CMH - Psychosis and Bipolar PDF

**Introductory talk on Psychosis** **What is psychosis?** Umbrella term for conditions and symptoms where people perceive and interpret reality in a very different way from those around them. Psychotic symptoms (e.g. delusions and hallucinations): - Can occur in isolation in the population - n...

**Introductory talk on Psychosis** **What is psychosis?** Umbrella term for conditions and symptoms where people perceive and interpret reality in a very different way from those around them. Psychotic symptoms (e.g. delusions and hallucinations): - Can occur in isolation in the population - not necessarily reflecting a major mental health condition - Occurs in a variety of MH conditions - incl. bipolar, schizophrenia, brief psychotic episode, drug-induced psychosis, some dementia presentations - Especially in EIS, diagnoses like "early psychosis" or "acute psychotic episode" often made, covering a range of conditions Main symptoms: - **Delusions** Are: - Preoccupying and subjectively important - Held for reasons that are difficult to make sense of - Generally directly relevant to the person experiencing them - Usually, though not invariably, false (except in DSM V - claims they're always false beliefs) Not: - Understandable in the context of the person's religion, culture or sub-culture (check with someone who knows!) - Amendable to challenge or counter-argument (at least not easily) - **Hallucinations** Are: - Perceptions without an external stimulus - Auditory, visual, tactile, olfactory (smell), gustatory (taste) - Normal in some situations (bereavement, when falling asleep) Not: - Easily distinguished from 'real' perceptions - In internal space *Note: Without great disruption to functioning or social decline, they're not always too significant.* - Passivity experiences - experiences where someone believes they are under control by another entity (force, agency or person).\ Their bodily functioning is not under their control and can be influenced by external beings. (Particularly in individuals with Schizophrenia). - Thought broadcast, insertion and withdrawal: Outside agency can access thoughts/insert or remove into train of thought. - Somatic passivity: Sensations or impulses originate from external force/agency/person - Disturbances to thinking and speech - e.g. Thought disorder (sometimes known as formal thought disorder) - Disorganisation/fragmentation of thought and speech - 'Knight's move' - jumps quickly from one idea to another & their thinking being disconnected - 'Word salad' - thinking completely without meaningful connection - *Tends to be more frequent in individuals who's psychosis fits standard criteria for Schizophrenia.* - Emotional and behavioural disturbances Pros and Cons of diagnosis (esp. of Schizophrenia) Pros: - Honesty - Avoidance of stigmatised labels may reinforce stigma - Relevant to prognosis - Communicates severity of needs to patient, family and others (e.g. benefits of agencies) - Relevant to treatment - Often need to think in terms of diagnosis to access relevant research - NICE and other guidelines Cons: - Stigma - may induce denial and flight from treatment, extinguish hope - Schizophrenia is a syndrome, not a disease you can test for - Diagnostic instability - Possibility that our systems of diagnostic classification will change anyway - Treatment often symptom-focused rather than disease focused - May not be appropriate with single episode **Epidemiology** - 5-10% of community population report a psychotic symptom in the last year - 1.5 - 2.5%: lifetime prevalence of psychosis of any type form - 0.75 - 1%: lifetime prevalence of schizophrenia - Men more at risk overall with typically and earlier onset - also more severely Risk factors and potential aetiological factors - Family Hx - lots of different genes contribute - Cannabis, esp. in early adolescence - Social deprivation - Urban environment - Migrant background - esp. Black Caribbean/Black African (ideas about discrimination/social defeat) - Trauma (childhood and adult) - Birth trauma, winter birth Likely to be a combination of biological vulnerability and accumulated environmental stresses. **What about Schizophrenia?** Clinical Picture: Before onset: Emotionally and socially detaches, solitary & mild cognitive, emotional, motor problems in childhood. Prodrome (phase lasting from a month to a few years before onset of acute symptoms): - Insidious loss of motivation, social withdrawal, decline in performance - Attenuated psychotic symptoms: misperceptions, illusions, unusual ideas (e.g. increased interest in conspiracy theories) *Not everyone has a prodrome - though those that do, tend to have a poorer prognosis than those with an acute onset.