Early Indicators of Schizophrenia - PowerPoint Presentation

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Early Indicators of Schizophrenia

Dr

Jim

Simm

*

,

FRCPC; CCSAM

Dr

Richard Tachere

*

,

MD; MPH

*

Dept. of Psychiatry, University of Manitoba.

CAPA Annual Conference

October 30

th

, 2016

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Disclosure

Dr. Simm has received honorarium payments for speaking on behalf of Janssen pharmaceuticals on the treatment of schizophrenia.

Dr. Tachere has no conflict of interest to declare.

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Stay Awake

...

WHY

???

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Introduction:

Schizophrenia can be a terrible mental illness:

robs young people of their potentials;

tears families apart;

has an enormous burden on our society (financial, legal, social, etc.)

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Facts:


Among the top 25 leading causes of disability globally

~ 3% of the total burden of human disease

~ 1% point prevalence

> 60% of patients with the first episode of the illness have persistence of symptoms & impairment in various domains of functioning.

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Facts:

In Canada:

- hospital bed occupancy: 1 in 12

(higher than any other single disease)

- direct health & non-health care costs ~ $2billion/yr.

- indirect costs ~ $1.4billion/yr.

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Facts:

Peak age of onset for first psychotic episode:

- Males: early to mid-20s;

- Females: the late-20s.

Early recognition and uninterrupted treatment can lead to optimal outcomes.

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Outline:

Meaning of psychosis and schizophrenia;

Approaches to Assessment, Diagnosis & Treatment;

The importance of early continuous treatment;

Conclusion.

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Overview

Schizophrenia is a major mental illness - the most well-known of the ‘psychotic’ disorders.

Most common age of onset is 15-25yrs

It affects ~ 1% of the population

B

ut what exactly is “psychosis”?

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Psychosis

…

The term “psychosis” refers to an impairment in reality testing.

Symptoms: hallucinations, delusions, disorganized speech, behavior, etc.

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The contemporary concept of psychosis

(DSM 5):

Abnormalities in one or more of 5 domains:

delusions,

hallucinations,

disorganized thinking (speech),

grossly disorganized or abnormal motor behavior (including catatonia), and

negative symptoms

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Signs and Symptoms of Psychosis

Delusions

Hallucinations

Replaying or rehearsing conversations out loud- i.e. talking to yourself (very common sign)

Inappropriate responses - laughing or smiling when talking of a sad event, making irrational statements.

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Signs and Symptoms of Psychosis

Catatonia - staying in the same rigid position for a long time, as if in a daze.

Intense & excessive preoccupation with religion or spirituality

Hypergraphia

, bizarre writing with paranoid themes, conspiracy theories,

etc

Frequent moves, trips, or walks that lead nowhere

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Delusions

Usually paranoid: others are plotting to harm you, are monitoring you, can read your thoughts, etc.

Often accompanied by ideas of reference: events or occurrences have a special meaning to you.

Grandiose delusions, often religious in nature (more common in mania)

Somatic - infestation, bizarre somatic complaints (e.g. in psychotic depression)

Jealousy – Often delusional disorder.

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Hallucinations

Auditory: most common; generally commenting on behavior, insulting comments or command hallucinations.

Often source is attributed to “talking through the wall”, radio waves; almost always human voices

These can be either inside the person's head or externally.

When external, they sound as real as an actual voice. Sometimes they come from no apparent source; at other times they come from real people who don't actually say anything.

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Hallucinations

…

Visual: 2

nd

most common; usually misinterpretation of real objects (i.e. illusions)

Olfactory/gustatory: less common but usually of foul odour or food is spoiled or tainted. (Consider psychotic depression if this is a prominent feature).

Tactile hallucinations: rare; often of being sexually violated.

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Differential Diagnosis: 3 broad groups

Psychoses:

(a) due to a mental or psychological disorder

(b) due to a general medical condition

(c) due to a substance (medication or drug of abuse)

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Examples…

Mental or Psychological

Other medical illnesses

Substances

Schizophrenia

Infections

Cocaine

Bipolar

Electrolyte

imbalances

LSD

MDD,

etc

Brain tumors,

etc

Amphetamines,

etc

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DSM 5: Schizophrenia

Symptoms: 2 or more of the 5 psychotic symptoms

Duration: at least for 6months

Functional impairment

Note:

One of the obstacles to early recognition and treatment is

lack of insight

.

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Complications of Schizophrenia

Suicidal thoughts; attempts & completed suicide;

Self-injury;

Anxiety disorders & obsessive-compulsive features;

Depression

Abuse of alcohol or other drugs, including tobacco

Inability to work or attend school

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Complications of Schizophrenia

Legal and financial problems and homelessness

Social isolation

Health and medical problems

Being victimized

Aggressive behavior, although it's uncommon

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So now that I’ve established that the most

likely diagnosis is schizophrenia,

What should I do?

