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Prodromal symptoms of schizophrenia observe, detect or intervene?

Prodromal symptoms of schizophrenia observe, detect or intervene?. מקרה 9 מוצג על ידי: גלוריה אילייביץ ילנה בוגדונוב ספי קרוננברג צור מאיר ולדימיר קרישטול ויטלי קליובקין שקמה קלר הקורס האינטראקטיבי למתמחים בפסיכיאטריה דן קיסריה 5.2.2009. מנחים: ד"ר יובל בלוך, שלוותא

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Prodromal symptoms of schizophrenia observe, detect or intervene?

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  1. Prodromal symptoms of schizophrenia observe, detect or intervene? מקרה 9 מוצג על ידי: גלוריה אילייביץ ילנה בוגדונוב ספי קרוננברג צור מאיר ולדימיר קרישטול ויטלי קליובקין שקמה קלר הקורס האינטראקטיבי למתמחים בפסיכיאטריה דן קיסריה 5.2.2009 מנחים: ד"ר יובל בלוך, שלוותא ד"ר איתן נחשוני, גהה

  2. Case 9 • 16 year old adolescent male with new onset of unusual symptoms. • Family– older brother has schizophrenia. • Mental status– bizarre ideas, vague speech, slightly disorganized, concrete thinking, possible paranoid ideation… • Medically – Blood, urine and toxicology tests are all normal.

  3. Prodrome • Prodrome refers to the period characterized by a change from a person’s premorbid function. • May include: depression, anxiety, irritability, sleep disturbance, social withdrawal and deterioration. • Three problems emerge: • A retrospective diagnosis • Not specific – MDD, bipolar, PTSD, developmental • Controversy surrounding validity

  4. UHR concept – an attempt to create a validated prognostic tool. • UHR criteria Age: 14 to 25, and one of the following: • Attenuated positive psychotic symptoms. • Brief limited intermittent psychotic symptoms (BLIPS) – frank psychotic symptoms not lasting more than a week. • Trait and state risk factor group– schizotypal; first-degree relative; significant decrease in functioning.

  5. Prediction of Psychosis in Youth at High Clinical Risk • Prospective, multicenter, longitudinal • N = 291 subjects with prodromal symptoms. • Follow up period –2.5y • Results: 35% conversion to psychosis, which dramatically increases with ≥2 risk factors (68% - 80%). • 5 Risk factors: genetics, thought content, suspicion/paranoia, social impairment, substance abuse. • Conclusions: prospective assessment of a “prodromal syndrome” is feasible and amenable to preventive intervention programs. Cannon et al. Arch Gen Psychiatry, 2008

  6. To prevent the continuous deterioration. Prevalence reduction. Facilitating normal development. Treating false-positive subjects. Stigma. Exposure to long-term side-effects. To Treat Or Not To Treat • Ethics; where are the limits?

  7. Psychosocial • Case management and psychoeducation. • Supportive therapy. • CBT and stress management. • Family-based treatment. • Combined psychosocial treatment.

  8. Psychopharmacology • Antipsychotics: • Risperidone + CBT vs. controls (supportive therapy) for 6 months. 35% of controls and 10% of treatment group developed psychosis. McGorry et al, Arch Gen Psychiatry, 2002; • RCT comparing olanzapine and placebo. After a year 38% of placebo developed psychosis vs. 16% in the treatment group. Yung et al MJA, 2007; • SSRIs:SSRIs vs atypical antipsychotics- naturalistic study. 25% developed a psychotic disorder all belonging to the antipsychotic group !!? Cornblat et al J Clin Psychiatry, 2007 • Others: D-serine, Sarcosine, Omega-3.

  9. Bottom line • 16 year old. • Family – older brother has schizophrenia. UHR! • Status – bizarre ideas, vague speech, slightly disorganized, concrete thinking, possible paranoid ideation…UHR! • Very high likelihood of development of schizophrenia. Definite need for continued observation; most probable need for intervention.

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