JMO Education Session 2016...2016/03/03 · Formal thinking Fish’s Psychopathology Elicing Disturbances in thought organisaon: Formal thought disorder • Allow >me • Encourage:

JMO Education Session 2016

Oliver Schubert MD PhD MRCPsych FRANZCP

Clinical Academic – Senior Lecturer Discipline of Psychiatry, University of Adelaide

Case Vignette

A 22-year-old man is brought to the ED department by the police. He reportedly had barricaded himself in his house with his dog for several days, and notified family members via text messages that he feared for his life as neighbours were threatening and monitoring him. Discuss your approach to assessment and management of this patient.

Learning Objectives: Skills –  Handle immediate risk and medical emergencies in a person presenting

with psychotic features –  Establish an initial working diagnosis –  Establish the presenting complaint and its history –  Take a focused background history asking for predisposing, precipitating,

and perpetuating factors contributing to the presentation –  Elicit the typical symptoms associated with psychosis in the mental state

examination, and describe them using appropriate terminology –  Establish a plausible working diagnosis and differentials, taking into account

the different DSM-5 defined disorders that can present with psychosis –  Establish a formulation of the presentation –  Conduct a risk assessment –  Formulate an appropriate management plan

Learning Objectives: Knowledge

–  Define psychosis & describe its main clinical features

–  Describe the epidemiology of psychotic disorders –  Describe etiopatholigical factors associated with

psychosis –  Describe the different DSM-5 defined disorders

that can present with psychosis, and distinguish between them

–  Describe principles of clinical management of

psychotic disorders

Diagostic hypothesis

Risk assessment

Recognizing and Handling immediate risk and medical emergencies in a person presenting with psychotic features

Skills:


Risk assessment

Immediate clinical considerations in psychosis

•  Have I fully understood the situation and the referral information? •  Is this a medical emergency in need of urgent attention? Examples:

–  Head trauma? –  Physical injuries (e.g. through self harm) –  Signs of dehydration or starvation? –  Delirium? NMS? –  Acute intoxication? (medications, drugs)

•  Is there behavioural disturbance in need of urgent attention? Examples:

–  Acute aggression? –  Acute self harming behaviours? –  Acute suicidality? –  Acute risk of absconding?

•  Are there acute risks to members of the treatment team (incl. myself)? Examples:

–  Acute aggression/ agitation? –  Sources of infection? –  Carrying weapons?

Exercise: Case Vignette

A 22-year-old man is brought to the ED department by the police. He reportedly had barricaded himself in his house with his dog for several days, and notified family members via text messages that he feared for his life as neighbours were threatening and monitoring him. What are immediate considerations in THIS scenario? What is your diagnostic hypothesis? Why?

DEFINITION & CORE CLINICAL FEATURES (SYMPTOM DOMAINS) ELICITING CORE CLINICAL FEATURES OF PSYCHOSIS

Knowledge & Skills


Risk assessment

Psychosis definition A mental disorder in which the thoughts, affective response, ability to recognise reality, and the ability to communicate and relate to others are sufficiently impaired to interfere grossly with the capacity to deal with reality. (Kaplan and Sadock’s Comprehensive Textbook of Psychiatry)

Ø Simply put, it is disordered reality testing

Psychosis: Symptom Domains

①  Disturbances of perception Hallucinations

②  Disturbances of reality interpretation/thought content Delusions

③  Disturbances of thought organisation Formal thought disorder

④  Disturbances of motor function Catatonia

①  Disturbances of perception: hallucinations

Definitions: A perception without an object (Esquirol, 1817) False perceptions that are not in any way distortions of real perceptions but spring up on their own as something quite new and occur simultaneously with and alongside real perception (Jaspers, 1962) An exteroceptive or interoceptive percept that does not correspond to an actual object (Smythies, 1956) A perception without an object (within a realistic philosophical framework) or the appearance of an individual thing in the world without any corresponding material event (within a Kantian framework) (Cutting 1997) A cognitive definition: coding, appraising, transforming information Mental images that (1) occur in the form of images, (2) are derived from internal sources of information, (3) are appraised incorrectly as if from external sources of information, and (4) usually occur intrusively (Horowitz, 1975) Simply put: A sensory perception not associated with an actual external stimulus.

