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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

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How to Assess for Early Psychosis

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How to assess for early psychosis l.jpg

How to Assess for Early Psychosis

Rachel Loewy, PhD

UCSF Prodrome Assessment Research

and Treatment (PART) Program


What is early psychosis l.jpg

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


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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)


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Psychosis

Model of Progression from Prodrome to Psychosis

1-3 yrs

3-5 yrs

ChildhoodAdolescence Adulthood

No Sx

Non-specific Sx

noticed by patient

Sub-psychotic Sx

affects functioning

Psychotic

level Sx

Treatment

success


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Who is at ultra-high-riskfor psychosis?


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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


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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


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UHR Conversion Rates:NAPLS study (N=291)

Full

Psychosis

Months

Cannon, et al, 2008


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Structured Interview for

Prodromal Syndromes (SIPS)

  • 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.


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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.


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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)


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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


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Suspiciousness

  • Excessive suspiciousness,

    paranoid thinking

    Grandiosity

  • Unrealistic ideas of special

    identity or abilities


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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


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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


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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


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Disorganized Symptoms

  • Neglect of personal hygiene

  • Odd appearance or behavior

  • Laughing at odd or

    inappropriate times

  • Trouble with attention, clear thinking, comprehension


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Impairment in Functioning

  • Decline in functioning at school or work

  • Problems in relationships with friends or family


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Structured Interview for

Prodromal Syndromes (SIPS)

Positive Symptoms Scale:

0 Absent

1 Questionable

2 Subthreshold

3-5 Attenuated Range

6 Fully Psychotic


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Structured Interview for

Prodromal Syndromes (SIPS)

  • 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?”


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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.


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Case Examples


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