TATALAKSANA PSIKOSIS

AWITAN DINI
EARLY ONSET PSYCHOSIS
PSYCHOSIS SPECTRUM
DISORDERS
50 % INSIDIOUS ONSET OF
SCHIZOPHRENIA
HISTORY
EMIL KREAPLIN
1856-1926

ENDOGENOUS
PSYCHOSIS
DEMENTIA PRAECOX 1896


VERY EARLY EARLY ONSET
TYPICAL ONSET-LATE ONSET
PSYCHOSIS. 2000-2004


EARLY ONSET PSYCHOSIS
MANAGEMENT ? MULTIMODAL
A
K
E
S
W
A
R
I
PREVENTION

SPECIFIC BIOLOGICAL RISK
(GENE)

NEURODEVELOPMENT/DEGENE-
RATIVE

CHILD PSYCHOLOGICAL TRAUMA

SPECIFIC RISK CONDITIONS
(POVERTY, ILLNESS, DRUG
ABUSE)
TREATMENT/REHABILITATION

PRODROMAL-ACUTE-CHRONIC

MEDICATION, T SYMPT, SE

DENIAL, COMPLIANCE,
RELAPSING

AGITATION-SUICIDE

CBT, FAM TH/, SOCIAL
INTERVENTION

EARLY DETECTION ASSESSMENT
PSYCHOLOGICAL PROTECTOR/BUFFER
PSYCHOEDUCATION. P SOLVING. RESILIENCE. COPING M
PSYCHOLOGICAL READINESS/FUNCTIONAL
WELLBEING
PREVENTION
ELIMINATE
RISK FACTORS
# GENETIC 70-80%

## NON GENE 20-30%

PREMORBID-
NEURODEVELOPMENT

OBSTETRIC
COMPLICATION

ENVIRONTMENT
PRE-PERINATAL

DEGENERATIVE P
PSYCHOLOGICAL

SOCIAL-CULTURE

PARENTING

MENTAL HEALTH CARE

SPECIAL EDUCATION

PSYCHOLOGICAL
BUFFER
SYMPTOMS PSYCHOSIS
PREVENTION OF PSYCHOSOCIAL DEVELOPMENT OF EARLY ONSET OF
PSYCHOSIS
GENES NON GENE ENVIRONMENT
ANTENATAL
FAM INFLUENCES
CHILDHOOD ILL
PREDISPOSITION PERSONALITY-VULNERABILITY

PRECIPITATION STRESSOR - BIO -PSY-SOCIAL

BEHAVIORAL EDUC/SOCIOCULTURE/SPI


COPING STRATEGIES EDUC/ SOCIOCULTURE/SPI

INEFFECTIVE EFFECTIVE


PATHOLOGIES MEDICATION
FAM / SOS INTERVENTION

CURATIVE/REHABILITATION
PRODROMAL STAGE
FIST ACUTE EPISODE OF PSYCHOSIS
MEDICATIONS
COGNITIVE BEHAVIORAL THERAPY
PSYCHOLOGICAL SUPPORT
EARLY ONSET PSYCHOSIS

ETIOLOGY GENETIC, NON GENE
NEURODEVELOPMENT/DEGENERATIVE
PARENTING, ENVIRONMENT
FACTC SR.. 7 th, . 14 26 +/- 5.5
ASSESSMENT PRODROMAL INSCIDIUS
ACUTE EPISODE
MANAGEMENT
INTERVENTION
MEDICATION-PSYCHOTERAPHY-SOCIAL INT
FOCUS MENTAL HEALTH (PREVENTION)
HOLISTIC APPROACH
BRAIN ???



