How to Assess for Early Psychosis

1. How to Assess for Early Psychosis Rachel Loewy, PhD UCSF Prodrome Assessment Research and Treatment (PART) Program

2. 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

4. 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)

5. Psychosis Model of Progression from Prodrome to Psychosis 1-3 yrs 3-5 yrs Childhood Adolescence Adulthood No Sx Non-specific Sx noticed by patient Sub-psychotic Sx affects functioning Psychotic level Sx Treatment success

6. Who is at ultra-high-riskfor psychosis?

7. 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

8. 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

9. UHR Conversion Rates:NAPLS study (N=291) Full Psychosis Months Cannon, et al, 2008

10. 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.

11. 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.

12. 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)

13. 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

14. Suspiciousness • Excessive suspiciousness, paranoid thinking Grandiosity • Unrealistic ideas of special identity or abilities

15. 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

16. 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

17. 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

18. Disorganized Symptoms • Neglect of personal hygiene • Odd appearance or behavior • Laughing at odd or inappropriate times • Trouble with attention, clear thinking, comprehension

19. Impairment in Functioning • Decline in functioning at school or work • Problems in relationships with friends or family

20. Structured Interview for Prodromal Syndromes (SIPS) Positive Symptoms Scale: 0 Absent 1 Questionable 2 Subthreshold 3-5 Attenuated Range 6 Fully Psychotic

21. 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?”

22. 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.

23. Case Examples