Transcript New Research in Early Psychosis - Early Assessment and Support

Rob Wolf
Bruce Neben
Ryan Melton
http://www.iepa.org.au
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Dropping Schizophrenia subtypes
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Adding Psychosis Risk Syndromes
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Includes shared psychotic disorder
Adds catatonia specifier
Attenuated Psychotic Symptoms Syndrome
Moving away from “prodrome”.
http://www.dsm5.org/Pages/Default.aspx
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Aims
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Rule out past and current psychosis
 POPS (presence of psychotic symptoms at 6 on SOPS-
scale of psychosis risk syndromes.
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Rule in one or more of 3 types of At risk syndromes
 BIPS (Brief Intermittent Psychotic State)
 Attenuated Positive Symptom State (APSS)
 Genetic Risk & Deterioration (GRD)
Rate severity of current at risk syndromes.
 Major changes
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 Rule out criteria emphasized
 Emphasis on more objective GAF.
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1 year RCT of 10 sites with 1268 individuals
(China).
Tx group received meds, family
psychoeducation (not mfg), skills training,
CBT.
Outcomes:
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Tx group lower drop out
Tx group greater improvement in insight, social
function, ADL’s, quality of life, employment &
education.
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Clinical trial of 106 individuals in their families
to determine if integrity to model predicted
outcome.
Results indicated those who received high
integrity to model had lower rates of
psychiatric symptoms when compared to those
who received lower/moderate integrity.
No difference in caregiver distress. (Did not
measure common mfg outcomes of EE and
communication).
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2 year RCT of 53 early course schizophrenia
individuals.
Tx group received intensive CET in addition to
medications and supportive therapy.
Outcomes:
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Tx group had greater preservation of gray matter in
left hippocampus, parahippocampul gyrus, and
fusiform gyrus.
Tx group had significantly greater gray matter
increase in amygdala.
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The largest longitudinal study on psychosis
Study of 2 ½ years after initial assessment
A consortium of longitudinal studies from 10
major universities
All NIMH funded
All studies contribute to a common database
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Affective psychosis may share a prodrome
with schizophrenia spectrum disorders
Conversions to affective psychosis were in the
minority- 10%
DSM IV diagnosis is unstable in first episode
and is not a good predictor of future diagnoses
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Prodrome- social and role functioning are
impaired
Role functioning is malleable and can be
impacted
Social impairment is stable and is difficult to
impact
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Overall risk of conversion to psychosis is 35%
Decelerating trend of conversion
Rate of conversion is highest in the first 6 months13%
 7 to 12 months 9%
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 Then 5%
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25 to 30 months- 2.7%
Most important prodromal factors predicting
conversion to frank psychosis
 Genetic risk with functional decline
 Unusual thought content
 Suspicion/paranoia
 Social functioning
 Substance abuse
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The most widely used illicit drug in the world,
youngest age of initiation, potency and use has
increased since 1970’s
In first-episode psychosis, rates of cannabis abuse
range from 15% to 65%
Most common reasons for use: reduce boredom,
something to do with friends, to improve sleep
Use can result in transient psychosis, mania, panic,
depression, and cognitive impairment
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Cognitive deficits from heavy usage can take 28 days to
several months to resolve
yes
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D’Souza (2005) 0, 2.5 mg, 5 mg of THC to clinically
stable SCZ and controls
 80% SCZ group had a brief, modest increase in their
typical positive symptoms/ 35% of controls
experiences psychosis
 At 5 mg there was significant cognitive impairment
in SCZ group and controls at 5 mg experienced
cognitive impairment similar to baseline cognitive
impairment of the SCZ group
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maybe
Andreasson’s famous Swedes study (1969-1970/ 45K
conscripts)
 2.4 X higher than nonusers
 6 X higher if used >50 X
Arseneault and Dunedin study (1972-73/ 1,037/ 26 years)
 3X between 15-18 lead to increased risk
 If age 15, 10% SCZ dx vs. 3% controls
Van Os (2002/ 4,104/ 3 years)
 Compared nonpsychotic vs psychotic disorders using
THC and found psychotic sxs. Increased in a dose
dependent nature (13% vs. 50%)
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Despite the significant increase in THC usage and the lower age of
exposure, the incidence of SCZ has not changed
There is striking uniformity in the incidence of SCZ in different
cultures though the rates of THC use vary widely
Most people with SCZ do not use THC (25%)
Most people who use THC do not develop SCZ (7%)
SCZ is believed to be a neurodevelopmental disorder that begins
in childhood, well before THC use begins
The self-medication hypothesis has been repeatedly disproven
THC use is linked to depression, cognitive impairments, negative symptoms,
anxiety
 Most studies show that THC usage precedes the onset of psychosis
 Most studies show reasons for THC usage are not associated with symptoms of
SCZ
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Endocannabinoids play an important role in
neurodevelopment which is occurring into mid 20’s,
exogenous cannabinoids interfere with that system
THC increases dopamine release in the frontal lobe via
binding to a CB1 receptor
Individuals with SCZ have a greater density of CB1
receptors in the prefrontal cortex.
