How to Assess for Early Psychosis

Rachel Loewy, PhD

UCSF Prodrome Assessment Research and Treatment (PART) Program

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

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)

Model of Progression from Prodrome to Psychosis

Childhood Adolescence Adulthood

3-5 yrs

1-3 yrs

Psychosis

No Sx Non-specific Sxnoticed by patient

Sub-psychotic Sxaffects functioning

Treatmentsuccess

Psychotic level Sx

Who is at ultra-high-riskfor psychosis?

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

Prodromal period of thought disorders

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

UHR Conversion Rates:NAPLS study (N=291)

0%

10%

20%

30%

40%

50%

6 12 18 24 30

Months

FullPsychosi

s

Cannon, et al, 2008

1) 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.

Structured Interview for Structured Interview for Prodromal Syndromes (SIPS)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.

Structured Interview for Structured Interview for Prodromal Syndromes (SIPS)Prodromal Syndromes (SIPS)

Structured Interview for Structured Interview for Prodromal Syndromes (SIPS)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)

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

Suspiciousness

• Excessive suspiciousness,

paranoid thinking

Grandiosity

• Unrealistic ideas of special

identity or abilities

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

• Difficulty getting the point across; trouble directing sentences towards a goal

• Rambling, going off track during

conversations

• Incorrect words, irrelevant topics

• Odd speech

Disorganized Communication

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

Disorganized Symptoms

• Neglect of personal hygiene

• Odd appearance or behavior

• Laughing at odd or

inappropriate times

• Trouble with attention, clear thinking, comprehension

Impairment in Functioning

• Decline in functioning at school or work

• Problems in relationships with friends or family

Structured Interview for Structured Interview for Prodromal Syndromes (SIPS)Prodromal Syndromes (SIPS)

Positive Symptoms Scale:

0 Absent1 Questionable2 Subthreshold3-5 Attenuated Range6 Fully Psychotic

Structured Interview for Structured Interview for Prodromal Syndromes (SIPS)Prodromal Syndromes (SIPS)

1. 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?”

Structured Interview for Structured Interview for Prodromal Syndromes (SIPS)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.

Case ExamplesCase Examples