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The Prodrome of Schizophrenia Professor Max Marshall.

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Presentation on theme: "The Prodrome of Schizophrenia Professor Max Marshall."— Presentation transcript:

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2 The Prodrome of Schizophrenia Professor Max Marshall

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

4 1.1 years first positive symptom first (negative or nonspecific) sign of mental disorder 5.0 years average duration maximum of positive symptoms first hospitalisation positive symptoms 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 Prephases of schizophrenia from first sign of mental disorder to first admission Results of the Mannheim ABC-study of 232 first admissions prodromal phase psychoti c prephase 6.3 years AB C Schizophrenia Study 2 months first social deficit 1.1 years first positive symptom first (negative or nonspecific) sign of mental disorder 5.0 years average duration maximum of positive symptoms first hospitalisation positive symptoms 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 Prephases of schizophrenia from first sign of mental disorder to first admission Results of the Mannheim ABC-study of 232 first admissions prodromal phase psychoti c prephase 6.3 years AB C Schizophrenia Study 2 months

5 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

6 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

7 months before first admission Self-care51 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 60 Sexual role behaviour 61 Work relationships 62 Interest in work place 63 General responsibility / interest 64 Dysfunctional general behaviour Dysfunctional behaviour in social / occupational roles AB C Schizophrenia Study 1 st positive symptom Onset of Social Disabilities (from IRAOS scale)

8 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

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

10 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.

11 Soft Neurological Signs

12 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)

13 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

14 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)

15 Thought Perseveration

16 HOUSE Disturbance of Receptive Language

17 Unstable Ideas of Reference

18 Acoustic Perception Disturbances

19 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 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 ROC curves of ten best symptoms in a model validation sample (n=80 / 80) CECERRCECERRR CECERRCECERRR Schizophren ia Project Diagnostic accuracy in model development sample area under the curve = (se=0.045; 95% CI: ) Diagnostic accuracy in model validation sample area under the curve = (se=0.047; 95% CI: ) Diagnostic accuracy in model development sample area under the curve = (se=0.045; 95% CI: ) Diagnostic accuracy in model validation sample area under the curve = (se=0.047; 95% CI: )

20 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

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

22 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

23 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

24 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

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

26 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

27 Why bother?  Access  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

28 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

29 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

30 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

31 The End


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