When Everything Seems Unreal:Psychosis at School

Sabina Abidi MD FRCPCChild/Adolescent PsychiatristAssistant Professor Dalhousie UniversityIWK Youth Psychosis TeamNova Scotia Early Psychosis Program

Objectives

Review the history of psychosis and psychotic disorders, current definitions and symptoms.

Know the markers that help identify youth at risk for psychosis and psychotic disorders.

Discuss the importance of early identification and treatment of youth with psychosis and psychotic disorders.

Psychosis – what is it?

“So…let’s talk about psychosis…”

What IS IT? Who knows?DefinitionCases

Psychosis is a brain disorder.

A medical illness - affects more than 8% of Canadians at any point in time

a serious disturbance in an individual’s reality testing

A process whereby the senses are distorted, making it difficult for the person to distinguish between real and unreal

Affects a person’s ability to think, perceive and act

Thinking, feelings, perception and behavior affected

PsychosisA BRAIN DISEASE

Normal Teen Brain Development

Lenroot & Giedd (2006)

Onset of Psychiatric Disorders in Adolescence

Prevalence in Childhood

Depression (1-2%)Bipolar Disorder (rare)Psychosis (rare)Anxiety Disorders (6-8%)Anorexia Nervosa (rare)

Total (7-10%)

Prevalence in Adolescence

Depression (6-8%)Bipolar Disorder (1%)Psychosis (1%)??Anxiety Disorders (10%)Anorexia Nervosa (0.2%)

Total (15 – 20%)

Age

Boys

Girls

Prevalence of Psychotic spectrum disorders per 1000 children/adolescents

(Reprinted) Spady et al. Prevalence of Mental Disorders in Children Living in Alberta, Canada, as Determined from Physician Billing Data. 2001.Arch Pediatr Adolesc Med. 155: pp.1156.

0 3 6 9 12 15 18

8

6

4

2

0

In males particularly, psychotic disorder(s) is a major disorder of adolescence

Hits adolescents in their prime – leads to a disruption in education-attainment, career building, employmentAlters relationships, family interactions, Alters sense of self, esteem, productivity

Symptoms of PsychosisWhat are common types of psychotic

experiences?

Positive Symptoms

Positive symptoms are things added in to people’s senses/thoughts/feelings/behaviour that are not normally there.

Positive symptoms include:Hallucinations

Delusions

Thought Disorder

Disorganized or Unusual behaviour

Hallucinations

Hallucinations can affect all senses:Sensory perceptions that occur in the

absence of any real stimulus but appear to be the result of faulty messages in the brain. Hearing (auditory)Seeing (visual)Touch (tactile)Smell (olfactory)Taste (gustatory)

Delusions Fixed beliefs created by illness which are held

only by the person experiencing the psychosis.

These can include:Belief in special abilities of self or others Belief that physical health is changedBelief that unusual coincidences have a special

importanceBelief that one is being controlled

Thought Disorder

Problems organizing thoughts.

Thoughts coming to fast or too slow.

Problems thinking and therefore speaking logically.

Problems keeping on topic.

Disorganized or Bizarre Behaviour:Everyone’s behaviour is a response to how

they interpret what is going on around them.

People with psychosis may behave differently than they usually do. may become extremely active or

agitated, may laugh inappropriately or display

inappropriate appearance, hygiene or conduct.

may behave in ways that reflect their thoughts

Negative symptoms refer to behaviours or experiences that have been reduced or lost because of the illness.

Negative Symptoms

Negative symptoms may include:

Problems getting motivated

Problems taking joy in things

Problems getting words out

Seeming flat and blunted

Cognitive Symptoms

Refers to problems with learning and concentration

Find it difficult to focus and pay attention find it hard to filter out all the various stimuli in their

environment. (may be highly sensitive to sounds, lights and even the

regular activities occurring in their immediate environment.)Easily distractedTrouble with working memory

Classroom/Tim’s example

Cognitive Symptoms

find the ability and speed in processing information and reaction time may be slowed

experience difficulties with memory, problem solving ability and judgement.

find it hard to organize activities in their lives, for example to manage the time and tasks needed to get their schoolwork completed.

