Psychosis Symposium Nov 2023 PDF

AN INTRODUCTION TO PSYCHOSIS Dr James Fallon Learning Objectives Epidemiology of Psychotic Disorders Prognosis and Recovery Concepts Early Intervention in Psychosis Treatment of Psychosis (Bio-psycho-social approach) When have we already learnt about Psychosis? Module 202: Neuroscience and Beha...

AN INTRODUCTION TO PSYCHOSIS Dr James Fallon Learning Objectives Epidemiology of Psychotic Disorders Prognosis and Recovery Concepts Early Intervention in Psychosis Treatment of Psychosis (Bio-psycho-social approach) When have we already learnt about Psychosis? Module 202: Neuroscience and Behaviour Schizophrenia: Neurobiology and Treatment Aetiology Neuropathology Neurophysiology (Glutamate Hypothesis, Dopamine Hypothesis) The interaction of GENES and ENVIRONMENT in Psychosis But remind me…. • What is psychosis? 3 Patients 3 Diagnoses Sam • 22 year old university student • Withdrawing from friends • Not attending course • Family worried Alanna • 17 year old college student • Not sleeping • Unusual behaviour at college • Very talkative Patricia • 72 year old retiree • Increasingly agitated • Praying constantly, talking about having sinned • Poor sleep Alanna • Increasingly bright and cheerful over recent weeks • Past couple of days has slept only hours • Full of energy • Talking rapidly and hard to interrupt • Friends say she has been uncomfortably flirty with strangers when out with them • Talking about being connected with everyone on the planet and the elements • Believes can control electricity Alanna’s diagnosis? Patricia • Mood declining over recent months • Talking about having committed terrible sins in the past • Family are sure she has not • Worried that she may be dead ‘I’m in hell’ • Pacing +++ • Takes hours to get to sleep • Wakes up at 5am Patricia’s diagnosis? Sam • Believes is being followed by MI5 who have implanted a device in his ear • Hearing voices • ‘We are coming for you. We will hurt you.’ • Feels as though other people can hear his thoughts • At times feels as though his movements are being controlled by the device • Stops talking mid-sentence at times • Withdrawn, not taking care of himself Sam’s Diagnosis? Prognosis 20% of patients will make a full recovery with medication and supportive treatments 35% have long periods of remission 35% will have persistent mild positive and negative symptoms, that can be managed in the community 10% have severe symptoms that are unresponsive to treatment, and these people may require institutionalized care Potential Longer-term Diagnoses Non-affective (no mood component) • Schizophrenia • Multiple Episodes • Continuous • Delusional Disorder Affective (mood component) • Bipolar Affective Disorder • Recurrent Depressive Disorder • Schizoaffective Disorder Diagnoses will evolve over time – this is normal! Epidemiology • Lifetime prevalence for all psychotic disorders = 3% (Perala 2007) • Schizophrenia 0.9% • Bipolar = 0.25% • • • • • Depression with psychosis = 0.35% Delusional Disorder = 0.18% Schizoaffective Disorder = 0.32% Substance induced psychosis = 0.42 Schizophreniform disorder = 0.07% Reminder Delusion - deeply held, unshakable beliefs, out of keeping with social, cultural, religious and educational norms • Persecutory delusions - the fixed, false belief that others are conspiring or acting against them. Can include, but is not limited to beliefs that others are poisoning, trying to harm them, observing them through others or cameras, cursing them etc. • Grandiose delusions - fixed, false beliefs that one has a special importance or has some special ability. Can take a lot of different forms - belief that is a celebrity, can control the weather, is Jesus or God etc. • Delusions of reference - fixed beliefs that events, objects and others interactions hold a special significance for them. This may manifest as belief in news reports, TV programmes or newspaper articles relating to them. • Nihilistic delusions - the patient will express a belief that they, others, the world around them is does not exist. Can manifest as a belief that they or others are dead (Cotard's delusion) • Delusion of guilt - fixed, false belief that they are evil, bad, have ruined their or more commonly other's lives. Can express the view they have committed some awful act that will result in them going to hell etc. • Erotomanic delusions - the fixed, false belief that a specific person is in love with them, even though they may never have spoken with them Thought alienation • Thought insertion - feeling that others are directly putting thoughts into their head. Thoughts are recognised as being foreign, important to establish that this is a true sense of thought insertion rather than others influencing their thoughts through conversation/other actions rooted in reality • Thought withdrawal - feeling that others