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

Dr. Rozylo Psychosis Lecture Flashcards

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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
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)
26
what antipsychotics are first line in treatment of prodrome (IF INDICATED)
second generation
27
what is a great resource for prodromal youth or youth with psychosis
Canadian Consortium for Early Intervention in Psychosis
28
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.
29
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)
30
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
31
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
32
how many genetic risk loci have been detected for schizophrenia
108 (and 80 single nucleotide polymorphisms)
33
list 6 changes seen in neuroimaging in those with psychosis/schizophrenia
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
34
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
35
what are the five cognitive deficits associated with psychosis
executive function processing function memory fine motor concreteness *need to know this
36
how do youth with psychosis typically present in terms of criteria for diagnosis
criteria for psychotic disorders tend to be incompletely or atypically presented
37
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
38
39
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
40
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
41
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
42
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
43
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
44
how do pediatric and adult manifestations of the following symptom cluster compare: negative symptoms
kids--> may be confused with oppositionality or depression
45
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
46
ddx psychosis in youth
delirium schiziphrenia BD MDD OCD ASD ID ADHD FASD anxiety trauma/stress response cultural factors personality factitious psychosis
47
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
48
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)
49
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 (?)
50
what is the BPRS-C? what ages does it cover?
Brief Psychiatric Rating Scale for Children ages 3-18
51
what is the K-SADS-PL
Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime version Psychotic Disorders Supplement; Affective Disorders supplement
52
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
53
when should you consult peds in a youth presenting with psychosis
if there is any atypicality in presentation or if young age below 16
54
what does the blood test DRVVT look for
lupus
55
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
56
what does the blood test ANti-VKGCAb look for
small cell lung cancer
57
what does blood test acetylcarnitine look for
disorder of fatty acid metabolism
58
what does blood test anticardiolipin antibody look for
antiphospholipid syndrome
59
what does blood test for cortisol screen for
pheochromocytoma
60
what does blood test for antisulphase A look for
leukodystrophy
61
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
62
what is the incidence of childhood onset schizophrenia
less than 0.04%
63
how does severity compare between childhood onset and adult onset schizophrenia
more severe if childhood onset
64
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
65
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%
66
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%
67
what medical comorbidities are associated with TREATMENT OF childhood onset SCZ
diabetes, hyperlipidemia, CV disease, obesity, hyperproalctinemia, dyskinesia
68
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
69
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
70
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.
71
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
72
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
73
describe a treatment pathway for catatonia
74
name a mnemonic for signs of NMS
FARM fever autonomic instability rigidity mental status changes +elevated CK, and CBC
75
ddx NMS
serotonin syndrome malignant hyperthermia malignant catatonia other drug related syndromes other neuro of infectious causes
76
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
77
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
78
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
79
list some scales that can monitor for EPS
Simpson Angus Scale Abnormal Involuntary Movement Scale TMAS ESRS
80
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
81
why is diagnosis of psychosis/SCZ in kids with ASD a challenge
82
how might core symptoms of ASD mimic symptoms of psychosis
83
describe the presentation of the "multidimensionally impaired group" of children
*note: transient psychotic symptoms, does NOT progress to SCZ, 38% develop BAD1
84
describe elements of history that may help distinguish ASD from ASD + psychosis
85
list 4 shared genetic causes of ASD and SCZ
22a11.2 16p11.2 (microdeletions, duplications) neurexin family genes oxytocin single nucleotide polymorphism
86

1. Child and Adolescent Psychiatry (32 decks)

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