STRESS INVOLVED TO SOMATIC
SYMPTOMS
HARMFUL STIMULUS
( STRESS)
ADAPTATION
SYNDROME
DISEASES OF
ADAPTATION
PROTEIN + FAT
DEPOTS
HEPATIC
GLYCOGEN
BLOOD
SUGAR
TISSUES
Trophic
Harmones
CEREBRAL
CORTEX
(CONFLICT)
ANTERIOR
PITUITARY
hypothalamus
Sympathetic Nervous
System (Efferent)
Sympathetic System
Amigdala
ADRENAL
Corticostiroids
ACTH
Corticostiroids
Portal System
ENDORPHINE
BIOPSYCHOSOCIAL STRESSOR
ENVIRONMENTAL NON GENETIC
20-30%
PREGNANCY AND BIRTH COMPLICATION
PERINATAL AND EARLY CHILHOOD BRAIN
DAMAGE
FOETAL MALDEVELOPMENT
SEASON OF BIRTH
HEAVY METAL Pb, Hg, As, Cd
DRUG ADDICTION
Misperception of Mental Illness
Past Understanding
71 % Due to emotional weakness
65 % Caused by bad parenting
45 % Victims fault (can be willed away)
43 % Incurable
35 % Consequence of sin
10 % Biological basis (involves the
brain)

Now Biological Basis 70 %-80% (Gene)
14
GENES CODE PROT DEVELOPMENT. 70-80%
TWIN STUDIES
CHROMOSOMES LOCUS 22q 11,6p22,8p12-21,
1q21-22,7q21-22,1q42,13q32-34 , 12q24
GENE
DTNBP1,COMT,NGG1,RGS4,GRM3,DISC1,G72,DAAO
(MULTIPLE GENE)
BRAIN
STRUCTUREVENT,CORTICAL/LIMBIC,SUBCORTICAL,
GREY/WHITE MATTER
FUNCTIONAL GENOMIC AND PROTEOMIC m RNA
CELLULAR STRUCTURES


PREVENTION
REDUCE THE RISK FACTOR DEVELOPING OF SR
1. GENETIC
2. NON GENETIC
* OBSTETRIC COMPLICATION
* VULNERABILITY TO DEVELOP SR
* PREMORBID NEUROBEHAVIORAL MANIFEST
* INFECTION, TRAUMA, INTOXICATION,
NUTRITION ..

* BRAIN NEUROTRANSMITTERS
NEURON GENES PROT SYNTHESIS
SYNAPSIS PRESYNAP POST SYNAP
RECEPTOR d1.2,3,4,5
ENZYM
PATHWAY DOPAMINERGIC
PATWAY GLUTAMINERGIC
PATHWAY
I. Dopaminergic Pathway => VTA Cortex
Mesolimbic & Mesocortical Dopaminergic
Pathway
II. 5 Pathway relate to Glutamatergic pyramidal neuron in the
prefrontal Cortex Brain stem
switch on-off

a. Cortical brainstem glutamate projection
b. Corticostriatal glutamate pathway
c. Thalamocortical glutamate pathway
d. Corticothalamic glutamate pathway
e. Corticocortical glutamatergic pathway

Risk Factors
MOLECULER PSYCHIATRY
GENE
ANALYZE DNA BY NEUTRON
Who ?
GENE TH/ PKU
RNA REPAIR
REPAIR NECLEOTIDE FOR GENE T/
GENE TRANSACTION
DISORDER NORMAL
Dysbindin-1 and schizophrenia: from genetics to neuropathology

Address correspondence to: Michael J. Owen, Department of
Psychological Medicine, Henry Wellcome Building, University of Wales
College of Medicine, Heath Park, Cardiff CF14 4XN, United Kingdom.
Phone: 44-920 74 32 48; Fax: 44-920 74 65 54; E-mail:
owenmj@cf.ac.uk.
Published May 1, 2004

The gene encoding dysbindin-1 has recently been implicated in
susceptibility to schizophrenia. In this issue of the JCI, Talbot et al.
show that, contrary to expectations, dysbindin-1 is located
presynaptically in glutamatergic neurons and is reduced at these
locations in schizophrenia . Further studies of dysbindin-1 and the
proteins with which it interacts can be expected to throw light on the
pathogenesis of schizophrenia.



Progressive losses of cortical gray matter volumes
and increases in ventricular volumes have been
reported in patients with chilhood onset
schizophrenia (COS) during adolescence.
Longitudinal studies suggest that the rate of cortical
loss seen in COS during adolescence plateaus during
early adulthood.
A Progressive neurodevelopmental disorder with
both early and late developmental abnormalities
The association of risk genes involved in circuitries
associated with SR .

