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Cognitive Therapy cognitive therapy for prevention and treatment of psychosis:

Cognitive Therapy cognitive therapy for prevention and treatment of psychosis: a research update and clinical workshop Tony Morrison Division of Clinical Psychology, University of Manchester & Psychosis Research Unit, GMWMHT . Objectives. Outline UHR and Psychosis

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Cognitive Therapy cognitive therapy for prevention and treatment of psychosis:

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  1. Cognitive Therapy cognitive therapy for prevention and treatment of psychosis: a research update and clinical workshop Tony Morrison Division of Clinical Psychology, University of Manchester & Psychosis Research Unit, GMWMHT

  2. Objectives • Outline UHR and Psychosis • Cognitive approach to understanding psychosis • Application of CT to people with distressing psychotic experiences (UHR, FEP and beyond) • Formulation • Normalisation • Strategies for common difficulties • Case illustrations, exercises, videos • Evidence base

  3. Psychosis ‘prodrome’ • A period of months to years prior to the onset of Psychosis (assessed retrospectively) • Progressive symptoms/signs • Mood • Thinking • Behaviour • Cognitive functions • Reduction in ability to function

  4. Onset of psychosis First psychotic symptom Build up Prodrome Emergence of psychosis

  5. Why is early detection important? • If psychosis is detected early, many problems can be prevented and functioning can be restored. • The earlier the problems are treated, the greater the chance of a successful recovery. • Onset is often in a critical stage of a young person’s life. Adolescents and young adults are just starting to develop their own identity, form lasting relationships, and make plans for the future. • People are help seeking and distressed.

  6. Ultra High Risk Criteria • Original PACE criteria (Yung et al. 1996) • Age between 14 and 30 years AND • Family history of DSM-IV psychotic disorder and reduction on GAF scale of ≥ 30 AND/OR • Attenuated symptoms, occurring several times during the week for at least one week AND/OR • Brief, limited or intermittent psychotic symptoms (BLIPS) for less than one week and resolving spontaneously Modified criteria now assessed using CAARMS

  7. Identification Study at PACEYung et al 1998 British Journal of Psychiatry 40% made transition at six months, 50% at one year Number not psychotic Months of assessment

  8. Intervention Study at PACE:The prevention of psychosisMcGorry et al 2002 Archives of General Psychiatry % making transition to psychosis Months

  9. PRIME Study: Olanzapine versus placeboMcGlashan et al. 2006 American Journal of Psychiatry *

  10. Early Detection: Problems • Ethics of interventions in pre-psychotic phase • Solution: • employ interventions with minimal risks / side effects • employ interventions that will be useful to those who will never become psychotic • informed choice • Balancing the costs and benefits of treatment must be weighted in some way according to the ratio of people actually helped to those unnecessarily treated

  11. Psychosis is not necessarily dreadful • Prediction not very accurate (e.g. 60% false positives) • Side effects of medication (and can be fatal) • atypicals commonly produce weight gain and sexual dysfunction; diabetes; cardiovascular problems • Effects of medication on developing brain unknown

  12. Caveats Distressing psychosis Indisputable that antipsychotics help some people a great deal Not anti-antipsychotics, but anti over-reliance (or exclusive reliance) on antipsychotics and lack of patient choice

  13. Antipsychotics Oversold? “Risperidone may well help people with schizophrenia, but the data in this review are unconvincing. People with schizophrenia or their advocates may want to lobby regulatory authorities to insist on better studies being available before wide release of a compound with the subsequent beguiling advertising. People given risperidone may wish to negotiate on length of prescription, ask about adverse effects, and help generate better evidence than currently exists.” (Rattehalli et al., 2010, p.18).

  14. Aripiprazole 10mg/day or 30mg/day Versus Placebo: PANSS Change in acute psychosis

  15. Antipsychotic-Induced Weight Gain in Chronic and First-Episode Psychotic Disorders: A Systematic Critical Reappraisal 20 Chronic RCT Chronic RCT FEP 3 kg 15 4 kg 10 kg 12 kg 5 0 12 24 36 48 Months Alvarez-Jimenez et al; CNS Drugs, 2008 Alvarez-Jimenez et al; CNS Drugs, 2008 22 (7): 547-562

  16. The British Journal of Psychiatry 2010 196, 116–121. doi: 10.1192/bjp.bp.109.067512 Twenty-five year mortality of a community cohort with schizophrenia Steve Brown, Miranda Kim, Clemence Mitchell and Hazel Inskip • Conclusions • People with schizophrenia have a mortality risk that is two to three times that of the general population. Most of the extra deaths are from natural causes. • The apparent increase in cardiovascular mortality relative to the general population should be of concern to anyone with an interest in mental health. • The most clinically useful intervention is probably to try to help people with schizophrenia stop smoking, to promote exercise and to facilitate effective health screening • .

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