Early intervention in personality disorders

Personality disorders have their onset in adolescence or early adulthood. It is now well-established that these conditions emerge in individuals who have heritable risk factors and who experience disruptions in the attachment process, a critical component of early development that, when successful, sets the stage for healthy, stable personality functioning in adulthood. The importance of early identification of, and intervention for, emerging personality disorders is increasingly recognized. A new dimensional model for personality disorders relies on assessing self and interpersonal functioning, impairment of which during adolescence may signal the early onset of potentially disabling personality disorders.

Family involvement in first-episode psychosis

In the Indian secular, pluralistic, and collectivist society, the family is the oldest and the most important institution that has survived through the ages. With rapid urbanization and an ever-expanding population, there is a scarcity of financial and human resources in the area of mental health. Though progressively decreasing in size, families continue to provide a valuable support system, which can be helpful in the management of various stressful situations. Yet, very often this resource is not adequately and appropriately utilized. This chapter describes the role of family involvement in first-episode psychosis, drawing from various research projects carried out by the Schizophrenia Research Foundation (SCARF) and from other Indian centres. It deals with the identification of prodromes, access to care, treatment adherence and follow-up, and stigma.

Early intervention for psychosis

This chapter provides a comprehensive review of some of the key issues in early intervention for psychosis using the example of a population-based service in Hong Kong, for which a full range of data is available. The authors review a number of studies addressing: (i) the DUP and its associated factors in Hong Kong; (ii) whether DUP can be changed by public awareness programmes; (iii) the immediate outcome of a two-year early intervention programme; (iv) whether the improved outcome can be sustained after the programme, over ten years; and (v) whether receiving one more year of intervention could further improve the outcome. The results show that even in a low-resource setting in Hong Kong, significant improvements in functioning can be achieved, with reduced hospitalization and reduced suicide. A long-term follow-up study observed that these effects are sustainable over ten years. Further improvements can be attained by providing longer intervention to a group that responded less favourably. However, these enhancements proved more difficult to sustain. Together, these suggest a possible dose effect on the impact and sustainability of early intervention for psychosis. Future work should aim to clarify the role of increased intervention resources such as manpower and a more defined specific programme (e.g. coaching, exercise, cognitive interventions). More work is also required to investigate the culture of early psychosis services (such as a hope-centred culture), as well as how more personalized needs of individual patients can be met.

Early interventions to prevent stigmatization and its consequences

People with mental illness are usually characterized by the unpredictability of their behaviour: this feature is central to the concept of ‘mentally ill’ and has found its expression in words such as ‘alien’ (describing a person whose behaviour is different and unpredictable) or ‘alienist’ (as a description of a psychiatrist who deals with mentally ill people). Unpredictability is the very basis of stigma: individuals with mental illness are separated from other people by their key characteristic of being different, alien, unpredictable—and therefore funny, dangerous, not belonging. The consequence of this fact for the fight against stigmatization is that a key element of work must be the education of parents, teachers, and others who influence the development of children in order that these children become adults who accept the notion that people with mental illness are similar to themselves (and to other people who do not have the illness) and that it is the illness that makes them different. Interventions against stigmatization must therefore begin not with the onset of illness or with the first encounter with a mentally ill person but with the concept formation—hence, early in life. Parents and teachers are, of course, not the only ones who influence children and the formation of concepts; media and other sources of information must participate in these efforts. The chapter also describes some of the measures that have been shown, in the course of several major studies in recent years, to be effective in reducing stigma.

Early detection and timely intervention for borderline personality disorder

Although borderline personality disorder (BPD) usually has its onset in young people, its diagnosis is often delayed, and specific treatment is usually only offered late in the course of the disorder. Over the past two decades, the explosion of knowledge about personality disorder has shown that BPD is neither a variant of normal adolescent development, nor a ‘passing phase’ of little consequence. In fact, BPD is associated with harmful personal, social, and economic consequences. This has provided solid ground for early diagnosis and treatment of both subthreshold borderline personality pathology (‘indicated prevention’) and full-syndrome disorder (‘early intervention’). Over the past two decades, the Helping Young People Early (HYPE) programme has been developed and researched in Melbourne, Australia. HYPE is a comprehensive and integrated indicated prevention and early intervention programme for youth (15–25 years of age). HYPE is comprised of a service model and an individual therapy, and incorporates the principles of cognitive analytic therapy. HYPE primarily aims to alter the life-course trajectory of young people with borderline personality pathology by improving functional outcomes, interpersonal relationships, and self-management, developing support networks independent of mental health services, promoting adaptive help-seeking, and avoiding or reducing iatrogenic harms.