GENETIC ABNORMALITY



IONOTROPIC -METABOTROPIC
SYNAPTOGENESIS
MESSAGE SIGNAL TO NEURON
SPEED 400 KM/Hour
Genotype>< Phenotype
Genotype : Gene protein /Neurotransmitter
structure Function Gene


Phenotype : behavioral symptoms
MIS-INFORMATION ??

NEGATIVE & POSITIVE SYMPTOMS SR
LEARNING/TRAININGPSYCHOTHERAPY?






PSYCHOLOGICAL READINESS >< GENES
PRODROMAL PHASE Medication ????
NEURODEGENERATIVE
I. ASYMTOMATIC
II. PRODROMAL/NEGATIVE SYMPTOMS
III. ACUTE PHASE
IV. NEGATIVE/COGNITIVE SYMPTOMS

EXCITOTOXIC (GENE PROG,PRENATAL ANOXIA,TOXINS,INFECTION) DEMENTIA,PARKINSONS d,ALS

NEURODEGENERATIVE
NMDA RECEPTOR=N-METHYL-d ASPARTATE
ASSESSMENT ?
EARLY DETECTION-BIG 7

BEHAVIORAL DEVELOPMENT

BEHAVIORAL/EMOTIONAL ADJUSTMENT
Big Seven RAINS-PM
Early Markers for chilhood onset psychosis
spectrum disorders
R : Relatives : genetic, heritability
A: Attention impairment
I : Impaired Cognitive Functioning
N : Neuromotor Difficulty
S : Social Impairment
P : Attenuated Positive Symptoms
M : Memory , (Impaired Working Memory)
O : other Areas of Concerns
TEMPERAMENTAL CHARACTERISTICS
NEW YORK LONGITUDINAL STUDY (NYLS)
1. ACTIVITY LEVEL
2. RHYTHMICITY/REGULARITY
3. APPROACH OR WIHDRAWAL
4. ADAPTABILITY
5.THRESHOLD OF RESPONSIVENESS
6. INTENSITY OF REACTION
7. QUALITY OF MOOD
8. DISTRACTIBILITY
9. ATTENTION SPAN AND PERSISTENCE

40% EASY CHILD.
60% PROBLEMS 15 % SLOW TO WARM UP. 10 % DIFFICULT
RELATIONSHIP WITH PEOPLE
PARENT,SIBLINGS, TEACHERS, OTHER ADULTS,
OTHER CHILDREN, MEDICAL CAREGIVERS ?

POS (+) :
SOCIAL COMPETENCE :
SOCIAL SKILL, COOPERATION, AFFECTION, INTEREST, HONESTY,
SENSITIVITY

NEG (-) :
AGGRESSIVENESS : OPPOSITION, DEFIANCE, REBELLION,
DISHONESTY, MANIPULATION, VIOLENCE, DESTRUCTIVENESS,
INSENSITIVITY,DISINTEREST
WITHDRAWL : INHIBITION, OVERCONFORMITY
TASK PERFORMANCE
WORK & PLAY ACHIEVEMENT >< UNDERACHIEVEMENT /
EXCESSIVE PREOCCUPATION WITH WORK OR PLAY
SCHOOL WORK,DOMESTIC, COMMUNITY,PLAY-LEISURE

POS (+)
TASK PERFORMANCE, ACHIEVEMENT, SKILL DEVELOPMENT,
MASTERY, INTEREST.
NEG (-)
UNDER : LOW ACH, LOW INTEREST, SCHOOL FAILURE,
TRUANCY
EXCESSIVE STRIVING/PREOCCUPATION WITH
WORK/PLAY
SELF RELATIONS
SELF-ASSURANCE >< POOR SELF RELATION/OVERCONCERN
FOR SELF
SELF REGARD,SELF CARE,SELF REGULATION
POS (+)
SELF ASSURANCE: AUTONOMY,SELF ACCEPTANCE,SELF
ESTEEM, SELF CARE, SELF-RELIANCE, SELF DIRECTION, SELF
CONTROL, SELF ORGANIZATION
NEG (-)
POOR SELF RELATION : LOW SELF ESTEEM,SELF NEGLECT,
SELF ABUSE, SELF DESTRUCTIVENESS , DEPENDENCY
OVERCONCERN: OVERCONTROL, OVER REGULATION,
HYPOCHONDRIASIS

