Psychosis in Children and Young People

• MRCPsych Course • Dr Gisa Matthies 1

Psychosis

• • • from the Ancient Greek ψυχή "psyche", for mind/soul ωσις "-osis", for abnormal condition or derangement 2

Psychosis

• • • • • • Schizophrenia Schizoaffective disorder Schizophreniform disorder Delusional disorder Bipolar affective disorder Depressive disorder 3

Psychosis

• Experience of psychosis challenges an individual’s fundamental assumption that they can rely on the reality of their thoughts and perceptions 4

Psychotic Symptoms

• • • • Hallucinations Delusions Thought disorder Negative symptoms 5

Schizophrenia in children and young people

• • Major psychiatric disorder Psychotic symptoms that alter the YP’s perception, thoughts, affect and behaviour 6

Prodromal Period

• • • • • • • • Deterioration in personal functioning Possibly precipitated by acute stress, distressing experience or physical illness Concentration and memory problems Unusual, uncharacteristic behaviour and ideas Unusual experiences and bizarre perceptual experiences Disturbed communication and affect Social withdrawal Apathy and reduced interest in daily activities 7

Delay in Diagnosis

• • • Insidious onset of prodromal period Delusions can be poorly systematised Thought disorganisation is common 8

Acute Episode

• Hallucinations, delusions, behavioural disturbance • Agitation, distress, fear, puzzlement 9

Residual Symptoms

• • Negative symptoms Persisting symptoms more common when condition starts in pre-adolescent children 10

‘

At risk mental states’ (ARMS) ‘Ultra high risk’ (UHR) • • • • Help seeking behaviour Attenuated positive schizophrenic symptoms, brief limited intermittent psychotic symptoms (BLIPS) A combination of genetic risk indicators, such as presence of schizotypal disorder, with recent functional deterioration Risk of developing schizophrenia over a 12 month period increased ( 1 in 5 to 1 in 10) Ruhrmann et al, 2010 11

But most YP with ‘ARMS’...

• • ...do not develop psychotic illness ...do have a mixture of other mental health problems (depression, anxiety, substance misuse, emerging PD) 12

Problems of using clinical label

• • Stigma Ethical issues 13

non specific symptoms ARMS/UHR dimensional view cusp of psychosis 14

Impairment and Disability

• Consequence of – disabling psychotic symptoms – – – adverse effects of poor physical health adverse effects of drug treatments stigma 15

Impairment and Disability

• Development and functioning: – Psychological – – Social Educational 16

Outcome Schizophrenia with onset in childhood and adolescence

• • 1/5 good outcome with only mild impairment 1/3 severe impairment requiring intensive social and psychiatric support Hollis, 2000 17

Greater impairment with early onset

• • Nature of disorder is more severe Disorder disrupts social and cognitive development • Severe impairment of ability to form friendships and love relationships • Impact on family relationships 18

Prognosis and Course Schizophrenia • • • • Chronic (only minority recover from first psychotic episode) Short term course worse for schizophrenia than for affective psychosis (12% in remission on discharge compared to 50% in affective psychosis) Recovery most likely in first 3 months of onset of psychosis YP who are still psychotic after 6 months have 15% chance of full remission Hollis & Rapoport, 2011 19

Prognosis cont.

• Associated with increased morbidity and mortality through both suicide and natural death.

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Predictors of poor outcome

• Premorbid social and cognitive impairments • • • Prolonged first psychotic episode Extended duration of intreated psychosis Presence of negative symptoms 21

Diagnosis historical

• • Kolvin’s studies in the early 70th distinguished autism from early onset psychosis DSM-111 and ICD-9 category of childhood schizophrenia removed and same diagnostic criteria across the age range 22

ICD -10 diagnostic criteria •At least one of: •Thought echo, thought insertion/withdrawal/broadcast •Passivity, delusional perception •Third person auditory hallucination, running commentary Persistent bizarre delusions •or two or more of: • Persistent hallucinations Thought disorder Catatonic behaviour Negative symptoms Significant behaviour change •Duration More than 1 month •Exclusion criteria Mood disorders, schizoaffective disorder Overt brain disease Drug intoxication or withdrawal 23

DSM IV - TR Diagnostic criteria for Schizophrenia A.

Characteristic symptoms successfully treated): : Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if (1) delusion s (2) hal lucinations (3 ) disorganised speech (e.g., frequent derailment or incoherence) (4) grossly d isorganised or catatonic behaviour (5) negative symptoms , i.e., a ffective flattening, alo gia, or avolition Note: Only one Criteri on A symptom is requ of a voice keeping up a running commentary on the person's behavior or thoughts, or two or more voices conversing with each other.

ired if delusions are bizarr e or halluc inations consist 24

DSM IV - TR Diagnostic criteria for Schizophrenia cont.

B.

Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).

C.

Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms) and may include periods of prodroma symptoms successfully treated) that meet Criterion A (i.e., active-phase l or resi symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

(or less if dual 25

DSM IV - TR Diagnostic criteria for Schizophrenia cont.

D.

Schizoaffective and Mood Disorder e xclusion: Sc or hizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, Mixed Episodes h ave occurred concu the active and residual periods.

rrent ly with th e act ive-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of E.

Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a g eneral me dical condition.

F.

