UHR ED ESORDI PSICOTICI: AGGIORNAMENTI E LINEE D INTERVENTO

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1 UHR ED ESORDI PSICOTICI: AGGIORNAMENTI E LINEE D INTERVENTO Maria Pontillo 1,2,3 Roberto Averna 1 1 Dipartimento di Neuroscienze, UOC di Neuropsichiatria, IRCCS Bambino Gesù 2 Scuola di Dottorato in Neuroscienze Cognitive, La Sapienza 3 Scuola di Psicoterapia Cognitiva (SPC)

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3 La Sindrome Psicotica Attenuata

4 Attenuated Psychosis Syndrome : recent onset psychotic-like symptoms clinically relevant distress and disability signi9icantly increased risk of conversion to a full-blown psychotic disorder

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6 The issues for inclusion of APS in new edition of DSM A majority of individuals with current APS have some other current psychiatric comorbidity A substantial proportion of individuals with APS do not go on to develop major psychopathology It is unclear if APS represents a trait or state vulnerability It is unclear if the distress/disability is related to APS or the comorbid mental disorder

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13 APS in adolescenza e preadolescenza: Criticità

14 Criticità per la diagnosi di APS in adolescenza/preadolescenza La maggior parte degli strumenti diagnostici disponibili sono stati validati sulla popolazione adulta I criteri utilizzati per gli adulti vengono applicati alla popolazione preadolescenziale ed adolescenziale Si hanno pochi dati disponibili sulla predittività dei criteri UHR in adolescenti e pre-adolescenti Come trattare le APS negli adolescenti/preadolescenti?

15 Pooled conversion rates in UHR sample increase from 9.6% to 37% at > 4- year follow- up with signioicantly lower conversion rates in 12 to 18-year olds (7.7% to 14.9%)

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17 Comprehensive Assessment for At Risk Mental States (CAARMS) Structured Interview for Prodromal Syndromes/ Scale of Prodromal Symptoms (SIPS/SOPS)

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26 First evidence for the predictivity utility of UHR criteria in adolescent and children (below the age of 12 years) in terms of BIPS when accompanied by signs of cognitive impairment, i.e. disorganized communication.

27 Gli interventi terapeutici nelle APS

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35 Esordi psicotici in età adolescenziale e preadolescenziale

36 Psicosi <18 anni: qualche dato Very early onset psychosis (VEOP) Early onset psychosis (EOP) Esordio prima dei 13 anni (David, 2011; Kumra, 2009) Esordio tra i 13 e i 17 anni (Hassan, 2011; Kumra, 2009) Prevalenza: 1/ bambini (McClennan, 2005) Prevalenza: 1-2/1000 adolescenti (McClennan, 2005) Sintomi negativi principali manifestazioni sul piano clinico (Russel, 1994; David et al. 2011) Maschi e femmine risultano affetti nella stessa misura (Werry, 1994;Hollis, 2000)

37 EOP/VEOP a confronto con AOP Maggiore severità in termini di decorso clinico e outcome (Kumra et al., 2008; Diaz- Caneja et al., 2015) Peggiore funzionamento premorboso (Schimmelmann et al., 2007) Sintomatologia negativa più severa (Kao et al., 2010) Alto tasso di anomalie genetiche associate (Kumra et al., 2008)

38 VEOP vs EOP Peggiore outcome a lungo termine Peggiore adattamento scolastico con più alto tasso di abbandono Ospedalizzazione più lunga ProXilo neurocognitivo maggiormente compromesso

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41 ROC-curve Cut-off for age of psychosis onset Clinical Characteristics <14.0 years More positive symptoms <14.7 years Poorer functioning

42 Secondary analyses Group 1 with age of psychosis onset <15 years (N=56) vs Group 2 with age of psychosis onset 15 years (N=32) Main Findings: Group 1: - higher PANSS positive scale scores (p=0.005) - lower C- GAS score (p=0.003) - higher PANSS total symptoms score (p=0.005) - shorter DUI (p=0.004)

43 the age of 15 years may be a more appropriate cut-off for detecting clinical differences in age of psychosis onset in CAD Age tailored therapeutic interventions are needed: Psychosocial intervention to improve social and general functioning could be of particular usefulness under the age of 15 years old. More studies ar needed to conoirm this!!!

