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Key points
- Mental disorders do not appear out of the blue. There are always early signs.
- For many people, the early signs of an issue will generally be the same with each episode.
- Learning these early signs allows for early intervention, which allows for more effective treatment.
In my career as a psychiatrist, I have observed many interesting patterns in patients’ lives. One of the most fascinating would usually begin something like this:
“Doctor, I am always tired but can’t sleep. I’ve stopped doing needlepoint, which I love. I cry for little things, even at commercials. Only my grandchildren cheer me up, but then I can’t wait for them to go home.”
When I’d flip back through their chart, I’d see that at the same time last year, they told me the exact same thing, almost word for word. One notable aspect of this is how tightly mood disorders are often entrained to seasons. In these cases, relapses appear at the same time annually.
The more interesting feature is how an individual’s symptom picture is the same, down to the words used, in the early part of every episode of illness. Some are textbook problems, like trouble sleeping, but others are unique to the person, such as the loss of interest in needlepoint, as mentioned earlier. Whatever they may be, this brief list of symptoms makes up their unique set of early warning signs (EWS), and this will be so throughout their illness.
I’d go over these symptom lists with all my patients, and make sure they knew that this list was just as the name implies: early warning signs. I’d emphasize that this was not the same as a full-blown episode of illness—and possibly, might not be a problem at all.
For instance, in cases where EWS are also common experiences (insomnia, irritability), some further exploration is in order.
The purpose of the EWS list, I’d explain, is to alert the patient (or someone close to the patient) that something may be amiss. An appointment can then be scheduled with their clinician so that work can begin to stop a potential relapse right away or explore what else was going on in their life. The EWS list should be made early in treatment and adjusted as the patient and clinician learn more and more about the patient’s life.
For the patient and treater, an EWS is a priceless thing to have, as ultimately you would like to prevent the recurrence of problems. Having a good set of EWS and a plan for how to intervene is like a secret passcode to break into a major problem before it has fully arrived.
The EWS system works because mental disorders rarely come on quickly. It can be weeks or months before these early symptoms turn into a full-blown episode of illness. If an EWS list is built correctly, it will rarely mislead. When EWS appear, the treatment team knows that a specific problem is coming. This provides time to act with medication adjustment, a change or initiation of therapy, or perhaps some change in daily life. Pulling someone out of work is rarely used as a clinical tool, but should be utilized more often in crises. There are many options—and they work best when implemented early.
So, how is a truly useful early warning sign system assembled? The best place to begin is the patient’s first episode of their disorder, or the first time they presented for help. The memory of how things first developed is usually much clearer than subsequent episodes. Patients often know answers to questions like, “What was the first thing you noticed that was different?” or “When do you think it all began?” Or the information may be recorded in the medical record. But if this is not available, there are other sources.
This is where a third member of the treatment team can be invaluable. There are things that this third person (a partner, friend, family member; any person who knows the patient well) will know that neither the clinician nor the patient will know. I have made this point in other posts but wish to emphasize it here as this resource, the third person, is vastly under-used in common clinical care.
Sleep is almost always on the list. After this, the clinician should go through the patient’s symptoms for mood, anxiety, obsessions, psychosis, addiction, or whatever problem(s) have occurred. Patients with depression commonly lose an interest; people with anxiety may feel the need to avoid some trigger; those with psychosis might notice a change in thinking about the world. In each case, it will be unique to the patient.
Lastly, explore a normal day in the life of the patient and see what has changed. How a person passes a usual day can be like a fingerprint—it is very personal to them. These changes may appear unimportant at first. Taking longer to do things, or skipping common chores, phone calls, or favorite TV shows, all may signal a bigger change than the day’s schedule. Unexplained changes are often a sign of a problem.
EWS become a coded language between patient and clinician. I have had patients call to say, “Doctor, I am crying at TV shows,” or “I can’t go over that bridge on my way to work,” or “I am home and feel afraid to go out, but I don’t know what I am afraid of.” The first person had a history of depression, the second panic disorder, and the third of psychosis. In each case, we had discussed early warning signs and they were reporting to me as agreed. A plan as to what to do was already thought through, so we could start right away.
The reasons for a relapse are many, but a few stand out. A change in medication; stopping or decreasing therapy; and some life stressors are the most common. But as illnesses progress and patients have had a few episodes, relapses may occur without “reason.” It may just happen.
I would tell patients that mental disorders are like bad backs. The first time you hurt it is by moving the couch. The second by moving a chair, and the third by just bending over. Then you have a “bad back,” and it may hurt a lot, or a little with no explanation. Mental disorders are the same, where the couch and chair are stressors, and back pain is the disorder itself. Like the bad back, if a mental disorder is not well treated and is allowed to relapse many times, it will become increasingly difficult to treat and the effects on the patient will be more chronic and severe.
An EWS system is free and allows a treatment team to head off relapses. No mental health patient should be without it. With growth in self-awareness, early warning signs may become more subtle. A patient may notice they carry anxiety in certain situations, feel more emotional with particular topics, or avoid events for what used to seem like good reasons.
These do not represent new problems. They represent self-knowledge, the basis for personal growth. Whether we call them EWS or something else, ultimately, they create the very possibilities of proceeding with life without being chained to predetermined feelings and actions. These benefits—not limited to those in mental health treatment—allow the freedom to live life more openly, unburdened by needless emotional struggles.
