Part One – Is Nick Sick? (11 minutes)
Part Two – Is Nick Sick? (9 minutes)
Response to the ‘Is Nick Sick?’ video blog
by Professor Jon Jureidini
“Patrick McGorry’s Orygen Youth Health, CAARMS training video1 on how to diagnose ‘Attenuated Psychosis’ demonstrates how not to carry out a psychiatric interview and interact with young people.”
As identified by Martin Whitely in his commentary about the CAARMS training DVD, describing Nick as being at ultra-high risk of psychosis (UHR) fails the common-sense test. Even more concerning is that Nick is labelled as having Attenuated Psychosis – in ordinary language, he is already mildly mad.
Professor McGorry justifies diagnosing young people like Nick as being at ‘ultra high risk’ because within the next 12 months they are ‘between two and four hundred times’ more likely to become psychotic than the ‘the general population’.2
But we must respect the ordinary everyday language meaning of ultra high risk. If I am labelled as being at ultra-high risk of something, I assume that I will probably be affected. I do not interpret that label as meaning I am simply much more at risk than my peers.
Even Professor McGorry acknowledges that nearly two-thirds of the people identified as being at ultra high risk of developing psychosis, don’t become psychotic.3 Independent evidence shows the conversion rate is as low as 8%4 With between 64% and 92% false positives, the true ‘ultra high’ risk is the risk of being incorrectly labelled.
The pay-off for testing for UHR is simply not sufficient to justify the cost. One cost is that Nick is now being taught to see himself as sick. Who knows if this might not even increase this vulnerable young man’s risk of ultimately being diagnosed with full-blown psychosis? And as Martin Whitely points out, it stigmatises him.
But more important to me than stigmatisation is the fact that the UHR label is an unexplanation; it ignores what is going on in Nick’s life. Unexplaining is different from saying ‘I don’t know’ (something we doctors would do well to say more often). Unexplanations distract from the difficult but rewarding task of working with a young person towards finding an explanation for their stress.
Nick makes it pretty easy for the listener. He tells us about being bullied into a trade that he doesn’t want to be in, and he invites the interviewer to explore his relationship with his father. The interviewer doesn’t notice, or chooses to ignore this invitation, instead sticking to a stereotyped list of questions that generate the sterile unexplanation of UHR.
It might be argued that the interviewer would come back to this later. However, in my experience, young people prefer us to show an interest in their difficult and intimate predicaments when they first get the courage to put them into words.
I am grateful to Martin Whitely for putting the CAARMS training video into the public domain because it provides a potential teaching tool for medical students in how not to carry out a psychiatric interview and interact with young people.
Byron Kaye, Medical Observer, McGorry stands firm on ‘flimsy’ accusations 11th Sep 2012 http://www.medicalobserver.com.au/news/mcgorry-stands-firm–on-flimsy-accusations
The following is a transcript of the interview with Nick and the introduction to the CAARMS Training DVD
Associate Professor Alison Yung.:
Hello and welcome to the CAARMS Training DVD. The CAARMS has two functions; First, to assess whether the person meets the ultra-high risk criteria for psychosis or not and second, to assess the range of psycho-pathology which we see typically in people in the prodrome preceding a first episode of psychosis. For this training video we’ll just focus on the first function, that of assessing the ultra high- risk criteria.
For this function we need only the first four sub-scales of the CAARMS; Unusual thought content, non bizarre ideas, perceptual abnormalities and conceptual disorganization. These four sub-scales assess sub-threshold and threshold versions of positive psychotic symptoms, delusions, hallucinations and formal thought disorder.
You notice that the interviewer assesses both the intensity, frequency and duration of these phenomena.
We’re going to show you four interviews of typical people who present to the Pace clinic.
Also in the DVD there will be slides showing the ratings for each of these people.
By viewing the DVD you’ll see both how the interviewer asks the questions and the responses that we commonly encounter at the clinic.
DVD also contains additional information. We hope that this resource assists you in your work.
Narrator: Nick is an 18 year old apprentice electrician in his first year of training. He is self-referred to PACE, encouraged by his sister, after confiding in her that he has been extremely anxious and has had great difficulty sleeping. He has not previously sought help for psychological issues but there is a family history of depression in the maternal aunt and of an unknown psychiatric condition in his mother’s grandmother. Nick is single and lives with his parents and three younger sisters. The family is of Italian origin. Nick did reasonably well at school and completed Year 12. He has a large circle of friends, enjoys playing sports and has had girlfriends in the past but is not in a relationship at the moment. He does not mind if his mother knows about his current problems but does not want his father informed.
