1. Sabina Abidi MD FRCPC
Child/Adolescent Psychiatrist
Assistant Professor Dalhousie University
IWK Youth Psychosis Team
Nova Scotia Early Psychosis Program

2. Objectives
 Review the history of psychosis and psychotic
disorders, current definitions and symptoms.
 Know the markers that help identify youth at
risk for psychosis and psychotic disorders.
 Discuss the importance of early identification
and treatment of youth with psychosis and
psychotic disorders.

3. Psychosis – what is it?

4.  “So…let’s talk about psychosis…”
 What IS IT? Who knows?
 Definition
 Cases

7.  Psychosis is a brain disorder.
 A medical illness - affects more
than 8% of Canadians at any
point in time
 a serious disturbance in an
individual’s reality testing
 A process whereby the senses are
distorted, making it difficult for
the person to distinguish
between real and unreal
 Affects a person’s ability to think,
perceive and act
 Thinking, feelings, perception
and behavior affected

8. Psychosis
A BRAIN DISEASE

9. Normal Teen Brain Development
Lenroot & Giedd (2006)

10. Onset of Psychiatric Disorders in Adolescence
Prevalence in Prevalence in
Childhood Adolescence
Depression (1-2%) Depression (6-8%)
Bipolar Disorder (rare) Bipolar Disorder (1%)
Psychosis (rare) Psychosis (1%)??
Anxiety Disorders (6-8%) Anxiety Disorders (10%)
Anorexia Nervosa (rare) Anorexia Nervosa (0.2%)
Total (7-10%) Total (15 – 20%)

11. Prevalence of Psychotic spectrum disorders per 1000
children/adolescents
In males particularly, psychotic disorder(s) is
Boys
8 a major disorder of adolescence
Girls
Hits adolescents in their prime – leads
6 to a disruption in education-attainment,
career building, employment
Alters relationships, family interactions,
4 Alters sense of self, esteem, (Reprinted) Spady et al. Prevalence
of Mental Disorders in Children
productivity Living in Alberta, Canada, as
Determined from Physician Billing
Data. 2001.Arch Pediatr Adolesc
Med. 155: pp.1156.
2
0
Age
0 3 6 9 12 15 18

12. Symptoms of Psychosis
 What are common types of psychotic experiences?

13. Positive Symptoms
 Positive symptoms are things added in to people’s
senses/thoughts/feelings/behaviour that are not normally
there.

14. Positive symptoms include:
 Hallucinations
 Delusions
 Thought Disorder
 Disorganized or Unusual behaviour

15. Hallucinations
 Hallucinations can affect all senses:
 Sensory perceptions that occur in the absence of any
real stimulus but appear to be the result of faulty
messages in the brain.
 Hearing (auditory)
 Seeing (visual)
 Touch (tactile)
 Smell (olfactory)
 Taste (gustatory)

16. Delusions
 Fixed beliefs created by illness which are held only by the
person experiencing the psychosis.
These can include:
 Belief in special abilities of self or others
 Belief that physical health is changed
 Belief that unusual coincidences have a special importance
 Belief that one is being controlled

17. Thought Disorder
 Problems organizing thoughts.
 Thoughts coming to fast or too slow.
 Problems thinking and therefore speaking logically.
 Problems keeping on topic.

18. Disorganized or Bizarre Behaviour:
 Everyone’s behaviour is a response to how they interpret
what is going on around them.
 People with psychosis may behave differently than they
usually do.
 may become extremely active or agitated,
 may laugh inappropriately or display inappropriate
appearance, hygiene or conduct.
 may behave in ways that reflect their thoughts

19. Negative Symptoms
Negative symptoms refer to behaviours or experiences
that have been reduced or lost because of the illness.

20. Negative symptoms may include:
 Problems getting motivated
 Problems taking joy in things
 Problems getting words out
 Seeming flat and blunted

21. Cognitive Symptoms
 Refers to problems with learning and concentration
 Find it difficult to focus and pay attention
 find it hard to filter out all the various stimuli in their environment.
 (may be highly sensitive to sounds, lights and even the regular activities
occurring in their immediate environment.)
 Easily distracted
 Trouble with working memory
 Classroom/Tim’s example

22. Cognitive Symptoms
 find the ability and speed in processing information and
reaction time may be slowed
 experience difficulties with memory, problem solving ability
and judgement.
 find it hard to organize activities in their lives, for example to
manage the time and tasks needed to get their schoolwork
completed.

