Transcript Psychosis in Children and Young People

Psychosis in Children and
Young People
• MRCPsych Course
• Dr Gisa Matthies
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Psychosis
• from the Ancient Greek
• ψυχή "psyche", for mind/soul
• -ωσις "-osis", for abnormal condition or
derangement
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Psychosis
• Schizophrenia
• Schizoaffective disorder
• Schizophreniform disorder
• Delusional disorder
• Bipolar affective disorder
• Depressive disorder
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Psychosis
• Experience of psychosis challenges an
individual’s fundamental assumption that
they can rely on the reality of their
thoughts and perceptions
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Psychotic Symptoms
• Hallucinations
• Delusions
• Thought disorder
• Negative symptoms
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Schizophrenia in children and young
people
• Major psychiatric disorder
• Psychotic symptoms that alter the YP’s
perception, thoughts, affect and
behaviour
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Prodromal Period
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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
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Delay in Diagnosis
• Insidious onset of prodromal period
• Delusions can be poorly systematised
• Thought disorganisation is common
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Acute Episode
• Hallucinations, delusions, behavioural
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disturbance
Agitation, distress, fear, puzzlement
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Residual Symptoms
• Negative symptoms
• Persisting symptoms more common
when condition starts in pre-adolescent
children
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‘At-risk mental states’ (ARMS)
‘Ultra high risk’ (UHR)
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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
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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)
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Problems of using clinical label
• Stigma
• Ethical issues
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ARMS/UHR
dimensional view
non specific symptoms
cusp of psychosis
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Impairment and Disability
• Consequence of
– disabling psychotic symptoms
– adverse effects of poor physical health
– adverse effects of drug treatments
– stigma
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Impairment and Disability
• Development and functioning:
– Psychological
– Social
– Educational
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Outcome
Schizophrenia with onset in childhood
and adolescence
• 1/5 good outcome with only mild
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impairment
1/3 severe impairment requiring
intensive social and psychiatric
support
Hollis, 2000
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Greater impairment with earlyonset
• Nature of disorder is more severe
• Disorder disrupts social and cognitive
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development
Severe impairment of ability to form
friendships and love relationships
Impact on family relationships
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Prognosis and Course Schizophrenia
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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
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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
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impairments
Prolonged first psychotic episode
Extended duration of intreated psychosis
Presence of negative symptoms
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Diagnosis historical
• Kolvin’s studies in the early 70th
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distinguished autism from early onset
psychosis
DSM-111 and ICD-9 category of
childhood schizophrenia removed and
same diagnostic criteria across the age
range
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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
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DSM IV - TR
Diagnostic criteria for Schizophrenia
A. Characteristic symptoms: Two (or more) of the following, each
present for a significant portion of time during a 1-month period (or
less if successfully treated):
(1) delusions
(2) hallucinations
(3) disorganised speech (e.g., frequent derailment or incoherence)
(4) grossly disorganised or catatonic behaviour
(5) negative symptoms, i.e., affective flattening, alogia, or avolition
Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations
consist of a voice keeping up a running commentary on the person's behavior or thoughts, or
two or more voices conversing with each other.
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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 (or less if
successfully treated) that meet Criterion A (i.e., active-phase
symptoms) and may include periods of prodromal or residual
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).
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DSM IV - TR
Diagnostic criteria for Schizophrenia cont.
D. Schizoaffective and Mood Disorder exclusion:
Schizoaffective Disorder and Mood Disorder With Psychotic Features have
been ruled out because either (1) no Major Depressive, Manic,
or Mixed Episodes have occurred concurrently with the active-phase
symptoms; or (2) if mood episodes have occurred during active-phase
symptoms, their total duration has been brief relative to the duration of
the active and residual periods.
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 general medical
condition.
F. Relationship to a Pervasive Developmental Disorder:
If there is a history of Autistic Disorder or another Pervasive
Developmental Disorder, the additional diagnosis of Schizophrenia is made
only if prominent delusions or hallucinations are also present for at least a
month (or less if successfully treated).
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Physical Healthcare
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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
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Incidence and Prevalence
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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
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Aetiology
• Complex interaction of genetic,
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biological, psychological and social
factors
Stress vulnerability model (Zubin &
Spring, 1977)
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High
Zubin& Spring (1977)
Model of Stress Vulnerability
ILLNESS
Stress
WELLNESS
Low
Vulnerability
High
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Genetics
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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)
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Environmental factors
• Perinatal risk factors are being
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researched
Urban living
Poverty
Child abuse
Evidence of dose response association
between childhood trauma and and
psychosis (Read et al, 2008)
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Cannabis
• May enhance the risk of schizophrenia in
vulnerable individuals during critical
period of adolescent brain development
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Assessment
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Detailed history
Developmental hx
Premorbid functioning
Mental state
Cognitive functioning
Physical examination
Exclude organic cause
Consider Neuroimaging
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Adolescents
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Engagement
Flexible, adapt to developmental stage and
age
Global functioning
Risk assessment
Substance use
Collateral information
Consent
Family involvement
Confidentiality
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Treatment
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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)
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Treatment
• Shift towards community treatment
• EIP teams: 14-35 years
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• Treatment for ARMS
Clinical staging approach
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• Monitoring/Tracking Mental States
• Case management
• Social support
• Psychosocial interventions
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Antipsychotic medication
Restrictive approaches (hospitalisation)
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Psychological and Psychosocial interventions
• Family interventions (relapse prevention:
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Leff and Vaughn, 1981,
psychoeducation, Birchwood, 1992)
CBT (Kingdon and Turkington, 1994)
Adherence therapy (Kemp et al, 1996)
Individual Placement Support (Killackey,
2008)
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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
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antipsychotic over another
Note: Exception: Clozapine
Compliance is poor
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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
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