Elevated levels of anandamide, an endogenous
cannabinoid receptor agonist, is found in the CSF of
people with SCZ
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Cannabis can induce a transient SCZ-like state with
positive, negative, and cognitive symptoms
These symptoms may be greater in magnitude and
duration for people with SCZ
Early and heavy exposure may result in a psychotic
disorder
Yet, the increase in use, the use of more potent forms,
and the earlier age of exposure has not resulted in an
increase in the rates of SCZ
Most people who use cannabis do not develop SCZ,
most people with SCZ do not use cannabis.
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FA reduce free radicals, improve antioxidant defense,
reduce cell injury and stabilize the cell membrane
Stabilize the serotonergic and dopaminergic systems
Reduced levels of FA in individuals with SCZ
Four controlled trials of FA supplementation that has
shown beneficial effects in patients with SCZ
Randomized, placebo-controlled trial of 1.2 g of w-3 FA for
12 weeks
 4.9% of treated group transitioned to psychosis vs. 27.5 %
of the placebo group
 PUFA significantly reduced positive and negative
symptoms and improved functioning
 Results were sustained after one year
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DSM III (1980)
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“a complete return to premorbid levels of
functioning in individuals with schizophrenia is so
rare as to cast doubt upon the accuracy of the
diagnosis.”
DSM IV (2000)
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Complete remission… is not common in this
disorder.
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Vanderbilt University
Oxford University
Yale Law School
USC Law Professor and Associate Dean
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Vanderbilt University
Oxford University
Yale Law School
USC Law Professor and Associate Dean
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Person with schizophrenia
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Shirley Glynn
Ellen Saks
Etc
What Coping Strategies do high functioning
people with schizophrenia use?
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Take medicine as prescribed
Staying healthy
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Exercise, regular sleep, eating healthy foods
Spiritual activities
Having pets or not living alone
Controlling the amount of stimulation in the
environment
An attitude of perseverance- Hope
Taking care to avoid:
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Drugs and Alcohol
Traveling
Crowded social situations
Isolation
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The clinicians illusion
Only 1/3 of people with schizophrenia come to
treatment
About 50% of people with schizophrenia have
good outcomes
Recovery:
“People are are able to live, work, learn and
participate fully in their community. For some
the ability to live a fulfilling and productive life
despite a disability….”
The President’s New Freedom Commission
on Mental Health
Generally better outcomes in the developing
world, especially Nigeria and India
 A greater percentage of people with
schizophrenia in the developing world work
and marry.
 In India 67% marry
 Results attributed to increased family and
community support and lack of financial
disincentives
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Recovery from schizophrenia is not only
possible, but probably common
Family and community support is critical
Self-care is critical
While some people will not have positive
outcomes, many can
What have we learned today that can help us
improve outcomes and support recovery?