Dr. Rozylo Psychosis Lecture Flashcards
How long is the prodrome generally in childhood/adolescent presentation psychosis
can be weeks to year but typically between 1-3 years
what is the conversion rate from prodrome to psychosis in childhood/adolescent presentation psychosis
conversion rates between 20-40% overall
what does a prodrome look like in childhood/adolescent presentation psychosis
subthreshold positive symptoms with or without negative symptoms
what % of youth with prodromal syndromes develop psychosis within one year
36-54%
what are “APS”?
“attenuated positive symptoms”–> youth who have at least ONE positive symptom (this is subthreshold for overt psychosis)
what are the prodromal syndromes?
APS (attenuated positive symptoms)
BLIPS
Genetic risk and deterioration syndrome
Ultra High Risk (UHR)
At Risk Mental State (ARMS)
Attenuated Psychosis Syndrome
what are “BLIPS”
brief limited intermittent positive symptoms
what is “Genetic Risk and Deterioration Syndrome”
a prodromal syndrome
a combination of functional decline and genetic risk
what factors go into determining whether someone is Ultra High Risk (UHR) Prodrome?
determined by premorbid cognitive and social skills + comorbidity + hx substance use + neurocognitive impairment
what % of those with UHR prodrome progress to psychotic disorder in one year? in 3 years?
1 year–> 22%
3 years–> 36%
what % of those with UHR prodrome who do NOT progress to psychosis DO progress to mood or anxiety disorders
70%
What factors are notable about Attenuated Psychosis Syndrome
smaller amount of grey matter
poorer functional outcomes
what symptom/trait is required for diagnosis of APS
presence of attenuated (subthreshold) POSITIVE psychotic symptoms within the past 12 months
*there USED TO BE a requirement for a 30% drop in SOFAS score for a month within the past year or SOFAS score 50 or less in the past 12 mo or longer, reflective of a drop in functioning, however since 2016 this is no longer required
what symptom/trait is required for diagnosis of BLIPS
presence of frank psychotic symptoms for LESS THAN ONE WEEK that spontaneously RESOLVE without treatment within the past 12 months
*there USED TO BE a requirement for a 30% drop in SOFAS score for a month within the past year or SOFAS score 50 or less in the past 12 mo or longer, reflective of a drop in functioning, however since 2016 this is no longer required
what are you particularly interested in on family history in a child with psychosis prodrome
presence of SCHIZOTYPAL PD or a first degree relative with psychotic disorder
What are the criteria called that help us determine who is at high risk for psychosis
Melbourne ultra high risk for psychosis criteria
what combination of factors suggest trait and state risk factors for psychosis
presence of SCHIZOTYPAL PD or a first degree relative with psychotic disorder
+
30% drop in SOFAS score for a month within the past year or SOFAS score 50 or less in the past 12 mo or longer, reflective of a drop in functioning
List 11 predictors of transition from prodrome to psychosis in children and teens
family history/genetic risk
negative symptoms
thought disorder
poor baseline social functioning
decline in social functioning
longer duration of symptoms before clinic entry
childhood trauma
cannabis (contradictory data)
neurocognitive deficits (some evidence)
changes in grey matter
thalamic connectivity changes
name a structured interview you can use for assessing kids with prodromal psychosis symptoms
SIPS–> Structured Interview for the Prodromal Symptoms
what is the structure of the SIPS interview
4 parts–>
- SOPS
+ - Global Assessment of Functioning
+ - Schizotypal personality disorder criteria
+ - Family History of psychotic symptoms
what is the SOPS portion of the SIPS interview
Scale of Prodromal Symptoms
–> positive sx, negative sx, disorganization, general symptoms
Other than the SIPS interview, what are some other scales that can be used in the assesment of prodromal youth
Comprehensive Assessment of At Risk Mental States (CAARMS)
Bonn Scale for the Assessment of Basic Symptoms
Schizophrenia Prodromal Instrument –Adult Version
what are the basic symptoms assessed in the Bonn Scale for the Assessment of Basic Symptoms
subjective disturbance of thought
affect
motor functioning
bodily sensation
perception and tolerance of stress
How do you treat prodrome in youth?