Interviewer: Okay Nick, so you’ve told me that um things haven’t been going very for a little while now since you started work, I just want to ask you some more detailed questions about the sorts of things you’ve been experiencing. So can you tell me, have you had the feeling that something odd is going on that you can’t explain?
Nick: No, not really, no. (shakes head)
Interviewer: No, Have you been feeling puzzled by anything?
Interviewer: Do you feel that you have changed in any way, who you are has changed?
Interviewer: Or that people around you have changed in in some way?
Nick: No, not not really.
Interviewer: Okay, have you felt that things around you have ahh a special meaning or that people have arranged things especially for you?
Interviewer: People been trying to give you any messages?
Interviewer: No? Now sometimes people have the feeling that someone or something outside of themselves are controlling their thoughts or their feelings – wondering if you’re having any experiences like that?
Nick: No, not like that.
Interviewer: So you haven’t had any feelings or impulses that seem to come from someone else not yourself?
Interviewer: Okay. Do you ever have the feeling that um ideas or thoughts are put into your mind that aren’t yours?
Interviewer: Okay. And what about the reverse process – having the the feeling that thoughts are being taken out of your head?
Nick: No, that’s never really happened.
Interviewer: Okay. Sometimes people feel that other people can read their minds or hear their thoughts. Does anything like that happen to you?
Interviewer: Can you tell me, has anyone been giving you a hard time or trying to hurt you in any way?
Nick: Well yeah, I suppose that’s that’s been a big thing for me um It’s gotten really bad. I feel like that all the time. Umm, I’ve actually started a new apprenticeship about three months ago ahm, and my dad got me into it because ahh one of his mates is doing doing him – doing him a favour so he is taking me on, umm, and my dad’s an electrician and he wants me to come in and take over the family business so, so I feel that I have to do it but I really don’t want to be there and I really don’t think that I’m really good at being an electrician so, since I started work um I’ve I’ve really felt while I was at work that I was really bad at what I was doing, ahhm and I actually felt – I actually felt at the time, I was starting to feel that the guys at work were thinking um that I’m really bad at what I’m doing and that they’re laughing at me behind my back and talking about me behind my back, so um, I mean the the guys that I work with they’ve all got families and you know they go fishing together so they’re all a close group of friends um whereas I’ve got nothing in common with them. So whenever we go on smoko breaks they all talk with each other, um and I tend to smoke by myself because I’ve got nothing to say to them really and um when during the smoko breaks you know when they’re laughing, ahh when they’re talking sometimes they look over in my direction and I feel that they’re actually talking about me and they’re laughing at me and you know and they think that I’m really bad at what I do, ummm, and I I mean I’ve made quite a few mistakes at work, umm and and I feel that they’re just waiting for me to stuff up because they know they they I just think that they know that I’m going to stuff up.
Interviewer: So has this been going on the whole time you’ve been at work?
Nick: Well it is it was alright when I started, umm, and then a few weeks into it I I really started to get worried because I’d made a few small, small mistakes, I started to think that you know they really were thinking well you know who have we hired here – he doesn’t know what he is doing, um and that actually got really bad about a month ago. Um, we had a really important deadline that we had to meet and we were quite stressed and um everyone was really busy and I was quite anxious because, um it was just a stressful time during that time and it got really bad there where every time I was at work and every minute I was actually just looking over my shoulder and looking at ah the other workers and seeing if they were looking at me and if they were talking about me and I felt that they were waiting for me to stuff up and and um, so so it got bad about a month ago- it’s not as bad now-it’s still, it’s still pretty bad but it’s not as bad as what it was about a month ago.
Interviewer: Ahuh, so in what way is it a bit better now, then it was a month ago?
Nick: Well I suppose back then it was a really stressful period um and everyone was busy at work and I was really stressed at work so I think it got worse around that time ahh but I suppose now it’s it’s a bit less stressful at work and not so busy so, it’s not as bad but I still look around and I still feel that as if they’re talking about me as if I’m really bad, they think that I’m really bad at my job.
Interviewer: Uhuh. How does, how do you respond to this? Has it made you do anything differently or?
Nick: Um, well, I’m, I’m always really nervous about going to work and and I hate going to work now, um, and I I don’t really do anything differently, ah, but, I’m always looking and and listening and and um trying tryna catch them out- trying to catch them talking about me, um.