Classification of hallucinations

•  According to sensory modality: –  Visual (usually organic states; drugs: solvents, petrol, LSD, mescaline)–  auditory (elementary: organic states; voices: SCZ, alcohol hallucinosis) –  Olfactory (organic states, esp. TLE; SCZ) –  Gustatory (depression, SCZ, organic states, medications, drugs) –  Tactile (formication, e.g. drug intoxication or withdrawal) –  visceral (SCZ, often with somatic delusions/ –  Kinaesthetic passivity; organic states, drug withdrawal)

•  Associated with sleep: –  Hypnagogic hallucinations –  Hypnopompic hallucinations

•  Occurring in inner subjective space (often in distress) –  Pseudohallucinations (personality disorders, grief, anxiety etc.)

Eliciting disturbances in perception (Hallucinations) Screening questions (examples): “Have you seen visions or other things that other people did not see? Have you heard noises, sounds, or voices that other people did not hear? Have you experienced smells or tastes that were unusual? Have you ever had any other bodily sensations which you found difficult to explain?” If auditory hallucinations (voices) are present: “How many voices do you hear? Are they male or female? What do they say? Do they speak to you directly or in the third person? Do they comment on what you are doing or thinking? Do they argue with each other? Do they ever give you commands or tell you to do things?”

②  Disturbances of reality interpretation: delusions

Definition: A false belief based on incorrect inference about external reality, that is not consistent with the patient’s intelligence and culture, and continues to be held with conviction despite reasoning to the contrary. (Kaplan & Sadock’s)

Simply put: A fixed false belief.

Classification of delusions

–  Primay vs. secondary delusions – Primary: direct result of psychopathology – Secondary: in response to other primary

psychiatric conditions (e.g depression, dementia etc)

–  According to content (11 types commonly recognized):

1. persecutory 2. grandiose, 3. control (‘passivity’) 4. thought interference (‘passivity’) 5. reference, 6. guilt, 7. love 8. jealousy 9. hypochondriacal 10. nihilistic 11. infestation.

Classification of delusions (ctd.)

–  According to plausibility Bizarre vs. non-bizarre delusions

–  According to organisation, complexity and stability

Systematised vs. non-systematised delusions –  In reference to mood

Mood-congruent vs. mood-incongruent

How do delusions develop? Delusions can arise: •  “out of the blue”: autochthonous delusion •  on seeing a normal percept: delusional perception •  on recalling a memory: delusional memory •  on a background of anticipation, odd experiences,

increased awareness: delusional mood “Laying down” delusions is an active process: 1.  Delusional mood/ delusional atmosphere 2.  Cognitive elaboration, delusional idea – subjective

relief 3.  Building a delusional system (elaboration)

Eliciting Disturbances in reality interpretation/thought content Delusions Screening questions (examples): “Do you ever feel like people are following you or trying to hurt you in some way? Have you ever felt you had special powers, such as reading other people’s minds? Have you ever been listening to the radio or TV and felt it was referring to you? Has anybody ever interfered with your thinking or your movements? Have you ever felt that anything was wrong with your body or health, or that you had some serious illness?” If any of the above are answered positively, they must be explored further: “Tell me more about this. How was/is this like? How does it affect you? How do you cope with it? Have you done anything about it, or are you planning to do anything? ”

③  Disturbances of thought organisation: formal thought disorder

Definitions: •  Disorders of reasoning •  A disturbance in the connectedness of ideas

•  i.e. structure or “form” of thinking, rather than its contents.

•  The inability to communicate thoughts and ideas in a logical and ordered manner

thinking

Streamofthought

Possessionofthought

Contentofthinking

Formofthinking

Fish’sPsychopathology

Thoughttempo

• Flightofideas• Inhibi>onorslowing

• circumstan>ality

Con>nuityofthought

• persevera>on• Thoughtblocking

Streamofthought

Transitorythinking

Grammarandsyntaxdisturbed

•  derailments•  fusion•  Subs>tu>ons•  Omissions

Drivellingthinking

Grammarandsyntaxdisturbed

• mixing• muddling•  Similartospeechdisorder:schizophasia/wordsalad

Desultorythinking

Grammarandsyntaxintact

•  Looseningofassocia>ons•  Suddenideas

Formalthinking

Fish’sPsychopathology

Elici5ngDisturbancesinthoughtorganisa5on:Formalthoughtdisorder•  Allow>me•  Encourage:

–  Spontaneousspeechorfreeformresponses–  Abstractideas–  Clarifica>on,explana>ons

•  Self-reflec>on(sinceyouarethediagnos>cinstrument)–  Doestheproblemliewithyouorthepa>ent?–  What/howmuchinforma>onhasbeenconveyed?–  Howhasthepa>entcommunicatedthisinforma>on?–  Howhard/easywasittogatherthisinforma>on?

