Hva er schizofreni?

Hva er psykose, hva er psykisk lidelse?
• Slagelse, DK, nov 2015
• Jan Olav Johannessen
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Mental illness and substance use disorders account for 60% of the nonfatal burden of disease amongst young people aged 15-34 (Public Health
Group 2005)
75% of mental health problems occur before the age of 25 (Kessler et al
2005)
14% of young people aged 12-17, and 27% of young people aged 18-24
experience a mental health problem in any 12 month period (Sawyer et al
2000, Andrews et al 1999, ABS 2008)
Økning i antall uføre
?
12
Hvordan man dypest sett
forstår hva psykisk lidelse
er, bestemmer både
organisering av og
innhold i behandlingen”
“
Jan Olav Johannessen
13
To viktigste spørsmål som mor stiller:
• «Hva er det som feiler gutten min?»
• Hvordan kommer det til at gå med gutten min
Hva er psykose, hva er psykisk lidelse?
• Slagelse, DK, nov 2015
• Jan Olav Johannessen
Hva er psykose?
Hva er psykisk lidelse?
(Når følelser blir lidelse…)
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33
38
Psykosen som psykologisk
sammenbrudd
• Hugdals forskning omkring stemmehøring
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45
Husk: Psykiske lidelser som dimensjoner
Jan Olav Johannessen
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“An air of desolation more calculated to fix than to remove”
Hvordan man dypest sett forstår
hva psykisk lidelse er,
bestemmer både organisering av
og innhold i behandlingen”
“
Jan Olav Johannessen
56
The ability to conceptualise what you
feel, what you experience
Wittgenstein’s duck
“An air of desolation more calculated to fix than to remove”
Harry Stack Sullivan
Forekomst varierer
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VOKSE OPP STORBY vs LAND (ikke drift) 8:1
2.generasjons innvandrere 4:1
Etnisitet i byer
Menn>Kvinner 6:4
:
Resultater
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•
F20-F29
Mænd
Kvinder
3,5
3,5
3
3
2,5
2,5
1,92
1,57
1,21
0,86
2
1,5
1
0,5
2,28
1,84
2
1,5
1,21
1
0,5
2000
2003
2005
2007
2009
2011
2000
2003
2005
2007
2009
2011
0,69
Johanne Olivia
Grønne Kühl
stud. med
PCK 28.05-2015
Det Sundhedsvidenskabelige Fakultet
Dias 64
Det sentrale: uheldige livshendelser!!
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Sykdom eller syndrom
Gen eller miljø
Traumer
Uhell
Tilfeldigheter
Uheldige livshendelser
(adverse life events)
• Traume
Tilfeldighet
The impact of trauma in childhood
and adulthood on clinical and social
functioning in first episode psychosis
Stain HJabcd, Joa Id, Larsen TKde, Johannessen JOd, ten Velden Hegelstad Wd, and Langeveld Jd
Conclusions
While it would appear that trauma in adulthood
had a greater impact on functioning in FEP than
childhood trauma, it is important to note that
childhood trauma increased the risk of experiencing
trauma as an adult. The association of trauma with
increased negative symptoms and poorer
premorbid functioning highlights the need to
address trauma in assessment and intervention for
FEP.
The Myth of Schizophrenia as a Progressive Brain Disease by
Zipursky, Reilly & Murray
Schizophrenia Bulletin: The Myth of Schizophrenia as a Progressive Brain Disease by
Zipursky, Reilly & Murray
http://schizophreniabulletin.oxfordjournals.org/content/early/2012/11/20/schbul.sbs135.abstra
ct
Abstract: Schizophrenia has historically been considered to be a deteriorating disease, a view
reinforced by recent MRI findings of progressive brain tissue loss over the early years of
illness. On the other hand, the notion that recovery from schizophrenia is possible is
increasingly embraced by consumer and family groups. This review critically examines the
evidence from longitudinal studies of (1) clinical outcomes, (2) MRI brain volumes, and (3)
cognitive functioning. First, the evidence shows that although approximately 25% of people
with schizophrenia have a poor long-term outcome, few of these show the incremental loss of
function that is characteristic of neurodegenerative illnesses. Second, MRI studies
demonstrate subtle developmental abnormalities at first onset of psychosis and then further
decreases in brain tissue volumes; however, these latter decreases are explicable by the effects
of antipsychotic medication, substance abuse, and other secondary factors. Third, while
patients do show cognitive deficits compared with controls, cognitive functioning does not
appear to deteriorate over time. The majority of people with schizophrenia have the potential
to achieve long-term remission and functional recovery. The fact that some experience
deterioration in functioning over time may reflect poor access, or adherence, to treatment, the
effects of concurrent conditions, and social and financial impoverishment. Mental health
professionals need to join with patients and their families in understanding that schizophrenia
is not a malignant disease that inevitably deteriorates over time but rather one from which
most people can achieve a substantial degree of recovery.
• Is there really such a thing as
SCHIZOPHRENIA?
Antistigma
“With (my patients at Chestnut Lodge) I came upon the
scene too late; most of the damage was already done. I
remain convinced that with schizophrenia in its moderate to
severe form, our current treatment efforts amount to
palliation and damage control. There is no doubt that our
efforts make a difference, but they effect little if any restitution
of what has been lost. For many vulnerable to schizophrenia,
the ultimate answer lies in early detection and preventive
intervention.”
Thomas McGlashan. Editor’s Introduction:
Early detection and intervention in schizophrenia,
Schizophrenia Bulletin, 1996, 22(2):197-9
The Trauma of Late Intervention
Early intervention group
Late intervention group
THE GRAND DSM V RAILROAD
Psychosis Risk
Syndrome
Bipolar Risk
Syndrome
Tenacious
Depression
Syndrome
Progression through the prodromal
period
mania
depression
mania
psychosis
Stage 1a
mania
depression
depression
psychosis
Stage 1b
Psychosis
schizophrenia
Stage 2+
Stages of onset of schizophrenia
