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Bipolar Disorders Resource Page at Currentpsychiatry.Com Web audio at CurrentPsychiatry.com Dr. Madaan: A management approach for when an adolescent shows early signs of schizophrenia AN OPTIMAL APPROACH Early identification and monitoring of at-risk patients has the potential to improve outcomes Vishal Madaan, MD n studies of schizophrenia, one of the more striking findings is University of Virginia Health System the delay in the initiation of treatment. That delay ranges from 1 Charlottesville, Virginia to 2 years for patients experiencing psychotic symptoms to several Durga P. Bestha, MBBS I 1 years if the prodromal phase is taken into account. Yet duration of Carolinas Medical Center Charlotte, North Carolina untreated psychosis has been found to be a critical factor in prognosis, 2,3 Venkata Kolli, MBBS, MRCPsych including psychosocial functioning, in patients with schizophrenia. Creighton University Medical Center Identification of individuals in the prodromal phase not only offers an Omaha, Nebraska opportunity to intervene at an earlier symptomatic stage, but might be Disclosures associated with a better response to antipsychotics and a better overall Dr. Madaan is an employee of University of Virginia Health System. treatment outcome as well. As an employee with the University of Virginia, Dr. Madaan has received research support from Eli Lilly and Company, Forest, Merck, Otsuka, Pfizer, Shire, and Sunovion. He also has served as a consultant for the NOW Coalition for Bipolar Disorder, and on the American Psychiatric Association’s Focus Self-Assessment editorial What’s in a name? board. Drs. Bestha and Kolli report no financial relationships with Several terms, including ultra high risk, clinical high risk, at-risk men- any company whose products are mentioned in this article or with manufacturers of competing products. tal state, psychosis risk syndrome, and schizophrenia/psychosis prodrome, have been used to describe the prodromal phase of schizophrenia. The proposal to include attenuated psychosis syndrome (APS) in the DSM- 5—originally intended to capture those with subthreshold delusions, hallucinations, or disorganized behavior, occurring at least once a week for the past month and worsening over the past year—gener- ated a debate about the validity of such a diagnostic category4,5 that culminated in the inclusion of APS as a condition for further study but not as a term for clinical use.6 Its presence in the DSM-5 brings to the forefront the importance of early clinical intervention in patients at risk of developing psychotic illness. continued FANATIC FANATIC STUDIO Current Psychiatry Vol. 13, No. 3 17 Box 1 A sequence of evolving symptoms he early, or preprodromal, phase of a veil that often obscures the underlying Tschizophrenia is characterized by 1) origins of a primary psychotic disorder. Next unspecified, basic symptoms, with the comes progression to the more specific beginning of subtle differences in volition; state of brief limited intermittent psychosis Schizophrenia and 2) central-vegetative functions, thoughts, (BLIPS). BLIPS is characterized by a burst of concentration, speech, and perception,8 which overt but transient psychotic symptoms (<1 prodrome are evident (and subjectively distressing) to the week), consisting of hallucinations, delusions, person experiencing them, but not to others. disorganized behavior and speech, or the Further along in the course of illness, more insidious subthreshold attenuated a decline in occupational or academic psychosis, which consists of unusual performance and changes in interpersonal thought content, such as ideas of reference, functioning often are noted.9 In addition, paranoia, grandiosity, and unusual perceptual extreme affective and anxiety symptoms and distortions leading to idiosyncratic behavior substance use disorders can occur, creating and speech. Clinical Point The prodromal phase Table 1 of schizophrenia can Schizophrenia prodrome: Attenuated and basic signs and symptoms be viewed as Attenuated Positive a sequence of • Unusual thought content evolving symptoms • Suspiciousness • Grandiosity • Perceptual abnormalities • Conceptual disorganization Negative • Social isolation or withdrawal • Avolition • Decreased expression of emotion • Decreased ideational richness • Deterioration in role Basic • Changes in emotional responsiveness • Inability to divide attention, slowed thinking • Decreased ability to discriminate between ideas and perception, fantasy and true memories • Derealization • Unstable ideas of reference • Visual, acoustic, and body perception disturbances Source: References 13-16 Schizophrenia is not inevitable to psychosis has been found to fluctuate The prodromal phase can be viewed as a from as low as 9% to as high as 76%,10 Discuss this article