What is psychosis? Psychotic Spectrum Symptoms in Youth Nick Weiss, MD PART Program Director, Child and Adolescent Psychiatry Clinics University of California, San Francisco Often thought of as catastrophically ALL or NOTHING But should be thought of as Set of symptoms hallucinations, delusions, marked disorganization, negative symptoms Set of disorders the Primary Psychotic Disorders : Schizophrenia and Schizoaffective Disorder) Neither I nor my immediate family members have a personal financial relationship with a manufacturer of pharmaceutical products or services that will be discussed in this presentation The Challenge Psychotic symptoms are fairly common in childhood and adolescence Primary psychotic disorders are exceedingly rare in children (<1/10k) and rare in adolescents (~5/1k), but not rare in adults (>1/100) Most youth who experience psychotic-like symptoms will never develop a primary psychotic disorder The schizophrenia prodrome is largely non-specific BUT we want to intervene early 1
Agenda The Psychosis Continuum Discuss The continuum theory of psychosis, The developmental model of psychosis The non-specific prodrome Provide tips on assessing psychotic-like symptoms in children and adolescents Outline our approaches to risk stratification ( UHR ) Psychotic experiences/symptoms much more common in the general population than previously thought Psychotic-like experiences exist on a broad spectrum of severity The Psychosis Continuum THE SPECTRUM OF SEVERITY: From AUDITORY DISTORTIONS to ILLUSIONS to HALLUCINATIONS 5.6% of 12 year old children in a large population sample were assessed as having had definite psychotic spectrum symptoms 13.8% had suspected symptoms Do you ever feel that your ears are playing tricks on you? Have you been feeling more sensitive to sounds? Have sounds seemed different? Louder or softer? Do you ever hear unusual sounds like banging, clicking, hissing, clapping, ringing in your ears? Do you ever think you hear sounds and then realize that there is probably nothing there? Do you ever hear your own thoughts as if they are being spoken outside your head? Do you ever hear a voice that others don't seem to or can't hear? Does it sound clearly like a voice speaking to you as I am now? Could it be your own thoughts or is it clearly a voice speaking out loud? 2
The Path to Serious Mental Illness The Final Straw Genetic predisposition Pre/ perinatal insults Neurodevelopmental anomalies; cognitive vulnerabilities Onset of PSYCHOSIS Later environmental hits & triggers Cognitive dysfunction; altered stress responsivity; DA dysregulation Neurodegeneration and chronicity Repeated episodes of psychosis; altered neuroplasticity % That Developed a Psychotic Disorder Genotype-Environment Interaction Unhealthy Families (Tienari et al., 2004) Model of Progression from Prodrome to Onset of Illness Duration of Untreated Psychosis and Rate of Relapse 1-3 yrs. 1 2 3 4 5 No Sx Non specific Sxs Sub-psychotic Sx Illness Tx noticed by client affects functioning Onset Success Short DUP, N=31 (treatment <1 year after psychosis onset) Long DUP, N=22 (treatment >1 year after psychosis onset) 90 80 70 60 50 40 30 20 10 0 6 12 18 24 # Months after treatment entry Adapted from Crow et al. (1986). Brit J. Psychiatry, 148, 120-127. 3
Basic Interview Strategies Conviction Target to developmental level and cultural context Join first, start positive or neutral, then ask? s in increasing order of severity ( mostly) Maintain a calm, supportive, and consistent tone Avoid compound and leading questions Watch for nonverbal cues and avoidance and interence by symptoms Normalize: Lots of kids have heard voices. Have you heard voices? Ask about delusional interpretations Could it be your imagination? Could the voice actually be your own thoughts? Could your mind be playing tricks on you? How would you know if you were wrong? How sure are you? Really, really sure? 60% sure? BUT NEVER CONFRONT OR CHALLENGE! Differential Diagnosis Medical Rule-Outs Substances Trauma and Abuse: Dissociation Anxiety and Mood Disorders Personality/Conduct Disorders Fantasy Developmental Disorders Bereavement Cultural/Linguistic Misunderstanding Always: Physical Exam, UTox, UTox, UTox, TSH,Metabolic Panel, VDRL Often: ESR, HIV, EEG, MRI Rarely: LP, Copper and Ceruloplasm, Cortisol, Heavy Metals Very Rarely: Arylsulfatase A, Karyotype, Cytogenetics 4
Worry Signs UHR Insidious decline prior to positive symptoms Progressive cognitive decline Motor abnormalities Social anhedonia, and other negative symptoms Family history of psychotic disorder More frequent attenuated positive symptoms More distressing attenuated positive symptoms Acting on symptoms with bizarre behaviors Poor family function Attenuated positive psychotic symptoms average frequency of at least once per week in the past month Brief psychotic symptoms (BLIPS, BIPS) at least several minutes per day and at least once per month but no more than 1 hour/day Family History or Schizotypal Personality Disorder + Functional Decline O Brien 2009 Conversion from UHR to Full Psychosis Controlled Studies for UHR Risperidone +psychosocial treatment (non-blind). Reduction in 6-month conversion rate, but no difference by 12 months Olanzapine Trend of reduction of 12-month conversion rate. CBT (non-blind) Reduction in 12-month conversion rate. Omega-3 Fatty Acids Reduction in 12-month conversion rate (5% v. 28%). 5
Example 1 Example Example #1: 2#3: Kelly is 14 years old. She has always been a good student, but began having attention problems this year. She also has started having difficulty staying on track during conversations at times. Teachers describe her as being odd but don t know exactly what is going on. John is 17. Recently, he started having more trouble concentrating on schoolwork, which led to his failing many classes. John has had the feeling of the presence of someone in the room at times when he was alone. He would often think that he felt the presence of his mother or his cat in the room. He would occasionally look around the room when this happened and realize no one was there. He sometimes thought that he heard his name being called when no one was around. These symptoms began three months ago. His mother reported that these symptoms were becoming increasingly worrisome. At UCSF: Local Resources Comprehensive clinical assessment, feedback and treatment recommendations Paid participation for some assessment procedures Neuropsychological evaluation Cognitive training Blinded medication trial Free consultation with psychiatrist Repeated evaluations every 6 months over 2 years 6
Treatment Services: PREP Intensive Case Management Multi-Family Group Individual Cognitive Behavior Therapy Evidence Based Medication Management Neuropsychological Assessment Vocational and Educational Support How do I refer someone? CALL 415-476-7278 Key References Amminger, G. P., M. R. Schafer, et al. "Long-chain omega-3 fatty acids for indicated prevention of psychotic disorders: a randomized, placebo-controlled trial." Arch Gen Psychiatry 67(2): 146-54. Bartels-Velthuis, A. A., J. A. Jenner, et al. "Prevalence and correlates of auditory vocal hallucinations in middle childhood." Br J Psychiatry 196(1): 41-6. Horwood, J., G. Salvi, et al. (2008). "IQ and non-clinical psychotic symptoms in 12-year-olds: results from the ALSPAC birth cohort." Br J Psychiatry 193(3): 185-91. McGlashan, T. H., R. B. Zipursky, et al. (2006). "Randomized, double-blind trial of olanzapine versus placebo in patients prodromally symptomatic for psychosis." Am J Psychiatry 163(5): 790-9. Poulton, R., A. Caspi, et al. (2000). "Children's self-reported psychotic symptoms and adult schizophreniform disorder: a 15- year longitudinal study." Arch Gen Psychiatry 57(11): 1053-8. 7