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Assessment

Goals

of initial evaluation include:

development of a therapeutic alliance;

obtaining information required for diagnosis;

identifying factors that can assist or impede recovery

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Assessment

Should include risk of:

suicide & deliberate self-harm

violence

neglect

victimization

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Assessment

Should include supports available:

Engagement with families

Other relevant social networks

Community mental health resources available

Non-adherence to treatment & service disengagement.

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Assessment

Goals

of full medical work-up include:

Detection of medical

etiologies

and/or comorbidities;

Identification of risk factors for possible medical disorders;

Providing a baseline against which pharmacological complications & side-effects can be assessed.

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Assessment

History is key especially family history;

Physical exam;

Investigations:

Comprehensive drug screen

Imaging: specific findings are quite rare without a neurological finding on exam; but family or patient will often insist and be unwilling to accept diagnosis until done.

Weight, glucose, lipid profile as baseline.

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Some non-specific physical findings on exam

A blank, vacant facial expression; e.g. staring while in deep thought, with infrequent blinking, etc.

Clumsy, inexact motor skills

Abnormal eye movements, e.g. difficulty focusing on slow moving objects

Unusual gestures or postures

Constant pacing

Movement could be slowed down - staying in bed (in extreme cases, catatonia)

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Assessment: Investigations

Type

Examples

Blood

CBC; extended

lytes

; LFT; BUN + Cr; TSH;

Vit

B12.

Urine

Urinalysis; street drug screen

Imaging

CT, MRI & EEG (where indicated)

Others

*Case-specific (e.g. syphilis, HIV, LP, etc.)

*If considering starting antipsychotics, then: lipid profile & FBS.

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Non-specific early symptoms

Withdrawal from friends and family

A drop in performance at school

Trouble sleeping

Irritability or depressed mood

Lack of motivation

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Non-specific early symptoms (other psychiatric disorders to consider)

Drugs/alcohol

Adjustment disorder

Mood disorder

Personality Disorder

ADHD (usually history of early difficulties in school)

Social anxiety disorder, etc.

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Early recognition and uninterrupted treatment can lead to optimal outcomes.

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Prodromal Stage:

*Early detection & interventions*

Stage

Symptoms

Prodromal

Transition rate:

*22%

within one year

*36% within three years

*

Significant decrease in functioning PLUS identified genetic risk or personality traits (schizoid or schizotypal) *

Attenuated psychotic symptoms

*Transient

psychotic symptoms

(brief in duration & remit spontaneously)

*Others: substance use; ADHD; anxiety; social withdrawal, etc.

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Progressive Stage:

Stage

Symptoms

Progressive

*Overt psychosis

*Deterioration

in symptoms

(the 5 domains in DSM 5)

*Deterioration in brain abnormalities

(thinning of frontal cortex; lateral ventricular enlargement; reduction of white matter integrity, etc.)

*Relapses & remissions clinical deterioration.

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Chronic/Residual Stage

Stage

Symptoms

Chronic/Residual

*Generally: poor functioning; social & occupational disability.

*Progression

of brain abnormalities

*Outcomes are heterogeneous.

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Clear evidence that early uninterrupted intervention decreases the burden of illness

Reduces # of relapses & hospitalizations

Higher functioning

Preservation of grey matter

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Antipsychotic Discontinuation and Relapse in Schizophrenia

Gitlin M, et al. Am J Psychiatry 2001;158:1835–42

1.0

0.8

0.6

0.4

0.2

0

0 12 24 36 48 60 72

Patients without psychotic symptom

exacerbation or relapse (%)

Week

Remaining well

Relapsed

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30

40

50

60

70

80

90

100

Self-Report

Clinician rating

Pill Count

MEMS*

Adherence Rate (%)

Adherence Measure

*Medication Event Monitoring System (MEMS

®

)

Adherence to Treatment Among Outpatients With Schizophrenia

Remington G. et al.

Scz Res

2007

.

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Enhancing Adherence

Patient engagement and active involvement;

Clear, simple instructions; (people recall at best 50% of what was said during appointments, and the 50% recalled is often not the same 50% as the clinician wanted to emphasize);

No blame environment;

Enquire about financial barriers.

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Enhancing Adherence

If you give out reading material, make sure that the patient and family can understand it;

The

best results

are seen with

Long Acting

Injectables

.

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Conclusions

Schizophrenia can be a devastating illness for the patient, family & society;

Early recognition

AND

early uninterrupted treatment are crucial to long term positive outcomes.