are removing thoughts from their head • Thought broadcasting - feeling that others know what they are thinking (should be distinguished from anxiety/social phobic symptoms of feeling others are judging them or thinking poorly of them) Hallucination - experiencing a perception in the absence of stimulus • Auditory hallucinations • • • • 2nd person auditory hallucination - the patient hears voice/s talking to them - 'you're a bad one' 'you are being followed' 3rd person auditory hallucination - the patient hears voices talking about them - 'he is a bad one' 'he is being followed' Running commentary - voice/s are heard describing what the person is doing as they go about their business Thought echo - the patient hears their thoughts repeated by a voice/s • Tactile hallucinations - the patient feels things touching their body, can occur in psychotic illnesses and organic conditions including delirium • Visual hallucinations - the patient sees things that are not present. More likely to occur in organic conditions including delirium, Lewy-body dementia than functional psychiatric illnesses. Can occur in psychosis, though considerably rarer than auditory or tactile. • Gustatory hallucinations - taste in the absence of stimuli, can occur in schizophrenia but also in temporal lobe epilepsy, lithium or disulfiram treatment • Olfactory hallucinations - the patient smells things that others cannot, can occur in epilepsy, can occur in psychotic illnesses (though rarer) Multiple hit theory Migration Neuregulin 1 Dysbindin Genetic vulnerability Maternal stress and malnutrition Viral exposure Obstetric complications Prenatal Urbanicity Cannabis use Subsequent hits 'First Hit' Ethnicity Risk of Schizophrenia Childhood trauma IQ Head injury Childhood Neurodevelopmental Stage Adolescence Adulthood Epidemiology of Schizophrenia • <1% of the population will have a diagnosis of schizophrenia at some point in their lives • Prevalence – 5-8 per 1000 • Incidence - 20 per 100 000 • The incidence is roughly the same around the globe, however, the course of the disease varies according to location. • Higher incidence in inner city, low socioeconomic environments & 2nd generation migrants. • Peak incidence: • 18-25 in men • 25-30 in women • Roughly equal incidence in both men and women What is Recovery? What impacts recovery? • Length of prodrome • Duration of Untreated Psychosis (DUP) • Critical period – first 5 years (Birchwood, 1998) Intervention should be Early • Improved outcomes • Reduced risk of unnatural death • Higher rates of symptomatic recovery • Duration of untreated psychosis • ‘toxic effect’ theory • Cognitive dysfunction • Negative symptoms Courts / prison Forensic Psychiatry Self referral Substance Misuse Service Primary Care Primary care level psychological services General Hospital Liaison Psychiatry Secondary Care Psychiatry Functional Learning disability Children and Young Peoples Working age Older peoples Dementia General community Early Intervention in Psychosis Inpatient Eating disorders General Community Teams Assertive Outreach Team Specialist Services Rehabilitation Crisis Team Perinatal psychiatry Inpatient Neurodevelopmental What is an Early Intervention in Psychosis Service? • Specialist Team - First Episode of Psychosis • Rapid access – referrals seen within 2 weeks • Anyone can refer • Aims – • Reduce Duration of Untreated Psychosis UK (Birchwood et al. 2013) 9 months (260.3 days) UK (Gumley et al. 2016) 11 months (44.37 weeks) • Improve functional recovery • 3 year period of support from specialist EIPS Intensive Multidisciplinary Support Medics Consultant Psychiatrist + Training grade doctors Care Coordinators / Lead Practitioners Small caseload – 12-15 patients Nurses Social Workers Occupational Therapists Psychologists Clinical or Counselling Psychologist Specialists Vocational specialist Peer support workers EIS Specialist Pharmacist Support staff Support Time and Recovery Workers The Early Intervention Approach (Treatment for comorbid conditions) Multimodal interventions in first episode psychosis Aims of EIPS • Early identification and treatment (DUP) (Birchwood, 1998) • Engagement and retention in service (Singh, 2010) • Reduce hospitalisation/acute care - 77% FEP admitted in 1st 3 months, 20% readmitted (Wade, 2009) • Reduce suicide/homicide/violence (Power, 2010) • Reduce relapse • Promote recovery – symptomatic/functional/personalised • Employment/education/training (Killackey, 2010) • Social inclusion • Reduce stigmatization • Flexible & assertive response Outcomes in First Episode Psychosis • • • • • Clinical – reduced DUP, symptom control Vocational Social Quality of life Risk reduction In 1998 only 15% of FEP under CMHT made a full or partial recovery. In 2007 52% FEP made a full or partial recovery under EIPS (Fowler, 2009) Direct Savings (McCrone 