Interviewer: Do you -Have you been getting to work every day?
Nick: Well, the past, the past few months I’ve, I’ve taken a few days off. Well I’ve been taking nearly one day off a week um, which has been really good, um.
Interviewer: That’s what I’m wondering about. What’s it like for you when you’re at home?
Nick: Oh, when I have the days off and and when I’m home I’m fine you know. I don’t think about work and um I don’t worry about what they’re thinking of me and a lot of the times when I get home from work and I think about what’s happened earlier in the day you know, I feel that it’s – you know what I was thinking at the time was pretty, you know ,pretty silly and you know, it was, like they care what I’m doing and how good I am um.
Interviewer: So you can see it differently when you are at home?
Nick: Yeah, when I’m at home I’m I’m less worried about it and and, you know, sometimes I think that what I was thinking was pretty silly at the time but then when I’m at work I’m I get really anxious and worried about it.
Interviewer: Okay so you’re having this really hard time at work and things are okay at home.
Nick: Hmm, yeah.
Interviewer: You had these, this sort of stuff happen to you anywhere else or is it just at work?
Nick: Aww not really anywhere else. There’s there was this time um, it was about a month ago, still during that period.
Interviewer: During that time-
Nick: Yeah there was a couple of times um when I was actually on the train on my way to work and I was really tired and really really stressed and I just didn’t want to go to work, um and I was just standing up on the train and um I saw a couple talking to each other and I saw another guy um start laughing and um I I started to think at the time that um, they were actually talking about me and and they were laughing about me and um I was, I was starting to to think they thought I was really bad at what I was doing; they, they knew that I was a bad electrician and I was really bad at what I was doing, so I got really anxious and really worried about that and really stressed; um and that that happened for, for two days.
Interviewer: Two days..
Nic: That happened twice. Yeah.
Interviewer: Yep. And what happened when the journey ended and you got off the train and you were away from those people. Where you still-did you still have those worries?
Nick: Well, I I was really umn stressed getting off the train, um, and then you know, as I was walking to work I was sort of thinking about it a bit and– you know, I was thinking you know, those people don’t even know me and I’ve never met em before and they don’t even know what I do, so you know I was starting to think you know how would they know that I’m bad at what I do, so I started to think that you know maybe what I was thinking was a bit, you know, a bit over the top, a bit stupid, but you know at the time I really was convinced that they were.
Interviewer: It sounds like a really hard time and then you got to work and the worries would have come again.
Nick: Yeah yeah, like, like on those days walking to work I sort of cleared my head a bit and you know thought that it was all pretty stupid and then I got to work and you know, when work started again and the guys came in to work and you know, again, I still started to sort of worry about what they were thinking and yeah.
Interviewer: Okay, so you’re using, um, marijuana with your friends on the weekends.
Interviewer: How are you feeling when you’re, when you’re stoned with your friends?
Nick: Oh, um it feels pretty good. I mean the reason I do it is is to relax um.
Interviewer: And that’s the effect that it has?
Nick: Yeah, yeah. I don’t, I just do it just to get away from things, and not to think about things or anything like that so.
Interviewer: Some people find that when they use marijuana they get more worried but that doesn’t sound like your experience?
Nick: Ah no, no never, never been worried or nervous or stressed when I’ve been with my mates and smoking so I suppose that’s why I do it with them, just to chill out on the weekends.
Interviewer: Mkay. Have you been feeling that you’re especially important in some way or that you’ve got special powers to do things?
Nick: No. Not really. No that hasn’t happened.
Interviewer: Okay. Now have you been feeling that there’s anything odd going on with your body that you can’t explain?
Interviewer: Or that your body’s changed in any way?
Interviewer: No?um, what about feeling guilty or that you deserve punishment. Does that come up for you at all with..
Nick: No. No.
Interviewer: With these things? Okay, fine.
Nick: Some-Sometimes at work I feel that, um, just with,ah with my stuff ups I think that, you know, the boss will, will catch me out and he’ll find me out and um that I will get punished but yeah I don’t actually feel the need that I need to be punished or anything like that.
Interviewer: Are you very religious Nick, have you had any religious experiences?
Nick: Ahh, no, not really.
Interviewer: Okay. And um, do you have a girlfriend?
Nick: Ah, I I used to a couple of years ago but I can’t be bothered looking after one at the moment.
