child & youth Mental Health Series First Episode Psychosis; Psychosis in Youth Sharman Robertson BSc MD FRCPC Date: February 25 2016 If you are connected by videoconference please mute your system and unmute to ask a question Please feel free to ask questions! By You will have had an opportunity to apply for professional credits or a certificate of attendance registering for today’s You will receive an email with a link to today’s online evaluation event… Visit our website to download slides You may and view archived events also want Sign-up to our distribution list to receive our event to… notifications Questions? [email protected] Speaker has nothing to disclose with regard to commercial support. Declaration of conflict Speaker does not plan to discuss unlabeled/ investigational uses of commercial product. Agenda • On Track First Episode Psychosis Program • Evolution of First Episode Psychosis Programs • Ontario Standards • Stress diathesis model • Clinical Features Psychosis in Youth • Differential Diagnosis • Treatment • Outcomes On Track • Recovery-based • Individuals aged 16-35 with first episode of psychosis (FEP) • Champlain District 1.3 million with satellites in Hawkesbury, Cornwall and Pembroke • Case management model • Interdisciplinary team • Follow for up to 3 years • Group, individual, family work Rationale of First Episode Programs • Early recognition of psychosis • Shorten DUP – Improve outcomes • Symptom resolution • Return to full function – Prevent relapse – Prevent • Cognitive decline • Treatment resistant symptoms • Loss of relationships • Loss of ability to be productive • Reduction of stigma • Rehabilitative model Long DUP • Longer DUP – Reduced treatment response – Poor functional outcome – Disrupted personal relationships – Increased legal involvement – Substance use – Disrupted school and work performance – Housing instability Ontario Perspective • Yearly incidence = 12 / 100,000 • Majority between ages of 14-35 years • First 3-5 years high risk for: – Suicide (2/3 of suicides) – Relapse – Hospitalization – Loss of social supports – Disruption of work, school, housing – Substance use – Legal problems Early Psychosis Intervention (EPI) Ontario • 1999: Making it Happen: Implementation Plan for Mental Health Reform- psychosis requires intensive care • 1999: Ontario Working Group for Psychosis advocated for EPI (clients, families and community mental health agencies) • 2004: MOHLTC announced EPI program funding 30 programs Early Intervention Ontario Network EPION • Formerly the Ontario Working Group • Ministry funded • Volunteer • Provides www.epion.ca – Networking – Research – Knowledge sharing – Conferences – Shapes policy – FEP advocacy Key Components • Early identification and facilitated access • Comprehensive assessment – Up to 3 months including treatment to establish dx – May lead to enrolment if criteria met • Treatment • Psychosocial supports • Family education and support • Public education • Research On Track Eligibility and Timelines • Age 16-35 years • < = 6 months of treatment for psychosis • Absence of severe substance use disorder, forensic history or established mood disorder • Contact client/family within 72 hours • In-person assessment within 2 weeks • 613-737-8069 Psychosis • Loss of touch with reality • Reduced ability to determine what is coming from within own thoughts and perceptions and what is happening in the environment • Not a diagnosis • Collection of signs and symptoms • Common end point for several mental illnesses Stress Diathesis Progression to Psychosis Neurochemistry: Dopamine • Dopamine (DA) hypothesis: – Too Much DA in certain brain areas • Efficacy of DA blocking medications • Psychotomimetic effect of stimulants – DA levels actually low in prefrontal cortex Serotonin: Modulates DA • 5HT-2 blockade: – reduces psychotic symptoms – Reduces side-effects caused by blocking DA – • Second generation anti-psychotics (SGA’s): – 5HT-2 blockers – Risperidone, olanzapine, seroquel – Older: clozapine Cortical Glutamate Regulates DA Neurons in 2 Possible Ways Direct action Indirect action as an as accelerator brake Cortex GLU GLU + + − GABA DA GLU = glutamate. Adapted from Tsapakis EM, et al. Adv Psychiatr Treat. 2002;8(3):189-197. Carlsson A, et al. Br J Psychiatry Suppl. 1999;(37):2-6. With Psychosis NMDA Receptors are under-firing Direct action as an accelerator Cortex DA is too low and we see: GLU -Lack of motivation, pleasure, depressed mood -Impaired ability to concentrate, pay attention remember -Impaired ability to plan, organize, use abstract concepts + NMDAR DA Hypofunctioning Adapted from Tsapakis EM, et al. Adv Psychiatr Treat. 2002;8(3):189-197. Citrome L. Curr Psychiatry Suppl. 