Embed Size (px)
Citation preview
First Episode Psychosis; Psychosis in Youth
Sharman Robertson BSc MD FRCPC
child & youth Mental Health Series
Date: February 25 2016
If you are connected by videoconference please mute your system and unmute to ask a question
Please feel free to ask questions!
By registering for today’s event…
You will have had an opportunity to apply for professional credits or a certificate of attendance You will receive an email with a link to today’s online evaluation
Visit our website to download slides and view archived events Sign-up to our distribution list to receive our event notifications Questions? [email protected]
You may also want to…
Speaker has nothing to disclose with regard to commercial support.
Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.
Declaration of conflict
Agenda • On Track First Episode Psychosis Program • Evolution of First Episode Psychosis
Programs • Ontario Standards • Stress diathesis model • Clinical Features Psychosis in Youth • Differential Diagnosis • Treatment • Outcomes
On Track
• Recovery-based • Individuals aged 16-35 with first episode of
psychosis (FEP) • Champlain District 1.3 million with satellites in
Hawkesbury, Cornwall and Pembroke • Case management model • Interdisciplinary team • Follow for up to 3 years • Group, individual, family work
Rationale of First Episode Programs
• Early recognition of psychosis • Shorten DUP
– Improve outcomes • Symptom resolution • Return to full function
– Prevent relapse – Prevent
• Cognitive decline • Treatment resistant symptoms • Loss of relationships • Loss of ability to be productive
• Reduction of stigma • Rehabilitative model
Long DUP
• Longer DUP
– Reduced treatment response – Poor functional outcome – Disrupted personal relationships – Increased legal involvement – Substance use – Disrupted school and work performance – Housing instability
Ontario Perspective
• Yearly incidence = 12 / 100,000 • Majority between ages of 14-35 years • First 3-5 years high risk for:
– Suicide (2/3 of suicides) – Relapse – Hospitalization – Loss of social supports – Disruption of work, school, housing – Substance use – Legal problems
Early Psychosis Intervention (EPI) Ontario
• 1999: Making it Happen: Implementation Plan for Mental Health Reform- psychosis requires intensive care
• 1999: Ontario Working Group for Psychosis advocated for EPI (clients, families and community mental health agencies)
• 2004: MOHLTC announced EPI program funding 30 programs
Early Intervention Ontario Network EPION
• Formerly the Ontario Working Group • Ministry funded • Volunteer
• Provides www.epion.ca – Networking – Research – Knowledge sharing – Conferences – Shapes policy – FEP advocacy
Key Components
• Early identification and facilitated access • Comprehensive assessment
– Up to 3 months including treatment to establish dx – May lead to enrolment if criteria met
• Treatment • Psychosocial supports • Family education and support • Public education • Research
On Track Eligibility and Timelines
• Age 16-35 years • < = 6 months of treatment for psychosis • Absence of severe substance use disorder,
forensic history or established mood disorder • Contact client/family within 72 hours • In-person assessment within 2 weeks
• 613-737-8069
Psychosis
• Loss of touch with reality • Reduced ability to determine what is coming
from within own thoughts and perceptions and what is happening in the environment
• Not a diagnosis • Collection of signs and symptoms • Common end point for several mental
illnesses
Stress Diathesis
Progression to Psychosis
Neurochemistry: Dopamine
• Dopamine (DA) hypothesis:
– Too Much DA in certain brain areas
• Efficacy of DA blocking medications • Psychotomimetic effect of stimulants
– DA levels actually low in prefrontal cortex
Serotonin: Modulates DA
• 5HT-2 blockade:
– reduces psychotic symptoms – Reduces side-effects caused by blocking DA –
• Second generation anti-psychotics (SGA’s): – 5HT-2 blockers – Risperidone, olanzapine, seroquel – Older: clozapine
+ −
Direct action as an
accelerator
Indirect action as
brake
+
GLU GLU
Cortex
GABA
DA
GLU = glutamate. Adapted from Tsapakis EM, et al. Adv Psychiatr Treat. 2002;8(3):189-197. Carlsson A, et al. Br J Psychiatry Suppl. 1999;(37):2-6.
