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Cognitive Therapy cognitive therapy for prevention and treatment of psychosis: a research update and clinical workshop Tony Morrison Division of Clinical Psychology, University of Manchester & Psychosis Research Unit, GMWMHT . Objectives. Outline UHR and Psychosis - PowerPoint PPT Presentation
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Cognitive Therapy cognitive therapy for prevention and treatment of psychosis:
a research update and clinical workshop
Tony Morrison
Division of Clinical Psychology, University of Manchester
& Psychosis Research Unit, GMWMHT
Objectives• Outline UHR and Psychosis• Cognitive approach to understanding psychosis• Application of CT to people with distressing
psychotic experiences (UHR, FEP and beyond)• Formulation• Normalisation• Strategies for common difficulties• Case illustrations, exercises, videos• Evidence base
Psychosis ‘prodrome’
• A period of months to years prior to the onset of Psychosis (assessed retrospectively)
• Progressive symptoms/signs• Mood• Thinking• Behaviour• Cognitive functions
• Reduction in ability to function
Onset of psychosis
Prodrome
First psychotic symptom
Build up
Emergence of
psychosis
Why is early detection important?
• If psychosis is detected early, many problems can be prevented and functioning can be restored.
• The earlier the problems are treated, the greater the chance of a successful recovery.
• Onset is often in a critical stage of a young person’s life. Adolescents and young adults are just starting to develop their own identity, form lasting relationships, and make plans for the future.
• People are help seeking and distressed.
Ultra High Risk CriteriaOriginal PACE criteria (Yung et al. 1996) Age between 14 and 30 years
AND Family history of DSM-IV psychotic disorder and reduction on
GAF scale of ≥ 30AND/OR
Attenuated symptoms, occurring several times during the week for at least one week
AND/OR Brief, limited or intermittent psychotic symptoms (BLIPS) for
less than one week and resolving spontaneously
Modified criteria now assessed using CAARMS
Identification Study at PACEYung et al 1998 British Journal of Psychiatry
0
5
10
15
20
25
0 1 2 3 4 5 6Months of assessment
Number notpsychotic
40% made transition at sixmonths, 50% atone year
Intervention Study at PACE:The prevention of psychosis
McGorry et al 2002 Archives of General Psychiatry
0 %
5 %
10 %
15 %
20 %
25 %
30 %
35 %
40 %
6 12
Needs based Tx
Specificinterventions
Months
% making transitionto psychosis
PRIME Study: Olanzapine versus placeboMcGlashan et al. 2006 American Journal of Psychiatry
19
102468
101214161820
AverageWeight Gain lb
Olanzapine
Placebo
16.1
37.9
05
10152025303540
Transition %
*
Early Detection: Problems• Ethics of interventions in pre-psychotic phase
• Solution:– employ interventions with minimal risks / side effects– employ interventions that will be useful to those who
will never become psychotic– informed choice
• Balancing the costs and benefits of treatment must be weighted in some way according to the ratio of people actually helped to those unnecessarily treated
• Psychosis is not necessarily dreadful• Prediction not very accurate (e.g. 60% false positives)• Side effects of medication (and can be fatal)
– atypicals commonly produce weight gain and sexual dysfunction; diabetes; cardiovascular problems
• Effects of medication on developing brain unknown
Caveats
• Distressing psychosis• Indisputable that antipsychotics help some
people a great deal• Not anti-antipsychotics, but anti over-
reliance (or exclusive reliance) on antipsychotics and lack of patient choice
Antipsychotics Oversold?• “Risperidone may well help people with
schizophrenia, but the data in this review are unconvincing. People with schizophrenia or their advocates may want to lobby regulatory authorities to insist on better studies being available before wide release of a compound with the subsequent beguiling advertising. People given risperidone may wish to negotiate on length of prescription, ask about adverse effects, and help generate better evidence than currently exists.” (Rattehalli et al., 2010, p.18).
Aripiprazole 10mg/day or 30mg/day Versus Placebo: PANSS Change in acute psychosis
kg
Months 12 24 0 4836
Chronic RCT Chronic RCT
10
5
20
15
12 kg
4 kg
3 kg
Alvarez-Jimenez et al; CNS Drugs, 2008
Antipsychotic-Induced Weight Gain in Chronic and First-Episode Psychotic Disorders: A Systematic Critical Reappraisal
FEP
The British Journal of Psychiatry 2010 196, 116–121. doi: 10.1192/bjp.bp.109.067512Twenty-five year mortality of a community
cohort with schizophreniaSteve Brown, Miranda Kim, Clemence Mitchell and Hazel
InskipConclusionsPeople with schizophrenia have a mortality risk that is two to three times that of the general population. Most of the extra deaths are from natural causes.
The apparent increase in cardiovascular mortality relative to the general population should be of concern to anyone with an interest in mental health.
The most clinically useful intervention is probably to try to help people with schizophrenia stop smoking, to promote exercise and to facilitate effective health screening.