Title: Psychosis in Children and Young People
1Psychosis in Children and Young People
- MRCPsych Course
- Dr Gisa Matthies
2Psychosis
- from the Ancient Greek
- ???? "psyche", for mind/soul
- -?s?? "-osis", for abnormal condition or
derangement
3Psychosis
- Schizophrenia
- Schizoaffective disorder
- Schizophreniform disorder
- Delusional disorder
- Bipolar affective disorder
- Depressive disorder
4Psychosis
- Experience of psychosis challenges an
individuals fundamental assumption that they can
rely on the reality of their thoughts and
perceptions
5Psychotic Symptoms
- Hallucinations
- Delusions
- Thought disorder
- Negative symptoms
6Schizophrenia in children and young people
- Major psychiatric disorder
- Psychotic symptoms that alter the YPs
perception, thoughts, affect and behaviour
7Prodromal Period
- 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
8Delay in Diagnosis
- Insidious onset of prodromal period
- Delusions can be poorly systematised
- Thought disorganisation is common
9Acute Episode
- Hallucinations, delusions, behavioural
disturbance - Agitation, distress, fear, puzzlement
10Residual Symptoms
- Negative symptoms
- Persisting symptoms more common when condition
starts in pre-adolescent children
11At-risk mental states (ARMS)Ultra high risk
(UHR)
- 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
12But most YP with ARMS...
- ...do not develop psychotic illness
- ...do have a mixture of other mental health
problems (depression, anxiety, substance misuse,
emerging PD)
13Problems of using clinical label
14ARMS/UHRdimensional view
cusp of psychosis
non specific symptoms
15Impairment and Disability
- Consequence of
- disabling psychotic symptoms
- adverse effects of poor physical health
- adverse effects of drug treatments
- stigma
16Impairment and Disability
- Development and functioning
- Psychological
- Social
- Educational
17OutcomeSchizophrenia with onset in childhood and
adolescence
- 1/5 good outcome with only mild impairment
- 1/3 severe impairment requiring intensive social
and psychiatric support
Hollis, 2000
18Greater impairment with early-onset
- Nature of disorder is more severe
- Disorder disrupts social and cognitive
development - Severe impairment of ability to form friendships
and love relationships - Impact on family relationships
19Prognosis and Course Schizophrenia
- 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
20Prognosis cont.
- Associated with increased morbidity and mortality
through both suicide and natural death.
21Predictors of poor outcome
- Premorbid social and cognitive impairments
- Prolonged first psychotic episode
- Extended duration of intreated psychosis
- Presence of negative symptoms
22Diagnosis historical
- Kolvins studies in the early 70th distinguished
autism from early onset psychosis - DSM-111 and ICD-9 category of childhood
schizophrenia removed and same diagnostic
criteria across the age range
23ICD -10 diagnostic criteria
- At least one of
- Thought echo, thought insertion/withdrawal/broadca
st - 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
24DSM 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) hall
ucinations (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.
25DSM 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. Durat
ion 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).
26DSM IV - TR Diagnostic criteria for Schizophrenia
cont.
D. Schizoaffective and Mood Disorder exclusion S
chizoaffective 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).
27Physical Healthcare
- 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
28Incidence and Prevalence
- 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 malegtfemale
- Adolescence equal sex ratio
29Aetiology
- Complex interaction of genetic, biological,
psychological and social factors - Stress vulnerability model (Zubin Spring, 1977)
30High
Zubin Spring (1977) Model of Stress Vulnerability
ILLNESS
Stress
WELLNESS
High
Vulnerability
Low
30
31(No Transcript)
32(No Transcript)
33(No Transcript)
34Genetics
- 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)
35Environmental factors
- Perinatal risk factors are being researched
- Urban living
- Poverty
- Child abuse
- Evidence of dose response association between
childhood trauma and and psychosis (Read et al,
2008)
36Cannabis
- May enhance the risk of schizophrenia in
vulnerable individuals during critical period of
adolescent brain development
37Assessment
- Detailed history
- Developmental hx
- Premorbid functioning
- Mental state
- Cognitive functioning
- Physical examination
- Exclude organic cause
- Consider Neuroimaging
38Adolescents
- Engagement
- Flexible, adapt to developmental stage and age
- Global functioning
- Risk assessment
- Substance use
- Collateral information
- Consent
- Family involvement
- Confidentiality
39Treatment
- 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)
40Treatment
- Shift towards community treatment
- EIP teams 14-35 years
41Treatment for ARMSClinical staging approach
- Monitoring/Tracking Mental States
- Case management
- Social support
- Psychosocial interventions
FIRST
- Antipsychotic medication
- Restrictive approaches (hospitalisation)
SECOND
42Psychological and Psychosocial interventions
- Family interventions (relapse prevention Leff
and Vaughn, 1981, psychoeducation, Birchwood,
1992) - CBT (Kingdon and Turkington, 1994)
- Adherence therapy (Kemp et al, 1996)
- Individual Placement Support (Killackey, 2008)
43High Expressed EmotionThe three dimensions
- Hostility
- Emotional over-involvement
- Critical comments
44Hostility
- 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 familys problems is the patients
mental illness, whether they are or not.
45Emotional 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.
46Critical 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
patients 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.
47Pharmacological Treatment
- Antipsychotics
- Dietary and lifestyle counselling
- No evidence of greater efficiency of one
antipsychotic over another - Note Exception Clozapine
- Compliance is poor
48PSYCHOSIS 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