OTHER FEELING, THOUGHTS & FUNCTION
REASONABLE CONTENTMENT >< DISTRESS
FEELING, THOUHGTS AND FUNCTIONS

POS (+)
REASONABLE CONTENTMENT : SENSE OF WELLBEING IN
FEELINGS,THOUGHTS AND PHYSICAL FUNCTION

NEG (-)
DISTRESS IN FEELING : ANXIETY, DEPRESSION, FEAR, ANGER,GUILT.
IN THINKING : REALITY
DISTORTIONS,PHOBIAS,OBSESSIONS,COMPULSIONS.DELUSIONS
IN PHYSICAL FUNCTION: EATING,GASTROINTESTINAL, SLEEP,
COLIC,TICS,SEX,PAIN
MANAGEMENT
EARLY DETECTION + INTERVENTION

EARLY DETECTION MENTAL HEALTH ASSESSMENT

INTERVENTION
- MEDICATION TREATMENT + MONITORING SE

- CBT + PSYCHOSOCIAL INTERVENTION

-Developmental stage and the phase of their recovery
-Focussing on Problem-solving
-Maintaining a spirit of hope and optimism
-COGNITIVE AND PSYCHOSOCIAL THERAPY



GOAL MANAGEMENT ?
ACADEMIC PERFORMANCE & MOTIVATION

SKILL AND INTEREST DEVELOPMENT

SOCIAL/BEHAVIORAL ADAPTATION

AFFECT/SELF ESTEEM
PARENTING
Physical : Nutrition, imunization, G
Development

Psychological : parenting, stimulation, psy
development, Education , moral, scurity,
satisfaction, self esteem and =
Adaptive/flexible Maturity

ENVIRONMENT
Water , polution, toxic material

School, peer group, teacher

Climate , weather , global warming

Insect, virus .
PSYCHOSOCIAL INTERVENTION+ THE CHILDS SPECIFIC
DIFFICULTIES Parents-Child


Family functioning
Problem solving
Communication skill
Relapse prevention
Specialized Educational programs
Academic Adjustment
Support at school
Teaching and Medication Education
To Promote Compliance with Treatment

PHARMACOTHERAPY BRAIN Biological
Response+ SYMPTOMS CONTROL
Synaptogenesis, Strengthen a synapse GOOD INFO
Neurogenesis >< atropy/apoptosis/necrosis
Good - Psychotherapeutic response (cooperative)
Learning / memory improvement
Endocrine response
Increase the efficiency of information processing in Brain
Circuits
Stress release calm, confident
Target Symptoms ( delution, hallucination, chronic pain,
panic etc)

MEDICATION TREATMENT
Typical , atypical anti psychotics & others

Acute , relapsing , Schizophrenia

Target symptoms , Monitoring Side effect

Maintenance Treatment

Complaince medication

Functioning
MEDICATION TREATMENT
62
TREATMENT
Remove
signs, symptoms
FUNCTIONAL
Restore
BRAIN
CIRCUIT
INFO
Minimize
relapse
risk of
Suicide/ Aggres
MONITORING
SIDE EFFECT
FARMAKO-
GENOMIC
2015???
TREATMENT
Prodromal phase Period of Deteriorating
function PSYCHOTROPIC DRUGS (PD)
Acute phase + Symptoms(H/W) PD
Recovery phase PD
Residual Phase Apathy, Lack of Motivation,
Withdrawal, restricted of flat affect PD
Chronically impaired remain sympt PD
Co Morbidity (Depression/Mania)PD
NOT COMPLIANCE SUPPORT!!!
30 % AMBIVALENCE TO DRUG

LACK OF INSIGHT

MANIA/HYPOMAN HAPPY

ACTUAL SIDE EFFECTS ALLERGY, EPS, M. SYND

SOCIAL ECONOMIC PROBLEMS + .

