Signs.

Early Warning Signs


The changes you experience may come under the following headings:

Changes in your thinking:

Ideas you had.

Beliefs you had.

Thought about others.

Speed or ease of thinking.

Changes in the way you feel:

More or less happy than usual.

More changeable mood.

More easily irritated.

More anxious or fearful.

Feeling more sensitive.

Changes in your behaviour:

Levels of energy.

Change in routines.

Changes in eating and/or sleeping patterns.

Relationships with others (especially family conflict).

Doing unusual things.

Risk taking e.g. driving faster.

Taking less of your medication.

With some conditions your Clinical Therapist may undertake a card sort

exercise or questionnaire with you to help identify these changes.

It is important that these changes are specific and personal to you.

For example; before major relapses Anne had problems with her sleep,

concentration and did not want to go out with her best friends. These signs

were:

Reduction in sleep of 2 hours for 3 nights in a row.

Not being able to read for more than 5 minutes at a time.

Spending more than 4 hours alone in my room for three days

in a row.

Q. Which of your signs might be the clearest? Write down what they are.

Be specific about how long the changes might go on before you get sick.

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

________________________________________________________________________

Changes

in

Thinking

Feeling

Behaviour

Early Warning Signs


Developing a Timeline

In looking at timelines there are two methods which can help you in thinking

about Early Warning Signs. The first is to develop a timeline about the order

of events prior to becoming unwell. This first type of timeline is the first one

below (see Reflective Activity 1).

The second kind of timeline which is useful to consider is a timeline which

outlines the history of a disorder over time, often over years. There is an

example of this below as well (see Reflective Activity 2).

You may like to have a look at both of these timelines to help gain some

information and understanding about the events and feelings that have

occurred in the past. This can serve as a guide to possible future planning.

It is valuable to try and get an idea of the order in which these changes

occur so that you can respond at the earliest possible stage. You can refer

back to the reflective question, which asked about your early warning signs

following a particular order.

Reflective Activity 1:

Reflect on the signs you have identified and put them in order from the first

change you notice until the last change you notice.

Example;

Date: Early Warning Sign:

11th May Not able to sleep.

Waking up 2 hours early.

13th May Can’t concentrate, watch TV or read a book.

14th May Staying in bedroom and not going out.

16th May Feel sick and need to see a Doctor, Clinical Therapist

or Psychiatrist.

Your thoughts go here.

Date/Day: Early Warning Signs:

_____________ ________________________________________

_____________ ________________________________________

________________ ___________________________________________________

________________ ___________________________________________________

Early Warning Signs


Your Clinical Therapist will help you develop a timeline that links what was

happening at the time. For example being on holidays, studying for exams,

problems at work or relationship problems. This should help you identify your

relapse signature. It will also highlight stressful triggers that you may be able

to mange more effectively to prevent early signs occurring.

Historical Illness Timeline Reflective Activity 2:

Example:

Year:

95 96 97 98 99 00 01 02 03 04

Highs

________ _________________________________________

Lows

Events

Child Vacation Separation New Vacation

Born Job

Do your own timeline:

Year

Highs

_________________________________________________________________________

Lows

Events

Q. What have you learnt from looking at this timeline?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Early Warning Signs


2. STRESS TRIGGERS

This section relates to Worksheet 9A found in the back of this Guide. As

you fill out these activities and questions you may like to transfer some of the

information over to the worksheet.

For many people, there is often a specific trigger before a relapse. This

trigger might be moving house, sitting exams, having a baby, starting or

changing a job, personal disorder, relationship breakups, redundancy or

death of someone close to you.

Q. Looking at your timeline, what can you identify as possible stress triggers?

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

The signs of stress are similar for most people. The first signs may be changes

in sleep pattern or appetite, feeling tense and irritable, having headaches

and backaches or feeling exhausted. Each person will have their own

particular signals that indicate that they are under too much stress and may

need to take things a little easier for a day or two.

If you are experiencing these signs of stress you may find it helpful to discuss

this with your Clinical Therapist and your supportive friends and family.

One strategy to manage stress is to avoid trigger situations altogether

however this may not always be possible and can restrict your lifestyle. A

more helpful approach may be to anticipate possible trigger situations and

stress. This will help you to plan ahead as to how you will deal with them.

Things to do could include:

Problem solving the cause of the stress trigger.

Making sure you stick to routines of eating and sleeping.

Relaxation strategies.

Share you feelings with someone you trust.

Have a break from demands.

Q. What stress reducing strategies do you think would be useful for you?

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Early Warning Signs


Preventing Relapse

It is important to realise that these signs are warnings that your body is under

strain, and even if you have no serious health worries at present that

continued stress and strain on your body may lead to major health

problems eventually.