•  Writedownverba>mexamples(mayciteintheMSE)Alsorefertoexamplesdocumentinthepsychopathologymodule

④ Disturbancesofmotorfunc>ons:catatonia

Defini>on:•  Aseveredisturbanceofmotorfunc5onswithmarked decrease in reac5vity to theenvironment

•  A state of increased muscle tone at rest,abolished by voluntary ac5vi5es (andthereby dis5nguished from extrapyramidalrigidity)

OyebodeF.:Sims’SymtomsintheMind

Catatonicphenomena•  Abnormali5esintheexecu5onofmovements

•  Catatonicexcitement•  Catatonicmu>sm/stupor/catalepsy/staring•  Catatonicposturing,stereotypies•  Catatonicrigidity

•  Abnormalmovementswheninterac5ngwithothers•  Catatonicopposi>on/nega>vism•  Automa>cobedience•  Ambitendency•  Echolalia,echopraxia•  Cereaflexibilitas(waxyflexibility)

•  Laboratoryfindings(non-specific)•  Leukocytosis•  IncreasedCrea>neKinase(CK);DDx:NMS•  Lowserumiron(in40%ofptswithmalignantcatatonia)

Elici5ngdisturbancesinmotorfunc5on:Catatonia

•  Observa>on•  Physical/neurologicalexamina>on

Examples:h\ps://www.youtube.com/watch?v=_s1lzxHRO4U

Exercise

•  In the following video clip,

1) Identify the presenting complaint and its history 2) Describe any core features of psychosis in this patient, using appropriate terminology

http://www.youtube.com/watch?v=ZB28gfSmz1Y

PSYCHOTIC DISORDERS: EPIDEMIOLOGY, AETIOLOGY & NEUROPATHOLOGY

Knowledge


Risk assessment

Epidemiology of common psychotic disorders

•  Point prevalence –  Schizophrenia 1:100 –  Bipolar disorder 1:100

•  Year incidence –  Schizophrenia: median 15/100,000 (range 7 – 40)

•  Geographical differences

•  Gender distribution –  Schizophrenia male:female = 1.4 : 1 –  Bipolar disorder male : female = 1:1

•  Age of onset: usually late teens to early 20s

The Developmental Hypothesis for Psychotic Disorders

Insel, Nature 2010

Schizophrenia: neuropathology •  Brain morphology:

–  Grey matter volume reductions •  Prefrontal cortex, anterior cingulate cortex (ACC), hippocampal

formation, thalamus, cerebellum •  Long term medication effects can explain some but not all of these

findings –  White matter integrity defects (widespread)

Johnstone & Crowe, Lancet 1976

healthy control schizophrenia

Schizophrenia: neuropathology

•  Cellular morphology and function: –  Reduced neuronal size, dendritic arborisation & spines –  Glia dysfunction (astrocytes, oligodendrocytes, microglia)

Lewis & Gonzalez-Burgos, 2008

Healthy control

schizophrenia

schizophrenia

Schizophrenia: neuropathology

•  Neurochemical dysfunction: –  Widespread synaptic deficits –  Multiple neurotransmitters implicated (dopamine, glutamate, GABA) –  Increased pre-synaptic dopamine synthesis (esp. striatum)

Psychotic Disorders – Aetiological factors: Genetics

•  Disorders “run” in families, “heritability” ±80% (schizophrenia, bipolar disorder)

•  Complex genetics (similar to other common disorders: diabetes, heart disease, obesity)

•  Rare & large structural DNA variants (copy number variations - CNVs) which run in families and can have large effect sizes

•  Rare & small structural DNA variants (single nucleotide polymorphisms - SNPs) with large effect size which can run in families “candidate genes”

–  Examples DISC-1 (Scottish SCZ family); TOP3B (isolated Finland cohort) •  Common small structural DNA variants (SNPs):

–  Most of these SNPs have a tiny effect size (<1%) –  can be inherited or occur through spontaneous mutation –  Very large samples (several 10,000s) required to identify common candidate

SNPs confidently: •  Nature (2014): 108 schizophrenia-associated loci (37,000 cases and 113,000

controls) – Genome wide association study (GWAS)

•  Risk-genes are usually not specific to one diagnosis –  E.g. DISC-1 predisposes to SCZ, Schizoaffective diosrder, Bipolar disorder,,