Early intervention in bipolar disorders

The concept of early intervention for bipolar disorder (BD) is both attractive and logical as there is often a considerable delay between the onset of BD symptoms and diagnosis. This chapter addresses key definitional and conceptual considerations for early intervention in BD and exposes the expansive gaps in our knowledge of the phenomenology of BD, prognostication, and disease progression and trajectory. These gaps highlight that early intervention for BD—in terms of treatment specificity and timing—is far from being realised. There are though significant risks associated with implementing early intervention strategies at this stage, which may range from unnecessarily prescribing potentially harmful medication to perhaps inadvertently accelerating the progression of the illness. Until there are major scientific and clinical advancements, this chapter provides a conservative yet involved approach for early intervention in BD.

Experiences and lessons from the Singapore Early Psychosis Intervention Programme

The long duration of untreated psychosis (DUP) and probable severe consequences were the impetus for establishing the Early Psychosis Intervention Programme (EPIP) in Singapore in the year 2001. EPIP is a comprehensive, integrated, patient-centred programme which aims to improve the outcome of patients with first-episode psychosis through public awareness and destigmatization initiatives, collaboration with community services, and provision of early engagement and phase-specific care of those with psychosis. In April 2007, the Singapore Ministry of Health launched its first ever National Mental Health Blueprint, and several community-based services were developed to improve mental healthcare and strengthen early detection and prevention of mental illnesses. The Blueprint thus provided the opportunity for the EPIP to strengthen its early intervention efforts beyond psychosis. This chapter discusses the role of the Community Health Assessment Team (CHAT) which is more broad-based, focusing on promoting awareness of youth mental health issues and encouraging this sector of the population to seek help early.

Introduction

This chapter starts with a historical review of the early intervention approach to psychiatric disorders. Historical documents suggest that the idea of early intervention had indeed already been proposed by professionals by the late nineteenth century. The circumstances which limited early intervention in that era are discussed. Some of these factors are still relevant to contemporary efforts in early detection and intervention for mental disorders. A narrow biological understanding of mental disorders inadvertently carries a highly deterministic view of inevitable illness progress. This view, coupled with an inadequate provision of care in the asylum era, were key factors which limited early detection efforts in the past. The availability of means to achieve a better outcome was identified as a key element required for early intervention.

Where next for early intervention programmes?

Early intervention treatments and approaches are reaching across the globe. There is no doubt though that these services are a low priority, especially in countries where adequate resources are not available. The practice of psychiatry has, in the last 50 years, moved from asylums, to community mental-health teams, to home treatments and early intervention. There appears to be an increasing body of evidence to suggest that early interventions can work in reducing the duration of untreated illness and aiding better recovery, but this needs to be researched in conditions other than psychoses, for which evidence is strong. This chapter provides recommendations for researchers, clinicians, and policymakers. All these recommendations are based on the principle of equity between physical and mental illness, and better integration between psychiatric services and social care and between primary care and psychiatric services.

Brain changes in psychosis

Schizophrenia is a complex disorder where risk genes involved in neuroplasticity are interacting with environmental risk factors. Schizophrenia and related psychotic illnesses are not degenerative in origin, but are disturbances of regenerative/plastic processes of the brain, involving neurogenetic events in the dentate region focusing on oligodendrocyte- and synaptogenesis-related processes. In order to prevent psychosis, persons at risk need to be identified at the early phases of the illness in order to initiate a phase-specific treatment. Therefore, understanding the mechanisms underlying the development of psychosis and strengthening the plasticity of the brain could effectively stop the progression of psychosis from the early at-risk mental state (ARMS) to the full picture of schizophrenia.