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1. Child and Adolescent Psychiatry > Dr. Rozylo Psychosis Lecture > Flashcards

Dr. Rozylo Psychosis Lecture Flashcards

1
Q

How long is the prodrome generally in childhood/adolescent presentation psychosis

A

can be weeks to year but typically between 1-3 years

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2
Q

what is the conversion rate from prodrome to psychosis in childhood/adolescent presentation psychosis

A

conversion rates between 20-40% overall

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3
Q

what does a prodrome look like in childhood/adolescent presentation psychosis

A

subthreshold positive symptoms with or without negative symptoms

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4
Q

what % of youth with prodromal syndromes develop psychosis within one year

A

36-54%

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5
Q

what are “APS”?

A

“attenuated positive symptoms”–> youth who have at least ONE positive symptom (this is subthreshold for overt psychosis)

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6
Q

what are the prodromal syndromes?

A

APS (attenuated positive symptoms)

BLIPS

Genetic risk and deterioration syndrome

Ultra High Risk (UHR)

At Risk Mental State (ARMS)

Attenuated Psychosis Syndrome

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7
Q

what are “BLIPS”

A

brief limited intermittent positive symptoms

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8
Q

what is “Genetic Risk and Deterioration Syndrome”

A

a prodromal syndrome

a combination of functional decline and genetic risk

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9
Q

what factors go into determining whether someone is Ultra High Risk (UHR) Prodrome?

A

determined by premorbid cognitive and social skills + comorbidity + hx substance use + neurocognitive impairment

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10
Q

what % of those with UHR prodrome progress to psychotic disorder in one year? in 3 years?

A

1 year–> 22%

3 years–> 36%

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11
Q

what % of those with UHR prodrome who do NOT progress to psychosis DO progress to mood or anxiety disorders

A

70%

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12
Q

What factors are notable about Attenuated Psychosis Syndrome

A

smaller amount of grey matter

poorer functional outcomes

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13
Q

what symptom/trait is required for diagnosis of APS

A

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

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14
Q

what symptom/trait is required for diagnosis of BLIPS

A

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

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15
Q

what are you particularly interested in on family history in a child with psychosis prodrome

A

presence of SCHIZOTYPAL PD or a first degree relative with psychotic disorder

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16
Q

What are the criteria called that help us determine who is at high risk for psychosis

A

Melbourne ultra high risk for psychosis criteria

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17
Q

what combination of factors suggest trait and state risk factors for psychosis

A

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

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18
Q

List 11 predictors of transition from prodrome to psychosis in children and teens

A

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

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19
Q

name a structured interview you can use for assessing kids with prodromal psychosis symptoms

A

SIPS–> Structured Interview for the Prodromal Symptoms

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20
Q

what is the structure of the SIPS interview

A

4 parts–>

  1. SOPS
    +
  2. Global Assessment of Functioning
    +
  3. Schizotypal personality disorder criteria
    +
  4. Family History of psychotic symptoms
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21
Q

what is the SOPS portion of the SIPS interview

A

Scale of Prodromal Symptoms

–> positive sx, negative sx, disorganization, general symptoms

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22
Q

Other than the SIPS interview, what are some other scales that can be used in the assesment of prodromal youth

A

Comprehensive Assessment of At Risk Mental States (CAARMS)

Bonn Scale for the Assessment of Basic Symptoms

Schizophrenia Prodromal Instrument –Adult Version

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23
Q

what are the basic symptoms assessed in the Bonn Scale for the Assessment of Basic Symptoms

A

subjective disturbance of thought

affect

motor functioning

bodily sensation

perception and tolerance of stress

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24
Q

How do you treat prodrome in youth?

A

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)

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25
Q

are antipsychotics generally recommended for treatment of prodrome in youth?

A

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)

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26
Q

what antipsychotics are first line in treatment of prodrome (IF INDICATED)

A

second generation

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27
Q

what is a great resource for prodromal youth or youth with psychosis

A

Canadian Consortium for Early Intervention in Psychosis

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28
Q

What is offered by/advocated for by EPI Canada

A

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.