Cluster A personality disorders, autism

Psychotic Disorders – Aetiological factors: Environment

•  In utero development, birth: –  Maternal infection(s) during pregnancy –  Maternal starvation/nutritional deficits: war/disaster situations –  Birth complications (hypoxia etc.) –  Advanced paternal age –  Winter birth*, born at higher geographical lattitudes*

•  Childhood development: –  Subtle evelopmental delays (milestones) - predominantly in schizophrenia, less

pronounced in bipolar disorder –  Learning difficulties (dyslexia etc.) – predominantly in schizophrenia –  Urban upbringing* –  Trauma (abuse etc.)

•  Teenage years –  Migration* & Minority membership –  Cannabis use (*probably proxy risks)

GENETIC PREDISPOSITION AND EVIRONMENT INTERACT TO INCREASE RISK: GxE

Exercise: A 22-year-old man is brought to the ED department by the police. He reportedly had barricaded himself in his house with his dog for several days, and notified family members via text messages that he feared for his life as neighbours were threatening and monitoring him. 1) Which questions do you ask in a focused history to elicit predisposing, precipitating, and perpetuating factors for this presentation? 2) Which factors would support a working diagnosis of schizophrenia?

Example psychosis formulation grid

Bio Psycho Social

predisposing Pre-term baby Grandfather had SCZ Regular cannabis from age 14

Lost father in accident when 10 (trauma)

precipitating Increased use of cannabis, use of amphetamines

Grief after break-up with girl-friend

Moving out of family home

perpetuating Poor self-efficacy Impulsive traits Limited illness insight

Unemployment, limited education

protective Rapid response to antipsychotics, few side effects

Preserved optimism

Supportive mother

DISORDERS WITH PSYCHOSIS AS A FEATURE

Knowledge


Risk assessment

From: Castle & Bassett,2010

‘due to substances’ Start here



u Mood disorders (MDD, Bipolar Disorder)

u Schizophrenia, Schizophreniform Disorder, Brief Psychotic Disorder

u Delusional Disorder u Schizoaffective Disorder u Schizotypal Disorder

u Psychosis due to medical illness/“organic psychosis” e.g delirium, dementia, tumors, infections, endocrine, autoimmune etc.

u Psychosis due to substances

DSM-5 disorders with Psychosis as a Feature



Psychosis due to medical illness Delirium

Dementia Psychosis due to other medical illnesses

Autoimmune encephalitis

Psychosis due to substances

Psychosis due to delirium •  Delirium = Clinical syndrome caused by a medical

condition, substance intoxication or withdrawal, or medication side effect that is characterized by a disturbance of consciousness with reduced ability to focus, sustain, or shift attention.

–  Hallucinations

•  Any modality, particularly visual and tactile, often shifting E.g. delirium tremens - formication

–  Delusions •  Typically fluctuating, non-systematised, often persecutory-

type –  Disorganization

•  Fluctuating, usually mediated by cogntive impairments (orientation, distractibility)

Psychosis due to dementia

•  Dementia = a disorder that is characterized by a decline in cognition involving one or more cognitive domains (learning and memory, language, executive function, complex attention, perceptual-motor, social cognition). The deficits must represent a decline from previous level of function and be severe enough to interfere with daily function and independence.

Psychosis in dementia:

•  Hallucinations: typically visual (Levy-Body Dementia - LBD) •  Delusions: typically persecutory type (Alzheimer’s), often mediated

by memory deficits (delusional elaboration •  Disorganization: usually mediated by cognitive deficits •  Motor disturbances: e.g. parkinsonian features and neuroleptic

sensitivity in LBD

Psychosis Due to other Medical Illness/Condition

•  Neurological (common examples): –  Epilepsy (esp. temporal lobe epilepsy (TLE)) and other complex partial

seizures ; seizure ‘aura’: •  gustatory and olfactory hallucinations (or any other modality) •  Altered perception of actual objects (unusually small or large) •  derealization (déjà vu; jamais vu), depersonalization •  Visceral symtoms (e.g. ‘rising’ gastric sensation) •  euphoria or intense anxiety

–  Parkinson’s disease –  Huntington’s disease –  brain tumours –  neurosyphilis

•  Systemic (common examples): –  hypothyroidism –  cerebral SLE –  paraneoplastic syndromes –  Autoimmune encephalitis (limibic encephalitis)- e.g. anti-NMDA

antibodies – see next slide •  Postpartum period (after giving birth):

