Psychosis in Children and Young People

1. Psychosis in Children and Young People • MRCPsych Course • Dr Gisa Matthies

2. Psychosis • from the Ancient Greek • ψυχή "psyche", for mind/soul • -ωσις "-osis", for abnormal condition or derangement

3. Psychosis • Schizophrenia • Schizoaffective disorder • Schizophreniform disorder • Delusional disorder • Bipolar affective disorder • Depressive disorder

4. Psychosis • Experience of psychosis challenges an individual’s fundamental assumption that they can rely on the reality of their thoughts and perceptions

5. Psychotic Symptoms • Hallucinations • Delusions • Thought disorder • Negative symptoms

6. Schizophrenia in children and young people • Major psychiatric disorder • Psychotic symptoms that alter the YP’s perception, thoughts, affect and behaviour

7. Prodromal 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

8. Delay in Diagnosis • Insidious onset of prodromal period • Delusions can be poorly systematised • Thought disorganisation is common

9. Acute Episode • Hallucinations, delusions, behavioural disturbance • Agitation, distress, fear, puzzlement

10. Residual Symptoms • Negative symptoms • Persisting symptoms more common when condition starts in pre-adolescent children

11. ‘At-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

12. 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)

13. Problems of using clinical label • Stigma • Ethical issues

14. ARMS/UHRdimensional view cusp of psychosis non specific symptoms

15. Impairment and Disability • Consequence of • disabling psychotic symptoms • adverse effects of poor physical health • adverse effects of drug treatments • stigma

16. Impairment and Disability • Development and functioning: • Psychological • Social • Educational

17. OutcomeSchizophrenia 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

18. Greater 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

19. Prognosis 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

20. Prognosis cont. • Associated with increased morbidity and mortality through both suicide and natural death.

21. Predictors of poor outcome • Premorbid social and cognitive impairments • Prolonged first psychotic episode • Extended duration of intreated psychosis • Presence of negative symptoms

22. Diagnosis historical • Kolvin’s 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

23. 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 criteriaMood disorders, schizoaffective disorder Overt brain disease Drug intoxication or withdrawal

24. 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.

25. 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). 

26. 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). 

27. Physical 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

28. Incidence 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: male>female • Adolescence: equal sex ratio

29. Aetiology • Complex interaction of genetic, biological, psychological and social factors • Stress vulnerability model (Zubin & Spring, 1977)

30. High Zubin& Spring (1977) Model of Stress Vulnerability ILLNESS Stress WELLNESS High Low Vulnerability 30

34. Genetics • 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)

35. Environmental 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)

36. Cannabis • May enhance the risk of schizophrenia in vulnerable individuals during critical period of adolescent brain development

37. Assessment • Detailed history • Developmental hx • Premorbid functioning • Mental state • Cognitive functioning • Physical examination • Exclude organic cause • Consider Neuroimaging

38. Adolescents • Engagement • Flexible, adapt to developmental stage and age • Global functioning • Risk assessment • Substance use • Collateral information • Consent • Family involvement • Confidentiality

39. Treatment • 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)

40. Treatment • Shift towards community treatment • EIP teams: 14-35 years

41. Treatment for ARMSClinical staging approach • Monitoring/Tracking Mental States • Case management • Social support • Psychosocial interventions FIRST • Antipsychotic medication • Restrictive approaches (hospitalisation) SECOND

42. Psychological 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)

43. High Expressed EmotionThe three dimensions • Hostility • Emotional over-involvement • Critical comments

44. 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.

45. 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 copewith the pity.

46. 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.

47. Pharmacological Treatment • Antipsychotics • Dietary and lifestyle counselling • No evidence of greater efficiency of one antipsychotic over another • Note: Exception: Clozapine • Compliance is poor

48. 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