Stages of decompensation:
0
Equilibrium
I
Overextension
II
Restricted consciousness
III
Disinhibition
IV
Psychotic disorganisation
1. destructuring of the external world
2. destructuring of the self
3. total fragmentation
V
Psychotic resolution
Docherty 1978 Am J Psychiatry
80
82
bizarre delusions
delusions
hearing voices
suspiciousness
isolation
problems with concentration
anxiety
sleeping problems
the ”Domino-effect”
SIPS Interview Probes Attenuated Psychotic Phenomena
PANSS Delusions
7
6
5
4
3
SIPS Unusual Thought
Content/Delusional Ideas
6
5
4
Psychosis
Threshold
2
3
2
1
1
0
Why study prodromal
syndromes and symptoms?
• DSM-5 and the “Psychosis risk
syndrome”: The need for a broader
perspective.
Invited editorial , Psychosis, vol 2, no2, june 2010, 93-110 Johannessen/McGorry
Psykiske lidelser utvikles i stadier
• There has been a growing recognition during
the past two decades that mental disorders in
general, and psychotic disorders in special, are
not static , sharply defined illnesses with
separate aethiologies and courses
(categories), but rather disorders that develop
in stages and overlap (dimensions)
(Sullivan 1927,Crow 1990, Docherty 1978, Alanen 1997, Johannessen 2006, McGorry 2006).
The idea of phase-specific treatments with its
derivative early intervention has grown in almost
an explosive manner throughout the last two
decades, with the aims of
a) reducing or preventing secondary morbidity , and
b) achieving primary prevention, i.e prevent the
transition from early (prodromal) stages into a fullthreshold psychosis.
McGlashan
Building of relations
(establishing alliances
and contacts)
No Engagement
Alanen
Social situation,
family situation,
individual state
of the patient
Gunderson
Support
Relationship
Building
Renewed
therapy
meetings
Working Alliance
Supportive
Psycotherapeu
tic community
Strcuture
Communicating
Problem
Solving
Renewed
therapy
meetings
Working Aliance
Analytic
Internalisation
Termination
Intermediate
phase
Therapy of the
primary family
Relationship
Using
Fortification
Integration
Cognitive
Enhancement
Therapy
Family and environmentcentered crisis
intervention
Attachment
Phases of
development
Basic phase
Protection
Engagement
(Relationship
Parameters)
Personal
Therapy
Initial
investigation
in the first
therapy meeting
Bonding
May be weeks
1-2 years
Hogarty
Engagement
Therapy of the
secondary family
Advanced
Phase
Relationship
Modifying
Individual therapy
Validation
Recovery
phase
91
• Current DSM and ICD systems do not have criteria to
define the initial threshold for so-called “caseness”.
• The current diagnostic systems define an “end state”
syndrome, derived from studying subsets of chronic
patients, and thus provides a spurious impression of
stability and validity, without considering the
complex evolution of symptoms during the onset of a
major mental disorder.
• A need for a new diagnostic infrastructure for
the early stages of mental illness
• And: time is running out for the more
established concepts such as schizophrenia.
• Unfortunately, the DSM V committees have
chosen not to evaluate this diagnosis at this
point of time.
• There is now comprehensive research
performed in what has been called
“Prodromal stage”,
“At risk mental health (ARMS)”,
“Ultra high risk (UHR)”
“Pre- psychosis”
” Psychosis risk syndrome”
• “Prodromes” are by definition retrospective
concepts, and all these concepts are
connected with serious ethical and stigma
aspects that need continuous and careful
reflection .
• It is deemed unethical and stigmatising to
label somebody as “may become psychotic” or
“pre-schizophrenia”.
• The symptoms in these stages are unspecific,
• With low predictive value as to what condition
or diagnosis that may be the next stage.
• Early stages of bipolar disorders has a similar,
or even longer, DUP, and the symptoms being
similar to those of non-affective psychosis.
(Yung/McGorry 2007).
The risk syndrome
• For some of these disorders there seems to be
an almost indistinguible early stage, or one
could hypothesize, a kind of shared early
pathway before manifest psychosis occurs.
• “The risk syndrome” should not be reserved
for the schizophrenia spectre only, but that
the scope should be broadened and include
bipolar psychoses as well.
Pluripotential risk syndrome
• A pluripotential risk syndrome that is
phenotypically broad and difficult to subtype
is perhaps the most useful model.
• This model indicates a need for care without
attempting to define an end-stage syndrome.
• Within the clinical staging framework each
stage is in fact a risk syndrome for the next.
Advantages:
• It will strengthen the dynamic understanding of
psychotic disorders,
• Support the strategies for early detection and
intervention,
• It will give new opportunities for developing
evidence-based treatments as we will be able to
filter out better defined sub-populations of patients,
• It will give us a better position in our efforts to
understand the evolution of onset of serious mental
illnesses.
Disadvantages
• stigmatising by labelling young people with an “at
risk for psychosis” diagnosis is indeed realistic, and
has to be answered.
• if this new concept will be used as an argument for
utterly medicalisation of young people with
beginning symptoms of what could develop into a
psychosis,
• contribute to overmedicalisation of normal humans
experiences,
• we underline that today’s knowledge-base do not
justify that.
POP screening prosedures
OT
el.
Outpat. clinics
Actual Yes / No
1st episode
anxiety or
depressive
disorder
PQ, selreport > cut,off or
Therapist Prodr. cheecklist > 2
PANSS=3
item;P1,P2,P
3;P5,P6.A9
Prodrome; ?
POP assesment,SIPS
24 hours
< 1 week
POP inclusion Yes / no
Continous treatement 2 years
Diagnoser: Gode knagger eller farlige stempler?
DIA
=
GNOSIS =
GJENNOM
KUNNSKAP
4 A’er
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Ambivalens
Autisme
Affektavflating
???
Diagnoser: Gode knagger eller farlige stempler?
Vi stiller alltid en diagnose
(også de som ikke stiller diagnoser….)
Mennesket har behov for å ordne/kategorisere/sortere
Kvinne/mann

