Transcript Early indicators of schizophrenia

Early Indicators of Schizophrenia
• Dr Jim Simm*, FRCPC; CCSAM
• Dr Richard Tachere*, MD; MPH
*Dept.
of Psychiatry, University of Manitoba.
CAPA Annual Conference
October 30th, 2016
Disclosure
• Dr. Simm has received honorarium payments for speaking on
behalf of Janssen pharmaceuticals on the treatment of
schizophrenia.
• Dr. Tachere has no conflict of interest to declare.
Stay
Awake
...WHY
???
Introduction:
• Schizophrenia can be a terrible mental illness:
 robs young people of their potentials;
 tears families apart;
 has an enormous burden on our society
(financial, legal, social, etc.)
Facts:
• Among the top 25 leading causes of disability globally
• ~ 3% of the total burden of human disease
• ~ 1% point prevalence
• > 60% of patients with the first episode of the illness
have persistence of symptoms & impairment in various
domains of functioning.
Facts:
• In Canada:
- hospital bed occupancy: 1 in 12
(higher than any other single disease)
- direct health & non-health care costs ~ $2billion/yr.
- indirect costs ~ $1.4billion/yr.
Facts:
• Peak age of onset for first psychotic episode:
- Males: early to mid-20s;
- Females: the late-20s.
• Early recognition and uninterrupted treatment
can lead to optimal outcomes.
Outline:
• Meaning of psychosis and schizophrenia;
• Approaches to Assessment, Diagnosis &
Treatment;
• The importance of early continuous treatment;
• Conclusion.
Overview
• Schizophrenia is a major mental illness - the
most well-known of the ‘psychotic’ disorders.
• Most common age of onset is 15-25yrs
• It affects ~ 1% of the population
 But what exactly is “psychosis”?
Psychosis…
•The term “psychosis” refers to an impairment
in reality testing.
•Symptoms: hallucinations, delusions,
disorganized speech, behavior, etc.
The contemporary concept of psychosis
(DSM 5):
Abnormalities in one or more of 5 domains:
• delusions,
• hallucinations,
• disorganized thinking (speech),
• grossly disorganized or abnormal motor
behavior (including catatonia), and
• negative symptoms
Signs and Symptoms of Psychosis
• Delusions
• Hallucinations
• Replaying or rehearsing conversations out loud- i.e.
talking to yourself (very common sign)
• Inappropriate responses - laughing or smiling when
talking of a sad event, making irrational statements.
Signs and Symptoms of Psychosis
• Catatonia - staying in the same rigid position for a long
time, as if in a daze.
• Intense & excessive preoccupation with religion or
spirituality
• Hypergraphia, bizarre writing with paranoid themes,
conspiracy theories, etc
• Frequent moves, trips, or walks that lead nowhere
Delusions
• Usually paranoid: others are plotting to harm you, are monitoring you,
can read your thoughts, etc.
• Often accompanied by ideas of reference: events or occurrences have a
special meaning to you.
• Grandiose delusions, often religious in nature (more common in mania)
• Somatic - infestation, bizarre somatic complaints (e.g. in psychotic
depression)
• Jealousy – Often delusional disorder.
Hallucinations
• Auditory: most common; generally commenting on behavior,
insulting comments or command hallucinations.
• Often source is attributed to “talking through the wall”, radio waves;
almost always human voices
• These can be either inside the person's head or externally.
• When external, they sound as real as an actual voice. Sometimes
they come from no apparent source; at other times they come from
real people who don't actually say anything.
Hallucinations…
• Visual: 2nd most common; usually misinterpretation of real
objects (i.e. illusions)
• Olfactory/gustatory: less common but usually of foul odour
or food is spoiled or tainted. (Consider psychotic depression
if this is a prominent feature).
• Tactile hallucinations: rare; often of being sexually violated.
Differential Diagnosis: 3 broad groups
• Psychoses:
(a) due to a mental or psychological disorder
(b) due to a general medical condition
(c) due to a substance (medication or drug of abuse)
Examples…
Mental or
Psychological
Other medical
illnesses
Substances
Schizophrenia
Infections
Cocaine
Bipolar
Electrolyte
imbalances
LSD
MDD, etc
Brain tumors, etc
Amphetamines, etc
DSM 5: Schizophrenia
• Symptoms: 2 or more of the 5 psychotic symptoms
• Duration: at least for 6months
• Functional impairment
• Note: One of the obstacles to early recognition
and treatment is lack of insight.
Complications of Schizophrenia
• Suicidal thoughts; attempts & completed suicide;
• Self-injury;
• Anxiety disorders & obsessive-compulsive features;
• Depression
• Abuse of alcohol or other drugs, including tobacco
• Inability to work or attend school
Complications of Schizophrenia
• Legal and financial problems and homelessness
• Social isolation
• Health and medical problems
• Being victimized
• Aggressive behavior, although it's uncommon
So now that I’ve established that the most
likely diagnosis is schizophrenia,
What should I do?