The person can beAnxious, irritableDepressionAnger and unpleasant behaviourRapid changes in mood

Mood Symptoms

Key Point

• Sometimes people with psychosis cannot recognize that they are ill and believe that nothing is wrong with them.

• This lack of insight can make it hard to get the person to accept treatment.

Psychotic experiencesand

impairment

HallucinationsDelusionsDisorganized andBizarre behavior

Lack of:EnergyMotivationDriveSocializationreactivityEmotionSlowed thoughts/speech

Memory deficitsPoor attentionPoor organizationConcrete thinking

AnxietyDepressionIrritabilityRapid swingsanger

disorder

The psychosis continuum orspectrum of symptoms

Psychotic like experiences(normal variant)

Psychotic disorder(schizophrenia)

PLEs associated with other disorders- anxiety- Depression- Stress- Grief/loss- trauma

PLEs + markers of risk - family history - social isolation - birth trauma - cannabis exposure

Types of disorders which present with symptoms of psychosis

SchizophreniaSchizophreniform DisorderBrief PsychosisSchizoaffective DisorderPsychosis NOSDelusional DisorderDrug Induced PsychosisBipolar Disorder (with psychosis)Psychotic DepressionSecondary to a medical condition

To be normal in adolescence it itself abnormal

Anna Freud

Prevalence of children’s mental disorders in Canada

0 3 6 9 12 15

bipolar disorder

schizophrenia

Tourette syndrome

eating disorder

OCD

PDD

substance abuse

any depressive disorder

conduct disorder

ADHD

any anxiety disorder

any disorder

estimated prevalence %

Adapted from Table 2. Waddell et al. 2002. Child Psychiatric Epidemiology and Canadian Public Policy-Making. The state of the science and the art of the possible. Can J Psychiatry

Why the focus on psychosis/psychotic disorders?

• Common among prison and homeless populations

• 80% will abuse substances during their lifetime

• 15-25x more likely to die from a suicide attempt than the general population

• 10% or patients die from suicide most often in the first 10 years after diagnosis

• More hospital beds in Canada are occupied (8%) by people with schizophrenia than by sufferers of any other medical condition

“Youth’s Greatest Disabler”

World Health Report 2001 (WHO, 2002) schizophrenia and other forms of psychoses affecting young people rank third worldwide as the most disabling conditionIf left untreated, there is a continuing slow increase in impairment for years

Epidemiology

Schizophrenia causes massive human and financial costs

Affects more than 1% of the world’s population

Affects all races, ethnicities, cultures equally

More severe presentation in men

Allow for a more broader definition of psychotic disorder (include psychosis NOS, brief episodes, delusional disorder) lifetime rate increases to 2-3%

Patients with schizophrenia itself die 12-15 years earlier before the average population – some quote up to 25 years earlier

Schizophrenia causes more lives lost than cancer and physical illness Mostly due to poor medical care, suicide and

deteriorating physical illness

The vast majority of psychiatric disorders have their onset in adolescence

The age of maximum incidence for schizophrenia in males is 15-25 years and 18-35 years in females

If left untreated, there is a continuing slow increase in impairment for years.

Life potential(social, occupational, financial…)

Age

Onset Of illness

Successive illness relapses

17

Outcomes of psychiatric illness in adolescenceAt

tain

men

t – in

life

Time - age

12 15 20

X – onset of psychiatric illness

X – onset of treatment effort

X – delay in treatment effort

Psychosis – why/how?

Phases of IllnessBirth

First Signs of Illness

Onset of Psychosis

First Treatment

Recovery/Stabilization Phase

Residual/Stable Phase

PremorbidPhase

ProdromalPhase

Duration of Untreated Psychosis

Etiology

Risk Factors

Genetic Family history of psychotic disorder/bipolar disorder

Environmental Higher incidence in urban populations Immigrant ethnic groups - social isolation Areas of Social defeat Childhood trauma exposure Cannabis exposure Perinatal factors

There is a definite interplay of genes and the environment

Genetics

50% of identical twins with a twin having schizophrenia will develop the disorder.

13% risk for children with one parents with schizophrenia.

