Rob Wolf Bruce Neben Ryan Melton

 Dropping Schizophrenia subtypes  Includes shared psychotic disorder  Adds catatonia specifier  Adding Psychosis Risk Syndromes  Attenuated Psychotic Symptoms Syndrome  Moving away from “prodrome”. 

 Aims  Rule out past and current psychosis  POPS (presence of psychotic symptoms at 6 on SOPS- scale of psychosis risk syndromes.  Rule in one or more of 3 types of At risk syndromes  BIPS (Brief Intermittent Psychotic State)  Attenuated Positive Symptom State (APSS)  Genetic Risk & Deterioration (GRD)  Rate severity of current at risk syndromes.  Major changes  Rule out criteria emphasized  Emphasis on more objective GAF.

 1 year RCT of 10 sites with 1268 individuals (China).  Tx group received meds, family psychoeducation (not mfg), skills training, CBT.  Outcomes:  Tx group lower drop out  Tx group greater improvement in insight, social function, ADL’s, quality of life, employment & education.

 Clinical trial of 106 individuals in their families to determine if integrity to model predicted outcome.  Results indicated those who received high integrity to model had lower rates of psychiatric symptoms when compared to those who received lower/moderate integrity.  No difference in caregiver distress. (Did not measure common mfg outcomes of EE and communication).

 2 year RCT of 53 early course schizophrenia individuals.  Tx group received intensive CET in addition to medications and supportive therapy.  Outcomes:  Tx group had greater preservation of gray matter in left hippocampus, parahippocampul gyrus, and fusiform gyrus.  Tx group had significantly greater gray matter increase in amygdala.

 The largest longitudinal study on psychosis  Study of 2 ½ years after initial assessment  A consortium of longitudinal studies from 10 major universities  All NIMH funded  All studies contribute to a common database

 Affective psychosis may share a prodrome with schizophrenia spectrum disorders  Conversions to affective psychosis were in the minority- 10%  DSM IV diagnosis is unstable in first episode and is not a good predictor of future diagnoses

 Prodrome- social and role functioning are impaired  Role functioning is malleable and can be impacted  Social impairment is stable and is difficult to impact

 Overall risk of conversion to psychosis is 35%  Decelerating trend of conversion  Rate of conversion is highest in the first 6 months- 13%  7 to 12 months 9%  Then 5%  25 to 30 months- 2.7%

Most important prodromal factors predicting conversion to frank psychosis  Genetic risk with functional decline  Unusual thought content  Suspicion/paranoia  Social functioning  Substance abuse

 The most widely used illicit drug in the world, youngest age of initiation, potency and use has increased since 1970’s  In first-episode psychosis, rates of cannabis abuse range from 15% to 65%  Most common reasons for use: reduce boredom, something to do with friends, to improve sleep  Use can result in transient psychosis, mania, panic, depression, and cognitive impairment  Cognitive deficits from heavy usage can take 28 days to several months to resolve

yes  D’Souza (2005) 0, 2.5 mg, 5 mg of THC to clinically stable SCZ and controls  80% SCZ group had a brief, modest increase in their typical positive symptoms/ 35% of controls experiences psychosis  At 5 mg there was significant cognitive impairment in SCZ group and controls at 5 mg experienced cognitive impairment similar to baseline cognitive impairment of the SCZ group

maybe  Andreasson’s famous Swedes study ( / 45K conscripts)  2.4 X higher than nonusers  6 X higher if used >50 X  Arseneault and Dunedin study ( / 1,037/ 26 years)  3X between lead to increased risk  If age 15, 10% SCZ dx vs. 3% controls  Van Os (2002/ 4,104/ 3 years)  Compared nonpsychotic vs psychotic disorders using THC and found psychotic sxs. Increased in a dose dependent nature (13% vs. 50%)

 Despite the significant increase in THC usage and the lower age of exposure, the incidence of SCZ has not changed  There is striking uniformity in the incidence of SCZ in different cultures though the rates of THC use vary widely  Most people with SCZ do not use THC (25%)  Most people who use THC do not develop SCZ (7%)  SCZ is believed to be a neurodevelopmental disorder that begins in childhood, well before THC use begins  The self-medication hypothesis has been repeatedly disproven  THC use is linked to depression, cognitive impairments, negative symptoms, anxiety  Most studies show that THC usage precedes the onset of psychosis  Most studies show reasons for THC usage are not associated with symptoms of SCZ

 Endocannabinoids play an important role in neurodevelopment which is occurring into mid 20’s, exogenous cannabinoids interfere with that system  THC increases dopamine release in the frontal lobe via binding to a CB1 receptor  Individuals with SCZ have a greater density of CB1 receptors in the prefrontal cortex.  Elevated levels of anandamide, an endogenous cannabinoid receptor agonist, is found in the CSF of people with SCZ

 Cannabis can induce a transient SCZ-like state with positive, negative, and cognitive symptoms  These symptoms may be greater in magnitude and duration for people with SCZ  Early and heavy exposure may result in a psychotic disorder  Yet, the increase in use, the use of more potent forms, and the earlier age of exposure has not resulted in an increase in the rates of SCZ  Most people who use cannabis do not develop SCZ, most people with SCZ do not use cannabis.

 FA reduce free radicals, improve antioxidant defense, reduce cell injury and stabilize the cell membrane  Stabilize the serotonergic and dopaminergic systems  Reduced levels of FA in individuals with SCZ  Four controlled trials of FA supplementation that has shown beneficial effects in patients with SCZ  Randomized, placebo-controlled trial of 1.2 g of w-3 FA for 12 weeks  4.9% of treated group transitioned to psychosis vs % of the placebo group  PUFA significantly reduced positive and negative symptoms and improved functioning  Results were sustained after one year

 DSM III (1980)  “a complete return to premorbid levels of functioning in individuals with schizophrenia is so rare as to cast doubt upon the accuracy of the diagnosis.”  DSM IV (2000)  Complete remission… is not common in this disorder.

 Vanderbilt University  Oxford University  Yale Law School  USC Law Professor and Associate Dean

 Vanderbilt University  Oxford University  Yale Law School  USC Law Professor and Associate Dean  Person with schizophrenia

 Shirley Glynn  Ellen Saks  Etc  What Coping Strategies do high functioning people with schizophrenia use?

 Take medicine as prescribed  Staying healthy  Exercise, regular sleep, eating healthy foods  Spiritual activities  Having pets or not living alone  Controlling the amount of stimulation in the environment  An attitude of perseverance- Hope

Taking care to avoid:  Drugs and Alcohol  Traveling  Crowded social situations  Isolation

 The clinicians illusion  Only 1/3 of people with schizophrenia come to treatment About 50% of people with schizophrenia have good outcomes

Recovery: “People are are able to live, work, learn and participate fully in their community. For some the ability to live a fulfilling and productive life despite a disability….” The President’s New Freedom Commission on Mental Health

Generally better outcomes in the developing world, especially Nigeria and India  A greater percentage of people with schizophrenia in the developing world work and marry.  In India 67% marry  Results attributed to increased family and community support and lack of financial disincentives

 Recovery from schizophrenia is not only possible, but probably common  Family and community support is critical  Self-care is critical  While some people will not have positive outcomes, many can  What have we learned today that can help us improve outcomes and support recovery?