23. Mood Symptoms
The person can be
 Anxious, irritable
 Depression
 Anger and unpleasant behaviour
 Rapid changes in mood

24. Key Point
•Sometimes people with psychosis cannot
recognize that they are ill and believe that
nothing is wrong with them.
•This lack of insight can make it hard to get
the person to accept treatment.

25. Memory deficits
Poor attention Cognitive deficits
Poor organization
Concrete thinking
Psychotic experiences
and
impairment
Negative
Mood disturbance
symptoms
Lack of: Anxiety
disorder
Energy Depression
Motivation Irritability
Drive Rapid swings
Socialization anger
reactivity
Emotion
Slowed thoughts/speech Positive symptoms Hallucinations
Delusions
Disorganized and
Bizarre behavior

26. The psychosis continuum or
spectrum of symptoms
Psychotic disorder
Psychotic like experiences
(schizophrenia)
(normal variant)
PLEs associated with other disorders
-anxiety
-Depression
-Stress PLEs + markers of risk
-Grief/loss - family history
-trauma - social isolation
- birth trauma
- cannabis exposure

27.  Types of disorders which present with symptoms
of psychosis
 Schizophrenia
 Schizophreniform Disorder
 Brief Psychosis
 Schizoaffective Disorder
 Psychosis NOS
 Delusional Disorder
 Drug Induced Psychosis
 Bipolar Disorder (with psychosis)
 Psychotic Depression
 Secondary to a medical condition

28. To be normal in adolescence it itself abnormal
Anna Freud

29. Prevalence of children’s mental disorders in
Canada
any disorder
any anxiety disorder
ADHD
conduct disorder
any depressive disorder
substance abuse
PDD
OCD
eating disorder
Tourette syndrome
schizophrenia
bipolar disorder
0 3 6 9 12 15
estimated prevalence %
Adapted from Table 2. Waddell et al. 2002. Child Psychiatric Epidemiology and Canadian Public Policy-Making. The state of the science and the art of the possible. Can J
Psychiatry

30. Why the focus on psychosis/psychotic
disorders?

31. • Common among prison and •More hospital beds in
homeless populations Canada are occupied
(8%) by people with
• 80% will abuse schizophrenia than by
substances during their sufferers of any other
lifetime medical condition
• 15-25x more likely to
die from a suicide
attempt than the general “Youth’s Greatest Disabler”
population
• 10% or patients die
from suicide most often
in the first 10 years after
World Health Report 2001
diagnosis
(WHO, 2002) schizophrenia
and other forms of psychoses
affecting young people rank
third worldwide as the most
disabling condition
If left untreated, there is a continuing slow increase in impairment for years

33.  Epidemiology
 Schizophrenia causes massive human and financial
costs
 Affects more than 1% of the world’s population
 Affects all races, ethnicities, cultures equally
 More severe presentation in men
 Allow for a more broader definition of psychotic
disorder (include psychosis NOS, brief
episodes, delusional disorder) lifetime rate increases to
2-3%

34.  Patients with schizophrenia itself die 12-15 years earlier
before the average population – some quote up to 25
years earlier
 Schizophrenia causes more lives lost than cancer and
physical illness
 Mostly due to poor medical care, suicide and deteriorating
physical illness

35.  The vast majority of psychiatric disorders have their onset
in adolescence
 The age of maximum incidence for schizophrenia in males is
15-25 years and 18-35 years in females
 If left untreated, there is a continuing slow increase
in impairment for years.

36. Life potential
(social, occupational, financial…)
Onset
Of
illness
Successive illness relapses
17
Age

37. Outcomes of psychiatric illness in adolescence
X – onset of
Attainment – in life
psychiatric
illness
X – onset of
treatment
effort
X – delay in
treatment
12 15 20 effort
Time - age

39. Psychosis – why/how?

40. Phases of Illness
Birth
Premorbid
Phase
First Signs of Illness
Prodromal
Phase
Onset of Psychosis
Duration of
Untreated
First Treatment Psychosis
Recovery/Stabilization Phase
Residual/Stable Phase

41.  Etiology
 Risk Factors
 Genetic
 Family history of psychotic disorder/bipolar disorder
 Environmental
 Higher incidence in urban populations
 Immigrant ethnic groups - social isolation
 Areas of Social defeat
 Childhood trauma exposure
 Cannabis exposure
 Perinatal factors
 There is a definite interplay of genes
and the environment

42.  Genetics
 50% of identical twins with a twin having schizophrenia
will develop the disorder.
 13% risk for children with one parents with schizophrenia.
 2% risk for first cousins of a person with schizophrenia
 >1% risk for the general population.