* Schizophrenia - **Acute (positive) symptoms** - Hallucinations involving any sense - Delusions - any context - Passivity experiences = thought withdrawal, insertion & broadcast and somatic passivity - Thought disorder - incoherence of speech when drifting between topics/pauses - Disorganised behaviour, deterioration in social functioning and self-care, distress - Often very frightened & may be at risk of harming themselves, less frequently at risk of harming others. **Negative symptoms** - what's observed after an acute episode of psychosis - Loss of drive and determination - Loss of interest in other people and capacity for forming relationships - Loss of emotional reactivity - Paucity of speech and loss of interests - Often the most disabling aspect of illness - Have an environmental component - Often accompanied by deficits in cognitive functioning, fall in mean IQ already present by onset of illness Symptom pictures that especially suggest schizophrenia - Positive symptoms for at least a month - 'First rank' symptoms - types of psychotic symptoms, much more associated with schizophrenia than other diagnoses: - Passivity experiences - Auditory Hallucinations in the third person - e.g. voices talking about a person rather than to them - Delusional perception - when they have a real perception and immediately attach a delusion to it - Psychotic symptoms with flattening or incongruity of affect, or with perplexity - e.g. disassociated response to information that expects a certain response - Content of delusions is bizarre or impossible - Hallucinations are really persistent **Other psychotic disorder** Other forms of psychosis - Brief psychotic disorders, sometimes stress-related - Schizoaffective disorder - Mania (occurs in bipolar) with psychotic symptoms - Severe depression with psychotic symptoms (in keeping with very depressed mood) - Post-natal/partum psychosis - Drug-induced psychosis - Delusional disorder Psychotic symptoms without a psychosis diagnosis - Isolated psychotic symptoms - Dementia or Parkinson's - Intoxication - Physical cause - incl. brain tumour, encephalitis, lead poisoning **Introductory talk on Bipolar Disorder** **What is Bipolar Affective Disorder** Also called manic depressive illness (soon being super-seeded by 'Bipolar'). - Episodes of both depression and of elevated mood, usually interspersed by stable mood - Most people who have manic episodes also have depressive ones - Depression is similar to in other contexts - not necessarily severe **Epidemiology** - Lifetime of Bipolar I: around 1% prevalence diagnosed --- similar around the world - "Bipolar Spectrum" incl. milder undiagnosed presentation (Bipolar II) - maybe up to 5-6% - Onset of Bipolar I: First diagnosis - median age early 20s - Often some evidence of unstable mood before then **Symptoms** Elevated mood (1) - Hypomania - Persistent elevation of mood - elated/expansive/irritable (regardless of what's happening) - Increased energy, activity, sociability, increased feeling of wellbeing - Feelings can be pleasant and sometimes cause the dilemma of whether they want treatment - Disinhibition (say and do things they may not usually), increased libido - Decreased sleep and need for sleep - Decreased concentration - Though sometimes they express being more focused than usual - More talkative & speech pressured - Difficult to interrupt - flow of thought and speech that's unusually rapid - Perceptions more vivid than usual - New ventures and mild overspending - May interfere with work & social life, but normal activities and routines continue to a degree - Depression and hypomania only, but not full blown mania = Bipolar II (DSM V) Elevated mood (2) - Mania - More severe than hypomania - Pressure of speech is more severe - uninterruptible - Flight of ideas - rapid jumps between topics, connections often unusual e.g. puns, rhymes - Very disrupted sleep/not sleeping at all - Restlessness and agitation - Loss of inhibitions and impulse control - Disregard of risk - Grandiose ideas - Irritability and aggression, occasionally violence - 1 week duration, complete disruption of work and social life *Example of hypomania:* "When you're high, it is tremendous. The ideas and feelings are fast and frequent like shooting stars, and you follow them until you find better and brighter ones. Shyness goes, the right words and gestures are suddenly there, the power to captivate others a felt certainty. There are interests found in uninteresting people. Sensuality is pervasive and the desire to seduce and be seduced irresistible. Feelings of ease, intensity, power, well-being, financial omnipotence and euphoria pervade one's marrow." Kay Redfield Jamieson - An Unquiet Mind (1996, Picador) **The transition to mania and its aftermath** "But