Transcript WELCOME Recent Advances in Psychopharmacology

How to Assess for
Early Psychosis
Rachel Loewy, PhD
UCSF Prodrome Assessment Research
and Treatment (PART) Program
What is Early Psychosis?
• Schizophrenia as prototype (schizophrenia,
schizoaffective, schizophreniform)
• Can include bipolar & unipolar depression
Early = A) Recent onset psychotic disorders
(within 3 yrs)
B) at imminent risk for onset of psychosis
What do we mean by “Prodromal?”
• Webster’s Definition:
An early symptom indicating the onset of a disorder
• Medical example:
– Fever is prodromal to measles
• Prodromal definition in relation to psychosis:
“Period preceding the onset of the first florid psychotic
episode, when there is increasing symptomatic
presentation and functional deterioration (NIMH).”
• Ultra-high-risk (UHR)
Model of Progression from
Prodrome to Psychosis
1-3 yrs
3-5 yrs
Childhood
No Sx
Adolescence
Non-specific Sx
noticed by patient
Sub-psychotic Sx
affects functioning
Adulthood
Psychotic
level Sx
Treatment
success
Who is at ultra-high-risk
for psychosis?
Prodromal period of thought disorders
Symptoms in this stage include:
Specific Symptoms:
• Positive Symptoms: experiences in excess of normal
functioning
Non-specific Symptoms:
• Negative Symptoms, Disorganization, Affective
Symptoms
– Cognitive
– Social
– Mood
– Functioning
Structured Interview for
Prodromal Syndromes (SIPS)
• Research diagnostic criteria
• 20% - 40% transition rate by 1 year
• Structured interview with patient and parents
requires 2-3 hours
UHR Conversion Rates:
NAPLS study (N=291)
50%
40%
Full
Psychosis
30%
20%
10%
0%
6
12
18
Months
Cannon, et al, 2008
24
30
Structured Interview for
Prodromal Syndromes (SIPS)
1) Attenuated Positive Symptom Prodromal Syndrome:
•
One or more subthreshold positive symptoms, not fully
psychotic in intensity: Unusual thought content /delusional
ideas, suspiciousness/ persecutory ideas, grandiosity,
perceptual abnormalities/distortions, conceptual
disorganization.
•
Currently present at a frequency of at least once
per week, onset or worsening in the past year.
Structured Interview for
Prodromal Syndromes (SIPS)
2) Brief Intermittent Psychosis Prodromal Syndrome:
• One or more fully psychotic symptoms:
• Hallucinations (auditory, visual, tactile, etc.),
• Delusions (thought broadcasting, thought insertion,
paranoia, grandeur, etc.) and
• Formal thought disorder (loosening of associations,
flight of ideas, etc.)
• Present intermittently for at least several minutes/day at
least once per month, but less than 1 hour/ day,
4 days/week over 1 month.
Structured Interview for
Prodromal Syndromes (SIPS)
3) Genetic Risk and Deterioration Prodromal Syndrome:
• Precipitous decline in role functioning rated on the
General Assessment of Functioning (GAF) scale
as a drop of at least 30% in the past 12 months
AND one of the following:
• Meets criteria for schizotypal personality disorder OR
• Has a family history of schizophrenia
(psychotic disorder in a first-degree relative)
Unusual Thinking
• Confusion about what is real
and what is imaginary
• Ideas of reference
• Preoccupation with the
supernatural (telepathy, ghosts,
UFOs)
• Other unusual thoughts:
Mind tricks, nihilistic ideas, somatic
ideas, overvalued beliefs, delusions of
control
Suspiciousness
• Excessive suspiciousness,
paranoid thinking
Grandiosity
• Unrealistic ideas of special
identity or abilities
Perceptual Disturbances
• Increased sensitivity to light and
sound
• Hearing things that other
people don’t hear
• Seeing things that others don’t see
• Smelling, tasting, or feeling unusual sensations that
other people don’t experience
Disorganized Communication
• Difficulty getting the point across;
trouble directing sentences towards
a goal
• Rambling, going off track during
conversations
• Incorrect words, irrelevant topics
• Odd speech
Negative Symptoms
• Wanting to spend more time alone
• Not feeling motivated to do things
• Trouble understanding
conversations or written materials
• Difficulty identifying and expressing
emotions
Disorganized Symptoms
•
Neglect of personal hygiene
•
Odd appearance or behavior
•
Laughing at odd or
inappropriate times
•
Trouble with attention, clear thinking, comprehension
Impairment in Functioning
• Decline in functioning at school or work
• Problems in relationships with friends or family
Structured Interview for
Prodromal Syndromes (SIPS)
Positive Symptoms Scale:
0
1
2
3-5
6
Absent
Questionable
Subthreshold
Attenuated Range
Fully Psychotic
Structured Interview for
Prodromal Syndromes (SIPS)
1. Onset: “When did (specific symptom) start?”
2. Duration of symptoms: “When (specific
symptom) occurs, how long does it last?”
3. Frequency: “How often does (specific
symptom) occur?”
Structured Interview for
Prodromal Syndromes (SIPS)
4. Degree of Distress: What is this experience like for you?
(Does it bother you?)
Fully Psychotic = May be afraid/worried or may not.
5. Degree to which it interferes with life: Do you ever act
on this experience? Do you ever do anything differently
because of it?
Fully Psychotic = They act on their belief.
6. Degree of Conviction/Meaning: How do you account
for this experience? Do you ever feel that it could it just
be in your head? Do you think this is real?
Fully Psychotic = Not able to induce doubt.
Case Examples