Relationship to a Pervasive Developmental Disorder: If there is a history of Aut istic Disorder or another Pervas ive Developmental Disorder, the additional diagnosis of Schi month (or less if successfully treated).

zophrenia is made only if prominent delusions or hallucinations are also present for at least a 26

Physical Healthcare

• • • • Life expectancy may be reduced by 16-25 years: 1/3 suicide, 2/3

cardiovascular

, pulmonary and infectious disease Effects of antipsychotic medication: cardio-metabolic disturbance and weight gain 59% smoke at first presentation (6x higher then non psychiatric population) Often multiple cardiovascular risk factors: poor nutrition, inadequate exercise, problematic tobacco and substance use, poor healthcare 27

Incidence and Prevalence • • • • • • • Limited epidemiological knowledge Pre-pubertal: rare, estimated 1.6-1.9 per 100,000 Prevalence increases rapidly from age 14 Peak incidence late teens early twenties Australian sample of first episode psychosis 1/3 were 15-19 years (Amminger 2006) Pre-pubertal: male>female Adolescence: equal sex ratio 28

Aetiology

• Complex interaction of genetic, biological, psychological and social factors • Stress vulnerability model (Zubin & Spring, 1977) 29

High Zubin& Spring (1977) Model of Stress Vulnerability ILLNESS Stress Low WELLNESS Vulnerability High

Genetics

• • • • • First degree relatives: Mean risk: 5.9% Controls: Mean risk: 0.5% First degree relatives 12x greater risk than that of general population Second degree relatives: 3.0-3.7% (when intervening parent has not developed illness: ~2 %), Gottesman, 1982 In prepubertal children: high rate ( up t0 10%) cytogenetic abnormalities (small structural deletions/duplications) 34

Environmental factors

• • • • • Perinatal risk factors are being researched Urban living Poverty Child abuse Evidence of dose response association between childhood trauma and and psychosis (Read et al, 2008) 35

Cannabis

• May enhance the risk of schizophrenia in vulnerable individuals during critical period of adolescent brain development 36

Assessment

• • • • • • • • Detailed history Developmental hx Premorbid functioning Mental state Cognitive functioning Physical examination Exclude organic cause Consider Neuroimaging 37

Adolescents

• • • • • • • • • Engagement Flexible, adapt to developmental stage and age Global functioning Risk assessment Substance use Collateral information Consent Family involvement Confidentiality 38

Treatment

• • • • • Small evidence base Increased sensitivity of C and YP to adverse effects of antipsychotic medication Greater severity of schizophrenia and prevalence of treatment resistance in C and YP C and YP with schizophrenia are more likely to have cognitive impairment, negative symptoms and less systematised delusions and hallucinations (possibly limiting use of CBT) Importance of families in providing care and support (emphasising family interventions) 39

Treatment

• • Shift towards community treatment EIP teams: 14-35 years 40

F I R S T

• Treatment for ARMS Clinical staging approach • • • • Monitoring/Tracking Mental States Case management Social support Psychosocial interventions

S E C O N D

• • Antipsychotic medication Restrictive approaches (hospitalisation) 41

Psychological and Psychosocial interventions • Family interventions (relapse prevention: Leff and Vaughn, 1981, psychoeducation, Birchwood, 1992) • • • CBT (Kingdon and Turkington, 1994) Adherence therapy (Kemp et al, 1996) Individual Placement Support (Killackey, 2008) 42

High Expressed Emotion The three dimensions

• Hostility • Emotional over-involvement • Critical comments

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Hostility

• Hostility is a negative attitude directed at the patient because the family feels that the disorder is controllable and that the patient is choosing not to get better. Problems in the family are often blamed on the patient and the patient has trouble problem solving in the family. The family believes that the cause of many of the family’s problems is the patient’s mental illness, whether they are or not.

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Emotional Over-involvement

• It is termed emotional over-involvement when the family members blame themselves for the mental illness. This is commonly found in females. These family members feel that any negative occurrence is their fault and not the disorders. The family member shows a lot of concern for the patient and the disorder. This is the opposite of a hostile attitude and a show that the family member is open minded about the illness, but still has the same negative effect on the patient. The pity from the relative causes too much stress and the patient relapses to cope with the pity .

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Critical Comments

• Critical attitudes are combinations of hostile and emotional over-involvement. It shows an openness that the disorder is not entirely in the patients control but there is still negative criticism. Critical parents influence the patient’s siblings to be the same way.

• Family members with high expressed emotion are hostile, very critical and not tolerant of the patient. They feel like they are helping by having this attitude. They not only criticise behaviours relating to the disorder but also other behaviours that are unique to the personality of the patient.

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Pharmacological Treatment

• • • Antipsychotics Dietary and lifestyle counselling No evidence of greater efficiency of one antipsychotic over another • • Note: Exception: Clozapine Compliance is poor 47

PSYCHOSIS AND SCHIZOPHRENIA IN CHILDREN AND YOUNG PEOPLE RECOGNITION AND MANAGEMENT

National Clinical Guideline Number X National Collaborating Centre for Mental Health Commissioned by The National Institute for Health & Clinical Excellence Published by The British Psychological Society and The Royal College of Psychiatrists DRAFT FOR CONSULTATION AUGUST 2012 48