STAR. Guide Number 9 Early Warning Signs

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1 STAR Guide Number 9 Early Warning Signs Mental Health Services January 2012

2 This Guide Belongs To: Clinical Therapist Name: Contact Number: Date Received: Date Completed: Key Support Person: Doctor/Psychiatrist: ACKNOWLEDGEMENTS These Guides are derived from the contributions of many health professionals, primarily the late Professor Ian Falloon. System To Aid Recovery 2

3 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. System To Aid Recovery 3

4 INTRODUCTION Early Warning Signs 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. System To Aid Recovery 4

5 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? System To Aid Recovery 5

6 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. System To Aid Recovery 6

7 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 Thinking Feeling Behaviour 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. System To Aid Recovery 7

8 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: 11 th May Not able to sleep. Waking up 2 hours early. 13 th May Can t concentrate, watch TV or read a book. 14 th May Staying in bedroom and not going out. 16 th May Feel sick and need to see a Doctor, Clinical Therapist or Psychiatrist. Your thoughts go here. Date/Day: Early Warning Signs: System To Aid Recovery 8

9 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: 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? System To Aid Recovery 9

10 2. STRESS TRIGGERS Early Warning Signs 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? System To Aid Recovery 10

11 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. System To Aid Recovery 11

12 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. System To Aid Recovery 12

13 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..think about ways that you can remember your plans in the future. 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. System To Aid Recovery 13

14 Plan Whenever I notice one of my early warning signs I will: 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. System To Aid Recovery 14

15 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 System To Aid Recovery 15

16 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. System To Aid Recovery 16

17 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? System To Aid Recovery 17

18 My Early Warning Signs that my disorder might be returning are: What are the coping strategies I can use to manage the Early Warning Signs? My support people are: 1. Ph: 2. Ph: System To Aid Recovery 18

19 FOR THE FAMILY Planning a Response to Early Warning Signs 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? System To Aid Recovery 19

20 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? System To Aid Recovery 20

21 NOTES: System To Aid Recovery 21

22 System To Aid Recovery 22

23 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 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 Easy to read Easy to understand Easy to follow Suited to your needs Were the activities in the Guide Useful Easy to follow Did they work 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 System To Aid Recovery 23

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