Psychosis in Children and Young People

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Psychosis in Children and Young People

• MRCPsych Course
• Dr Gisa Matthies

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Psychosis

• from the Ancient Greek
• ???? "psyche", for mind/soul
• -?s?? "-osis", for abnormal condition or
  derangement

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Psychosis

• Schizophrenia
• Schizoaffective disorder
• Schizophreniform disorder
• Delusional disorder
• Bipolar affective disorder
• Depressive disorder

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Psychosis

• Experience of psychosis challenges an
  individuals fundamental assumption that they can
  rely on the reality of their thoughts and
  perceptions

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Psychotic Symptoms

• Hallucinations
• Delusions
• Thought disorder
• Negative symptoms

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Schizophrenia in children and young people

• Major psychiatric disorder
• Psychotic symptoms that alter the YPs
  perception, thoughts, affect and behaviour

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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

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Delay in Diagnosis

• Insidious onset of prodromal period
• Delusions can be poorly systematised
• Thought disorganisation is common

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Acute Episode

• Hallucinations, delusions, behavioural
  disturbance
• Agitation, distress, fear, puzzlement

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Residual Symptoms

• Negative symptoms
• Persisting symptoms more common when condition
  starts in pre-adolescent children

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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
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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)

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Problems of using clinical label

• Stigma
• Ethical issues

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ARMS/UHRdimensional view
cusp of psychosis
non specific symptoms
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Impairment and Disability

• Consequence of
• disabling psychotic symptoms
• adverse effects of poor physical health
• adverse effects of drug treatments
• stigma

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Impairment and Disability

• Development and functioning
• Psychological
• Social
• Educational

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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
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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

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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
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Prognosis cont.

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

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Predictors of poor outcome

• Premorbid social and cognitive impairments
• Prolonged first psychotic episode
• Extended duration of intreated psychosis
• Presence of negative symptoms

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Diagnosis 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

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ICD -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

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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) 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. 
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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. 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). 
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DSM 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). 
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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

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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 malegtfemale
• Adolescence equal sex ratio

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Aetiology

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

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

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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)

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Cannabis

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

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Assessment

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

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Adolescents

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

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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)

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Treatment

• Shift towards community treatment
• EIP teams 14-35 years

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Treatment for ARMSClinical staging approach

• Monitoring/Tracking Mental States
• Case management
• Social support
• Psychosocial interventions

FIRST

• Antipsychotic medication
• Restrictive approaches (hospitalisation)

SECOND
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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)

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High Expressed EmotionThe three dimensions

• Hostility
• Emotional over-involvement
• Critical comments

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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 familys problems is the patients
  mental illness, whether they are or not.

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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 cope with the pity.

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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
  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.

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Pharmacological Treatment

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

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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