2% risk for first cousins of a person with schizophrenia

>1% risk for the general population.

Low High

Low

High

Stress

- adverse acute & chronic life events

- developmental challenges

Vulnerability

- family history of psychotic disorders

- Obstetric complications

Psychotic symptoms

No symptoms

Less severe

Psychotic-like

Symptoms or

Prodromal symptoms

Stress-Vulnerability Model of Schizophrenia

It is important to remember thatpsychosis is not caused by:

· Family upbringing.· Problems with other people.

· Having a “weak” character.

Dopamine in brain functionDopamine is important in three areas of brain

function:Mesolimbic-frontal cortex circuits

( psychotic symptoms).Basal ganglia (control of muscle movement).

Parkinson’s disease; loss of dopamine cellsHypothalamus-Pituitary (control of the

hormone, prolactin).

Dopamine Pathways*

Four pathways:

1. Nigrostriatal2. Mesolimbic3. Mesocortical4. Tuberoinfundibular

Duration of Untreated Psychosis (DUP)Historically youth experience long DUP before

coming into contact with psychiatric services 2-5 years

Long DUPS translate to very poor clinical and social outcomes

We now know that if this illness is caught early, prognosis can be very positive with effective treatment

Treatment

Rational therapy for psychotic disorder

Antipsychotic medication along with therapy/education are the cornerstone of effective treatment programs when dealing with a known chronic psychotic illness such as schizophrenia

Antipsychotic MedicationsAll antipsychotic medications influence

communication between brain cells involving the neurotransmitter, dopamine.

Each medication may also influence a number of other neurotransmitters in the brain, but the effect on dopamine seems to be one common factor in reducing psychosis.

First and Second Generation Antipsychotics“Traditional” or “First Generation”

antipsychotic medications (1950-1988) (dopamine blockade):Haloperidol, Chlorpromazine, Thioridazine and

many others.

Second Generation antipsychotics (serotonin-dopamine antagonism)“Clozapine / Clozaril (1990)Risperidone / Risperdal (1992)Olanzapine / Zyprexa (1996)Quetiapine / Seroquel (1998)Ziprasidone / Zeldox (2008)Paliperidone / Invega (2008)Aripiprazole (Abilify, 2009)

Side effects

First generation (due to Dopamine receptor blockade):

Extrapyramidal (movement) symptoms (EPS) Muscle stiffness, restlessness, involuntary movements. The use of anti-parkinsonian “side effect” meds.

Prolactin (hormonal) elevation. Ammenorhea and sexual dysfunction

“Dysphoria” (feeling bad).Difficulty with concentration and memory.

Side effectsSecond generation antipsychotics:

Sedation (early in treatment)Sexual dysfunctionWeight gain

Metabolic dysregulation Dylipidemia Hypertriglyceridemia Risk for diabetes Cardiac dysfunction Glaucoma Stroke

Extrapyramidal side effects still a concern

General treatment guidelinesIndividual basisTry to treat with one medication at a time.If there is an insufficient clinical

improvement after 3-6 months, try a different medication.

Use continuous treatment with medication for as long as possible.

Treatment: How Long?

50% of patients who do not take medication in the first year will relapse

Treatment40-60% with effective treatment (medicine,

therapy, education, rehabilitation) can lead productive lives achieving life goals had prior to the onset of illness

Key PointsPsychosis is treatable.Medication is a necessary, but not sufficient, part of a total treatment plan.

The stress-vulnerability model helps us understand treatment.

Adherence with treatment, including medications, is a critical issue.

Challenges to TreatmentNon-adherenceDepression/risk of suicideSubstance use/abuseExcessive stress/expectations

Predictors of Non-AdherenceDenial of illnessSymptoms of Illness

DelusionsDepression Cognitive impairment

Belief that medications no longer needed (I’m cured).

