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The Prodrome of Schizophrenia

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Presentation on theme: "The Prodrome of Schizophrenia"— Presentation transcript:

1 The Prodrome of Schizophrenia
Professor Max Marshall

2 Overview What is the prodrome? How can it be detected?
What do we do in the LEAD clinic? Development of LEAD clinics

3 Prephases of schizophrenia
1.1 years first positive symptom (negative or nonspecific) sign of mental disorder 5.0 years average duration maximum of symptoms hospitalisation negative and unspecific symptoms Prephases of schizophrenia from first sign of mental disorder to first admission Results of the Mannheim ABC-study of 232 first admissions prodromal phase psychotic prephase 6.3 years A B C Schizophrenia Study 2 months 1.1 years first positive symptom (negative or nonspecific) sign of mental disorder 5.0 years average duration maximum of symptoms hospitalisation negative and unspecific symptoms Prephases of schizophrenia from first sign of mental disorder to first admission Results of the Mannheim ABC-study of 232 first admissions prodromal phase psychotic prephase 6.3 years A B C Schizophrenia Study 2 months first social deficit

4 Prodromal Symptoms Two phases in emergence: Pre-psychotic
Non- specific: dep/anx/restless/conc/worry/self conf/energy Specific: basic symptoms Sub-psychotic BLIPS and Attenuated Symptoms

5 Social Deterioration Social Deterioration is a key aspect of the prodrome If there is no social deterioration it is questionable whether the prodrome is present “Decay” not “drift” - social deterioration follows symptoms

6 Onset of Social Disabilities (from IRAOS scale)
10 20 30 40 50 60 months before first admission Self-care 51 Leisure activity 52 Speed of coping with daily activities 53 Communication/social withdrawal 54 Lack of consideration and friction 55 Behaviour in emergencies 56 Participation in family life 57 Marriage or equiv. - emotional 58 Marriage or equiv. - sexual 59 Parental role Sexual role behaviour 61 Work relationships 62 Interest in work place 63 General responsibility / interest 64 Dysfunctional general behaviour behaviour in social / occupational roles 1st positive symptom A B C Schizophrenia Study

7 How do we detect it? State-Trait Approaches
i.e.: Risk factors plus deterioration Specific non-psychotic symptoms Basic symptoms Sub-psychotic symptoms Brief limited psychotic symptoms Attenuated psychotic symptoms

8 STATE-TRAIT APPROACHES
Genetic loading Soft signs Schizotypy PLUS Social deterioration

9 Soft Neurological Signs
Neurological soft signs (NSS) are minor neurological signs indicating non-specific cerebral dysfunction. Patients with first-episode psychosis show an excess of NSS, particularly in motor coordination and sequencing, sensory integration and in developmental reflexes.

10 Soft Neurological Signs

11 Schizotypy DSM IV Axis II disorder Present in 1-3% of population
Associated increased rate schizophrenia (20-40%) Present in families of people with psychosis Some traits analogous to psychotic symps Assessed by SPQ (Raine)

12 Elements of Schizotypy
Cognitive Perceptual magical thinking, unusual perceptual experiences, ideas of reference, paranoid ideation Interpersonal no close friends, constricted affect, undue social anxiety Disorganised odd/eccentric behaviour, odd speech

13 Basic Symptoms (Huber)
Subtle, sub-clinical, subjective disturbances in: drive, stress tolerance, affect, thinking, speech, perception & motor actions Phenomenologically distinct from psychotic symptoms An early expression of somatic disturbance underlying development of psychosis Measured using: SPI-A (Schizophrenia Proneness Instrument – Adult version)

14 Thought Perseveration

15 Disturbance of Receptive Language
HOUSE

16 Unstable Ideas of Reference

17 Acoustic Perception Disturbances

18 ROC curves of ten best symptoms in a model validation sample (n=80 / 80)
1.0 0.8 0.6 0.4 0.2 0.0 sensitivity 1-specificity Hypothetical curve for an optimal diagnostic test with an area under the curve of 1.0 Hypothetical curve for a completely undifferentiating test with an area under the curve of 0.5 Diagnostic accuracy in model development sample area under the curve = 0.852 (se=0.045; 95% CI: ) model validation sample area under the curve = 0.836 (se=0.047; 95% CI: ) CE R Schizophrenia Project

19 At Risk Mental States Alison Yung & Pat McGorry
Comprehensive Assessment of At Risk Mental States (CAARMS) SIPS/SOPS Brief Limited Intermittent Psychotic Symptoms (BLIPS) Of psychotic intensity but limited duration Attenuated Psychotic Symptoms Of sub-psychotic intensity

20 Development of psychosis
time uncharacteristic prodromal symptoms with little diagnostic accuracy onset attenuated psychotic symptoms psychotic pre-phase transient psychotic symptoms initial prodrome rather persisting psychotic symptoms First psychotic episode climax Detection and Intervention Detection and Intervention characteristic prodromal symptoms with good diagnostic accuracy

21 Effectiveness of Early Detection
State-Trait Approaches Not all patients have them; if no deterioration does not predict immediate risk ARMS Short range prediction only – already almost psychotic SPI-A – long range Promising, but no gold standard study No formal synthesis of diagnostic studies

22 The LEAD Clinic Mike Fitzsimmons, Kishen Neelan, Caroline Johnson, myself Running for 18 ms, Daisyfield CMHT Assess service users who are not psychotic but might have prodromal symptoms

23 Purpose of the clinic To see if it was feasible
To assess demand and service user and carer’s reactions To train ourselves and refine our assessments To understand how it might contribute to the EIS

24 The LEAD Assessment Genetic Risk Schizotypy (SPQ)
Deterioration (Cornblatt scales) Soft Signs (Neurological Rating Scale) Basic Symptoms (SPI-A) Attenuated/BLIPS (CAARMS)

25 Findings so far So far seen 34 service users
About half are clearly prodromal, though to different degrees of risk Although the assessments takes 3 hours no one has yet failed to complete it

26 Why bother? Access Safety Resource Management
We need a quick process for identifying people in the prodrome Safety We have to show that decisions not to accept have a sound/defensible basis Resource Management We need to match the level of input to the level of risk We need to be able to discharge

27 Why have a clinic? Efficiency
More than one person is required The assessments are difficult and highly structured Supervision and quality control is essential Accuracy Requires a quiet and controlled ambience Training and development Easier to bring in new or techniques

28 How could we make it better?
Should embed clinics in the service We should extend the clinic to assess all non-psychotic service users Should do follow up at one year and discharge if improved Should have a stepped care model so only highest risk are taken on by service Should extend remit to assess all complex cases

29 Working group Set up a LEAD clinic working group
Warren, Jeff, Faith, Alison, Mike, Imran Agreed to roll out LEAD clinics across EIS Developing an operational policy Training program IT support Service Evaluation Examining Admin Support

30 The End


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