43. Stress-Vulnerability Model of Schizophrenia
High
Stress Less severe Psychotic symptoms
-adverse acute Psychotic-like
& chronic life
events Symptoms or
- developmental Prodromal
challenges symptoms
No symptoms
Low
Low High
Vulnerability
-family history of psychotic disorders
-Obstetric complications

44. It is important to remember that
psychosis is not caused by:
Family upbringing.
Problems with other people.
Having a “weak” character.

45. Dopamine in brain function
 Dopamine is important in three areas of brain
function:
 Mesolimbic-frontal cortex circuits
 ( psychotic symptoms).
 Basal ganglia (control of muscle movement).
 Parkinson’s disease; loss of dopamine cells
 Hypothalamus-Pituitary (control of the hormone,
prolactin).

46. Dopamine Pathways*
Four pathways:
1. Nigrostriatal
2. Mesolimbic
3. Mesocortical
4. Tuberoinfundibular

47.  Duration of Untreated Psychosis (DUP)
 Historically youth experience long DUP before coming
into contact with psychiatric services
 2-5 years
 Long DUPS translate to very poor clinical and social
outcomes
 We now know that if this illness is caught
early, prognosis can be very positive with effective
treatment

48.  Treatment

49. Rational therapy for psychotic disorder
 Antipsychotic medication along with therapy/education
are the cornerstone of effective treatment programs when
dealing with a known chronic psychotic illness such as
schizophrenia

50. Antipsychotic Medications
 All antipsychotic medications influence
communication between brain cells involving the
neurotransmitter, dopamine.
 Each medication may also influence a number of other
neurotransmitters in the brain, but the effect on
dopamine seems to be one common factor in reducing
psychosis.

51. First and Second Generation Antipsychotics
 “Traditional” or “First Generation” antipsychotic
medications (1950-1988) (dopamine blockade):
 Haloperidol, Chlorpromazine, Thioridazine and many
others.
 Second Generation antipsychotics (serotonin-
dopamine antagonism)
 “Clozapine / Clozaril (1990)
 Risperidone / Risperdal (1992)
 Olanzapine / Zyprexa (1996)
 Quetiapine / Seroquel (1998)
 Ziprasidone / Zeldox (2008)
 Paliperidone / Invega (2008)
 Aripiprazole (Abilify, 2009)

52. Side effects
 First generation (due to Dopamine receptor
blockade):
 Extrapyramidal (movement) symptoms (EPS)
 Muscle stiffness, restlessness, involuntary movements.
 The use of anti-parkinsonian “side effect” meds.
 Prolactin (hormonal) elevation.
 Ammenorhea and sexual dysfunction
 “Dysphoria” (feeling bad).
 Difficulty with concentration and memory.

53. Side effects
 Second generation antipsychotics:
 Sedation (early in treatment)
 Sexual dysfunction
 Weight gain
 Metabolic dysregulation
 Dylipidemia
 Hypertriglyceridemia
 Risk for diabetes
 Cardiac dysfunction
 Glaucoma
 Stroke
 Extrapyramidal side effects still a concern

54. General treatment guidelines
 Individual basis
 Try to treat with one medication at a time.
 If there is an insufficient clinical improvement after 3-
6 months, try a different medication.
 Use continuous treatment with medication for as long
as possible.

55. Treatment: How Long?
 50% of patients who do not take medication in the
first year will relapse

56. Treatment
 40-60% with effective treatment
(medicine, therapy, education, rehabilitation) can lead
productive lives achieving life goals had prior to the
onset of illness

57. Key Points
 Psychosis is treatable.
 Medication is a necessary, but not
sufficient, part of a total treatment plan.
 The stress-vulnerability model helps us
understand treatment.
 Adherence with treatment, including
medications, is a critical issue.

