Research Findings and Clinical Tools for Preventing Psychosis MMC Dana Center May 28, 2009 2:00-4:30

1. Research Findings and Clinical Tools for Preventing PsychosisMMC Dana CenterMay 28, 20092:00-4:30 Wm. R. McFarlane, MD Donna Downing, MS, OTR/L

2. Disclosures There are no significant financial interests or other relationships with manufacturers of commercial products and/or providers of commercial services discussed in this educational presentation.

3. NOTE: In order to receive CEU�s, you must complete and sign the evaluation in your packet. Thank you!

4. What is PIER?

5. Today�s Agenda 2:00-3:15 Clinical Tools Lessons from Outreach Understanding the �Prodrome� of Psychosis Many Faces Video Clinical Screening Tools Case Vignettes How to Refer to PIER 3:15-3:45 The Roots of Psychosis Biology and the Adolescent Brain 3:45-4:15 Research Findings Early PIER Results International Results in Early Intervention 4:15-4:30 Questions, Comments

6. Lessons from Outreach

7. Community Education and Training Results

8. Referral sources

9. Screening and treatment entry

10. Identification efficiency Of those 780 individuals screened by both a referring person and a PIER staff: 19% were found to be prodromal 10% were found to already have a very early psychosis 52% were referred to another provider for treatment of another psychiatric disorder 81% were offered treatment earlier than would have occurred previously Almost 30% were found to have a psychosis or to be at risk.

11. Outreach Lesson Learned: Community Partners Easily Learn the Symptoms and Refer Appropriately

12. Understanding the �Prodrome� of Psychosis

15. Signs of prodromal psychosiscontinued 2. A significant deterioration in functioning Unexplained decrease in work or school performance Decreased concentration and motivation Decrease in personal hygiene Decrease in the ability to cope with life events and stressors 3. Withdrawal from family and friends Loss of interest in friends, extracurricular sports/hobbies Increasing sense of disconnection, alienation Family alienation, resentment, increasing hostility, paranoia

21. Signs of prodromal psychosis Uncharacteristic, peculiar behavior Sudden change in hygiene New interest in religion Change in peer group and activities Risky behaviors that are outside the norm Not dressing appropriately for the season

23. �Many Faces�

24. Clinical Tools to help Detect Prodromal Symptoms *Look for copies in your handouts

25. PRIME Screen To be completed as an interview (not a self-report) For use in clinical practice Helps put words to difficult concepts Gives clinicians a tool to ask basic screening questions Can be incorporated into other MH screening procedures, e.g., intakes Should be used in consultation with PIER

26. Structured Interview for Prodromal Syndromes (SIPS)McGlashan, T., et al, 2003 Research tool that PIER Assessors use to evaluate symptoms Not to be used as a tool in clinical practices How this can be helpful� Review the categories and �anchor descriptions� to help understand the spectrum of each symptom area

28. 3 Case Vignettes*Look for copies with your handouts

29. Should Max be referred? Max is a 21 y.o. art student at a local college, living in an apartment with a close friend from HS. He is close to his parents, who live about � hour away. His girlfriend attends the same college, and they tend to spend a lot of time together. Both enjoy smoking marijuana several times a week, but do not think they have a problem with substances. They also drink alcohol on occasion. Max is a gifted artist and has a 3.0 GPA. When he was 16, Max saw his best friend die in a skiing accident, which was extremely traumatic. Periodically during the past five years he has had nightmares. Max never went to therapy afterwards, but through the years he has talked about the accident with family and friends. Lately, Max has been feeling anxious and a bit overwhelmed by his course load. Last night he told his girlfriend that he has been hearing his name called periodically for the past several months, but when he checks, no one has been calling him. He�s also finding it uncomfortable to be in crowds and worries that people are looking at him when out in public. He wonders if this is due to fatigue or smoking pot. Max is beginning to feel bothered by these experiences, and his girlfriend is encouraging him to see someone at the school counseling service. He agrees to see a counselor, who then wonders� SHOULD MAX BE REFERRED TO PIER?

30. Should Max be referred? Max is a 21 y.o. art student at a local college, living in an apartment with a close friend from HS. He is close to his parents, who live about � hour away. His girlfriend attends the same college, and they tend to spend a lot of time together. Both enjoy smoking marijuana several times a week, but do not think they have a problem with substances. They also drink alcohol on occasion. Max is a gifted artist and has a 3.2 GPA. When he was 16, Max saw his best friend die in a skiing accident, which was extremely traumatic. Periodically during the past five years he has had nightmares. Max never went to therapy afterwards, but through the years he has talked about the accident with family and friends. Lately, Max has been feeling anxious and a bit overwhelmed by his course load. Last night he told his girlfriend that he has been hearing his name called periodically for the past several months, but when he checks, no one has been calling him. He�s also finding it uncomfortable to be in crowds and worries that people are looking at him when out in public. He wonders if this is due to fatigue or smoking pot. Max is beginning to feel bothered by these experiences, and his girlfriend is encouraging him to see someone at the school counseling service. He agrees to see a counselor. MAX SHOULD BE REFERRED TO PIER.

31. Should Jon be referred? Jon is a 14 year-old high school freshman who lives with his parents and younger brother. He has always been a good student, tends to get good grades, completes his work at school, and is involved in the chess club 2 afternoons a week. Jon�s chess club teacher, who also happens to be his English teacher, has noticed several changes in him recently. He has stopped going to chess club, and his English grades have been dropping, mostly because he isn't completing his homework. His teacher also said that Jon has had trouble focusing-- his mind seems to be 'off in space'-- he's just not the kid he used to be. Then, Jon passed in a writing assignment that was dark and morose, and contained overly detailed images of death, which worried the teacher significantly. The teacher took his concerns to the school social worker, who agreed to follow up with Jon and his family. When she called home to the family, she spoke with his mom, who shared that Jon's father had just been diagnosed with lung cancer. The family has been experiencing a lot of stress, mainly due to the uncertainty of Dad�s prognosis and numbers of MD appointments. This situation has been particularly difficult for Jon, who is very close to his father. After speaking with the mom, the social worker determined that Jon's problems started about the same time his father was diagnosed. There is a family history of Bipolar I Disorder, but not in the immediate family. Should Jon be referred to PIER?

32. Should Jon be referred? Jon is a 14 year-old high school freshman who lives with his parents and younger brother. He has always been a good student, tends to get good grades, completes his work at school, and is involved in the chess club 2 afternoons a week. Jon�s chess club teacher, who also happens to be his English teacher, has noticed several changes in him recently. He has stopped going to chess club, and his English grades have been dropping, mostly because he isn't completing his homework. His teacher also said that Jon has had trouble focusing-- his mind seems to be 'off in space'-- he's just not the kid he used to be. Then, Jon passed in a writing assignment that was dark and morose, and contained overly detailed images of death, which worried the teacher significantly. The teacher took his concerns to the school social worker, who agreed to follow up with Jon and his family. When she called home to the family, she spoke with his mom, who shared that Jon's father had just been diagnosed with lung cancer. The family has been experiencing a lot of stress, mainly due to the uncertainty of his prognosis and numbers of MD appointments. This situation has been particularly difficult for Jon, who is very close to his father. After speaking with the mom, the social worker determined that Jon's problems started about the same time his father was diagnosed. There is a family history of Bipolar I Disorder, but not in the immediate family. Jon should NOT be referred to PIER.

33. Should Katie be referred? Katie is a 16 y.o. junior at a large, public HS, and lives at home with her biological parents and younger brother. Since freshman year, she has maintained a �B� average and has been active in field hockey and theater, but lately, she�s been forgetting assignments and missing practices. For the past three years, she has consistently volunteered at the Boys and Girls Club with 2 of her close friends every Saturday. Recently, she has been finding excuses not to volunteer. When she was 7, Katie was diagnosed with ADHD�she�s taken Ritalin periodically since then with good results. In the past couple of months, Katie has seemed preoccupied, distractible, and more withdrawn. She shared some �dark thoughts� (e.g., fleeting suicidal thoughts and unfounded fears of getting hurt) with her mother, who is now seeking some advice from a friend who is a therapist. The therapist is not alarmed, considering that Katie is 16 and has been having relationship difficulties with her boyfriend of 1 year. A month ago, Katie shared she thought she saw the form of someone in her bedroom as she was falling asleep, but when she turned on the light, no one was there. She has had this experience twice more, but the last time, the form remained when she turned on the light. Mom knows that Katie is also feeling stressed about the future�especially about whether to apply to college or not. Mom doesn�t think she is doing drugs. SHOULD KATIE BE REFERRED?

34. Should Katie be referred? Katie is a 16 y.o. junior at a large, public HS, and lives at home with her biological parents and younger brother. Since freshman year, she has maintained a �B� average and has been active in field hockey and theater, but lately, she�s been forgetting assignments and missing practices. For the past three years, she has consistently volunteered at the Boys and Girls Club with 2 of her close friends every Saturday. Recently, she has been finding excuses not to volunteer. When she was 7, Katie was diagnosed with ADHD�she�s taken Ritalin periodically since then with good results. In the past couple of months, Katie has seemed preoccupied, distractible, and more withdrawn. She shared some �dark thoughts� (e.g., fleeting suicidal thoughts and unfounded fears of getting hurt) with her mother, who is now seeking some advice from a friend who is a therapist. The therapist is not alarmed, considering that Katie is 16 and has been having relationship difficulties with her boyfriend of 1 year. A month ago, Katie shared she thought she saw the form of someone in her bedroom as she was falling asleep, but when she turned on the light, no one was there. She has had this experience twice more, but the last time, the form remained when she turned on the light. Mom knows that Katie is also feeling stressed about the future�especially about whether to apply to college or not. Mom doesn�t think she is doing drugs. KATIE SHOULD BE REFERRED.