ACTIVE FOLLOW UP–> monitor regularly for up to THREE YEARS using a structured, validated assessment tool
CBT may delay onset of psychosis
supportive and family therapy
education
monitoring of safety issues
treat comorbid conditions
treatments to prevent development or persistence of social, educational or vocational problems
(see following cards regarding antipsychotics)
are antipsychotics generally recommended for treatment of prodrome in youth?
no not recommended unless psychological interventions are ineffective, there are severe, prolonged attenuated symptoms, or if there is a risk to self or others (i.e if it becomes psychosis…. lol)
what antipsychotics are first line in treatment of prodrome (IF INDICATED)
second generation
what is a great resource for prodromal youth or youth with psychosis
Canadian Consortium for Early Intervention in Psychosis
What is offered by/advocated for by EPI Canada
Community interventions to increase detection of new cases
Easy and rapid access to services
Integrated biopsychosocial care plan
–Psychosocial interventions
–Education and vocational plans
–Treatment of comorbidities (including addictions)
–Multidisciplinary teams, including a psychiatrist
–Formal processes for evaluation of quality services and patient outcome.
List 10 risk factors for psychosis
pre/perinatal risk
paternal age
infection during pregnancy
being part of a famine/eating disorder mothers
placental insufficiencies
urban environment
childhood trauma
cannabis
social isolation
immigrant status (first generation)
what is the etiology of psychosis
multifactorial
genes + environment –> creating neurodevelopmental challenges
?amino acids ?neurotransmitter
neuronal development in prefrontal and temporal cortices
abnormalities in GLUTMATE and GLUTAMINE
list 5 genetic syndromes associated with psychosis
15q13.3 deletion or duplication
22q11.2 deletion syndrome (De George/velocardiofacial syndrome)
Marfan syndrome
Huntingtons disease (childhood onset)
Mosaic Turner
how many genetic risk loci have been detected for schizophrenia
108
(and 80 single nucleotide polymorphisms)
list 6 changes seen in neuroimaging in those with psychosis/schizophrenia
- decreased total grey matter in cortex, hippocampus and amygdala
- larger ventricles (particularly the LATERAL ventricle)
- smaller brain volume –> PROGRESSIVE DECLINE over adolescence
- in COS: total, frontal, temporal, parital grey matter loss
- smaller cerebellum and insula sizes
- deficits in brain connectivity
are negative symptoms more or less common in youth with psychosis compared to adults
negative symptoms and thought disorder are LESS common in youth with psychosis compared to adults
what are the five cognitive deficits associated with psychosis
executive function
processing function
memory
fine motor
concreteness
*need to know this
how do youth with psychosis typically present in terms of criteria for diagnosis
criteria for psychotic disorders tend to be incompletely or atypically presented
how do hallucinations/delusions tend to present in in youth with psychosis compared to adults
less elaborate hallucinations
somatic and visual are more frequent
less elaborate delusions–> often have adolescent themes
80% have AH
how do youth with psychosis compared to adults present in terms of social functioning
failure to meet social and academic outcomes, often for the first time
how do pediatric and adult manifestations of the following symptom cluster compare:
delusions
kids–> usually POORLY elaborated and VAGUE; may build on real experiences i.e being teased
adults–> usually SPECIFIC and COMPLEX
how do pediatric and adult manifestations of the following symptom cluster compare:
hallucinations
kids–> often MULTIMODAL (auditory, visual, tactile); often given names which may be stereotypic i.e the devil
adults–> AUDITORY much more common than any other modality; seldom personalized
how do pediatric and adult manifestations of the following symptom cluster compare:
disorganized speech
kids–> may be hard to distinguish from developmental language disability especially given premorbid disabilities
adults–> clear difference from previous state
how do pediatric and adult manifestations of the following symptom cluster compare:
disorganized behaviour
kids–> similar to adults, but parents may exert more control and minimize effects
how do pediatric and adult manifestations of the following symptom cluster compare:
negative symptoms