Cortical Glutamate Regulates DA Neurons in 2 Possible Ways
Adapted from Tsapakis EM, et al. Adv Psychiatr Treat. 2002;8(3):189-197. Citrome L. Curr Psychiatry Suppl. 2011;10(9):S10-S14.
With Psychosis NMDA Receptors are under-firing
+
Direct action as an
accelerator
GLU
Cortex
DA NMDAR Hypofunctioning
DA is too low and we see: -Lack of motivation, pleasure, depressed mood -Impaired ability to concentrate, pay attention remember -Impaired ability to plan, organize, use abstract concepts
With psychosis there is no brake for DA in the mesolimbic area
−
Indirect action as
brake
+
GLU
Cortex
GABA
DA
NMDAR Hypofunctioning
DA is too high in the mesolimbic area - delusions and hallucinations
Clinical Features
Pre-pubertal Psychosis
• Rare, less common than autistic spectrum disorder
• Abnormal development: – Soft neurological S+S – LDs – Expressive/receptive language delays – Attachment issues – Autistic features – Reduced response to treatment
Mental Status Examination
• Appearance, self-care – Dressed for weather, clean, dishevelled, mannerisms,
sunglasses, make-up, unusual costumes, body odour • Behaviour
– Guarding, slowing, agitation, aggression, vigilance, responding to internal stimuli, grandiosity, mannerisms
• AIMs/EPS – Dyskinetic movements of mouth, lips, face – Tremor, stiffness, lack of facial expression, restlessness,
robotic gate • Affect
– Flat, reduced, robotic, labile, hostile, euphoric, angry, perplexed, fearful, depressed, superficial
Mental Status Examination
• Mood – Numb, depressed (neuro-vegetative signs and
symptoms), bored, swings, elated, irritable • Speech
– Pressured, over-inclusive, prolongation of response latency, slow, muteness
Mental Status Examination
Thought form – Tangentiality:
• Jumping from topic to unrelated topic – Circumstantiality:
• Starting at one topic and speaking of partially related themes, over -inclusive of detail, eventually getting back to first point.
– Loosening of associations: • Ideas are not related to each other and syntax of language is
breaking down – Flight of ideas:
• Rapid-fire thoughts that the person can not slow down – Poverty of thought:
• Lack of output or devoid of content – Thought blocking – Prolongation of response latency
Thought Form Disorders in Children
Developmental stage of child is important. Normally thought form disorganized before the age of 7 years. Possible to detect thought form disorganization after this.
Mental Status Examination
• Thought content – Delusions
• Paranoid • Referential • Control • Religious • Pseudo-philosophical • Somatic • Grandiose • Erotomanic
– Hallucinations • Auditory, visual, olfactory, senesthetic, gustatory
Children - content involves animals, cartoons, super heros Adolescents - content similar to adults
Mental Status Examination
– Hallucinations • Auditory, visual, olfactory, tactile, gustatory
Children – Transient hallucinations possible during times of stress, loss. True hallucinations accompanied by LDs, attachment issues soft neuro S + S. Adolescents – Transient hallucinations seen with personality DO, panic attacks, trauma history.
Mental Status Examination
• Attention and concentration • Ability to use abstract concepts
– Similarities and proverbs • Insight and judgement
– Do they think they have an illness? – How do they explain their circumstances? – Does medication help? – What are their strategies to deal with symptoms? – What is their motivation to use strategies?