THE IMPACT OF NON COMPLIANCE
RELAPSING

AGITATION

SCHIZOPHRENIA CHRONIC

DRUGS - RESISTANT

SUICIDE

COMBINATION


MEDICATION PRIORITY + PSYCHOLOGICAL
INTERVENTION MORE EFFECTIVE
PSYCHOTHERAPY ? IS IT NEEDED?
HISTORY
LEVEL OF DEVELOPMENT
CURRENT PROBLEMS
ABILITY TO COOPERATE WITH TREATMENT
WHAT INTERVENTION MOST LIKELY TO HELP ?
PSYCHOLOGICAL BUFFER


Psychodinamic PT/ to understanding the issue that
motivate and influence a child behavior, thought and
feelings. To identified a typical behavior patterns,
defenses and responses to inner conflict and struggles
Inner struggles are brought to light.


reduce symptoms
provide insight
improve functioning
quality of life
PSYCHOEDUCATION
Reduce relapse & Hospitalisation
Improve function quality of life
Awareness to disorders
Promoting early detection of prodromal symp
Increasing Medication adherence
Preventing suicide, agitation, comorbiditas
Reducing stigma & Guilty.
Increasing self esteem & wellbeing. Adaptive
Iifestyle


CONTENT OF PSYCHOEDUCATION IN GROUP
INTRODUCTION
WHAT IS EARLY ONSET PSYCHOSIS?
TO IDENTIFY WHAT TRIGGER FACTORS ?
SYMPTOM PRODROMAL---- ACUTE EPISODE
COURSE AND OUTCOME
TREATMENT?
MONITORING ?
EARLY DETECTION?
WHAT TO DO ? WHEN A NEW PHASE IS DETECTED?
LIFESTYLE REGULARITY
STRESS MANAGEMENT TECHNIQUE ?
PROBLEM SOLVING TECHNIQUE ?


COGNITIVE BEHAVIORAL THERAPY
COGNITIVE CHILD THOUGHTS AND
BELIEFS TO INFLUENCE MOOD AND ACTION

BEHAVIORAL CHANGE BEHAVIORS IN
ACCURATE BELIEFS TO POSITIVE WAY
(ADAPTIVE AND REALISTIC WAY)
FAMILY FOCUSED THERAPY (FFT)
SUPPORT AND COOPERATION OF FAMILY &
CAREGIVERS
IMPROVE FAMILY FUNCTIONING
TRAINING IN COMMUNICATION
COPING STRATEGIES
PSYCHOEDUCATION
RELAPSE PREVENTION TECHNIQUES
PSYCHOSOCIAL SKILL
INTERPERSONAL INTERACTION
FINDING COGNITIVE DEFICIT (ATTENTION)
PERCEPTUAL DISTURBANCE (IMPAIRED
RECOGNATION OF FACIAL EMOTIONS)
TO APPRECIATE FACIAL EXPRESSION (AFFECTIVE
CHANGES, ANGER, SADNESS) RELATED SOCIAL
INTERACTION
SLEEP AND SOCIAL ACTIVITY
INTEGRATE PHYSICAL & PSYCHOLOGICAL
PSYCHOLOGICAL PROTECTOR/BUFFER
RESILIENCY PEER , ENVIRONMENT PRESSURE
CHILD INTERPERSONAL SKILL UNDERSTANDING
DISABILITY
COMMUNICATION SKILL
SOCIAL SKILL REACH HIS OR HER POTENTIAL
COPING MECHANISM DECREASE THE STRESS
RESPON
SELF CONTROL
EMOTIONAL INTELLIGENCE LIFE SUCCESS (NOT
SCHOOL) SURVIVAL
PROBLEMS SOLVING INDIVIDUALIZED EDUCATION

PSYCHOLOGICAL READINESS
GENETIC AND NON GENETIC BIOLOGICAL
FACTORS CAN BE CHANGED BY EXPERIENCE


CERETAKER EARLY IN LIFE LEARNING &
TRAINING TO COPE LIFES CHALLENGES
PRIMARY LEARNING STYLE
VISUAL LEARNERS SEEING READING

AUDITORY LEARNERS LISTENING AND
MUSIC

KINESTHETIC LEARNERS DOING AND
MOVING


GENES + NON GENES
EARLY ONSET OF PSYCHOSIS




PRODROMAL SYMPTOM



EARLY DETECTION + INTERVENTION


PSYCHOLOGICAL READINESS
CHILDS WELLBEING


THANK YOU