Ung/gammel

levende/død

norsk/svensk

vestlending/østlending

syk/frisk

nerver/ikke nerver

eller
psyke/soma

osv, osv

F.20.13
Diagnoser: Gode knagger eller farlige stempler?
Diagnoser  samlebetegnelse
• Samlebetegnelse i medisin
= hva er galt med mennesket
• Samlebetegnelse i bil/maskin
= hva er galt med bilen
• Samlebetegnelse i samfunnet
= hva er galt i samfunnet
• Knyttet til stigma/antistigma
= samlebetegnelse på ”grupper”
Lars Thorgaard (LTH 3-R)
Schizofreni er:
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A separation/attachment disorder
Distrust/loss of trust disorder
A relation disorder
An identity disorder
A paroxysmal and relapse disorder
A control and loss of control disorder
A selfcare-failing disorder
Diagnoser: Gode knagger eller farlige stempler?
Diagnoser: ICD10/DSM IV
• nyttige
• uunngåelige
• Vite hva vi gjør
Behandlingsresultat, hvorfor er det
ingen som spør?
• ER der noen der blir goe’
• Lokalpolitiker, 1986
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117
I
S
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FORELØPIG
Utredning, behandling og oppfølging av personer med psykoselidelser
Utkast til endelig versjon 2.11.2012
Hovedgrep
Nasjonale retningslinjer
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Fasespesifikk tilnærming
Dimensjonell psykoseforståelse
Behovstilpasset behandling
Standardisert ”Utrednings- og behandlingslinje”
Helhetlig perspektiv
Behandlingsresultat-perspektiv
119
Remisjon og recovery
%
Kontroll
Tidlig oppdagelse
Odds ratio
Remisjon
46.6
52.5
1.3
Recovery*
12
31
2.5
*p<.017
GLOBAL MENTAL HEALTH CAMPAIGN STRATEGY #101
Early
Intervention!
No way!
WPA
Maybe Later?
THE CAMPAIGN FOR GLOBAL MENTAL HEALTH
THE
LANCET’S
Dr Richard
Horton