The Prodrome of Schizophrenia

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 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 6.3 years 6.3 years 2 months 2 months psychotic prephase psychotic prephase prodromal phase prodromal phase A A B B Schizophrenia Schizophrenia 1.1 years 1.1 years 5.0 years 5.0 years average duration average duration C C Study Study positive symptoms positive symptoms negative and unspecific symptoms negative and unspecific symptoms first social deficit first hospitalisation first hospitalisation first (negative or nonspecific) sign of mental disorder first (negative or nonspecific) sign of mental disorder first positive symptom first positive symptom maximum of positive symptoms maximum of positive symptoms

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. 51 Self-care 52 Leisure activity 53 Speed of coping with daily activities Dysfunctional general behaviour 54 Communication/social withdrawal 55 Lack of consideration and friction 56 Behaviour in emergencies A B Schizophrenia C Study 57 Participation in family life 58 Marriage or equiv. - emotional 59 Marriage or equiv. - sexual Dysfunctional behaviour in social / occupational roles 60 Parental role 61 Sexual role behaviour 62 Work relationships 63 Interest in work place 64 General responsibility / interest 30 20 10 months before first admission 60 50 40 0 1st positive symptom Onset of Social Disabilities (from IRAOS scale)

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. HOUSE Disturbance of Receptive Language

16. Unstable Ideas of Reference

17. Acoustic Perception Disturbances

18. sensitivity 1.0 Hypothetical curve foran optimal diagnostic test with an area under the curve of 1.0 Hypothetical curve fora completely undifferentiating test with an area under the curve of 0.5 0.8 0.6 0.4 Diagnostic accuracy in model development sample area underthe curve =0.852 (se=0.045; 95% CI: 0.76-0.94) Diagnostic accuracy in model validation sample area under the curve = 0.836 (se=0.047; 95% CI: 0.74-0.93) 0.2 0.0 Schizophrenia Project CE R 0.0 0.2 0.4 0.6 0.8 1.0 1-specificity ROC curves of ten best symptoms in a model validation sample (n=80 / 80)

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

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 • 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