–  Postpartum psychosis (1% of new mothers) –  Psychotic depression with peripartum onset (10-15% of new mothers

suffer from peripartum depression)

Psychosis due to autoimmune encephalitis (Limbic Encephalitis, LE)

•  Only recently recognized and described •  May be responsible for up to 5% of first-episode psychoses (exact rate

unknown) •  Anti-NMDA receptor encephalitis (most common type) •  In females up to 50% have an ovarian teratoma •  Symptoms:

–  Prominent psychiatric manifestations: anxiety, agitation, bizarre behavior, hallucinations, delusions, disorganized thinking

–  Insomnia, memory deficits, decreased level of consciousness, stupor with catatonic features

–  Seizures –  Frequent dyskinesias: orofacial, choreoathetoid movements, dystonia, rigidity,

opisthotonic postures –  Autonomic instability: hyperthermia, fluctuations of blood pressure,

tachycardia, bradycardia, cardiac pauses, and sometimes hypoventilation requiring mechanical ventilation.

–  Language dysfunction: diminished language output, mutism. Echolalia is often noted in the early stages or in the recovery phase of the disorder.

•  Other forms: auto-antibodies against: AMPA rec; GABA-B rec; VGKC-associated: LGI1; CASPR-2



Psychosis Due to Substances

•  Illicit substances: –  Most common (in the Australian setting):

•  Amphetamines, Methamphetamine, other stimulants •  Alcohol – e.g alcoholic hallucinosis (visual, tactile, auditory

hallucinations without delirium) •  Cannabis (usually in patients with existing or predisposed to

psychotic disorders) –  Less common but important:

•  Hallucinogens (e.g. LSD & ‘herbal’ equivalents) •  Ketamine (‘special K’) •  Phencyclidine (PCP, ‘angel dust’)

•  prescribed medications: –  Particularly corticosteroids






u Psychosis due to medical illness/“organic psychosis” e.g delirium, dementia, tumors, trauma, infections, endocrine, autoimmune etc.


DSM-5 disorders with Psychosis as a Feature

Schizophrenia Schizophreniform disorder

Brief psychotic disorder Delusional disorder

Schizoaffective disorder

Defining “schizophrenia”

Emil Kraepelin (1856-1926) “dementia praecox” 1893

Eugen Bleuler (1857-1939) “schizophrenia” 1908

Kurt Schneider (1887-1967) “first rank symptoms” 1959

Defining “schizophrenia” –  Emil Kraepelin (1893) – dementia praecox –  Eugen Bleuler (1908) – primary (4 A’s) and secondary

symptoms •  Autistic behaviour & thinking •  Abnormal associations •  Abnormal affect •  Ambivalence

–  Kurt Schneider (1959) – first rank symptoms •  Auditory hallucination features (voices conversing between

themselves, running commentary) •  Audible thoughts •  Delusional perception •  Passivity phenomena (made affects, actions, feelings,

impulses)

–  ICD-9 (1978) and DSM-III (1980) – categorical classification (‘lists and cut-offs’); especially ICD criteria were firmly based on Schneider’s first rank symptoms.

Schizophrenia: Domains of Clinical Features

1. Psychotic –  Hallucinations –  Delusions –  Catatonia

2. Disorganisation –  Formal thought disorders –  Inappropriate affect –  Bizarre behaviours

3.  Negative (Deficit) Symptoms –  Avolition, anhedonia,

apathy, affective blunting, alogia

4.  Neurocognitive Impairment (overlaps with negative symptoms)

“+ ive symptoms” “-ive symptoms”

DSM-5 (2013) 31 “Task Force” members

DSM-5 Diagnostic Criteria for Schizophrenia

A.  Two or more of the following for 1 month (or less if successfully treated): 1.  Delusions 2.  Hallucinations

3.  Disorganised speech 4.  Grossly disorganised or catatonic behaviour 5.  Negative symptoms At least one of these symptoms must be (1), (2), or (3)

B.  Decline in one or more major areas of functioning since onset of disturbance. C.  Continuous disturbance for at least 6 months (prodromal, negative, attenuated

symptoms) Exclusion of mood or schizoaffective disorders, substance, general medical condition, or

pervasive developmental disorder. •  Caution: Subtypes no longer valid in DSM-5 (e.g. ‘paranoid schizophrenia’) •  Specifiers:

–  With catatonia –  First episode (acute, partial or full remission) –  Multiple episodes (acute, partial or full remission –  Continuous