Attitudes of family and friends

Support NetworkStigmaInsightDistressed by side

effects Drug induced

dysphoria (feeling bad) or akathisia (restlessness)

Cost of Medication

Depression

Major depression during course of illness : 60%Post-psychotic Depression: 25%Attempted suicide: 25% - 40%Successful suicide: 10% - 13%

Challenges: Substance Use/Abuse

Substance use is very common in first episode psychosis

Up to 80%Cannabis and alcohol are most frequently abused

substances

Cannabis and Early Psychosis

People with psychotic disorders have higher rates of cannabis use than the general population

Cannabis use is associated with poorer functional and clinical outcomes in this population, e.g. greater psychotic symptom severity the effects of which can last up to 4 years later

Cannabis misuse associated with 4 times the risk of psychotic relapse

One of the strongest predictors or risk factors associated with the onset of psychotic illness

There is little evidence that the high rates if cannabis are is related to self-medication for distressing symptoms or side effects of meds

Common Issues in RecoveryDaily Life

Lack of structure/disorganization

Lack of supports required to return to school or work

Negative experiencesNo plan to help

recoveryLack of motivation

RelationshipsTrying to establish

independence from familyLoneliness/Separation from

social groups Increased anxiety in social

groupsDifficulties in re-establishing

relationships

Recovery takes time

Why Early Intervention??

Age

Boys

Girls

Prevalence of Psychotic spectrum disorders per 1000 children/adolescents

(Reprinted) Spady et al. Prevalence of Mental Disorders in Children Living in Alberta, Canada, as Determined from Physician Billing Data. 2001.Arch Pediatr Adolesc Med. 155: pp.1156.

0 3 6 9 12 15 18

8

6

4

2

0

In males particularly, schizophrenia is a major disorder of adolescence

Hits adolescents in their prime – leads to a disruption in education-attainment, career building, employmentAlters relationships, family interactions, supportAlters sense of self, esteem, productivity

Phases of IllnessBirth

First Signs of Illness

Onset of Psychosis

First Treatment

Recovery/Stabilization Phase

Residual/Stable Phase

PremorbidPhase

ProdromalPhase

Duration of Untreated Psychosis

Secondary prevention

?Primary prevention

“It is not an easy task to recognize psychosis in the early stages and motivate a young

psychotic person, who might have persecutory delusions or other delusional beliefs, to accept psychiatric treatment.”

Nordentoft M et al. Does a detection team shorten duration of untreated psychosis? Early Intervention in Psychiatry 2008;2 :22-26.

Challenges in identifying the prepsychotic phase –

The earliest symptoms identified are non-specific:

Sleep disturbance behavioral disturbance Depressed mood social withdrawal Anxiety irritability

In youth, changes that occur as part of the normal developmental continuum can complicate psychiatric diagnoses. Patient age, gender, developmental stage, identity, culture, belief system are all significant diagnostic and therapeutic factors

The differential diagnosis for psychosis is widespread in youth and depends upon a number of environmental factors that must be examined 40% cases – initial diagnosis has cause to be

changed in 3 months

Recognition of youth in trouble

Less than ½ of child & adolescent psychiatric disorders are identified in primary care settings & only a fraction are referred for mental health services

Recognition of youth in trouble

Direction of help-seeking behaviorHelp seeking behavior in adolescents is

primarily directed to friends, family and teachers before physicians

Warning signsGradual onset of change in behavior, appearance, attitude

etc“he’s not himself”, “something’s up with him”

Isolation from friends, adopting new/unusual friend groupDecline in grades and overall functioning over timePoor hygieneOnset or increase in substance abuse, esp marijuanaOdd or bizarre comments, beliefs, behaviorsEasily distracted, sensitive to noise/light, wearing

headphones often with little eye contactAppearing to be “out of touch” or daydreaming a lot,

staringLow mood, frustration, irritability, sadness, confusionAvoiding hallways, crowds, busesFatigue during day (poor sleep)

How can you help?Early identification

What do these youth really look like?SupportReduce stigma/increase acceptance

Substance use declining grades/functioning changes in behavior

Help access service/assessment

Studies are now showing with earlier identification there is a decline in the

transition rate to psychotic disorder in youth at high risk.

www.e-earlypsychosis.cawww.psychosissucks.cawww.teenmentalhealth.org

IWK Health Centre Youth Psychosis Team464-4110 (Central Referral)

Nova Scotia Early Psychosis program473-2976