Childhood onset diagnoses in a case series of teens at clinical high risk for psychosis

Clinical psychopathology in youth at familial high risk for psychosis

AIM

While the course of psychopathology has been explored from an index mental health diagnosis onwards, there are few detailed, prospective studies of the occurrence of clinical psychopathology in youth with familial risk for severe mental illnesses such as psychosis. We sought to describe the appearance of Axis I psychopathology in a unique sample of adolescents with a family history of schizophrenia (FHR).

METHODS

One hundred and sixty two first- and second-degree relatives (mean age 15.7 ± 3.6; range 8-25) of probands with schizophrenia or schizoaffective disorder were assessed at baseline and annual intervals for up to 3 years, focusing on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) Axis I psychopathology.

RESULTS

Fourteen individuals (8.6%) developed a psychotic disorder. One hundred and five subjects (65%) met criteria for an Axis I disorder over the course of the study, the most common of which was a depressive episode (40 subjects; 25%). Of the 148 individuals who did not develop psychosis, 91 (61%) had one or more Axis I disorders compared with 10/14 converters who had a comorbid Axis I disorder (71%). Ordered by increasing age of onset, diagnoses included cognitive and externalizing disorders, anxiety disorders, affective disorders, substance use disorders and psychotic disorders.

CONCLUSIONS

In addition to an elevated risk of psychosis, young FHR relatives manifest a broad range of non-psychotic Axis I psychopathology in childhood and adolescence. This breadth of diagnoses has implications for the structure and function of mental health services for young people.

Motor Dysfunction as a Risk Factor for Conversion to Psychosis Independent of Medication Use in a Psychosis-Risk Cohort

The Structured Interview for Psychosis-Risk Syndromes (SIPS) contains criteria for the Attenuated Positive Symptom Syndrome (APSS), a period of subthreshold positive symptoms that predates full-blown psychosis. Motor abnormalities are often associated with these symptoms but have not been adequately studied. We assessed a diverse sample of 192 APSS participants (27.1% female; 47.9% white; mean age = 20.03 years) for motor dysfunction (SIPS G.3. score) at baseline and conversion to psychosis every 3 months for up to 2 years. Fifty-nine (30.7%) participants converted to psychosis. Baseline G.3. score was significantly higher among converters than nonconverters (mean difference = 0.66; t[95.929] = 2.579, p < 0.05). No significant differences in baseline G.3. were found between demographic groups or those with differential medication use. These results point to the use of G.3. as a potential predictor of psychosis among APSS individuals and potentially implicate the shared biological underpinnings of motor dysfunction in the APSS and full-blown psychotic illnesses.

Smell identification in individuals at clinical high risk for schizophrenia

Smell identification deficits exist in schizophrenia, and may be associated with its negative symptoms. Less is known about smell identification and its clinical correlates in individuals at clinical high risk (CHR) for schizophrenia and related psychotic disorders. We examined smell identification, symptoms and IQ in 71 clinical high-risk (CHR) subjects and 36 healthy controls. Smell identification was assessed using both the 40-item University of Pennsylvania Smell Identification Test (UPSIT; Doty, R.L., Shaman, P., Kimmelman, C.P., Dann, M.S., 1984. University of Pennsylvania Smell Identification Test: a rapid quantitative olfactory function test for the clinic. Laryngoscope 94, 176-178) and its extracted 12-item Brief Smell Identification Test (Goudsmit, N., Coleman, E., Seckinger, R.A., Wolitzky, R., Stanford, A.D., Corcoran, C., Goetz, R.R., Malaspina, D., 2003. A brief smell identification test discriminates between deficit and non-deficit schizophrenia. Psychiatry Research 120, 155-164). Smell identification did not significantly differ between CHR subjects and controls. Among CHR subjects, smell identification did not predict schizophrenia (N=19; 27%) within 2 years, nor was it associated with negative or positive symptoms. This is the third prospective cohort study to examine smell identification in CHR subjects, and overall, findings are inconclusive, similar to what is found for other disorders in adolescents, such as autism spectrum, attention deficit and anxiety disorders. Smell identification deficit may not have clear utility as a marker of emergent schizophrenia and related psychotic disorders.

A case report of cognitive behavioural therapy for social anxiety in an ultra-high risk patient

AIM

Psychological treatments such as cognitive behavioural therapy (CBT) may have efficacy in young people at ultra-high risk (UHR) for psychosis. Case reports can illuminate the obstacles and challenges, and potential trajectory of symptom changes, observed with this treatment.

METHODS

This is a detailed case report of a young adult at UHR for psychosis who received manualized CBT for accompanying social anxiety.

RESULTS

Cognitive deficits and suspiciousness created initial challenges for successful implementation of CBT. Engagement in treatment occurred with slowing of pace and simplification of material, and modelling of social interaction. Treatment of social anxiety was accompanied by decreases in suspiciousness, conceptual disorganization, and social anhedonia, and increase in range of affect.

CONCLUSIONS

Adaptation of manualized CBT to accommodate cognitive deficits and suspiciousness in UHR patients may improve engagement. CBT focused on social anxiety can lead to improvement across symptom domains in UHR patients.