Interviewer: Another area that I need to ask you about is the area of ah perceptions, what you see and hear
Interviewer: And that kind of thing. Um so I’m wondering if you’ve noticed any changes in in your vision, do you, um are things looking different to you?
Nick: NarI needed, I needed glasses. I need to get glasses, um so um things were getting a bit blurry um, but.
Interviewer: So glasses have improved your vision?
Nick: Yeah. Yeah.
Interviewer: In more recent times has there been a change in the way things look to you?
Interviewer: The colours brighter?
Nick: No, no that’s all the same
Interviewer: Anything like that
Interviewer: Um. Okay. And what about um hearing things. Have you been hearing things that other people can’t hear?
Interviewer: Any changes to the way you perceive sound at all?
Nick: No. No.
Interviewer: Any strange sensations in smell, smelling strange things, or things smelling different?
Interviewer: And, um, I asked you whether you had any strange sensations on your skin. Whether you’ve um felt things crawling on your skin or underneath your skin?
Interviewer: Anything like that?
Nick: No. No.
Interviewer: No. And what about your ability to communicate with people Nick? Have you felt like um, you’re able to communicate clearly, that people understand what you’re saying? You’re able -
Interviewer: to get your message across?
Nick: Yeah, never really had problems with that.
Interviewer: Okay. Do you have um trouble finding the correct word to use at all?
Nick: Aw, sometimes, I mean I’m I’m not the best at English so sometimes I, you know I can’t find the right – I’m thinking of the word that I’d use or I heard a couple of days ago and I just can’t think of it at the time, um, I think of it later on sometimes but- so sometimes I find- have trouble finding the right word, but, it doesn’t happen very often.
Interviewer: It doesn’t happen very often, it’s not something that you’re really worried about?
Nick: I still, they still understand what I’m trying to say.
Interviewer: Yep. Do you ever have the feeling that, um, you go off on tangents and that people don’t follow what you’re on about?
Interviewer: No? So do you think your activity level has dropped off a bit? Are there things you used to do that you don’t do now?
Nick: Well, I, I mean I always used to go out with my friends. Go out drinking. Go out clubbing and go to the gym with them, um but, since, since work has started I really haven’t been in the mood to do anything like that. So I haven’t been in the mood to go out with them.
Interviewer: So does that mean you’re not going out at all now?
Nick: Oh, sometimes they drag me out like a lot of the times I don’t want to go but sometimes they just drag me out, and when we actually go out I have a great time with them. So it’s like, it’s like nothing.
Interviewer: So you are still able to enjoy yourself at times but-
Interviewer: But it’s a bit hard to get yourself going?
Nick: Yeah, yeah. I just feel I don’t have the energy and just don’t want to do it anymore.
The DVD is paused. Take each of the 4 subscales and rate the Global Assessment and Frequency and Duration for each. Press Continue and the answers will follow.
UNUSUAL THOUGHT CONTENT – GLOBAL RATING SCALE
|0Never,absent||1Questionable||2Mild||3Moderate||4Moderately severe||5Severe||6Psychotic and Severe|
|NoUnusualContent.||Mildelaboration of conventionalbeliefs as held by aproportion of the population.||Vague sense that something is different or not quite right with the world, a sense that things have changed but not able to be clearly articulated. Subject not concerned/worried about this experience.||A feeling of perplexity, a stronger sense of uncertainty regarding thoughts than 2.||Referential ideas that certain events, object or people have a particular and unusual significance. Feeling thatexperience may be coming from outside the self. Belief not held with conviction, subject able to question.Does not result in change of behavior.||Unusual thoughts that contain completely original and highly improbable material.Subject can doubt (not held with delusion conviction) or which the subject does not believe all the time.May result in some change in behavior, but minor.||Unusual thoughts containing original and highly improbable material held with delusional conviction (no doubt).May have marked impact on behavior.|
Alison Yung: Unusual thought content. Nick receives a zero for unusual thought content as he does not answer positively to any of the questions.
Non-Bizarre ideas. He does rate on the Non-Bizarre ideas sub-scale however because of the experiences he has been having at work lately. He receives a Global score of 5 with his persecutory ideas – feelings that other people know that he is bad at his job. As he has experienced these thoughts about strangers on the train it is highly unlikely that they are true. However these thoughts are not held with delusional conviction as he is able to question these thoughts. Thus the intensity is not as high as a score of 6. These thoughts have resulted in Nick taking some time off work. Hence they have resulted in some change in behavior. They are not very easy for Nick to dismiss which means that the intensity is not as low as a score of 3.
