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/UHR dimensional 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. Outcome Schizophrenia 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 criteria Mood disorders, schizoaffective disorder Overt brain disease Drug intoxication or withdrawal

24. Diagnostic criteria for Schizophrenia
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. Diagnostic criteria for Schizophrenia cont.
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. Diagnostic criteria for Schizophrenia cont.
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 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 per 100,000
Prevalence increases rapidly from age 14
Peak incidence late teens early twenties
Australian sample of first episode psychosis 1/3 were 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. Model of Stress Vulnerability
High
Zubin& Spring (1977)
Model of Stress Vulnerability
ILLNESS
Stress
This is a classic diagram, often used as an aid to engagement and a first step to explaining the development of a psychotic episode with clients and their carers.
When explaining this graph try to get the group to identify where someone would be ‘plotted’ on the graph if they had a high risk of psychosis as opposed to a low risk
WELLNESS
Low
Vulnerability
High 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: % (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: years

41. Treatment for ARMS Clinical 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 Emotion The 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 cope with 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