2011;10(9):S10-S14. With psychosis there is no brake for DA in the mesolimbic area Indirect action as brake Cortex GLU + − GABA NMDAR Hypofunctioning DA DA is too high in the mesolimbic area - delusions and hallucinations Clinical Features Pre-pubertal Psychosis • Rare, less common than autistic spectrum disorder • Abnormal development: – Soft neurological S+S – LDs – Expressive/receptive language delays – Attachment issues – Autistic features – Reduced response to treatment Mental Status Examination • Appearance, self-care – Dressed for weather, clean, dishevelled, mannerisms, sunglasses, make-up, unusual costumes, body odour • Behaviour – Guarding, slowing, agitation, aggression, vigilance, responding to internal stimuli, grandiosity, mannerisms • AIMs/EPS – Dyskinetic movements of mouth, lips, face – Tremor, stiffness, lack of facial expression, restlessness, robotic gate • Affect – Flat, reduced, robotic, labile, hostile, euphoric, angry, perplexed, fearful, depressed, superficial Mental Status Examination • Mood – Numb, depressed (neuro-vegetative signs and symptoms), bored, swings, elated, irritable • Speech – Pressured, over-inclusive, prolongation of response latency, slow, muteness Mental Status Examination Thought form – Tangentiality: • Jumping from topic to unrelated topic – Circumstantiality: • Starting at one topic and speaking of partially related themes, over -inclusive of detail, eventually getting back to first point. – Loosening of associations: • Ideas are not related to each other and syntax of language is breaking down – Flight of ideas: • Rapid-fire thoughts that the person can not slow down – Poverty of thought: • Lack of output or devoid of content – Thought blocking – Prolongation of response latency Thought Form Disorders in Children Developmental stage of child is important. Normally thought form disorganized before the age of 7 years. Possible to detect thought form disorganization after this. Mental Status Examination • Thought content – Delusions Children - content involves animals, • Paranoid cartoons, super heros • Referential Adolescents - content similar to adults • Control • Religious • Pseudo-philosophical • Somatic • Grandiose • Erotomanic – Hallucinations • Auditory, visual, olfactory, senesthetic, gustatory Mental Status Examination – Hallucinations • Auditory, visual, olfactory, tactile, gustatory Children – Transient hallucinations possible during times of stress, loss. True hallucinations accompanied by LDs, attachment issues soft neuro S + S. Adolescents – Transient hallucinations seen with personality DO, panic attacks, trauma history. Mental Status Examination • Attention and concentration • Ability to use abstract concepts – Similarities and proverbs • Insight and judgement – Do they think they have an illness? – How do they explain their circumstances? – Does medication help? – What are their strategies to deal with symptoms? – What is their motivation to use strategies? Mental Status • Suicidal thinking – Passive vs. active – Plan – Association with delusions of control or impulses – Association with command hallucinations – Degree of control a person feels they have over the thoughts/impulses – Awareness of coping strategies – Ability to use coping strategies – Alliance with their team – Hopelessness – Emotional reaction to these thoughts • Calm and resolved vs. fearful of it actually happening Mental Status – Homicidal thinking • Past history of violence • Medication non-adherence • Substance abuse • Delusions of persecution or control – Know the delusional system • Association with command auditory hallucinations • Insight into this as a symptom • Emotional reaction to these thoughts – Fear and shame – Aggression – Flatness What Things Besides Schizophrenia Cause Psychosis? • Drug or alcohol induced psychosis • General medical conditions • Mood disorders • Schizophrenia spectrum disorders Substance and Alcohol Induced Psychosis • Withdrawal states; • Cannabis alcohol, anxiolytics, • Prescription drugs sedatives, GHB • Stimulants; – amphetamines, cocaine • Hallucinogens; LSD,PCP, ecstasy Can Drugs Cause Schizophrenia? • Certain drugs can mimic psychosis when a person is high • In a drug induced- psychosis symptoms are gone within one month after stopping the drug Can Drugs Cause Schizophrenia? • If symptoms last longer than one month something else is going on -possibly schizophrenia • If psychosis occurs with drug use that person’s nervous system is vulnerable to psychosis • Taking drugs at that point may lead to more psychosis!! General Medical Conditions • Rarely a cause of psychosis (<10%) • Seizure disorders • Genetic conditions; – Huntington’s, Wilsons disease – Velocardiofacial syndrome • Infections; encephalitis, meningitis, HIV/AIDs • Dementia Mood Disorders • Major Depressive Disorder • Bipolar disorder Schizophrenia