•  Severity specifier for psychosis symptoms (last 7 days: –  0 (not present) to 5 (present and severe)

ICD-10 Diagnostic Criteria for Schizophrenia (WHO, 1992)

Either criterion 1 or 2 as below, for 1 month. 1.  At least one of:

–  Thought echo, thought insertion or withdrawal, or thought broadcasting –  Delusions of control, influence or passivity, or delusional perception –  Voices discussing between themselves, running commentary, or voices coming from

part of the body –  Persistent bizarre delusions

2.  At least 2 of: –  Persistent hallucinations with delusions without clear affective content, or with

persistent over-valued ideas –  Neologisms or thought blocking –  Catatonic behaviour –  Negative symptoms (not secondary)

Not exclusively during manic or depressive episode, and not due to organic brain disease or substances.

•  Subtypes

–  Paranoid, hebephrenic, catatonic, undifferentiated, simple

Schizophrenia Schizophreniform disorder

Brief psychotic disorder Delusional disorder

Schizoaffective disorder Schizotypal disorder

Disorders related to schizophrenia

•  Schizophrenia, Schizophreniform Disorder, and Brief Psychotic Disorder: timeframes (according to DSM) –  Schizophrenia = at least 6 months of symptoms –  Schizophreniform Disorder = more than 1 month

but under 6 months –  Brief Psychotic Disorder = more than 1 day but

under 1 month •  Schizophreniform Disorder often (but not

always) progresses to Schizophrenia •  Brief Psychotic Disorder is commonly

subsequently re-diagnosed as something else

Disorders related to schizophrenia (ctd.)

•  Delusional Disorder Definition: Isolated delusions in an otherwise high-functioning person

–  No hallucinations, bizarre behavior, thought disorganization, or functional deterioration

– Common examples: persecutory, jealous, grandiose, hypochondriacal or somatic, erotomanic

– Less common than other psychoses

Disorders related to schizophrenia (ctd)

•  Schizoaffective disorder – DSM criteria:

•  Major mood episode concurrent with symptoms that meet criteron A for schizophrenia

•  Patient experiences of delusions and/or hallucinations also in the absence of prominent mood symptoms

Disorders related to schizophrenia (ctd)

•  Schizotypal disorder – DSM criteria:

•  Ideas of reference •  Excessive social anxiety •  Odd beliefs or magical thinking •  Unusual perceptions (e.g.illusions) •  Odd/eccentric behaviour or appearance •  No close friends or confidants •  Odd speech •  Inappropriate or constricted affect •  Suspiciousness or paranoid ideas






u Psychosis due to medical illness/“organic psychosis” e.g delirium, dementia, tumors, infections, endocrine etc.


Disorders with Psychosis as a Feature

See: Mood Disorders lecture…

PRINCIPLES OF MEDICAL MANAGEMENT OF PSYCHOTIC DISORDERS ESTABLISHING A MANAGEMENT PLAN

Knowledge & Skills


Risk assessment

Chlorpromazine 1952

Jean Delay and Pierre Deniker, Paris

Antipsychotic medication

Typicals (1st generation) Proposed mechanism of action: mainly DR2 antagonism (note: anticholinergic effects; antihistaminic effects)

•  High potency e.g. haloperidol –  ↑ EPSEs –  ↓ anti-cholinergic SEs –  ↓ sedation

•  Low potency e.g. chlorpromazine –  ↓ EPSEs –  ↑ anti-cholinergic SEs –  ↑ sedation

•  Advantages –  Low cost –  Longer experience in use –  More depot options

•  Disadvantages –  EPSE and anti-cholinergic SEs

Atypicals (2nd generation) Proposed mechanism of action: DR2 antagonism + many other effects (e.g. DR1-5 activity, 5-HT activity etc.)

•  Prototype is clozapine •  Others include risperidone,

paliperidone, olanzapine, quetiapine, amisulpride, aripiprazole, ziprasidone, asenapine

•  Advantages

–  Tolerability –  Clozapine for treatment-resistant

schizophrenia •  Disadvantages

–  Higher cost –  Mainly oral options –  Metabolic & cardiac SEs

Leucht et al., The Lancet 2013

Which medication? Efficacy of AP medication for psychosis symptoms

Leucht et al., The Lancet, 2012

Efficacy of AP medication on relapse rates, hospitalization, problematic behaviour

Leucht et al., The Lancet,2013

Other common side effects: Metabolic Syndrome Sexual dysfunction Prolactin elevation QTc prolongation Extrapyramidal side effects

Antipsychotic medications – side effects

How long is medication needed?