somewhere, this changes. The fast ideas are far too fast, and there are far too many; overwhelming confusion replaces clarity. Memory goes. Humour and absorption on friends' faces are replaced by fear and concern - you are irritable, angry, frightened, uncontrollable. Finally there are only others' recollections of your behaviour - your bizarre, frenetic, aimless behaviour - for mania has at least some grace in obliterating memories...... Credit cards revoked, bounced cheques to cover, explanations due at work, apologies to make, intermittent memories (what *did* I do?), friendships gone or drained, a ruined marriage." Mania with Psychotic symptoms - Psychotic symptoms occur in about 2/3 people with mania - Characteristically: - In keeping with elevated mood - Grandiose delusions, persecution because of special abilities/missions - Second person auditory hallucinations - talking to them, not about them - Once mania is severe, insight is rare **Risk in Bipolar Disorder** - At extreme: severe recklessness due to beliefs about physical invulnerability/special powers - E.g. jumping from buildings because they believe they'll survive - More frequently: - Spending - Socially disinhibited behaviour (work/social life) - Sexual disinhibition - Reckless new ventures - Dangerous driving - Physical risk taking e.g. in sport **Prognosis:** - Much more time in depressive than manic episodes (5% vs. 20%) - Suicide a risk in depression -- overall rate around 20 times greater than general population - Increasingly depressed rather than manic as get older - Worse prognosis with: - Early onset - Co-morbidities: drug and alcohol problems, anxiety, personality disorder - Some people function very highly **Living with Bipolar Disorder** - Large majority of people live uneventfully in community - Most people recover well between episodes, but around 10-20% remain significantly unwell - Compatible with high functioning - e.g. bipolar lawyers, doctors, clinical psychologists, bankers etc. - Co-morbid drug and alcohol problems an anxiety, social damage from mania impact on functioning - Employment rate: 30-50% **Risk Factors:** - Considerable genetic component: 67% risk for twins, 15-20% for children of a parent with bipolar disorder - Life events - triggers for individual episodes - Can begin after childbirth, high risk of recurrence post-natally - Organic mania, especially if late onset. Hormonal causes, taking steroids (most common), stimulants. - Some psychological risk factors found: - E.g. rigid black/white thinking - Over-sensitivity to disruption of routines - Differs from most psychiatric disorders in not having clear & substantial social risk factors (such as deprivation), but emerging evidence on link with childhood abuse **Psychosis** To cover: A framework for thinking about management of mental health conditions and types of interventions (service setting for mental health care, physical, pharmacological, psychological, social) *Class task: What symptoms do you think he may have from this description? Give them correct technical names as much as you can:* *What symptoms of psychosis?* - Prodrome: Deterioration in functioning, withdrawal - Hallucinations - third person auditory - Delusions - bizarre, impossible, out of blue - Passivity experiences - breakdown of boundary between self and outside world e.g. thought broadcast - Thought disorder - fragmented & incoherent speech *What **risks** would you be concerned about?* - Self-harm - suicidal ideals resulting from psychotic symptoms (e.g. command hallucinations, persecutory delusions) OR depression - following psychotic episode - Self-neglect and lack of caution - not caring for self-neglecting physical health, not keeping safe - Harm from others - high rates of being a victim of crimes/violence for people with psychosis - Harm to other - especially with positive symptoms AND drug use - Around 50-60% admitted with first episode - open under Mental Health Act - Home management of acute psychosis feasible: - Some cooperation and adherence - Reasonable social circumstances - Intensive support from crisis/home treatment (and family) - Some people decline What are immediate needs when someone has acute & severe mental health problems? - Immediate assessment and management of risks - Further assessment of diagnosis - If very recent, might psychosis remit without treatment? - Are there possible physical causes for the psychosis? - e.g. ?drugs, ?inflammatory conditions, ?infections, ?immunological condition - Begin the assessment of history, physical health, personality and coping resources, family and social circumstances (continues throughout management) - If need for treatment pressing, decide (as collaboratively as possible) what setting is appropriate: - Inpatient admission needed? - Compulsory treatment required? - Treatment at home possible e.g with support of crisis resolution team and early intervention service? Services available - UK First onset & acute relapses --- Early Intervention Services / Acute inpatient wards / Crisis & Home Treatment Teams / Crisis Houses and Day Hospitals Continuing Care (first three years) --- EIS / Supported Housing / Day and Vocational Services / Welfare Services Continuing Care (after first three years) --- Supported Housing / Day and Vocational Services / Welfare Services Assertive Outreach Teams / Rehabilitation Services / Community Mental Health Teams or Psychosis Team / Primary Care *Class task: What could help at this point?* - Medical intervention - antipsychotic - Involve family General principles of good psychosis care - Needs assessed and re-assessed throughout - Multidisciplinary approach - with an identified care coordinator to maintain engagement, ensure there is a plan, avoid fragmentation. - Collaborative decision making involving service users wherever possible - A holistic approach -- optimal physical, psychological & social care - Recovery approach: - Supporting people in achieving their own goals - Fostering hope, achieving well-being - Attention to physical as well as mental well-being - markedly reduced life expectancy is mainly due to physical illness and is probably partly iatrogenic. - Kindness and compassion - Currently great financial pressure -- but good community care can save money **Treatment** Early Intervention Services for Psychosis - Mandatory since 2001 in UK, popular worldwide - Specialist service for early psychosis, involved from the beginning even while people still in hospital/with crisis team - Aims: - Improve recovery and prevent relapse in 3 years after first episode (some evidence) - Detect psychosis early in community (hard to do) - Reduce number of people who may be in prodrome (at risk mental state) who become psychotic - Some evidence they improve prognosis at least while under their care - Then either discharge to primary care or continuing care services such as community mental health teams Antipsychotic Medication - Around since 1950s - Atypicals -- new generation with allegedly better side effect profile and effectiveness for negative symptoms, introduced from 1980s onward - Evidence -- not many trials comparing antipsychotics with placebo recently (?ethics), but older studies suggest: - In acute episode of schizophrenia: 81% improve with an antipsychotic, 52% without (Haddad et al meta-analysis) - Time-course: most improvement in first 6 weeks, some further up to 6 months. Second drug may improve further. - Prevention of relapse: two large meta-analyses show 55% relapse in a year without  antipsychotics vs. 14% and 22% respectively with them - Evidence more limited re prevention of relapse in the longer term after the initial year or two after a first episode- and now some suspicions of adverse effects on social functioning/cognition in long term. Sept 2023: RADAR trial publication. *Dopamine Hypothesis of Schizophrenia* - Old theory (1963), not fully proven, but not superseded - **Dopamine** is a brain neurotransmitter -- carries signals between nerve endings. - Dopamine **over-activity in mesolimbic system (at D2 receptors)** results in positive symptoms like hallucinations) - **Mesolimbic system** is concerned with reward, motivation, dreaming, imagination - Antipsychotics block this excessive dopamine activity - Other systems e.g. **serotonin** probably also relevant. - Mechanism for symptoms, not a causal explanation Psychological Interventions in Psychosis - Generalist Interventions that should be offered to all and can be delivered by non-specialists: For service user: - Psychoeducation - Relapse prevention work -- developing a relapse signature and a plan for response - Developing self-management skills - *Peer support - ?unpaid forms, e.g. support groups, in contact with others who have similar experiences* For family: - Psychoeducation and support CBT for Psychosis - Past 30 years -- adaptation of CBT first to delusions, then to broader range of psychotic symptoms and associated distress - Assumption: psychotic experiences on a continuum with normal - Does not require acceptance of an illness model -- interest in understanding individual experiences - Assumption: some people's genetic make up and experiences pre-dispose them to interpret anomalous experiences in a certain way - Client and therapist collaborate in re-evaluating the ways of reasoning and appraising experiences that underlie delusions and psychotic experiences - Depression and anxiety accompanying psychosis also worked with. - Evidence -- generally supported though still some