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29
Q

List 10 risk factors for psychosis

A

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)

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30
Q

what is the etiology of psychosis

A

multifactorial

genes + environment –> creating neurodevelopmental challenges

?amino acids ?neurotransmitter

neuronal development in prefrontal and temporal cortices

abnormalities in GLUTMATE and GLUTAMINE

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31
Q

list 5 genetic syndromes associated with psychosis

A

15q13.3 deletion or duplication

22q11.2 deletion syndrome (De George/velocardiofacial syndrome)

Marfan syndrome

Huntingtons disease (childhood onset)

Mosaic Turner

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32
Q

how many genetic risk loci have been detected for schizophrenia

A

108

(and 80 single nucleotide polymorphisms)

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33
Q

list 6 changes seen in neuroimaging in those with psychosis/schizophrenia

A
  1. decreased total grey matter in cortex, hippocampus and amygdala
  2. larger ventricles (particularly the LATERAL ventricle)
  3. smaller brain volume –> PROGRESSIVE DECLINE over adolescence
  4. in COS: total, frontal, temporal, parital grey matter loss
  5. smaller cerebellum and insula sizes
  6. deficits in brain connectivity
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34
Q

are negative symptoms more or less common in youth with psychosis compared to adults

A

negative symptoms and thought disorder are LESS common in youth with psychosis compared to adults

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35
Q

what are the five cognitive deficits associated with psychosis

A

executive function

processing function

memory

fine motor

concreteness

*need to know this

36
Q

how do youth with psychosis typically present in terms of criteria for diagnosis

A

criteria for psychotic disorders tend to be incompletely or atypically presented

37
Q

how do hallucinations/delusions tend to present in in youth with psychosis compared to adults

A

less elaborate hallucinations

somatic and visual are more frequent

less elaborate delusions–> often have adolescent themes

80% have AH

38
Q
A
39
Q

how do youth with psychosis compared to adults present in terms of social functioning

A

failure to meet social and academic outcomes, often for the first time

40
Q

how do pediatric and adult manifestations of the following symptom cluster compare:

delusions

A

kids–> usually POORLY elaborated and VAGUE; may build on real experiences i.e being teased

adults–> usually SPECIFIC and COMPLEX

41
Q

how do pediatric and adult manifestations of the following symptom cluster compare:

hallucinations

A

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

42
Q

how do pediatric and adult manifestations of the following symptom cluster compare:

disorganized speech

A

kids–> may be hard to distinguish from developmental language disability especially given premorbid disabilities

adults–> clear difference from previous state

43
Q

how do pediatric and adult manifestations of the following symptom cluster compare:

disorganized behaviour

A

kids–> similar to adults, but parents may exert more control and minimize effects

44
Q

how do pediatric and adult manifestations of the following symptom cluster compare:

negative symptoms

A

kids–> may be confused with oppositionality or depression

45
Q

how do pediatric and adult manifestations of the following symptom cluster compare:

common comorbidities

A

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

46
Q

ddx psychosis in youth

A

delirium

schiziphrenia

BD

MDD

OCD

ASD

ID

ADHD

FASD

anxiety

trauma/stress response

cultural factors

personality

factitious psychosis

47
Q

list possible medical etiologies on the differential for childhood onset psychosis/schizophrenia

A

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

48
Q

list psychiatric illnesses that can be misdiagnosed as schizophrenia in youth

A

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)

49
Q

list 6 SCREENING tools that can be used in the evaluation of psychosis in youth

A

Youth Self Report

Child Behaviour Checklist

Behaviour Assessment System for Children

BPRS-C

K-SADS-PL

Bunny-Hamburg Global Rating (?)

50
Q

what is the BPRS-C? what ages does it cover?

A

Brief Psychiatric Rating Scale for Children

ages 3-18

51
Q

what is the K-SADS-PL

A

Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version

Psychotic Disorders Supplement; Affective Disorders supplement

52
Q

List 3 scales for TRACKING symptoms of psychosis in children

A

PANSS (NOT validated in children but is used to track)

Young Mania Rating Scale (for mania)

Children’s Global Impression Scale

53
Q

when should you consult peds in a youth presenting with psychosis

A

if there is any atypicality in presentation or if young age below 16

54
Q

what does the blood test DRVVT look for

A

lupus

55
Q

what workup should be done by psych/peds in first presentation psychosis when indicated?

