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How To Recognize and Respond to Prodromal Psychosis

How To Recognize and Respond to Prodromal Psychosis. Rajiv Tandon University of Florida. OUTLINE OF PRESENTATION. WHY CURRENT EMPHASIS ON TOPIC DEFINING PRODROMAL PSYCHOSIS DSM-5 APPROACH IMPLICATIONS FOR PRACTICE. FIVE ARS QUESTIONS. 2 Introductory questions Outcome ARS Treatment ARS

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How To Recognize and Respond to Prodromal Psychosis

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  1. How To Recognize and Respond to Prodromal Psychosis Rajiv Tandon University of Florida

  2. OUTLINE OF PRESENTATION WHY CURRENT EMPHASIS ON TOPIC DEFINING PRODROMAL PSYCHOSIS DSM-5 APPROACH IMPLICATIONS FOR PRACTICE

  3. FIVE ARS QUESTIONS 2 Introductory questions Outcome ARS Treatment ARS Cognition ARS

  4. Kraepelinian PESSIMISM of Dementia Praecox The patient may never achieve restitutio ad integrum IRREVERSIBLE DECLINE DEMENCE UNIFORMLY BAD OUTCOME PROGRESSIVE DECLINE

  5. Schizophrenia, Circa 1898 Called a disease of the mind, it afflicts more than one third of patients in mental institutions. A severely disabling and chronic illnessaffecting diverse aspects of higher brain function, it causes impaired cognition, distorted perceptions and hallucinations. Highly resistant to standard treatments, it can present abruptly in healthy individuals or develop insidiously. Kraepelin E, Dementia Praecox and Paraphrenia, 1919 Dementia Praecox

  6. Psychopathological Domains Disorganization Negative Symptoms Positive Symptoms Functional lmpairment Mood Symptoms Cognitive Deficits Motor symptoms Tandon et al., Schizophrenia Research 2009; 110: 1-23.

  7. Course of Schizophrenia Good Function Stable Relapsing Psycho- pathology Premorbid Progression 15 20 30 40 50 60 70 Age (Years)

  8. New Findings: Stages & Dimensions of Illness Disorganization Positive Symptoms Negative Symptoms Functional lmpairment Mood Symptoms Cognitive Deficits Motor Symptoms Tandon et al., Schizophrenia Research 2009; 110: 1-23

  9. An integrative model of schizophrenia. Early developmental derailment Peri-adolescent brain dysmaturation Genetic susceptibility Post-illness onset deterioration Normal development Premorbid deficits The epigenetic landscape Environmental factors Psychotic “break” Relapses Cognitive deficits Perceptual distortions Functional decline Birth Adolescence Adulthood

  10. PRODROMAL PSYCHOSIS WHY Need to prevent illness or at least prevent progression AS EARLY AS POSSIBLE HOW By early identification and effective treatment WHEN IN PRODROMAL PHASE Tools to identify those at risk for “conversion” Tools to intervene to reduce risk

  11. Course of Schizophrenia Good Function Stable Relapsing Psycho- pathology Premorbid Progression 15 20 30 40 50 60 70 Age (Years)

  12. Phases of the schizophrenic illness. Recovery Premorbid Prodromal Transitional Psychotic

  13. Premorbid Premorbid Recovery Prodromal Transitional Psychotic Manifestations Cognitive Neuromotor Behavioral

  14. Premorbid and Prodromal Schizophrenia: How Do We Know? Tracking Back History of individuals who develop schizophrenia Were there points of intervention?

  15. Premorbid and Prodromal Schizophrenia: How Do We Know? “Unaffected Family Members” 1st and 2nd Degree Relatives Do they manifest particular psychopathology?

  16. Diagnoses Among HR relatives of Schizophrenia (n=76) Attention Deficit Disorder 20 Oppositional Defiant Disorder 11 Depression 10 Conduct Disorder 7 Anxiety Disorders 6 Bipolar Disorder 4 Adjustment Disorder 2 Substance use disorder 2 No diagnosis 26 Total adds up to >76 because of comorbid disorders in some subject 5 patients developed a psychotic disorder ( not included above)

  17. Premorbid Premorbid Recovery Prodromal Transitional Psychotic Window of opportunity for Early recognition and Primary prevention?