debate. - Tends to be used once stabilised -- research interest in use in acute phase Effects of Antipsychotics - Reduced positive symptoms of psychosis - Reduced risk of relapse - Reduced symptoms of mania - Limited/no effect on negative or cognitive symptoms -- possibly make them worse, but uncertain as yet. Side Effects - Weight gain - Metabolic syndrome: diabetes, hypertension, raised cholesterol and lipids - Motor side effects (less with atypicals) e.g. muscle spasm, repetitive movements (tardive dyskinesia) - Sedation - Raised prolactin -- sexual dysfunction, breast engorgement and lactation, periods stop, long-term osteoporosis risk - Cardiac arrhythmias - Neuroleptic malignant syndrome -- rare and very serious condition with fever, confusion, muscle rigidity and breakdown, unstable pulse Other Individual Psychological Treatments in Psychosis - Third wave CBT Therapies - E.g. Acceptance and Commitment Therapy (ACT) - Art and Music Therapy - Cognitive Remediation - Cognitive training to improve the cognitive deficits in Schizophrenia - e.g. in planning and organising activities --- increasingly offered to improve functioning Family Therapy - Risk of relapse is greater with 20+ hours face to face contact in "high expressed emotion" family environment: - Hostility or critical comments - Emotional over-involvement (over-protectiveness, treating adult like a child) - Known for 30 years that therapy to reduce expressed emotion in families also reduces relapse -- but still often poorly implemented. - Behavioural family therapy is one of the models of family therapy aimed at reducing Expressed Emotion - Generally some way into recovery from acute episode *Some other approaches to families* - Psycho-education packages -- e.g. "REACT", e-siblings - Individual emotional and practical support - Relatives' groups - Multi-family therapy -- education, peer support and learning and behavioural family therapy - Open Dialogue approach -- an innovative approach to developing dialogues at the time of a psychotic crisis --- encourages involvement of whole family and network in decision making and the reality of a psychotic crisis. *Class task: Suggestions regarding further help and support?* - Psycho-education with mother - Family therapy - CBT - regarding distress and low mood - Peer support - EIS involvement - Review physical care Social Difficulties and Interventions in Severe Mental Illness Financial problems - Benefits advice, debt counselling Housing/daily living skills - Supported housing, housing support workers, "Housing First" schemes Lack of activity, role & income - Supported employment (IPS model), social firms, day activities Loneliness and isolation - Day activities and social groups, peer support, befriending Challenges for Longer Term Management - Resistant positive symptoms (delusions, hallucinations etc. after two courses of medication) - Approx. 20-30%.  More likely with more relapses. - May respond to Clozapine and/or CBT and/or management of comorbidities/non-adherence/maintaining factors - Negative symptoms - Apathy, social withdrawal, loss of interest - Influenced by environment - No clearly useful interventions. - Cognitive deficits - Increasingly a focus - Cognitive remediation as promising newer strategy - Stigma and social exclusion - Especially unemployment, loneliness and lack of friends Physical Health Care in Psychosis - Currently: 15-20yrs earlier death with psychosis (Causes: cardiovascular/metabolic/suicide) - Important to focus on this from the beginning -- early weight gain on antipsychotics may contribute to early death many years later. - Physical health monitoring -- blood pressure, lipids and blood glucose, BMI annually from beginning - Encourage weight management and exercise programme from the start, attention to diet - 70-80% smoke - Support access to physical health care services Common Comorbidities in Psychosis - Depression - Drugs and Alcohol, esp. Cannabis use - Anxiety - PTSD - increases likelihood of developing psychosis - also psychosis can increase risk of trauma *Comorbidities and whether they are successfully treated have a major impact on outcomes.* At Risk Mental States (ARMS) - Great interest in possibility of preventing full-blown psychosis by intervening in prodrome - At risk mental state (ARMS) - where young people show indications of being at high risk of psychosis onset - ARMS phenomena include social decline, fluctuating mood, attenuated positive symptoms - Possible interventions to prevent transition to psychosis: CBT, antipsychotics - But false positives still a big problem **Bipolar Disorder** *Class task: What features of mania does the vignette suggest Flora may currently have?