kids–> may be confused with oppositionality or depression
how do pediatric and adult manifestations of the following symptom cluster compare:
common comorbidities
kids–> ASD, ADHD, ODD, anxiety disorders, depression
adults–> depression, SUDs, cannabis use assoc with earlier adult onset but rare before middle-teen years, ASD sx before age 3
ddx psychosis in youth
delirium
schiziphrenia
BD
MDD
OCD
ASD
ID
ADHD
FASD
anxiety
trauma/stress response
cultural factors
personality
factitious psychosis
list possible medical etiologies on the differential for childhood onset psychosis/schizophrenia
seizure disorder
antiNMDA receptor encephalitis
HSV encephalitis
lysosomal storage diseases
neurodegenerative disorders
CNS system tumours
progressive organic CNS disorder i.e SCLEROSING PANENCEPHALITIS
metabolic disorders
chromosomal disorders ie de george
list psychiatric illnesses that can be misdiagnosed as schizophrenia in youth
psychotic depression
bipolar
ASDs and pervasive developmental disorders
OCD
GAD
PTSD
multidimensionally impaired (not DSMV but describes those with multiple language or learning disorders, mood lability and transient psychotic symptoms)
list 6 SCREENING tools that can be used in the evaluation of psychosis in youth
Youth Self Report
Child Behaviour Checklist
Behaviour Assessment System for Children
BPRS-C
K-SADS-PL
Bunny-Hamburg Global Rating (?)
what is the BPRS-C? what ages does it cover?
Brief Psychiatric Rating Scale for Children
ages 3-18
what is the K-SADS-PL
Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version
Psychotic Disorders Supplement; Affective Disorders supplement
List 3 scales for TRACKING symptoms of psychosis in children
PANSS (NOT validated in children but is used to track)
Young Mania Rating Scale (for mania)
Children’s Global Impression Scale
when should you consult peds in a youth presenting with psychosis
if there is any atypicality in presentation or if young age below 16
what does the blood test DRVVT look for
lupus
what workup should be done by psych/peds in first presentation psychosis when indicated?
complete physical exam by peds with focus on neuro exam
blood work + extended blood work (see other card)
ECG for QTc
Urine (see other card)
consider plasma amino acids and chromosome microarray
LP for NMDA, HSV if indicated
MRI/CT for head imaging if have neuro findings or if very young age of presentation
EEG if indicated
what does the blood test ANti-VKGCAb look for
small cell lung cancer
what does blood test acetylcarnitine look for
disorder of fatty acid metabolism
what does blood test anticardiolipin antibody look for
antiphospholipid syndrome
what does blood test for cortisol screen for
pheochromocytoma
what does blood test for antisulphase A look for
leukodystrophy
what regular and extended blood work should be ordered when indicated when working up first presentation psychosis
CBC-D
lytes
BUN
Cr
Extended lytes
LFT, INR, PTT
TSH
B12
iron studies
fasting lipids
fasting glucose, HbA1C
prolactin
CRP, ESR
drVVT, lupus anticoagulant
ANA screen
ds DNA
anti-VKGCAb
factor VIII
von willebrand activity and antigen
homocysteine
acylcarnitine
random cortisol, am cortisol if indicated
thyroperoxidase, thyroglobulin, T3, T4
IgG, IgA, IgM
Compliment C3, C4
anticardiolipin antibody
NMDA receptor antibody
vitamin D
porphobilinogens
antisulphase A
what is the incidence of childhood onset schizophrenia
less than 0.04%
how does severity compare between childhood onset and adult onset schizophrenia
more severe if childhood onset
in what age group may psychotic symptoms be considered “normative”
incidence of psychotic symptoms in healthy children is high–> tends to diminish after age 6–> can be up to 5%
SCZ often misdiagnosed for this reason
what % of those diagnosed with ADULT onset SCZ have been found to meet criteria for autism/autism spectrum disorders before onset of psychotic symptoms
27%
what % of children with childhood onset SCZ show premorbid disturbances in social, motor and language domains, learning disabilities and comorbid moor or anxiety disorders
67%
what medical comorbidities are associated with TREATMENT OF childhood onset SCZ
diabetes, hyperlipidemia, CV disease, obesity, hyperproalctinemia, dyskinesia
what psychiatric comorbidities are common in childhood onset SCZ
OCD
ADHD
expressive and receptive language disorders
auditory processing deficits
executive functioning deficits
mood disorder, primarily MDD
what is treatment for childhood onset SCZ
psychoeducation!!