58. Challenges to Treatment
 Non-adherence
 Depression/risk of suicide
 Substance use/abuse
 Excessive stress/expectations

59. Predictors of Non-Adherence
 Denial of illness  Support Network
 Symptoms of Illness  Stigma
 Delusions  Insight
 Depression  Distressed by side effects
 Cognitive impairment
 Drug induced dysphoria
 Belief that medications no (feeling bad) or
longer needed (I’m cured). akathisia (restlessness)
 Attitudes of family and  Cost of Medication
friends

60. Depression
 Major depression during course of illness : 60%
 Post-psychotic Depression: 25%
 Attempted suicide: 25% - 40%
 Successful suicide: 10% - 13%

61. Challenges:
Substance Use/Abuse
 Substance use is very common in first episode psychosis
 Up to 80%
 Cannabis and alcohol are most frequently abused
substances

62. Cannabis and Early Psychosis
 People with psychotic disorders have higher rates of cannabis use
than the general population
 Cannabis use is associated with poorer functional and clinical
outcomes in this population, e.g. greater psychotic symptom
severity the effects of which can last up to 4 years later
 Cannabis misuse associated with 4 times the risk of psychotic
relapse
 One of the strongest predictors or risk factors associated with the
onset of psychotic illness
 There is little evidence that the high rates if cannabis are is related
to self-medication for distressing symptoms or side effects of
meds

63. Common Issues in Recovery
 Daily Life  Relationships
 Lack of  Trying to establish independence
structure/disorganization from family
 Lack of supports required  Loneliness/Separation from social
to return to school or work groups
 Negative experiences  Increased anxiety in social groups
 No plan to help recovery  Difficulties in re-establishing
 Lack of motivation relationships
 Recovery takes time

64.  Why Early Intervention??

65. Prevalence of Psychotic spectrum disorders per 1000
children/adolescents
Boys
8
In males
Girls particularly, schizophrenia is a
major disorder of adolescence
Hits adolescents in their prime – leads
6
to a disruption in education-attainment,
career building, employment
Alters relationships, family interactions,
4 (Reprinted) Spady et al. Prevalence
support of Mental Disorders in Children
Living in Alberta, Canada, as
Alters sense of self, esteem, Determined from Physician Billing
Data. 2001.Arch Pediatr Adolesc
productivity Med. 155: pp.1156.
2
0
Age
0 3 6 9 12 15 18

66. Phases of Illness
Birth
Premorbid
Phase
First Signs of Illness
Prodromal
?Primary prevention
Phase
Onset of Psychosis
Duration of
Secondary Untreated
prevention
First Treatment Psychosis
Recovery/Stabilization Phase
Residual/Stable Phase

67. “It is not an easy task to recognize psychosis in the early
stages and motivate a young psychotic person, who
might have persecutory delusions or other delusional
beliefs, to accept psychiatric treatment.”
Nordentoft M et al. Does a detection team shorten duration of untreated psychosis? Early Intervention in Psychiatry 2008;2 :22-26.

68.  Challenges in identifying the prepsychotic phase –
 The earliest symptoms identified are non-specific:
 Sleep disturbance behavioral disturbance
 Depressed mood social withdrawal
 Anxiety irritability
 In youth, changes that occur as part of the normal developmental
continuum can complicate psychiatric diagnoses. Patient
age, gender, developmental stage, identity, culture, belief system
are all significant diagnostic and therapeutic factors
 The differential diagnosis for psychosis is widespread in youth
and depends upon a number of environmental factors that must
be examined
 40% cases – initial diagnosis has cause to be changed in 3
months

69. Recognition of youth in trouble
 Less than ½ of child & adolescent psychiatric
disorders are identified in primary care settings &
only a fraction are referred for mental health
services

70. Recognition of youth in trouble
 Direction of help-seeking behavior
 Help seeking behavior in adolescents is primarily
directed to friends, family and teachers before
physicians

71. Warning signs
 Gradual onset of change in behavior, appearance, attitude etc
 “he’s not himself”, “something’s up with him”
 Isolation from friends, adopting new/unusual friend group
 Decline in grades and overall functioning over time
 Poor hygiene
 Onset or increase in substance abuse, esp marijuana
 Odd or bizarre comments, beliefs, behaviors
 Easily distracted, sensitive to noise/light, wearing headphones
often with little eye contact
 Appearing to be “out of touch” or daydreaming a lot, staring
 Low mood, frustration, irritability, sadness, confusion
 Avoiding hallways, crowds, buses
 Fatigue during day (poor sleep)

72.  How can you help?
 Early identification
 What do these youth really look like?
 Support
 Reduce stigma/increase acceptance
 Substance use
 declining grades/functioning
 changes in behavior
 Help access service/assessment

74. Studies are now showing with earlier identification there
is a decline in the transition rate to psychotic disorder
in youth at high risk.

75.  www.e-earlypsychosis.ca
 www.psychosissucks.ca
 www.teenmentalhealth.org
 IWK Health Centre Youth Psychosis Team
 464-4110 (Central Referral)
 Nova Scotia Early Psychosis program
 473-2976