44 Gli interventi nelle psicosi ad esordio adolescenziale e preadolescenziale

45 EOP/VEOP: Interventi Punti critici: Necessità intervento precoce sui sintomi psicotici Il trattamento farmacologico non può essere d elezione per queste condizioni (Liberman, 1994) L efxicacia degli interventi psicosociali, benchè riconosciuta, è stata esaminata solo per gli AOS (Bechdolf et al., 2005; Pilling et al., 2002)

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47 CBT Cogni(ve Remedia(on Psychoeduca(onal and family interven(on Haddock et al Ueland and Rund 2004 Rund et al Ueland and Rund 2005 Asarnow et al Puig et al Amminger et al Calvo et al. 2014

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52 Psychol Med Apr;45(6): doi: /S X. Epub 2014 Oct 22. An(depressant, an(psycho(c and psychological interven(ons in subjects at high clinical risk for psychosis: OASIS 6- year naturalis(c study. Fusar- Poli P 1, Frascarelli M 1, Valmaggia L 1, Byrne M 1, Stahl D 1, RoccheR M 1, Codjoe L 1, Weinberg L 1, Tognin S 1, Xenaki L 1, McGuire P 1. Author informa(on Abstract BACKGROUND: Recent randomized controlled trials suggest some efficacy for focused interven]ons in subjects at high risk (HR) for psychosis. However, trea]ng HR subjects within the real- world serng of prodromal services is hindered by several prac]cal problems that can significantly make an impact on the effect of focused interven]ons. METHOD: All subjects referred to Outreach and Support in South London (OASIS) and diagnosed with a HR state in the period were included (n = 258). Exposure to focused interven]ons was correlated with sociodemographic and clinical characteris]cs at baseline. Their associa]on with longitudinal clinical and func]onal outcomes was addressed at follow- up. RESULTS: In a mean follow- up ]me of 6 years (s.d. = 2.5 years) a transi]on risk of 18% was observed. Of the sample, 33% were treated with cogni]ve behavioural therapy (CBT) only; 17% of subjects received an]psycho]cs (APs) in addi]on to CBT sessions. Another 17% of subjects were prescribed with an]depressants (ADs) in addi]on to CBT. Of the sample, 20% were exposed to a combina]on of interven]ons. Focused interven]ons had a significant rela]onship with transi]on to psychosis. The CBT + AD interven]on was associated with a reduced risk of transi]on to psychosis, as compared with the CBT + AP interven]on (hazards ra]o = 0.129, 95% confidence interval , p = 0.007). CONCLUSIONS: There were differen]al associa]ons with transi]on outcome for AD v. AP interven]ons in addi]on to CBT in HR subjects. These effects were not secondary to baseline differences in symptom severity.

53 non ci sono studi che rendono evidenti maggiori effetti degli antipsicotici di seconda generazione rispetto ai tipici ma è il pro9ilo degli effetti collaterali ad essere differente.

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56 Ongoing Research

57 Ef9icacy of CBT for Command Hallucinations in psychosis Collabora(on Birchwood, Birmingham University VEOP/EOP longitudinal study Purpose, clinica trial OMEGA 3 in UHR Age effect on clinical presentation of UHR in CAD COMT, Schizofrenia and executive function Lin, Wood, Birmingham University Bossong M, University of Utrecht Lin, Wood, Birmingham University Papaleo Psychotic symptoms in 22q11ds (longitudianal data) Eliez, Guipponi, Geneva U. Neurocognitive function in 22q11ds Pilot study on effect of CBT group therapy (social skills) on adolescence with severe psychiatric disorder Pilot study on effect of family intervention (psychoeducational) for EOP/VEOP Schneider, Morrow, Swillen Nicolò, Pellecchia Nicolò

58 58 Grazie per la cortese attenzione!