A

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

56
Q

what does the blood test ANti-VKGCAb look for

A

small cell lung cancer

57
Q

what does blood test acetylcarnitine look for

A

disorder of fatty acid metabolism

58
Q

what does blood test anticardiolipin antibody look for

A

antiphospholipid syndrome

59
Q

what does blood test for cortisol screen for

A

pheochromocytoma

60
Q

what does blood test for antisulphase A look for

A

leukodystrophy

61
Q

what regular and extended blood work should be ordered when indicated when working up first presentation psychosis

A

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

62
Q

what is the incidence of childhood onset schizophrenia

A

less than 0.04%

63
Q

how does severity compare between childhood onset and adult onset schizophrenia

A

more severe if childhood onset

64
Q

in what age group may psychotic symptoms be considered “normative”

A

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

65
Q

what % of those diagnosed with ADULT onset SCZ have been found to meet criteria for autism/autism spectrum disorders before onset of psychotic symptoms

A

27%

66
Q

what % of children with childhood onset SCZ show premorbid disturbances in social, motor and language domains, learning disabilities and comorbid moor or anxiety disorders

A

67%

67
Q

what medical comorbidities are associated with TREATMENT OF childhood onset SCZ

A

diabetes, hyperlipidemia, CV disease, obesity, hyperproalctinemia, dyskinesia

68
Q

what psychiatric comorbidities are common in childhood onset SCZ

A

OCD

ADHD

expressive and receptive language disorders

auditory processing deficits

executive functioning deficits

mood disorder, primarily MDD

69
Q

what is treatment for childhood onset SCZ

A

psychoeducation!!

vocational training, educational accomodations

cognitive remediation

antipsychotic meds–> fail two and get clozapine!! remember fluvoxamine!!

treat comorbidities

70
Q

is clozapine more or less efficacious in childhood onset SCZ compared to adult onset SCZ?

A

clozapine tends to be MORE efficacious in childhood onset SCZ compared to adult onset.

71
Q

describe how to conduct a lorazepam challenge for catatonia

A

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

72
Q

treatment of catatonia

A

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

73
Q

describe a treatment pathway for catatonia

A
74
Q

name a mnemonic for signs of NMS

A

FARM

fever

autonomic instability

rigidity

mental status changes

+elevated CK, and CBC

75
Q

ddx NMS

A

serotonin syndrome

malignant hyperthermia

malignant catatonia

other drug related syndromes

other neuro of infectious causes

76
Q

list some complications of NMS

A

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

77
Q

what do you do if you strongly suspect NMS

A

CALL ICU

STOP ANTIPSYCHOTICS

supportive–> fluids, cooling, lower BP, benzos for agitation

consider dantrolene, bromocriptine, amantadine (limited evidence)

ECT

78
Q

name a useful tool for metabolic monitoring in the treatment of psychosis/SCZ

A

use the TMAS–> tool for monitoring antipsychoticside effects from the EPI canada website

79
Q

list some scales that can monitor for EPS

A

Simpson Angus Scale

Abnormal Involuntary Movement Scale

TMAS

ESRS

80
Q

what is the incidence of presence of psychosis in ASD

A

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

81
Q

why is diagnosis of psychosis/SCZ in kids with ASD a challenge

A
82
Q

how might core symptoms of ASD mimic symptoms of psychosis

A
83
Q

describe the presentation of the “multidimensionally impaired group” of children

A

*note: transient psychotic symptoms, does NOT progress to SCZ, 38% develop BAD1

84
Q

describe elements of history that may help distinguish ASD from ASD + psychosis

A
85
Q

list 4 shared genetic causes of ASD and SCZ

A

22a11.2

16p11.2 (microdeletions, duplications)

neurexin family genes

oxytocin single nucleotide polymorphism

86
Q
A

1. Child and Adolescent Psychiatry (32 decks)

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