Many mental and physical health problems are made worse by continued

high stress. Heart disease, asthma, stomach ulcers, diabetes, epilepsy and

even cancer can be made worse by stress.

For a person who is prone to having relapses of a mental disorder it is

particularly important to deal with and solve any problems that may have

led to high stress promptly. Otherwise the high stress is likely to lead to the

beginnings of another major relapse.

3. EARLY WARNING SIGNS AND THE IMPORTANCE OF

REGULAR MEDICATION

It used to be thought that almost all relapse of mental disorder occurred

because the people were not taking their medicine regularly, or not in the

correct dose. Although this is one of the common causes of a major

relapse, it is not the only one.

Even when you are taking medicine in the best way, you may still

experience periods of relapse. This may happen as a result of high stress,

from hormone problems or for reasons that are hard to identify.

Most of these relapses begin after early warning signs have been present for

at least a few days. One early warning sign for many people is that they

have difficulty taking medicine regularly. This might be a sign of loss of

concentration or becoming more concerned about worrying thoughts. This

is a very important sign, because it occurs when it is most important to be

getting the maximum benefits from the medicine.

Any reduction in taking your medication (even missing a few tablets) should

be addressed quickly, and efforts made to address this concern to help you

stay well.

Understanding Stress

This Guide has looked at the importance of solving any

problems that have caused a stress reaction. If you

become skilled at solving problems in life, it is possible

to avoid relapse. However, not all major relapses are

caused by stress.

Many may be caused by changes in your brain and

body chemistry that you cannot always clearly

understand. Listed over the page are some other

possible reasons for major relapses.

Early Warning Signs


Take a minute to review these:

Taking street drugs.

Not taking medicine as prescribed.

Smoking a lot.

Physical health problems.

General Health

Physical health problems may affect brain and body functioning in many

ways. But they can also add considerably to overall life stress. So it is

important to do your best to keep healthy and to go to your family Doctor

whenever you need their advice or help with health problems.

When your brain chemistry is disturbed, either by continuous high levels of

stress, changes due to taking street drugs, or reducing your medicine, or for

any other reason you may begin to develop the signs of a major relapse.

The early signs of a major relapse may be rather similar to the signs of stress,

but they may have some features that you can recognise as rather

different, and can help you decide whether this is an every day stress

reaction or the beginning of a major relapse.

Developing an Early Warning Signs Plan

A note about the process: As you go through the process of developing an

Early Warnings Signs plan it is important to know that your clinical therapist

has a form called an Early Warning Signs and Management Plan Form

which is designed to have similar information to what you identify in this

Guide.

By going through this Guide together the goal is to have a plan that both

you and the Clinical Therapist are aware of. This plan can also be shared

with your supportive family and friends where appropriate. The Clinical

Therapist puts a copy of the plan on your clinical file.

It is important to have a plan of action clearly worked out before early

warning signs appear. The exact details may depend on your life situation at

that time. For example, if a very stressful event has just occurred, such as a

death in your family. Alternatively, if the early warning signs appear shortly

after your doctor has recommended a lower dosage of medicine, the

response may be to increase the dosage to the earlier level. Sometimes the

doctor will prescribe a small amount of short term medication that you can

use when early signs appear.

High levels of everyday stress are often present when people are out of

work, have little money, or where there are continued problems finding

enough support with family and friends from the community. In such cases

a small increase in stress may overwhelm a person's ability to cope and

lead to a high risk of a major relapse.

Early Warning Signs


Your plan can include the things to be done by you, your Clinical Therapist,

your doctor and your family and friends. It is important that everybody

involved in the plan has a copy and knows what to do. You will need to

contact your Clinical Therapist or Doctor without delay. Any early warning

sign is an emergency and you must arrange a meeting without delay.

Now you can make an action plan on your

Early Warning Signs Management Plan. Some

suggestions to consider are listed below. Tick

the ones that you think are helpful.

Whenever I Notice My Early Warning Signs I Will:

Contact my Clinical Therapist or Doctor immediately – (If they are

not available straight away, contact a family member or support

person who is familiar with your plans for early warning signs).

Make sure I am taking my medicine as recommended.

Avoid taking any street drugs.

Check on any stressful things that have happened.

Check on any continuous high stresses in my life as you go through

this process.

You may be able to remember the early warning signs and plans that you

have made today, and even tomorrow. But you may need to remember all

these things many months or years from now. So it is important that you

make several copies of the Early Warning Signs Management Plan

Worksheet 9A and put these in places that will help you and those people

who you have involved in the plan to remember exactly what you would

like them to do.