vocational training, educational accomodations
cognitive remediation
antipsychotic meds–> fail two and get clozapine!! remember fluvoxamine!!
treat comorbidities
is clozapine more or less efficacious in childhood onset SCZ compared to adult onset SCZ?
clozapine tends to be MORE efficacious in childhood onset SCZ compared to adult onset.
describe how to conduct a lorazepam challenge for catatonia
admin 1 mg of lorazepam for sx of catatonia
rate sx after 2-5 min
if no change, give another 1 mg
if improvement of 50% or more in symptoms, treat with increasing doses of lorazepam
treatment of catatonia
lorazepam
typically hold APs but may need to weight this against treating underlying etiology
ECT (flumazenil to counteract lorazepam as indicated)
taper lorazepam very slowly i.e OVER A YEAR–> some people need to stay on it
for some reason, longer acting benzos do NOT work as well–> all studies are with lorazepam and titrating to clonazepam does not work as well clinically
describe a treatment pathway for catatonia
name a mnemonic for signs of NMS
FARM
fever
autonomic instability
rigidity
mental status changes
+elevated CK, and CBC
ddx NMS
serotonin syndrome
malignant hyperthermia
malignant catatonia
other drug related syndromes
other neuro of infectious causes
list some complications of NMS
dehydration
electrolyte imbalances
acute renal failure assoc with rhabdo
MI
cardiomyopathy
cardiac arrhythmias including torsades and MI
resp failure from chest wall rigidity, aspiration pneumonia, PE
DVT
thrombocytopenia
DIC
seizures from hyperthermia and. metabolic derangements
hepatic failure
sepsis
what do you do if you strongly suspect NMS
CALL ICU
STOP ANTIPSYCHOTICS
supportive–> fluids, cooling, lower BP, benzos for agitation
consider dantrolene, bromocriptine, amantadine (limited evidence)
ECT
name a useful tool for metabolic monitoring in the treatment of psychosis/SCZ
use the TMAS–> tool for monitoring antipsychoticside effects from the EPI canada website
list some scales that can monitor for EPS
Simpson Angus Scale
Abnormal Involuntary Movement Scale
TMAS
ESRS
what is the incidence of presence of psychosis in ASD
6-64% of children with ASD (includes both psychosis in mood disorders as well as primary psychotic disorders)
*both ASD and psychotic disorders can present with communication deficits, restricted interests, repetitive behaviours
*kids with childhood onset SCZ often have comorbid ASD dx
why is diagnosis of psychosis/SCZ in kids with ASD a challenge
how might core symptoms of ASD mimic symptoms of psychosis
describe the presentation of the “multidimensionally impaired group” of children
*note: transient psychotic symptoms, does NOT progress to SCZ, 38% develop BAD1
describe elements of history that may help distinguish ASD from ASD + psychosis
list 4 shared genetic causes of ASD and SCZ
22a11.2
16p11.2 (microdeletions, duplications)
neurexin family genes
oxytocin single nucleotide polymorphism