Emsley et al., J Clin Psychiatry 2012

Antipsychotic treatment resistance Antipsychotic augmentation strategies

•  Treatment resistance –  Up to 1/3 of patients fail to respond to antipsychotic medication –  After 2 failed trials of antipsychotic monotherapy (4-8 weeks each), clozapine

is indicated •  caution: treatment resistance by non-adherence – consider depot trial before moving

to clozapine –  In severe refractory cases, ECT is a treatment option

•  Antipsychotic augmentation strategies –  Treatment with 2 (or more) antipsychotics is generally NOT recommended –  Augmentation with a mood stabilizer (if affective component) –  Augmentation with antidepressant (if affective component) –  Augmentation with metformin (if MetS cannot otherwise be controlled) –  Augmentation with omega-3 fatty acids or antioxidants (preliminary results

indicate benefits) –  Augmentation with aripiprazole (an antipsychotic!) – e.g. if prolactin elevation

becomes clinically problematic and there are no alternatives

Non-Pharmacological Treatment of psychotic disorders

•  In most cases, non-pharmacological therapies AUGMENT pharmacotherapy

•  Psychotherapies –  CBT-based, including mindfulness-based therapies,

metacognitive therapy (MCT) –  Family therapy (to address high expressed emotions -

HEE) –  Neurocognitive remediation, Cognitive Enhancement

Therapy (CET) •  Social/occupational therapies

–  Social skills training –  Vocational rehabilitation

Psychotic disorders – Course of illness in an Australian clinical population

Single episode

8%

Multiple episodes

with good recovery in between

30%

multiple episodes

with partial recovery in between

32%

continous chronic illness

without deterioration

20%

continous chronic illness

with deterioration

10%

Peoplelivingwithpsycho>cillness2010ReportonthesecondAustralianna>onalsurvey

Psychotic disorders – functional outcomes in an Australian clinical population (Personal and Social

Performance scale - PSP)

Peoplelivingwithpsycho>cillness2010ReportthesecondAustralianna>onalsurvey

Normal 6%

Very mild disablity

18%

Somewhat disabled

26% Moderately

disabled 28%

Significantly disabled

17%

Extremely disabled

5%

Medical Issues in Schizophrenia

•  Reduced life expectancy –  Mean age of death in 50s (>20 years less than general population!)

•  Increased co-morbid illnesses: –  Cardiovascular disease –  Metabolic syndrome –  Respiratory disease etc.

•  Mediators: –  Smoking & substance abuse –  Lifestyle (SE disadvantages, sedentary) –  Medication adverse effects –  self-care, including chronic illness care

•  Clinical barriers: –  Less able to communicate symptoms (sometimes in delusional terms) –  Symptoms often attributed to “psychiatric” causes –  Fewer interventions (e.g. cardiovascular) offered despite higher disease

prevalence and incidence

Phase-specific management principles

1) Acute psychosis with behavioural disturbance (e.g. presenting to ED, GP, acute services)

–  Assessing and containing risks to self or others

2) Early recovery phase (e.g. psychiatric inpatient unit, intensive community treatment)

–  Resolution of psychotic symptoms (=achieving remission) –  Clarification of diagnosis –  Engagement (patient & family)with treatment services –  Early Psychoeducation

3) Late recovery phase (e.g. community mental health teams, private psychiatrist, GP)

–  Psychotic relapse prevention –  Functional optimisation (= achieving full recovery) –  Address co-morbidities (e.g substance use) –  Optimizing general medical care (people with

schizophrenia have a reduced life expectancy up to 25 years!)

Exercise

A 22-year-old man is brought to the ED department by the police. He reportedly had barricaded himself in his house with his dog for several days, and notified family members via text messages that he feared for his life as neighbours were threatening and monitoring him. Assuming this man’s diagnosis is schizophrenia, how would a management plan look like?