  18. Premorbid Recovery Transitional Prodromal Psychotic Manifestations Cognitive decline Affective dysregulation Social withdrawal Educational decline Subthreshold positive & negative Symptoms

  19. New Findings: Stages & Dimensions of Illness Disorganization Positive Symptoms Negative Symptoms Functional lmpairment Mood Symptoms Cognitive Deficits Motor Symptoms Tandon et al., Schizophrenia Research 2009; 110: 1-23

  20. J. H Childhood: Attention problems Youngest child of a successful businessman. Not very attentive and somewhat shy in grade school, and according to parents, he was “too good” a kid compared to his sibs and peers- not drinking, taking drugs, running around with a rowdy crowd or sexually active.

  21. High school-Social withdrawal In high school, began withdrawing. He stopped making friends and kept to himself.  Losing all interest in athletic activities.  He did not date.  Spent hours in his room, strumming on his guitar and listening to music, especially the Beatles.   

  22. College: Educational decline Age 19-20 Drifts aimlessly through two years of college, playing his guitar, listening to music, and watching movies. Age 21 Drops out of college and goes to hollywood but fails to launch a musical career, returns to sporadically attend class and spends most of his time alone ( same movie dozens of times).  Parents are pleased however, now that he says he has a girlfriend, a budding actress who talks to him off and on and that he travels a lot Age 22 Moves back to live with parents

  23. Beginning symptoms: Mood Age 19 “anxiety attack” led him to see a doctor who tested him for dizziness.  All tests negative, but the doctor notes a strange “ flatness of affect” A “depressive reaction is diagnosed and an antidepressant is prescribed. Not continued. Age 20: Makes suicidal gesture and is further withdrawn. Taken to a psychiatrist for “depression” Psychiatrist says hospitalization unnecessary and does psychotherapy twice a week

  24. The Breaking point and Missed Opportunities Tells psychiatrist about his obsession With an actress dominating his mind but fails to reveal some “ really crazy thoughts” Writes to psychiatrist: “My mind is on the breaking point the whole time.  A relationship I had dreamed about went absolutely nowhere.  My disillusionment was complete”. Parents express increasing concern to their son about his absent occupational goals and frequent mysterious absences. Psychiatrist prescribes “Tough Love” regimen in which the parents were to get John out of the nest and leave him on his own no matter what. Age 22: Given by father $200 and asked to be on his own. Some days later.. Writes to “girlfriend” he was thinking of kidnapping her, highjack a plane and ask to be installed in the whitehouse. This is not mailed

  25. March 30 1981

  26. Course of Schizophrenia Good Function Psycho- pathology Stable Relapsing Premorbid Progression Poor 15 20 30 40 50 60 70 Age (Years)

  27. Pathophysiology of schizophrenia may involve a cascade of Sequential, cumulative events Early developmental derailment Genetic susceptibility Peri-adolescent brain dysmaturation Post-illness onset neurodeteriorationh Normal development The epigenetic landscape Premorbid deficits Prodrome” Environmental Factors Family environment Drugs of abuse Stress Psychosis functional decline Dopaminergic dysregulation Glutamatergic/ GABA abnormality Neurochemical Sensitization Oxidative stress Birth Adolescence Adulthood

  28. Attenuated positive syndrome Brief Intermittent psychosis Family history+ decline

  29. Prediction of Psychosis in Youth at High Clinical Risk OUTCOMES Risk of conversion 35% during f/u period 5 clinical features improved prediction: “genetic” risk for schizophrenia + deterioration, higher severity of unusual thought content, suspicion/paranoia, greater social impairment, history of substance abuse Controls Prodromal patients 1.00 0.75 0.50 0.25 0 Survival Distribution Function 0 200 400 600 800 1000 Days Since Baseline Assessment Cumulative survival distribution function modeling time to conversion to psychosis in 291 clinical high-risk (prodromal) patients and 134 demographically comparable normal control subjects (dashed line). Cannon TD, et al. Arch Gen Psychiatry. 2008;65:28-37.

