16 | AWARE 3 – Weighting

COURSE

Host: In the Weighting theme, after diagnosis the next sub-theme you mentioned was course.

Expert: Yes. We found that an acute presentation where there has been a step change trumped acute on chronic which trumped chronic presentations. The clinical reality is that people who have been chronically unwell, or have been unwell for a while start to loose touch with hope and could be at as much risk or at a higher risk than those who get acutely unwell. Acute risk seemed to get more priority.

Host: Was there a relationship between the diagnosis and course?

Expert: That is a legitimate question as often people with personality disorder and alcohol misuse or substance use have ongoing risk and present repeatedly or frequently in crisis. One can see why there might be a degree of desensitization to the risk with which they are presenting due to the chronicity on display. In short yes, when there is an acute escalation in risk the assessors felt the need to do something definitive but for chronic risk there was a sense of not much has changed, why now.

Host: What kind of statements did you get in the qualitative analysis?

Expert: For acute risk we had statements like “…she was presenting as quite labile… was quite unsettled, agitated, disinhibited,… we have to do something.” For chronic risk we had statements like “I didn’t think it was an appropriate referral, he has long term on-going problems, more could have been done by the locality team, before referring.” You can hear the two contrasting approaches in acute risk we need to do something now but in chronic risk it is someone else’s responsibility, why are they being referred to the most expensive bit of the system whose job is to deal with the most acutely unwell. But how do you say that the chronic risk has gone past a threshold that something definitive needs to happen.

Host: Essentially you are saying that there is a natural predisposition in crisis professionals to take more seriously acute presentations but that it is important to remember that people who have been chronically unwell may have completely lost touch with hope and might feel more trapped than those who are acutely unwell and that risk needs to be taken seriously.

Expert: In the actual PROTECT training, we run case study simulations on a model of suicidality called STEPS in which we take trainees through the different stages of predisposition, ideation, intention, action, contemplation in post action, repeat action and back into life in motion with a safe recovery. We will talk about this in detail in a future episode as to how, static, stable, dynamic and fluid factors interact, however one thing that always stands out for me is to how limited an understanding participants have of the different approaches that need to be taken for acute risk, chronic risk and acute on chronic risk.

Host: Can you tell us more about these different approaches.

Expert: It’s a bit difficult to explain without the STEPS diagram, I guess listeners can imagine a tiered system of progression. We will talk about this later on as well when we discuss progression of suicidality from ideation to intention to action, please remember that it is not sequential in real life and people fluctuate all the time between these tiers, but say for illustration purposes if you are dealing with acute risk, that involves someone going in a short period of time from life in motion or predisposition through to ideation, intention formation and action, so a sudden peak in risk, now our response to this needs to be like a response to someone having a myocardial infarction.

Host: So, taking definitive steps, like in a patient with chest pain having a heart attack.

Expert: Yes, so jump in and do what needs to be done. In chronic risk though like someone with personality disorder or chronic depression, there suicidality may be going along with minor fluctuations going in between ideation and intention sometime peaking into action. Now every time they present in crisis it will be inadvisable to admit them, the response to them however needs to be equally thorough but is qualitatively different to the one of a patient having a heart attack. I think of them as patients who have a severe diabetic illness and they need rigorous support to help them stay on top of their diabetes, a lot of that is self-monitoring and self-regulation, taking adequate insulin, eating appropriately, avoiding hypoglycemic states, getting adequate wound care if they get a cut and so on.

Host: So, for chronic risk, rigorous support like in severe diabetes, but care that is primarily led by the person and the person has to take charge of their recovery.

Expert: Yes, so we draw on the person’s internal coping strategies, help them understand, that suicidal urges come in waves, every time they can use an internal coping strategy successfully, they learn that these urges can be mastered, so the focus is very much on learning distress tolerance. There may be a temptation to rationalize the risk away as low or non-existent as not much has changed but people with chronic risk need rigorous safety planning, particularly as it is more likely that they would be managed in the community. So a lot of work, and maybe even more work needs to go into chronic risk management than acute risk management where you step in and take control.

Host: And this additional work is to prevent people with chronic risk tipping into suicidal action, assuming if you are in that ideation – intention tier of the STEPS model it will not take much to tip one over into a full blown crisis.

Expert: That is exactly correct, understanding triggers, early warning signs, when to use internal coping strategies, when to use external coping strategies, when has it become a crisis, when is it an emergency, so clarity over what to do when and with whom is essential. So, a lot of work involved in mitigating chronic risk, just like in supporting people with severe diabetes.

Host: So, for acute risk, deliver care like you would for someone having a heart attack and for chronic risk, deliver care for someone with severe diabetes, now what about presentations which are acute on chronic?

Expert: Put simply this is like caring for those with a severe diabetes in the midst of a heart attack. So they really should be the top of your response list but unfortunately if you are not able to differentiate acute on chronic risk from chronic risk one is bound to take the wrong approach. That is why it is so important to predefine in a person centered way for each individual what does acute on chronic look for them, so for someone who self harms it might be that their frequency of self harming goes up from once or twice a week to daily or they go from self-harming on the concealed parts of their body to on their neck and face or their cuts are getting quite deep and are no longer superficial. This discussion needs to be undertaken when the person is calm and almost like an advanced directive care should be preplanned for these situations. In my experience designing this safety net actually decreases the frequency of such crisis.

Host: I know that you talk about this kind of ultra high risk scenarios in the suicide prevention training for GPs and primary care professionals.

Expert: Yes, it’s a training program called LIFE, designed for primary care folk, they are the ones who deal with a lot of chronic ongoing risk and doing this work up when the going is good provides clear trigger points of when to escalate to secondary care for short term intensive crisis support for the difficult period to subside and for them to return back to primary care. Supporting people with Personality Disorder is a challenge even in secondary care, so you can imagine how difficult it is in primary care with 10 minute appointments, but remember it can be a sequence of 10 minute appointments, that is what management of chronic risk involves and if one or two of those 10 minute appointments are utilized for forward planning a lot of risk can be managed.

Host: This has been a really informative and an in-depth discussion on the course of illness, acute risk remember heart attack, chronic risk remember severe diabetes, acute on chronic risk, think heart attack in a person with severe diabetes.

Expert: And make sure that there is clarity on how you will spot the heart attack in a person with diabetes. I feel we have gone of at a tangent from the AWARE factors.

Host: But it was important to understand the different approaches or else people might just rationalize away chronic risk as low risk rather than do the safety planning work up that is needed. Have we covered the course of the illness discussion?

Expert: Yes, I think we have.

Host: That brings us to the third of the subthemes in weighting, social factors.