Mental Status
• Suicidal thinking – Passive vs. active – Plan – Association with delusions of control or impulses – Association with command hallucinations – Degree of control a person feels they have over the
thoughts/impulses – Awareness of coping strategies – Ability to use coping strategies – Alliance with their team – Hopelessness – Emotional reaction to these thoughts
• Calm and resolved vs. fearful of it actually happening
Mental Status
– Homicidal thinking • Past history of violence • Medication non-adherence • Substance abuse • Delusions of persecution or control
– Know the delusional system • Association with command auditory hallucinations • Insight into this as a symptom • Emotional reaction to these thoughts
– Fear and shame – Aggression – Flatness
What Things Besides Schizophrenia Cause Psychosis?
• Drug or alcohol induced psychosis • General medical conditions • Mood disorders • Schizophrenia spectrum disorders
Substance and Alcohol Induced Psychosis • Withdrawal states;
alcohol, anxiolytics, sedatives, GHB
• Stimulants; – amphetamines, cocaine
• Hallucinogens; LSD,PCP, ecstasy
• Cannabis • Prescription drugs
Can Drugs Cause Schizophrenia?
• Certain drugs can mimic psychosis when a person is high
• In a drug induced- psychosis symptoms are gone within one month after stopping the drug
Can Drugs Cause Schizophrenia?
• If symptoms last longer than one month something else is going on -possibly schizophrenia
• If psychosis occurs with drug use that person’s nervous system is vulnerable to psychosis
• Taking drugs at that point may lead to more psychosis!!
General Medical Conditions
• Rarely a cause of psychosis (<10%) • Seizure disorders • Genetic conditions;
– Huntington’s, Wilsons disease – Velocardiofacial syndrome
• Infections; encephalitis, meningitis, HIV/AIDs • Dementia
Mood Disorders
• Major Depressive Disorder • Bipolar disorder
Schizophrenia Spectrum Disorders
• Brief psychotic disorder • Schizophreniform disorder • Schizophrenia • Schizoaffective disorder • Delusional disorder
Schizophrenia: Core Symptom Clusters
II. Negative symptoms affective flattening alogia avolition anhedonia
III. Cognitive symptoms attention memory executive functions (e.g., abstraction)
IV. Mood symptoms dysphoria suicidality hopelessness
I. Positive symptoms delusions hallucinations disorganized speech catatonia
Social/occupational dysfunction work interpersonal relationships self-care
Personality Disorders
• Borderline PD • Paranoid PD • Schizotypal PD
Autistic Spectrum Disorders
• It is possible to have autistic spectrum disorder and schizophrenia together
• Must have prominent delusions/hallucinations and thought form disorganization
Anxiety Disorders and OCD
• Panic disorder • OCD
Treatment
• Case management • Stage specific • Acute psychosis:
– Assessment, avoid premature diagnostic closure – Patient and family psycho-education and support – Crisis management – Symptom management
• Antipsychotic, antidepressant, antianxiety medication • Low dose • Metabolic management
Treatment
• Stabilization: – CBT – CRT – Neuropsychological testing – Recreation therapy:
• Social and exercise groups
– Occupational therapy: • Scholastic and vocational support
Treatment
• Reintegration: – Back to work and school – WRAP – FWRAP – Encourage activities outside of On Track – Relapse prevention – Attempt discontinuation of medication for some – Taper to lowest preventative dose for most
On Track Outcomes
• N= 95 • Mean age 26.4 years, 61% male
Baseline Endpoint
Admission rates 1.09 (SD = 1.11) 0.6 (SD = 0.06) ER visits 1.68 (SD = 1.41) 0.07 (SD = 0.30) Hospital days 17.86 (SD=20.95) 1.32 (SD = 8.14) PANSS total 70.67 (SD=20.95) 53.13 (SD=18.01) CGI 4.36 (SD = 1.13) 2.87 (SD = 1.14) GAF 49.20 (SD=13.57) 61.78 (SD=17.54)
School enrollment increased 45% Unemployment decreased by 33%
Questions?
Join us next time: TBD with Dr. Davis-Faroque – March 17, 2016 @ CHEO
for participating in today’s Mental Health Series
Thank you!
