rob wolf bruce neben ryan melton
TRANSCRIPT
Rob WolfBruce NebenRyan Melton
http://www.iepa.org.au
Dropping Schizophrenia subtypes Includes shared psychotic disorder Adds catatonia specifier
Adding Psychosis Risk Syndromes Attenuated Psychotic Symptoms
Syndrome Moving away from “prodrome”.
http://www.dsm5.org/Pages/Default.aspx
Aims Rule out past and current psychosis
POPS (presence of psychotic symptoms at 6 on SOPS-scale of psychosis risk syndromes.
Rule in one or more of 3 types of At risk syndromes BIPS (Brief Intermittent Psychotic State) Attenuated Positive Symptom State (APSS) Genetic Risk & Deterioration (GRD)
Rate severity of current at risk syndromes. Major changes
Rule out criteria emphasized Emphasis on more objective GAF.
1 year RCT of 10 sites with 1268 individuals (China).
Tx group received meds, family psychoeducation (not mfg), skills training, CBT.
Outcomes: Tx group lower drop out Tx group greater improvement in insight,
social function, ADL’s, quality of life, employment & education.
Clinical trial of 106 individuals in their families to determine if integrity to model predicted outcome.
Results indicated those who received high integrity to model had lower rates of psychiatric symptoms when compared to those who received lower/moderate integrity.
No difference in caregiver distress. (Did not measure common mfg outcomes of EE and communication).
2 year RCT of 53 early course schizophrenia individuals.
Tx group received intensive CET in addition to medications and supportive therapy.
Outcomes: Tx group had greater preservation of gray
matter in left hippocampus, parahippocampul gyrus, and fusiform gyrus.
Tx group had significantly greater gray matter increase in amygdala.
The largest longitudinal study on psychosis
Study of 2 ½ years after initial assessment
A consortium of longitudinal studies from 10 major universities
All NIMH funded All studies contribute to a common
database
Affective psychosis may share a prodrome with schizophrenia spectrum disorders
Conversions to affective psychosis were in the minority- 10%
DSM IV diagnosis is unstable in first episode and is not a good predictor of future diagnoses
Prodrome- social and role functioning are impaired
Role functioning is malleable and can be impacted
Social impairment is stable and is difficult to impact
Overall risk of conversion to psychosis is 35%
Decelerating trend of conversion Rate of conversion is highest in the first 6
months- 13% 7 to 12 months 9%
Then 5% 25 to 30 months- 2.7%
Most important prodromal factors predicting conversion to frank psychosis
Genetic risk with functional decline Unusual thought content Suspicion/paranoia Social functioning Substance abuse
The most widely used illicit drug in the world, youngest age of initiation, potency and use has increased since 1970’s
In first-episode psychosis, rates of cannabis abuse range from 15% to 65%
Most common reasons for use: reduce boredom, something to do with friends, to improve sleep
Use can result in transient psychosis, mania, panic, depression, and cognitive impairment Cognitive deficits from heavy usage can take 28
days to several months to resolve
yes
D’Souza (2005) 0, 2.5 mg, 5 mg of THC to clinically stable SCZ and controls 80% SCZ group had a brief, modest increase in
their typical positive symptoms/ 35% of controls experiences psychosis
At 5 mg there was significant cognitive impairment in SCZ group and controls at 5 mg experienced cognitive impairment similar to baseline cognitive impairment of the SCZ group
maybe Andreasson’s famous Swedes study (1969-1970/ 45K
conscripts) 2.4 X higher than nonusers 6 X higher if used >50 X
Arseneault and Dunedin study (1972-73/ 1,037/ 26 years) 3X between 15-18 lead to increased risk If age 15, 10% SCZ dx vs. 3% controls
Van Os (2002/ 4,104/ 3 years) Compared nonpsychotic vs psychotic disorders using
THC and found psychotic sxs. Increased in a dose dependent nature (13% vs. 50%)
Despite the significant increase in THC usage and the lower age of exposure, the incidence of SCZ has not changed
There is striking uniformity in the incidence of SCZ in different cultures though the rates of THC use vary widely
Most people with SCZ do not use THC (25%) Most people who use THC do not develop SCZ (7%) SCZ is believed to be a neurodevelopmental disorder that
begins in childhood, well before THC use begins The self-medication hypothesis has been repeatedly
disproven THC use is linked to depression, cognitive impairments, negative
symptoms, anxiety Most studies show that THC usage precedes the onset of psychosis Most studies show reasons for THC usage are not associated with
symptoms of SCZ
Endocannabinoids play an important role in neurodevelopment which is occurring into mid 20’s, exogenous cannabinoids interfere with that system
THC increases dopamine release in the frontal lobe via binding to a CB1 receptor
Individuals with SCZ have a greater density of CB1 receptors in the prefrontal cortex.
Elevated levels of anandamide, an endogenous cannabinoid receptor agonist, is found in the CSF of people with SCZ
Cannabis can induce a transient SCZ-like state with positive, negative, and cognitive symptoms
These symptoms may be greater in magnitude and duration for people with SCZ
Early and heavy exposure may result in a psychotic disorder
Yet, the increase in use, the use of more potent forms, and the earlier age of exposure has not resulted in an increase in the rates of SCZ
Most people who use cannabis do not develop SCZ, most people with SCZ do not use cannabis.
FA reduce free radicals, improve antioxidant defense, reduce cell injury and stabilize the cell membrane
Stabilize the serotonergic and dopaminergic systems Reduced levels of FA in individuals with SCZ Four controlled trials of FA supplementation that has
shown beneficial effects in patients with SCZ Randomized, placebo-controlled trial of 1.2 g of w-3
FA for 12 weeks 4.9% of treated group transitioned to psychosis vs.
27.5 % of the placebo group PUFA significantly reduced positive and negative
symptoms and improved functioning Results were sustained after one year
DSM III (1980) “a complete return to premorbid levels of
functioning in individuals with schizophrenia is so rare as to cast doubt upon the accuracy of the diagnosis.”
DSM IV (2000) Complete remission… is not common in this
disorder.
Vanderbilt University Oxford University Yale Law School USC Law Professor and Associate Dean
Vanderbilt University Oxford University Yale Law School USC Law Professor and Associate Dean
Person with schizophrenia
Shirley Glynn Ellen Saks Etc
What Coping Strategies do high functioning people with schizophrenia use?
Take medicine as prescribed Staying healthy
Exercise, regular sleep, eating healthy foods Spiritual activities Having pets or not living alone Controlling the amount of stimulation in
the environment An attitude of perseverance- Hope
Taking care to avoid:
Drugs and Alcohol Traveling Crowded social situations Isolation
The clinicians illusion Only 1/3 of people with schizophrenia
come to treatment
About 50% of people with schizophrenia have good outcomes
Recovery:
“People are are able to live, work, learn and participate fully in their community. For some the ability to live a fulfilling and productive life despite a disability….”
The President’s New Freedom Commission
on Mental Health
Generally better outcomes in the developing world, especially Nigeria and India
A greater percentage of people with schizophrenia in the developing world work and marry.
In India 67% marry Results attributed to increased family and
community support and lack of financial disincentives
Recovery from schizophrenia is not only possible, but probably common
Family and community support is critical Self-care is critical While some people will not have positive
outcomes, many can What have we learned today that can help
us improve outcomes and support recovery?