Assessment
• Goals of initial evaluation include:
development of a therapeutic alliance;
obtaining information required for diagnosis;
identifying factors that can assist or impede
recovery
Assessment
• Should include risk of:
 suicide & deliberate self-harm
 violence
 neglect
 victimization
Assessment
• Should include supports available:
 Engagement with families
 Other relevant social networks
 Community mental health resources available
 Non-adherence to treatment & service disengagement.
Assessment
• Goals of full medical work-up include:
Detection of medical etiologies and/or comorbidities;
Identification of risk factors for possible medical
disorders;
Providing a baseline against which pharmacological
complications & side-effects can be assessed.
Assessment
• History is key especially family history;
• Physical exam;
• Investigations:
Comprehensive drug screen
Imaging: specific findings are quite rare without a
neurological finding on exam; but family or patient
will often insist and be unwilling to accept
diagnosis until done.
Weight, glucose, lipid profile as baseline.
Some non-specific physical findings on exam
• A blank, vacant facial expression; e.g. staring while in
deep thought, with infrequent blinking, etc.
• Clumsy, inexact motor skills
• Abnormal eye movements, e.g. difficulty focusing on
slow moving objects
• Unusual gestures or postures
• Constant pacing
• Movement could be slowed down - staying in bed (in
extreme cases, catatonia)
Assessment: Investigations
Type
Blood
Urine
Imaging
Others
Examples
CBC; extended lytes; LFT;
BUN + Cr; TSH; Vit B12.
Urinalysis; street drug screen
CT, MRI & EEG (where
indicated)
*Case-specific (e.g. syphilis,
HIV, LP, etc.)
*If considering starting
antipsychotics, then: lipid
profile & FBS.
Non-specific early symptoms
• Withdrawal from friends and family
• A drop in performance at school
• Trouble sleeping
• Irritability or depressed mood
• Lack of motivation
Non-specific early symptoms (other
psychiatric disorders to consider)
• Drugs/alcohol
• Adjustment disorder
• Mood disorder
• Personality Disorder
• ADHD (usually history of early difficulties in school)
• Social anxiety disorder, etc.
•Early recognition and uninterrupted
treatment can lead to optimal
outcomes.
Prodromal Stage: *Early detection & interventions*
Stage
Prodromal
Transition rate:
*22% within one year
*36% within three years
Symptoms
*Significant decrease in
functioning PLUS identified
genetic risk or personality
traits (schizoid or schizotypal)
*Attenuated psychotic
symptoms
*Transient psychotic symptoms
(brief in duration & remit spontaneously)
*Others: substance use; ADHD;
anxiety; social withdrawal, etc.
Progressive Stage:
Stage
Progressive
Symptoms
*Overt psychosis
*Deterioration in symptoms
(the 5 domains in DSM 5)
*Deterioration in brain
abnormalities (thinning of frontal
cortex; lateral ventricular enlargement;
reduction of white matter integrity, etc.)
*Relapses & remissions
clinical deterioration.
Chronic/Residual Stage
Stage
Symptoms
Chronic/Residual
*Generally: poor functioning;
social & occupational
disability.
*Progression of brain
abnormalities
*Outcomes are
heterogeneous.
Clear evidence that early uninterrupted
intervention decreases the burden of illness
Reduces # of relapses & hospitalizations
Higher functioning
Preservation of grey matter
Patients without psychotic symptom
exacerbation or relapse (%)
Antipsychotic Discontinuation and Relapse in
Schizophrenia
1.0
0.8
Relapsed
0.6
0.4
Remaining well
0.2
0
0
12
24
36
48
60
72
Week
Gitlin M, et al. Am J Psychiatry 2001;158:1835–42
Adherence to Treatment Among Outpatients With Schizophrenia
100
Adherence Rate (%)
90
80
70
60
50
40
30
Self-Report
Clinician rating
Pill Count
Adherence Measure
*Medication Event Monitoring System (MEMS®)
Remington G. et al. Scz Res 2007.
MEMS*
Enhancing Adherence
• Patient engagement and active involvement;
• Clear, simple instructions; (people recall at best 50% of
what was said during appointments, and the 50% recalled
is often not the same 50% as the clinician wanted to
emphasize);
• No blame environment;
• Enquire about financial barriers.
Enhancing Adherence
• If you give out reading material, make sure that
the patient and family can understand it;
• The best results are seen with Long Acting
Injectables.
Conclusions
• Schizophrenia can be a devastating illness for the
patient, family & society;
• Early recognition AND early uninterrupted
treatment are crucial to long term positive
outcomes.