The 'at-risk mental state' for psychosis in adolescents: clinical presentation, transition and remission

Despite increased efforts over the last decade to prospectively identify individuals at ultra-high risk of developing a psychotic illness, limited attention has been specifically directed towards adolescent populations (<18 years). In order to evaluate how those under 18 fulfilling the operationalised criteria for an At-Risk Mental State (ARMS) present and fare over time, we conducted an observational study. Participants (N = 30) generally reported a high degree of functional disability and frequent and distressing perceptual disturbance, mainly in the form of auditory hallucinations. Seventy percent (21/30) were found to fulfil the criteria for a co-morbid ICD-10 listed mental health disorder, with mood (affective; 13/30) disorders being most prevalent. Overall transition rates to psychosis were low at 24 months follow-up (2/28; 7.1 %) whilst many participants demonstrated a significant reduction in psychotic-like symptoms. The generalisation of these findings may be limited due to the small sample size and require replication in a larger sample.

Practitioner review: schizophrenia spectrum disorders and the at-risk mental state for psychosis in children and adolescents--evidence-based management approaches

BACKGROUND

Schizophrenia spectrum disorders are severe mental illnesses which often result in significant distress and disability. Attempts have been made to prospectively identify and treat young people viewed as at high risk of impending nonaffective psychosis. Once a schizophrenia spectrum disorder has developed, prompt identification and management is required.

METHODS

This article reviews the literature relating to the assessment and management of 'at-risk mental states' (ARMS) and the treatment of schizophrenia spectrum disorders in children and adolescents. A systematic search of the literature was undertaken using EMBASE, MEDLINE, PsycINFO databases for the period January 1970-December 2012.

RESULTS

Evidence suggests that young people fulfilling the ARMS criteria are at high risk of adverse mental health outcomes but that the majority do not develop nonaffective psychosis over the medium term. Although clinical trial findings have been inconsistent, psychosocial approaches, such as cognitive behaviour therapy, may reduce the risk of transition to psychosis and improve some symptoms, at least over the short term. The effectiveness of psychotropic medication for the ARMS is uncertain although there is accumulating evidence for potential adverse effects of antipsychotic medication, even at low dose, in this population. For the schizophrenias, clinical trial findings suggest that, as in adults, antipsychotics should be selected on the basis of side-effect profile although clozapine may be helpful in treatment refractory illness. There are almost no studies of psychosocial treatments for schizophrenia in young people under 18, and some caution must be exercised when extrapolating the findings of adult studies to younger individuals.

CONCLUSIONS

A stepped care approach to the ARMS in young people represents a plausible potential management approach for those at high risk of serious mental health problems. However, predictive models currently lack precision and should focus on accurately identifying those at high risk for a variety of poor outcomes who may benefit most from intervention. There is also an urgent need for age-specific research in the area of psychosocial treatments for children and adolescents with schizophrenia.

Public stigma associated with psychosis risk syndrome in a college population: implications for peer intervention

OBJECTIVES

This study compared stigma associated with the psychosis risk label and diagnostic labels for nonpsychotic and psychotic mental disorders among young adult peers.

METHODS

Urban college respondents (N=153) read an experimental vignette describing a young adult experiencing prodromal symptoms who was randomly assigned a diagnostic label (major depression, generalized anxiety disorder, schizophrenia, or psychosis risk with and without accurate information about the psychosis risk label) and answered questions about stigma toward the individual in the vignette.

RESULTS

Compared with labels for nonpsychotic disorders, schizophrenia elicited more negative stereotyping and the at-risk label invoked greater social distance and less willingness to help. Any increased social distance appeared to be reduced by accurate information about the at-risk state. No differences in stigma were found for the psychosis risk and schizophrenia labels.

CONCLUSIONS

The psychosis risk label alone appeared to evoke greater status loss and discrimination. Accurate information may minimize some stigmatizing attitudes among college peers.

Evaluation and treatment of children and adolescents with psychotic symptoms

In recent years, there have been increasing efforts to develop early detection and prevention strategies for patients at risk of the development of psychotic disorders. These efforts have led to improved recognition and characterization of psychotic symptoms in youth. This review focuses on the evaluation of children and adolescents with psychotic symptoms who are experiencing functional impairment but who do not meet current criteria for schizophrenia. For this article, emphasis is placed on the evaluation of symptoms, differential diagnosis, and consideration of potential interventions.

Adolescent attention deficit hyperactivity disorder and susceptibility to psychosis in adulthood: a review of the literature and a phenomenological case report

AIM

In contrast to affective disorders, some forms of personality disorders and drug addiction, schizophrenia is commonly not considered to be a sequela of attention deficit hyperactivity disorder. However, attention deficit hyperactivity disorder and the prodromal stages of schizophrenia spectrum disorders do exhibit a number of common central features. To facilitate the early treatment of schizophrenic symptoms, the detection of discrete and subtle alterations in the prodromal stages of incipient psychoses is particularly important.

METHODS

We review the literature on the prodromal symptoms of psychosis and present a case report, in which a phenomenological approach was used to identify subtle alterations linked to anomalous self-experience.

RESULTS

Using the Examination of Anomalous Self-Experience symptom checklist, the case report presented here reveals attention deficit hyperactivity disorder symptoms in adolescence as a precursor state of psychosis in adulthood.

CONCLUSIONS

The characteristics of this schizophrenia spectrum disorder case and its time course are derived from the specific distribution pattern of Examination of Anomalous Self-Experience items. When treating adolescent attention deficit hyperactivity disorder patients, the rare possibility of the development of schizophrenia spectrum disorder from attention deficit hyperactivity disorder like symptoms should be kept in mind.