* - Disinhibition - risky driving - Grandiose ideas - and Delusions - Auditory and Second person hallucinations - Flight of ideas (unusual connections in ideas) - speaking in rhymes - Decreased need for sleep - Impulsive & spending - luxury ski trip - Elated and expansive mood - Heightened perceptions - Loss of normal inhibitions - reckless Immediate/short-term Management of Manic Episodes - Risk assessment and management: - What can be done to manage any risks? e.g. don't drive, stay away from work for a while, stop credit card - Is hospital admission needed because risks are too great/cooperativeness is not sufficient for home treatment? - Medication (antipsychotics/mood stabilisers/ benzodiazepines) - Self care -- sleep, routines, reducing stress Longer-term Management of Bipolar Disorder **General & Self-Management of Mania** - Prevention of relapse, self management of mood swings - Good self-care, calming activities, routines, stress management, coping strategies for life events - Strategies for detecting and managing prodrome of relapse - Define individual signs of early relapse (not sleeping, being more active etc.) - Collaborative plans for client, family and friends, staff to monitor for relapse signs - Plans for action when signs of relapse (increase rest, reduce stimulation, time off work etc.) - Advance directives - Risk management - Warning systems at work, credit card limits. *What risks would you be concerned about?* - Reckless behaviour - driving - General disinhibition - social, sexual, academic, - Financial risk *What might be helpful to Flora in the coming days and weeks?* - Psychoeducation - Risk management - CBT - Medication - antipsychotics first, followed by mood stabilisers if no response **Drugs Used in Bipolar Disorder** - Lithium -- around since 1949 and seems to be most effective treatment (Lithium + valproate even more), especially for relapse prevention and reducing suicides - but can have permanent effects on kidney, thyroid and toxic state can develop. Blood tests 3 monthly required. - Valproate, Carbamazepine, Lamotrigine - anti-epileptics now also used as mood stabilisers. Significant efficacy and important side effects. Lamotrigine especially for bipolar depression. - Antipsychotics -- effective against mania (first choice in UK), some uses in bipolar depression and in relapse prevention. - Antidepressants -- use in bipolar tricky because can trigger mania **Specialist Psychological Therapies** - CBT -- individual and group packages with principles of monitoring and managing mood, self-management. Some evidence of benefit, NICE guidelines 2014 recommend offering to everyone. - Interventions to reduce conflict and stresses in relationships and families. - Bipolar depression -- psychological treatment may be best. Management of Acute Mania - Risk management - Antipsychotics (first choice in UK when severe) and/or mood stabilisers, benzodiazepine often added - Calming routines, sleep, avoidance of stress and substance use - Mixed episodes (combined depression and mania), rapid cycling -- similar management Bipolar Depression - Not easily distinguished from depression in people without bipolar disorder - Has received less attention than mania but often more problematic - Treatment options: - Psychological -- CBT and other effective depression treatments - Complex drug options, still contested: antidepressant combined with antipsychotic/lamotrigine/some antipsychotics on their own\* *A tricky topic of which we aren't expecting you to develop much knowledge!* Longer Term Management and Relapse Prevention - Good self care and self management, relapse prevention plans, advance directives - Psychological treatments - Treatment of comorbidities (anxiety, substance misuse, emotionally unstable personality disorder) - Social interventions as for psychosis - Consider maintenance medication -- collaborative decision, taking account of: - Number, severity and frequency of episodes - How readily recognised and treated - Side effects and toxic effects *Group task: Flora's annual CPA (Care planning) meeting is approaching - what should be discussed?* - Supported employment / support returning to education - Peer support / mentorship - Lithium - for relapse prevention - to be offered - Therapy - re: taking public transport/town centres Pregnancy and Bipolar - Bipolar disorder is not usually a reason to advise against having a baby, but careful planning needed if possible - Consider that: - Approx a third of bipolar women have a manic or depressive episode during pregnancy - Approx 50% have an episode just after birth - Valproate (especially), Lithium, Carbamazepine harm unborn child - Great caution also needed in prescribing when breastfeeding - People may take uncharacteristic risks/be less inhibited and more reckless when manic