Risk

Bio Psycho Social

Immediate: Contain risk of aggression

Short/intermediate term Symptom resolution

Long term Relapse prevention, functional recovery, healthy lifestyle promotion

Management grid: Psychosis example

Risk

Bio Psycho Social

Immediate: Contain risk of aggression

Inpatient admission PICU High level of observation

Benzodiazepine Sedating antipsychotic

Low stimulus environment Reassurance

Organize care for dog

Short/intermediate term Symptom resolution

Open ward Dynamic risk assessment

Selection of suitable antipsychotic, dose titration, assessment of response & side effects

Engagement with treating team Psychoeducation Anxiety management techniques

Family meeting to modify HEE environment, Family psychoeducation NGO ‘package’

Long term Relapse prevention, functional recovery, healthy lifestyle promotion

Non-adherence: Recommend depot medication

Optimizing antipsychotic treatment Metabolic monitoring

CBT for psychosis (targeting delusions) Neurocognitve remediation treatment

Supported re-entry into apprenticeshp Peer support (NGO) Group family therapy

Management grid: Psychosis example

Further reading •  Talley and O’Connor. Clinical Examination •  Bloch S & Singh BS (2007). Foundations of Clinical Psychiatry

(3rd ed). Melbourne University Press, Melbourne •  Castle, D. and Basset, D. (2014) A Primer of Clinical Psychiatry

(2nd Ed). Elsevier Australia. •  Casey P and Kelly B. Fish’s Clinical Psychopathology. Signs and

Symptoms in Psychiatry (3rd ed). Gaskell, London, 2007 •  Oyebode F. Sims’ Symptoms in the Mind. An introduction to

Descriptive Psychopathology (4th ed.). Saunders Elsevier: London, 2008

Appendix

•  Summary of diagnostic workflow in psychosis

•  Risk assessment in psychosis •  5-minute OSCE psychosis: suggested

structure and question domains

Typical diagnostic workflow in psychosis 1) Is it psychosis?

–  Have I really understood the referral information, the presenting complaint, and it’s history?

–  Can I elicit any of the core symptom domains of psychosis (MSE)? 2) What is causing the psychosis? (establishing a working diagnosis and differentials)

–  Evidence of underlying medical conditions/ neuropsychiatric disorders? –  Evidence of substances? Medications? –  Does this fit with a psychiatric disorder?

•  Schizophrenia or related disorder? •  Mood disorder (psychotic mania, psychotic depression)? •  Other psychiatric disorder presenting with symptoms resembling

psychosis: e.g. OCD, severe social anxiety, dissociation, borderline personality disorder)

3) If it is a psychiatric disorder, what are the likely predisposing, precipitating, perpetuating and protective factors? (Establishing a formulation) + Risk assessment 4) What other information do I need in order to be sure (Further investigations)?

–  Collateral history (relative/friend, GP, other healthcare worker, old documentation etc.)

–  Investigations (e.g. UDS for stimulants, EEG to exclude TLE, neuroimaging if head trauma or to exclude tumors, bloods to exclude acute inflammation, thyroid problems, autoantibodies etc)

–  Further observations and assessment over time (OPD vs admission, neurocognitive testing etc.)

Risk Assessment 1.  What are the risks?

–  Not only risk to life, but also risk to patient’s welfare, risk to dependents, public disruptions

–  Past history, where available, is a good indicator 2.  Are the current risks amenable?

–  Static vs. stable vs. dynamic vs. future risks 3.  How can the current risks be contained?

–  Can the patient take responsibility for treatment? (insight & judgement)

–  Level of supervision required •  Ranges from voluntary community treatment to detained

inpatient supervision to PICU –  Does anyone else need to be told?

•  E.g. Tarasoff case (duty to protect), police, firearms notification, child protection agencies

•  Suicide in schizophrenia: –  20-40% attempt –  5-10% complete (esp. fist 2 years after onset/diagnosis

If you have 5 minutes to assess someone with psychosis (OSCE):

Understand presenting complaint (empathic exploration)

“from what you have told me, I understand that you have experienced the following….”

Screen for core psychotic symptoms (see previous example questions) and follow up whenever there is a positive or unclear answer

“you have said that… can you tell me more about this/ I would like to clarify….”

Screen for possible causes and co-morbidities

Recent organic illness (!) Recent drug or alcohol use Recent stressors Mood disorders If time: common risk factors (family history etc.)

Screen for the impact of symptoms and associated risks !

“how is … affecting you?”, “how are you coping?” (EtOH, drugs?), “are you still able to work/ do usual activities” “have you thought about doing anything about…” (risk to others!) “have things been so stressful that you felt life was not worth living anymore?”

Documents

JMO Education Session 2016...2016/03/03 · Formal thinking Fish’s Psychopathology Elicing Disturbances in thought organisaon: Formal thought disorder • Allow >me • Encourage: