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Families: Causing or Preventing the Onset of Psychosis?

Families: Causing or Preventing the Onset of Psychosis?. Fifth Annual Grampians Mental Health Conference March 1-2, 2005 William R. McFarlane, M.D. Center for Psychiatric Research Maine Medical Center Portland, Maine University of Vermont. A biosocial hypothesis.

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Families: Causing or Preventing the Onset of Psychosis?

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  1. Families: Causing or Preventing the Onset of Psychosis? Fifth Annual Grampians Mental Health Conference March 1-2, 2005 William R. McFarlane, M.D. Center for Psychiatric Research Maine Medical Center Portland, Maine University of Vermont

  2. A biosocial hypothesis Major psychiatric disorders are the result of the continuous interaction of specific brain defects with specific social and environmental inputs.

  3. Functioning as an effect of psychotic episodes

  4. Effects of multiple relapses Adapted from Lieberman, J., et al., J Clin, Psychiatry, 1996; 57: 5-9

  5. Biologic risk factors • Genetic risk • 80-85% heritability • Non-genetic biologic risk • Prenatal infections (influenza) • Prenatal toxic exposure (lead) • Obstetrical complications • Traumatic (head trauma, perinatal to adolescence) • Autoimmune (Rh incompatibility, increasing risk with multiple births) • Nutrition (starvation, omega-3 deficiency) • Heavy cannabis, other psychotogenic drug exposure • Non-heritable genetic risk • Age of father >50; probably natural mutations in spermatogenesis

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

  7. * p < 0.001 **p = 0.582 G X E interaction: p=0.018 Tienari, Wynne, et al, BJM, 2004

  8. Effects of EE and medication on relapse in schizophrenia Bebbington and Kuipers, 1994

  9. Effects of EE and contact on relapse in schizophrenia Bebbington and Kuipers, 1994

  10. Components of expressed emotion: Prodromal vs. chronic phase All differences, prodromal vs. chronic: p<0.01

  11. Mothers’ Protectiveness and Fusion over Time during Prodrome

  12. Fathers’ Protectiveness and Fusion over Time during Prodrome

  13. Role of Family Assessment • To identify interpersonal stressors in the family relationships of prodromal young people • Determine young person and family members’ contributions to these dynamics • To identify relationships that might buffer stressors from within and outside the family • To determine what specific components of the family system are affected by treatment • If even one person is affected by treatment, the whole system will change to accommodate

  14. Withdrawal "Oddness" Functional deterioration Social & performance deficits Social deficits Critical comments CD, EOI Anxiety Panic Misattribution High EE Psychosis Illusions Dread Insomnia Anorexia Perceptual distortions Pervasive anxiety Biosocial causal interactions in late schizophrenic prodrome Early prodrome Late prodrome Acuteonset

  15. Quantitative behavioral genetics: Evocative gene-environment interaction “The parental response to the child in early adolescence appears to have the effect of protecting the child from a pathway to “full–blown” antisocial characteristics” “Knowledge of an individual’s genotype, combined with early intervention at the level of the family environment, may well prove to be the critical combination for preventing serious psychopathology” Towers, Spotts and Reiss, 2002

  16. Portland Identification and Early Referral(PIER) Reducing the incidence of major psychotic disorders in a defined population

  17. Project Overview

  18. Greater Portland Population ~260,000 Portland

  19. Professional and Public Education • Reducing stigma • Information about modern concepts of psychotic disorders • Increasing understanding of early stages of mental illness and prodromal symptoms and signs • How to get consultation, specialized assessments and treatment quickly • Ongoing inter-professional collaboration

  20. Clinical Strategies

  21. Signs of prodromal psychosisSchedule of Prodromal Syndrome (SOPS), McGlashan, et al A clustering of the following: 1. Changes in behavior, thoughts and emotions, with preservation of insight, such as: • Unusual perceptual experiences • “Presence”, imaginary friends, fleeting apparitions, odd sounds • Heightened perceptual sensitivity • To light, noise, touch, interpersonal distance • Magical thinking • Derealization, depersonalization, grandiose ideas, child-like logic • Unusual fears • Avoidance of bodily harm, fear of assault (cf. social phobia) • Disorganized or digressive speech • Receptive and expressive aphasia • Uncharacteristic, peculiar behavior • Satanic preoccupations, unpredictability, bizarre appearance • Reduced emotional or social responsiveness • “Depression”, alogia, anergia, mild dementia

  22. Signs of prodromal psychosis • 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, extracurriculars, sports/hobbies • Increasing sense of disconnection, alienation • Family alienation, resentment, increasing hostility, paranoia

  23. Other entry criteria • Ages 12-35 • Brief psychotic episode (< 1 month) • Prodromal symptoms or recent deterioration (>30% GAF decrease) in youth with a first or second degree relative with a psychotic disorder. • Schizotypal personality disorder combined with recent deterioration (>30% GAF decrease) are also at risk.

  24. Family-aided Assertive Community Treatment (FACT): Clinical and functional intervention • Rapid, crisis-oriented initiation of treatment • Psychoeducational multifamily groups • Case management using key Assertive Community Treatment methods • Integrated, multidisciplinary team; outreach PRN; rapid response; continuous case review • Supported employment and education • Collaboration with schools, colleges and employers • Cognitive assessments used in school or job • Low-dose atypical antipsychotic medication • 10-20 mg aripiprazole, 2.5-7.5 mg olanzapine, 0.25-3 mg risperidone • Mood stabilizers, as indicated by symptoms: • SSRIs, with caution, especially with aripiprazole, family history of manic episodes • Antimanic drugs: lamotrigine 50-150 mg, valproate, 500-1500mg, lithium

  25. Key clinical strategies in family intervention specific to prodromal psychosis • More individualized, multidimensional family assessment • Thorough orientation regarding psychosis onset • Education about psychosis, stress and emotional moderation • Maximum social support for all members of the family • Psychoeducational MFG for stress reduction, optimal problem solving, CD reduction, social support, sharing, cross-parenting, buddy development • Solving developmental, family, vocational, educational, social and romantic problems that threaten stability

  26. Key clinical strategies in family intervention specific to prodromal psychosis • Strengthening relationships and creating an optimal, protective home environment: • Reducing intensity • Adjusting expectations and performance demands • Minimizing internal family stressors • Marital stress • Sibling hostility • Conceptual and attributional confusion and disagreement • Buffering external stressors • Academic and employment stress • Social rejection at school or work • Cultural taboos • Entertainment stress • Romantic and sexual complications

  27. Key clinical strategies in family intervention specific to prodromal psychosis • Treatment for parents and siblings, if psychiatric disorders present, especially depression and bipolar disorder • Single family PE, if necessary, because of logistics or extreme family distress, negativity, and/or abuse • PRN single family crisis intervention as needed • PRN family or marital therapy in rare instances • Creating reduced-stimuli environments for school and work • Collaborative clarification of normal adolescent issues vs. symptoms and disability • Adapting school and work characteristics to current cognitive functioning • Focusing more on symptoms and functioning, less on diagnosis

  28. PIER: Twelve month outcomes Preliminary data for SOPS-positive prodromal cases from the first 24 months of intake: n = 44 Intake: May 7, 2001- May 6, 2003 Outcome: May 7, 2002- May 6, 2004

  29. PIER referral sources

  30. Demographics of referred and treated cases

  31. Screening and treatment entry

  32. ConversionsScoring 6 on SOPS, at any time, year 1n=39 • Cases not converted 34 87.2% • Cases converted, 1-6 days 2 5.1% • Cases converted, 7-30 days 2 5.1% • SOPS conversions 1 2.6% • Scoring 6, 4 days/week for >30 days • Schizophreniform disorder 0 0.0% • Total days in conversion 75 (of 14,235)

  33. Course of conversionn = 8, year 1 and 2, to date Current status Schizophrenia ? Not hospitalized Asymptomatic *mean interval = 32 weeks

  34. PACE, PRIME and PIER12 month outcome

  35. Relapse outcomes in clinical trials 1980-1997

  36. SOPS scores at baseline and 12 months p=.000 p=.000 p=.000 p=.000

  37. GAF: Baseline and 12 month n=36; t=5.236; p=.000

  38. Estimated treated incident population for schizophrenia • Population 260,000 • ECA incidence rate 1 / 10,000 • Expected incident population 52 • Mood disorders & false positives 8 • De facto schizophrenia spectrum 31 • Treated population, maximum <60% • Identified population, maximum <67%

  39. Clinical observations • Family types • None observed to date. • Great variety • Majority are loving, supportive, some with one parent with CD. • A few are highly dysfunctional, some with untreated bipolar disorders. • High proportion of relatives with psychiatric disorders. • Most prodromal young people develop hostility and irritability. • Many begin to be extremely frightened, distracted and increasingly disorganized. • Almost all family members are anxious, frightened, confused; some are annoyed, resentful, critical and impatient with increasing failures and social withdrawal. • Misattribution often leads to disagreements along stereotypical gender lines, leading in turn to increasing marital distress, leading to increasing general tension in relationships, anxiety at psychological level and increasing and persisting arousal at the psychophysiological level. • The nodal and essential family element is ignorance about the prodromal state, which is, by definition, all but universal at present in lay and professional cultures .

  40. Conclusions • Public education is beginning to influence attitudes, knowledge and behavior. • Increasingly accurate referrals are coming from outside the mental health system. • May be affecting the final common pathway to psychosis for many cases • Medication at low doses is adequate but appears essential for prevention of imminent, and perhaps later, psychosis. • Very low conversion rates accompany evidence-based, comprehensive treatment (~10%; 0% for schizophrenia). • A substantial, though presently unknown, proportion of the incident population can be identified and prevented from developing psychosis, in the short term.

  41. Conclusions • Family intervention, at least, is accompanied by high treatment acceptance and retention, including medication. • Family and psychosocial intervention may be having an effect on functioning beyond medication effects. • Deficiencies for family-based treatment • Variety of family realities • Other unknown variables not targeted • Other known variables not targeted: CD

  42. PIER Sponsors PIER has been made possible with the generous support of: • Center for Mental Health Services • NIMH • Robert Wood Johnson Foundation • Maine Health Access Foundation • Bingham Fund • Betterment Fund • Brain Foundation • State of Maine • American Psychiatric Foundation • UnumProvident Foundation • Wrendy Haines Fund

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