Because these thoughts occur most days when he is at work. and last for more than an hour he rates a frequency and duration score of 4.
Frequency and Duration
|Absent||Less than once a month||Once a month to twice a week – less than one hour per occasion||Once a month to twice a week – more than one hour per occasionOR3 to 6 times a week – less than one hour per occasion||3 to 6 times a week – morethan an hour per occasionORdaily – less than an hour per occ.||Daily – morethan an hour per occ.ORseveral times a day||Continuous|
Pattern of Symptoms
|No relation to substance use noted||Occurs in relation to substance use and at other times as well||Noted only in relation to substance use|
Level of Distress (In Relation to Symptoms)
Not At All Distressed Extremely Distressed
Perceptual Abnormalities – Global Rating Scale
|0Never,absent||1Questionable||2Mild||3Moderate||4Moderately severe||5Psychotic but not severe||6Psychotic and severe|
|No abnormal perceptual experience||Heightened or dulled perceptions, distortions, illusions (e.g. lights/shadows).Not particularly distressing.Hypnogogic/hypnopompic experiences.||More puzzling experiences, more intense/vivid distortions/illusions, indistinct murmuring, etc.Subject unsure of nature of experiences. Able to dismiss. Not distressing.Derealisation/depersonalisation||Much clearer experience than 3, such as name being called, hearing phone ringing etc, but may be fleeting/transient. Able to give plausible explanation for experience. May be associated with some distress.||True hallucinations, i.e. hearing voices or conversation, feeling something touching body. Subject able to question experience with effort.May be frightening or associated with some distress.||True hallucinations which the subject believes are true at the time of, and after , experiencing them. May be very distressing|
Perceptual Abnormalities – Nick states that he needed glasses. However, he does not report experiencing any perceptual abnormalities so for this sub-scale he rates a zero.
Disorganised Speech – Global Rating Scale
|0Never,absent||1Question able||2Mild||3Moderate||4Moderately severe||5Severe||6Psychotic|
|Normal logical speech, no disorganization, no problems communicating or being understood.||Slight subjective difficulties, eg problems getting message across. Not noticeable by others.||Somewhat vague, some evidence of circumstantiality or irrelevance in speech. Feeling of not being understood.||Clear evidence of mild disconnected speech and thought patterns. Links between ideas rather tangential. Increased feeling of frustration in conversation.||Marked circumstantiality or tangentiality in speech, but responds to structuring in interview. May have to resort to gesture, or mime to communicate.||Lack of coherence, unintelligible speech, significant difficulty following line of thought. Loose associations in speech.|
Disorganised speech – Nick reports that he sometimes has trouble finding the correct word at the right time. However people still understand what he is saying so he rates a global score of 2 for disorganized speech. He said that this does not happen very often so he rates a frequency and duration score of 1.
Nick meets the PACE intake criteria for Group 2, the Attenuated Psychosis group. He also meets the drop in functioning criteria.
Note: Nick is played by an actor, however the interviewer is a doctor employed by Orygen Youth Health
- Orygen Youth Health Centre, 2009, “Comprehensive Assessment of At Risk Mental State (CAARMS) Training DVD”, The PACE Clinic, Department of Psychiatry, University of Melbourne. see http://www.eppic.org.au/risk-mental-state accessed 3 September 2012 ↩
- McGorry P. Right of Reply – Patrick McGorry on Early Intervention for Psychosis. December 11, 2010. http://speedupsitstill.com/reply-patrick-mcgorry-early-intervention-psychosis#more-1075 ↩
- Professor McGorry wrote “the false positive rate (for UHR) may exceed 50-60%” McGorry P.D. ‘Is early intervention in the major psychiatric disorders justified? Yes’, BMJ 2008;337:a695 http://www.bmj.com/cgi/content/full/337/aug04_1/a695 (accessed 3 August 2010) Professor McGorry’s close colleague Alison Yung identified the conversion rate from UHR to first episode psychosis was 36% in an article in the Medical Journal of Australia titled Is it appropriate to treat people at high-risk of psychosis before first onset — Yes Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-yes ↩
- Professor David Castle, Medical Journal of Australia, 21 May 2012, Is it appropriate to treat people at high-risk of psychosis before first onset — No Available at https://www.mja.com.au/journal/2012/196/9/it-appropriate-treat-people-high-risk-psychosis-first-onset-no ↩