35. There is HOPE with Early Treatment with mental illness� Early detection makes a difference It is associated with More rapid and complete recovery Preserved brain functioning Preserved psychosocial skills Decreased need for intensive treatments Preserved network of supports

36. It�s Easy to Make a Referral

38. The young person and family come to PIER for an orientation session. If they agree to participate in the research and treatment, they all sign their own consent form. Then a 2-day assessment is scheduled. Afterwards, a PIER clinician meets with the family for a feedback session, where treatment decisions are made (assigned to low-risk or high-risk group).

39. Primary Eligibility Guidelines

40. Keep in Mind the 30-Day Rule� Call Fast!

41. Talking About PIER to Young People and Their Families�

42. Example of Talking With a Family

43. Understanding the Biology of Psychosis and the Developing Brain

44. Healthy Teen Brain Active limbic system Developing prefrontal cortex Developing reflexes Well-connected pathways for information processing -Aamodt, S. & Wang, S. (2008)

45. What Factors Trigger Brain Changes?

47. Interaction of attention and arousal (vulnerability)

48. Psychosis is an unusual sensitivity to: Sensory stimulation Prolonged stress, strenuous demands Rapid change Complexity Social disruption Illicit drugs and alcohol Negative emotional experience

53. Risks for symptom exacerbation and relapseIntensity, negativity and complexity Critical comments Over-involvement Lack of warmth Crowding Excessive pressure to perform Interactions with conflict Multiple sources of input

54. Risks for symptom exacerbation and relapse High rate of change Excessive life events per unit of time Disruption of social supports Lack or loss of "bridging" cues Entry into a new context Multiple functional levels involved incompensating

55. Risks for symptom exacerbation and relapsePhysical and chemical factors Stimulants Hallucinogens Dependence on depressants Unknown environmental toxins Loud noises Distracting noises, echoes Bright lights

56. What Happens to the Brain When There is an Onset of Psychosis?

57. Altered Brain Function in Psychosis Prefrontal cortex activity lessens due to metabolic and structural changes The limbic system, which assists with attention and the integration of thoughts and feelings, becomes overactive Hypoactivity of the cingulate cortex creates emotional lability and disconnection of thoughts and feelings Superior temporal cortex activity decreases, interfering with speech and comprehension

58. Functions of the Prefrontal Cortex Establishing a cognitive set Problem-solving Planning Attention Initiative Motivation Integration of thought and affect Mental liveliness

61. Cortical volume reduction, in childhood-onset schizophrenia, ages 14-19

62. Early PIER Research Findings

66. Functional outcomes, one year of intake (treated n = 16)

67. The Benefits of Early Intervention

68. Differences between treated prodromal and post-psychotic states Maintenance of insight (prevention of loss) Continued dysphoric/ego-dystonic response to prodromal/psychotic symptoms High acceptance of, and adherence to, treatment Low rates of substance abuse More open to discontinuing heavy drug and alcohol abuse

69. Differences between treated prodromal and post-psychotic states Less resistance to family inclusion by patient Stronger family involvement Higher motivation to continue with school and/or work More trusting and grateful therapeutic relationships Higher sensitivity to treatments Higher likelihood of improving course of functioning

70. Relapse vs. Recovery

72. The PIER Program: Part of an International Community Of Research

73. Trials of Indicated Prevention Buckingham, UK EDIE, UK German Research Network OPUS, Denmark TIPS, Norway, Denmark PACE, Australia PRIME, North America PIER, Maine EDIPPP, USA

74. Psychosis prevention studies: One year rates for conversion to psychosis

76. Additional Community Mental HealthTreatment Options Maine�s Mental Health Network at 761-6644 or 1-866-857-6644 211 for statewide resources 774-HELP for local community resources NAMI-ME at 1-800-464-5767 for family, consumer, and educational supports

77. NOTE: In order to receive CEU�s, you must complete and sign the evaluation in your packet. Thank you!

78. References Aamodt, S. & Wang, S. (2008) Welcome to your brain. New York: Bloomsbury. McGlashan, T, Miller, TJ, Woods, SW, Rosen, JL, Hoffman, R, Davidson, L. (2003). Structured Interview for Prodromal Syndromes. New Haven: PRIME Clinic, Yale School of Medicine. Rey, J.M. (2007) Does marijuana contribute to psychotic illness? Current Psychiatry, 6(2), 36-47. Simpson, A.R. (2001). Raising teens: A synthesis of research and a foundation for action. Boston: Center for Health Communication, Harvard School of Public Health.