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 Adolescence Adulthood No Sx Non-specific Sx noticed by patient Sub-psychotic Sx affects functioning 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

Cannon, et al, 2008

12 18

Months

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 Absent Questionable Subthreshold 3-5 Attenuated Range 6 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