Psychosis Prodrome Outline Psychosis is on a continuum o Clinicians assume the distribution of psychosIf you want to learn more check out 812 mmhg to atm
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is to be bimodal o But it is actually semi-continuous o 15 % of individuals who have hallucinations but do not come into contact with the medical field (not due to drugs of medical problems) 1% meets psychotic disorder DX First episode psychosis o Definition o Typical course o Duration of untreated psychosis is bad because it predicts a number of poor outcomes: community/social interactions, quality of life, depression/anxiety, negative symptoms, disorganized symptoms, and psychotic symptoms Violence in untreated psychosis – there is a myth in science of psychosis o Rates of violence are elevated, but only if psychosis is untreated. If the individual has ever been treated, rate of violence goes down to that of the general population. The mere prescription of the drug can do this. o Violence is rare any violence (34.5%), serious violence (16.6%), severe violence leading to bodily harm of others (0.6%) o Before treatment the rate of violence is high because untreated o Homicides rare during first episode, 1.6 homicides per 1000 o After treatment the rate of violence is – homicide annual rate is 0.11 per 1000 patients o Why does society believe the myth that all people, especially those with psychosis, are violent? They only show the bad parts, make you think that every homicide is by a psychotic person. More likely men, drugs, lower socioeconomic class – predict probability of committing violent act. Early identification and prevention o Is treatment after onset and management of symptoms the best we can do in the medical field? The field has shifted towards a model of early identification and prevention. o New model = early identification and prevention o Model in Australia vs USA o Prodromal phase: psychotic risk period; an early symptom indicating the onset of a disorder. Period preceding onset of first florid psychotic episode when there is increasing symptomatic presentation and functional deterioration. o Medical example – fever is prodromal to measles Course of the prodrome o Early prodrome symptoms/course – (usually high school age) usually starts with negative symptoms; stop being expressive, develop alogia (reduction in quantity of speech), have perceptual abnormalities (illusions – elongating table), changes in motor activity (writing, threading a needle), avolition (lack of motivation), asociality (stop hanging out with friends), anhedonia (stop enjoying otherwise enjoyable things to them), lose friendships, develop educational problems, vocational problems (can’t work anymore) o Late prodrome symptoms/course – mood symptoms develop (anxiety/depression), further social withdrawal, very isolated, changes in social cognition (recognizing and understanding others’ emotions). Attenuated psychotic symptoms; unusual thoughts, suspiciousness, paranoia, bizarre thinking – main transition btwn early and late o Onset o Premorbid phase Home video studies Diagnostic criteria in DSM5 for attenuated psychosis syndrome - symptoms with sufficient severity and/or frequency to warrant clinical attention How do you define psychosis? o Intensity: conviction (how much someone believes something is true), degree of implausibility (how bizarre the symptom is – how impossible the thing they believe is), preoccupation (are they thinking about it constantly), disruption (how much it affects their lives) o Frequency: at least 1 hr a day at an avg frequency of 4 days per week over 1 month (def present for more than ½ days over 1 month) – frequency reduced in prodromal phase to bout once a week o Urgency: seriously disorganizing or dangerous, regardless of duration. What % of individuals identified as being at risk develop a psychotic disorder? 8-10% identified to have it. 15% of population has low level symptoms o What are the most common trajectories for those who do not convert to a psychotic disorder? 20-35% (out of the 15% that have symptoms) transition rate by 2 years. This is how many people actually develop the disorder based off of those with the symptoms. Rate rises as time goes on. This is bad because it can lead to self fulfilling prophecies. What differentiates converters (someone we identify as being at risk that actually develops a psychotic disorder) from non-converters? o Neuropathology Reduced synaptic density/connectivity – McGlashan and Hoffman ∙ Connections multiply from birth – age 5 and plateau until adolescence ∙ Pruning (normal developmental process) occurs in adolescence to increase efficiency ∙ Converters have reduced white matter integrity ∙ Converters have greater grey matter reduction in cortex: o Orbitofrontal cortex – decision making, reasoning (delusions) o Para hippocampal – memory (cognitive impairments) o Fusiform – facial recognition (social cognition)o Cerebellar – motor functions ∙ Greater presynaptic dopamine o Reduced dopamine synthesis in the striatum o Dopamine abnormalities are related with conversion o Demographics Male gender Genetic risk o Symptoms – negative and disorganized symptoms, general symptoms (reduced tolerance to stress), higher positive symptoms = more likely to convert Comorbid symptoms ∙ Anxiety, depression, substance use (30% control and 40% CHR use cannabis) o Drug abuse o Cognition - individuals who convert have more cognitive impairments than those who don’t; cognitive impairment is not as severe in the prodromal than it is when people have diagnostic schizophrenia o Social cognition – is impaired in prodromal phase but not to the level of the first episode of chronic schizophrenia (MSCEIT & TASIT) o Stress reactivity/HPA axis – hypo pituitary adrenal axis (fight or flight system); cortisol (salivation); axis is irregular Stress reactivity and abnormalities in HPA axis predict the development of psychosis in individuals who are at risk What happens to the youth who do not convert? o Within 2 years: 36% symptom remission 30% functional recovery 40% experiencing continued attenuated psychosis and functional impairment Most common nonpsychotic Axis I conditions (mood and anxiety) about 25% Can conversion to psychosis be prevented in clinical high-risk youth? o Why early intervention? Greatest risk of deterioration in first 1.5 yrs of illness Prevent decline – cognitive, social, vocational Reduce duration of untreated psychosis Reduce chance of violence to self and others o Do clinical trials show that treatment is effective for preventing conversion? 10% treated convert 30% untreated convert o What are recommendations from different agencies about use of antipsychotics and psychosocial therapy? Do not give people antipsychotics unless people are fully psychotic (someone reaches the first episode) Throughout the world, recommendation is careful and frequent monitoring and offering psychotherapyo What are some barriers to treatment? Denial on part of patient and family due to stigma Poor recognition of symptoms by others during early stages, until frank psychosis begins o Lack of mental health education Limited knowledge on part of mental health providers Child-adult chasm – most present mid-late teens and early adulthood Few programs in the USA (15-20) Summary 1: Most psychotic illness begin in early 20s Current mental health services intervene late Service gap a critical period – adolescence Need for care precedes psychiatric diagnosis The untreated psychotic period is of greatest risk for violence to self and others (reduces to roughly the level of general population from antipsychotics) The earlier psychosis is identified and treated, the better the outcome Summary 2: New advances have allowed up to better predict who is at risk Early treatments may delay or prevent psychosis onset Early intervention may prevent self harm and harm to others Community awareness of warning signs and early referral are critical to reach those who need help most