2010) • • Reduced use of in-patient beds – admission and readmission £11,685 for EIPS vs £14,062 for standard care • Relapse doubles the cost of illness (SOHO study, 2009) Indirect Savings • Lost employment – annual saving £2087 per person in EIPS - 36% employed in EIPS vs 27% standard care (Garety, 2006) • Other areas – reduced costs associated with criminal behaviour, drug use, homelessness, carer’s needs (McCrone & Knapp 2011) Summary – why Early Intervention? Early detection & treatment Bio psycho social approach Promote recovery Prevent relapse Saves money People like it! Variable outcomes BUT message of hope essential Let’s come back to Sam… What is the most common symptom or sign in acute psychosis? Compulsory Treatment • What is our legal framework for compulsorily treating? • If you were to deprive someone of their liberty what criteria would you use? Treatment of Psychosis Bio-psycho-social Approach Biological – medical treatment Psychological – CBT for psychosis, family work Social – OT, wellbeing, employment, housing, finances, peer support, and more! NICE recommendations on treating FEP • Second Generation Antipsychotics are treatment of choice, offer early • Choice is guided primarily by profile of side effects and its relevance to patient • NICE CG 155 - For children and young people with first episode psychosis offer: oral antipsychotic medication in conjunction with psychological interventions (Family Intervention + individual CBT) [2013] • Joint choice of drug with patient / carer / Dr • Use Clozapine if no response to 2 others (including 1 atypical) Antipsychotics Typical Oral​ Atypical Oral​ Long Acting Injectables ​ (Depot antipsychotics)​ Chlorpromazine​ Amisulpride​ Aripiprazole ​ Haloperidol​ Aripiprazole​ Olanzapine emboate​ ​ Lurasidone​ Paliperidone palmitate ​ ​ Quetiapine​ (Risperidone)​ ​ Olanzapine​ Flupenthixol (Depixol)​ Typicals​ ​ Risperidone​ Haloperidol (Haldol)​ Treatment resistant ​ Clozapine​ Atypicals​ Dopamine pathways Prefrontal Cortex Mesocortical Midbrain Mesolimbic Ventral Tegmental Area Substantia Nigra Hypothalamus Tuberoinfundibular Pituitary Gland Nucleus Accumbens Caudate Nucleus + Putamen Nigrostriatal Nigrostriatal Mesocortical Mesolimbic Tuberuoinfundibular So what goes wrong in schizophrenia? We know that “too much dopamine” can cause psychotic symptoms Dopamine pathways Negative symptoms Prefrontal Cortex Mesocortical Midbrain Ventral Tegmental Area Substantia Nigra Hypothalamus Tuberoinfundibular Pituitary Gland Mesolimbic Nucleus Accumbens +++ Caudate Nucleus + Putamen Nigrostriatal Positive symptoms Typical Antipsychotics Typical antipsychotic -ve effect on –ve symptoms Prefrontal Cortex Mesocortical Midbrain Ventral Tegmental Area Substantia Nigra Mesolimbic Nucleus Accumbens +++ Reduction in positive symptoms Caudate Nucleus + Putamen Nigrostriatal Hypothalamus Tuberoinfundibular Pituitary Gland Typical antipsychotics are D2 receptor antagonists. This means they block the effect of dopamine at the level of the synapse. Therefore most effective at addressing +ve symptoms What about side effects? Typical Antipsychotic Side Effects Dopamine has inhibitory effect on prolactin release. Reduced dopamine by D2 antipsychotics therefore causes Hyperprolactinaemia Ventral Tegmental Area Substantia Nigra Hypothalamus Tuberoinfundibular Pituitary Gland Caudate Nucleus + Putamen Nigrostriatal Too little dopamine effect in Nigrostriatum causes Extrapyramidal Side Effects Typical vs Atypical Antipsychotics Typical Atypical • Potent D2 blockade • Less potent D2 blockade • May worsen negative symptoms • Serotoninergic effects (5HT2A antagonism) • High levels of EPSEs • Fewer EPSEs • Reduced negative symptoms • Fewer metabolic effects • More metabolic effects Extrapyramidal side effects Parkinsonism Akathisia Acute dystonia Tardive dyskinesia Metabolic Syndrome • Hypertension • Central obesity • Hypercholesterolaemia • Low HDL • Insulin resistance Receptor Side Effects Sub-receptor Monoamine (Neurotransmitter) Effect D2 Dopamine Parkinsonism. Tardive dyskinesia. Raised prolactin Complex! May reduce EPSEs Sexual/fertility side effects Alpha-1 Noradrenaline Postural hypotension H1 Histamine Sedation Weight gain M1 Cholinergic (Muscarinic) Antagonism: Constipation, Urinary retention, blurred vision, confusion etc 5-HT2A Agonism (clozapine only): Saliva overproduction Side effect profiles of antipsychotics What drug will we pick for Sam? Clozapine • Treatment-resistant psychosis​ • Most effective antipsychotic​ • Problems with haematological sideeffects (in 1-3%) necessitate blood test monitoring​ • Acts on range of neurotransmitter systems (including D4 receptors and serotonin system)​ • Low propensity to cause EPS​ • Hypersalivation and hypotension may occur Short story of Early Intervention… https://www.youtube.com/watch?v=Y UKES_xShE4&t=9s