  30. DSM-5 Revision PrinciplesClinical Utility, Validity, Reliability The DSM is above all a manual to be used by clinicians, and changes made for DSM-5 must be implementable in routine specialty practices. Recommendations should be guided by research evidence. Continuity with previous editions should be maintained when possible REDUCE USE of NOS SIMPLIFY REDUCE ARTIFICIAL COMORIBIDITY

  31. TANGO DANCE ICD DSM

  32. DSM-5 Current Timeline Sept. 2010-April 2011: Ongoing revisions to proposed DSM-5 diagnostic criteria, based on public comment and results from first phase of field trials July 2010-March 2011: DSM-5 Field Trials, Phase I June 2011-February 2012: DSM-5 Field Trials, Phase II July-August 2011: Revised draft diagnostic criteria posted on DSM5.org

  33. DSM-5 Current Timeline 2012: Prepare final draft text 2012: Revised draft criteria released to APA Assembly and Board of Trustees for final review 2012: Final revisions to draft criteria 2012: APA Assembly approval of DSM-5 2012: APA Board of Trustees approval of DSM-5 2013: Release of DSM-5 at the APA Annual Meeting in San Francisco, Ca

  34. Select Proposals Schizophrenia & Related Disorders Replace current subtypes with dimensions Include diagnosis of “ultra high-risk for psychosis” Modify criteria for Schizoaffective Disorder Delink catatonia from schizophrenia

  35. DSM-5 Risk Syndromes Psychosis Risk Syndrome to identify individuals who may be in early stages of major psychotic disorder Minor Neurocognitive Disorder to identify patients at risk for developing major neurocognitive disorder, such as dementia

  36. Should we introduce a “Psychosis Risk Syndrome” in DSM-V and ICD-11 • PROS • Will allow early targetting of illness to prevent deterioration and better outcomes • We have tools to better define such high-risk conditions • CONS • What about the negative consequences of false positive diagnoses

  37. Proposed APS Criteria • All six of the following: • Characteristic symptoms: at least one of the following in attenuated form, with intact reality testing but of sufficient severity and/or frequency that it is not discounted or ignored; • Delusions • Hallucinations • Disorganized speech • Frequency/Currency: symptoms meeting criterion A must be present in the past month and occur at an average frequency of at least once per week in the past month; • Progression: symptoms meeting criterion A must have begun in or significantly worsened in the past year; • Distress/Disability/Treatment Seeking: symptoms meeting criterion A are sufficiently distressing and disabling to the patient and/or parent/guardian to lead them to seek help; • Symptoms meeting criterion A are not better explained by any other DSM-5 diagnosis, including substance-related disorder; • Clinical criteria for any DSM-5 psychotic disorder have never been met.

  38. Ongoing Field Trials • University of Toronto • Michael Bagby, MD. • Comparisons: schizophrenia, schizoaffective, schizotypal, avoidant, OCPD • Academic diagnosticians • Actively enrolling APS as of March 2011 • University of Texas HSC at San Antonio • Mauricio Tohen, MD. • Comparisons: schizophrenia, bipolar, major depression, other • Academic diagnosticians • No APS enrolled yet as of March 2011

  39. Should we introduce a “Psychosis Risk Syndrome” in DSM-V and ICD-11 VIGOROUS DISCUSSION IS ONGOING

  40. The Example of Diabetes Mellitus Impaired Fasting Glucose as a high-risk condition for development of Diabetes Mellitus

  41. Monitoring of Impaired Glucose: WHEN Routine examinations More Frequent Screening if” Family History of Diabetes Mellitus Obesity OTHER RISK CONDITIONS

  42. IF Impaired Fasting GlucoseWhat to Do Education More frequent monitoring Treat comorbid conditions Reduce risk factors (eg., obesity) Increase protective factors (eg., exercise, diet)

  43. IF Impaired Fasting GlucoseWhat Not to Do Start insulin Start vigorous oral hypoglcemic treatment Give dismal prognosis

  44. Parallels with Attenuated Psychosis Syndrome

  45. Monitoring of Attenuated Psychosis Syndrome: When Routine examinations More Frequent Screening if” Family History of Schizophrenia Appearance of “soft psychotic symptoms” WITH DECLINE IN FUNCTION

  46. Attenuated Psychosis Syndrome: What to Do Education More frequent monitoring Treat comorbid conditions Depression, Anxiety Disorders Reduce risk factors Substance abuse, Family stress Increase protective factors Family environment, Structure, Social integration

  47. Attenuated Psychosis Syndrome: What Not to Do Start antipsychotic therapy Give dismal prognosis

  48. SUMMARY of PROs Symptomatic Functionally Impaired Cognitively Impaired Treatment Seeking Reliable and Valid No adequate DSM-IV alternative Similar to MCI Promotes treatment and prevention research Woods SW, et al. The case for including Attenuated Psychotic Symptoms Syndrome in DSM-5 as a psychosis risk syndrome. Schizophrenia Research 2010;123:199-207

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