at sequence of evolving symptoms7 (Box 18,9), prompting ethical concerns about a high www.facebook.com/ starting with subtle differences evident false-positive rate, the assumption of inev- CurrentPsychiatry only to the person experiencing them and itability associated with the term “schizo- often progressing to brief limited inter- phrenia prodrome,”9 and the potential for mittent psychosis (BLIPS) or attenuated overdiagnosis and misdiagnosis. Concerns psychosis.8 about psychosocial stigma and exposure In fact, prodrome is a retrospective diag- to antipsychotic medications have been Current Psychiatry 18 March 2014 nosis. The predictive power of conversion expressed as well.11 Table 2 Commonly used screening tools for psychosis risk states Bonn Scale for the Assessment of Basic Uses basic symptoms approach Symptoms (BSABS) Cognitive-Perceptive Basic Symptoms Two overlapping basic symptoms criteria used to identify (COPER) and the high-risk criterion early stages of schizophrenia prodrome Cognitive Disturbances (COGDIS) Comprehensive Assessment of At-Risk Uses predominantly criteria for ultra high risk; assesses Mental States (CAARMS) positive, negative, disorganized, cognitive, and general symptoms Frankfurt Complaint Questionnaire (FCQ) Evaluates subjective symptoms of schizophrenia but is useful in suspected prodrome as well Schizophrenia Proneness Instrument Assesses predominantly self-perceived cognitive and for Adults (SPI-A) perceptual changes; uses basic symptoms approach SPI Child & Youth (SPI-CY) Similar to SPI-A, modified for children Structured Interview of Prodromal Uses predominantly criteria for ultra high risk; assesses Symptoms/Scale of Prodromal Symptoms positive, negative, disorganized, and general symptoms Clinical Point (SIPS/SOPS) Source: Reference 8 Identifying patients in the early prodromal period offers A case for early engagement mal symptoms of psychosis)—have been the opportunity In retrospect, patients who eventually found to be useful in screening a large to more effectively progress to psychotic illness are common- sample to identify those who might need ly found to have been in the prodromal further evaluation.17 engage them phase for several years. Yet many patients’ first contact with psychiatric services oc- Increased risk of conversion. Several curs during a florid episode of acute psy- clinical factors are associated with an in- chosis. Identifying patients in the early creased risk of conversion to psychotic ill- prodromal period offers the opportunity ness.9 In addition to family history, these to more effectively engage them and form include: a therapeutic alliance.12 Any young adult • greater severity and longer duration of who presents with a decline in academic attenuated positive symptoms or occupational function, social with- • presence of bizarre thoughts and drawal, perplexity, and apparent distress behavior or agitation (Table 113-16) without a clear • paranoia precipitating factor should therefore be • decline in global assessment of func- closely monitored, particularly if he (she) tioning score over the previous year has a family history of psychosis. • use of either Cannabis or amphetamines. Screening tools. A variety of inter- A history of childhood trauma, increased views and rating scales (Table 28) have sensitivity to psychosocial stressors, been developed to assess and monitor and dysregulation of the hypothalamic- at-risk persons, a number of which have pituitary axis also have been associated been designed to detect basic symp- with progression to psychosis.18 toms in the early phase of prodrome. In Recent evidence suggests that the pro- addition to the structured scales, sev- dromal phase is a predictor not only for eral self-report tools—including the psychosis but also for other disabling psy- Prodromal Questionnaire-Brief (PQ-B), chiatric illnesses, such as bipolar disorder Youth Psychosis At Risk Questionnaire- and obsessive-compulsive disorder.19 Brief (YPARQ-B), Prime Screen-Revised, From a phenomenological standpoint, Current Psychiatry and PROD-screen (Screen for prodro- disturbance of the sense of self—charac- Vol. 13, No. 3 19 Table 3 tus experienced by immigrants faced with multiple social, cultural, and language International clinical practice barriers.21 The presence of obsessive- guidelines for the prepsychotic compulsive symptoms during the pro- period dromal phase has been linked to signifi- • Engage the person at risk cant impairment in functioning, an acute • Assess and monitor mental state switch to psychosis, and an increased risk Schizophrenia • Provide support and treat comorbidities of suicide.22 prodrome • Provide psychoeducation to patient and family • Advise on help patients develop coping skills Monitor or treat? An optimal for psychotic symptoms approach
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