This Guide provides an Early Warning Signs Management Plan at the end so

that you can develop your early warning signs plan. A good way to start your

plan is to consider the things that you will do when you notice one of your

early warning signs occurring. There are a few suggestions above you might

like to consider. Write a few below.

Families and Early Warning Signs

Your family can be a great help when identifying Early Warning Signs and

developing a plan. There is a section at the back of this Guide for your family

to work through.

….Think

about ways

that you can

remember

your plans in

the future.

Early Warning Signs


Plan

Whenever I notice one of my early warning signs I will:

1. __________________________________________________________________

__________________________________________________________________

2. __________________________________________________________________

__________________________________________________________________

3. __________________________________________________________________

_________________________________________________________________

4. __________________________________________________________________

__________________________________________________________________

5. __________________________________________________________________

__________________________________________________________________

Some people who might need to know about the

Early Warning Signs Management Plan are the

people you live with, close friends and family,

neighbours, workmates or fellow students, teachers,

your family doctor, in addition to your Clinical

Therapist and doctor, and most important of all, YOU!

Plans to help you remember may include:

Making copies of the Early Warnings Signs Management Plan and put

them in places where they cannot be missed. Maybe on a notice

board at home, behind the toilet door or on the refrigerator.

Putting the plan in a special envelope for your support people to take

their own copy home and put it in a place where they can access it

easily.

Early Warning Signs


You may want other people to put the sheet somewhere special as well.

Write down what you will do to make sure each person will remember the

plan. Write this next to his or her name on the list below.

Remember the Plan:

Person

Name

Plan to help them remember

Early Warning Signs


Your Clinical Therapist and your Doctor will check on your Early Warning

Signs Management Plan regularly when they meet with you.

Make Sure That Everybody Who Might Need To

Help Recognise Your Early Warning Signs, Knows

About The Plan And Will Be Able To

Remember It In The Future

Summary:

Reflect on what your early warning signs are and record them

on the plan.

Ask other people in your support network to help you with this

plan and to help you when any early warning signs are noticed.

Be clear about the benefits and how important this plan is!

be clear about the unwanted effects that can occur if early

warning signs are let go.

As soon as you start to miss doses of medication find the

problem and sort it out.

Early Warning Signs

Worksheet 9A –

EARLY WARNING SIGNS AND MANAGEMENT PLAN

FOR THE CONSUMER:

What are your stress triggers and sense the time it takes to

develop Early Warning Signs?

What are the coping strategies I can use to manage the stress

triggers?


Early Warning Signs


My Early Warning Signs that my disorder might be returning are:

1. _____________________________________________________

2. _____________________________________________________

3. _____________________________________________________

4. _____________________________________________________

5. _____________________________________________________

What are the coping strategies I can use to manage the Early

Warning Signs?

My support people are:

1. ___________________________Ph: _______________

2. ___________________________Ph: ________________

Early Warning Signs


FOR THE FAMILY

Planning a Response to Early Warning Signs

As a family member your involvement and support is very valuable in

understanding and developing a response to Early Warning Signs. You may

like to take some time to work with your family member and their Clinical

Therapist to develop a support and action plan.

What are the stress triggers you are aware of for your family

member?

What are the ways you can help identify the stress triggers for

your family member?

Early Warning Signs


What will you do when you notice Early Warning Signs

appearing in your family member?

What are the ways you can assist your family member in

avoiding relapse?

Early Warning Signs


NOTES: _____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Early Warning Signs


Early Warning Signs


We Value Your Feedback Date: _____/______/_____

This evaluation is designed to provide feedback regarding the System to

Aid Recovery (STAR). Please take a moment to fill in this form and return it to

either your Clinical Therapist or to the reception desk. You may like to post it

in by sending it to South West Healthcare Mental Health Services, Koroit

Street, Warrnambool, Vic 3280.

1. Did you complete most of the activities in this Guide with your

Clinical Therapist or did you complete them in your own time?

Clinical Therapist Completed in own time

Did not complete most of the activities

2. Were there any problems with this material?

Yes No Unsure

3. What were they?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

4. What recommendations do you have for improvements?

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Thank You – This form is private and confidential

If 1 is the worst it could possibly be and 5 is the best, rate the following

statements about this STAR Guide and associated activities

Was the Guide…. 1 2 3 4 5

Easy to read

Easy to understand

Easy to follow

Suited to your needs

Were the activities in the Guide… 1 2 3 4 5

Useful

Easy to follow

Did they work

star - south west healthcare · · 2013-11-26the system to aid recovery (star) provided by mental...

Documents