Assessment and treatment of individuals at high risk for psychosis

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

AIM

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

METHODS

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

RESULTS

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and modest harmonization for CHR-P criteria. The semi-structured interview, named Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

CONCLUSIONS

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Development of the PSYCHS: Positive SYmptoms and Diagnostic Criteria for the CAARMS Harmonized with the SIPS

Aim

To harmonize two ascertainment and severity rating instruments commonly used for the clinical high risk syndrome for psychosis (CHR-P): the Structured Interview for Psychosis-risk Syndromes (SIPS) and the Comprehensive Assessment of At-Risk Mental States (CAARMS).

Methods

The initial workshop is described in the companion report from Addington et al. After the workshop, lead experts for each instrument continued harmonizing attenuated positive symptoms and criteria for psychosis and CHR-P through an intensive series of joint videoconferences.

Results

Full harmonization was achieved for attenuated positive symptom ratings and psychosis criteria, and partial harmonization for CHR-P criteria. The semi-structured interview, named P ositive SY mptoms and Diagnostic Criteria for the C AARMS H armonized with the S IPS (PSYCHS), generates CHR-P criteria and severity scores for both CAARMS and SIPS.

Conclusion

Using the PSYCHS for CHR-P ascertainment, conversion determination, and attenuated positive symptom severity rating will help in comparing findings across studies and in meta-analyses.

Temporal trends in psychotic symptoms: Repeated cross-sectional surveys of the population in England 2000-14

BACKGROUND

The number of antipsychotic prescriptions dispensed annually in England has increased substantially over the past decade. It is not known whether this is due to changes in prescribing practices, or an increase in the prevalence of psychosis. To our knowledge, no previous studies have investigated temporal trends in prevalence of psychotic symptoms in non-clinical populations.

METHODS

We used data from the nationally representative Adult Psychiatric Morbidity Surveys 2000, 2007 and 2014 to (1) test whether the prevalence of psychotic symptoms increased between 2000 and 2014; (2) compare prevalence of psychotic symptoms to the prevalence of being prescribed antipsychotic medication; and (3) identify correlates of experiencing psychotic symptoms.

RESULTS

There was a small increase in the prevalence of psychotic symptoms in 2014 compared to 2000 (prevalence in 2000 5.6%, 95% confidence intervals (CI) 5.1% to 6.2%; prevalence in 2014 6.8%, 95% CI 6.1% - 7.6%). This corresponded to an adjusted odds ratio of 1.2 (95% CI 1.02-1.40, p=0.026) for experiencing psychotic symptoms in 2014 compared to 2007. By comparison, antipsychotic medication use doubled over this period (prevalence in 2000 0.6%, 95% CI 0.4%-0.7%; prevalence in 2014 1.2% 95% CI 0.9%-1.5%; aOR 2.22 (1.52-3.25) p<0.001). Correlates of reporting psychotic symptoms included ethnic minority identity, younger age, lower social class, alcohol and cannabis use, and any psychiatric diagnosis.

CONCLUSIONS

While the rates of antipsychotic prescription doubled between 2000 and 2014, the odds of having psychotic symptoms rose only slightly. The reasons for this warrant further investigation.

Defense mechanisms in adolescents at high risk of developing psychosis: an empirical investigation

Research within psychotherapy and psychopathology frameworks has been inspired by the central concept of defense mechanisms, which play a pivotal role in psychoanalysis. Defense specificities have only recently been studied systematically in the context of several clinical diagnoses. The present study aimed to explore the specificities of defense mechanisms in adolescents at ultra-high risk of developing psychosis and test the relationship between defensive functioning and attenuated psychotic symptoms. Twenty-six adolescent inpatients at ultra-high risk of developing psychosis and a matched clinical control group of inpatients not at risk of psychosis were interviewed. Two observer-rater methods, the Defense Mechanism Rating Scales and the Psychotic-Defense Mechanism Rating Scales were applied to interview transcripts to assess the individual use of defenses. Ultra-high-risk patients demonstrated lower defense mechanisms (i.e., total instances of defense mechanisms observed) and lower overall adaptiveness of the defenses presented. When specific differences between groups were observed, psychotic defenses were the sole defenses that could partially discriminate between ultra-high-risk and not at-risk patients. Regarding the relationship between defense mechanisms and subthreshold psychotic symptoms, psychotic defenses were associated with negative and disorganization symptoms, rather than with positive symptoms. The psychological vulnerability of ultra-high-risk patients is discussed and treatment implications for psychotherapy with such challenging patients are addressed.

Does Hippocampal Volume Predict Transition to Psychosis in a High-Risk Group? A Meta-Analysis

Schizophrenia has a prodromal phase of several years in most patients, making it possible to identify patients at clinical high risk (CHR) for developing the disorder. So far, these individuals are identified based on clinical criteria alone, and there is no reliable biomarker for predicting the transition to psychosis. It is well-established that reductions in brain volume, especially in the hippocampus, are associated with schizophrenia. Therefore, hippocampal volume may serve as a biomarker for psychosis. Several studies have already investigated hippocampal volume in CHR groups. Based on these studies, the present meta-analysis compares the baseline left and right hippocampal volume of CHR patients who developed a psychosis with that of CHR patients without such a transition. Our results show no statistically significant effect of the hippocampal volume on the transition risk for psychosis.

Four reasons why early detection centers for psychosis should be renamed and their treatment targets reconsidered: we should not catastrophize a future we can neither reliably predict nor change

Since the 1990s, facilities for individuals at putative risk for psychosis have mushroomed and within a very short time have become part of the standard psychiatric infrastructure in many countries. The idea of preventing a severe mental disorder before its exacerbation is laudable, and early data indeed strongly suggested that the sooner the intervention, the better the outcome. In this paper, the authors provide four reasons why they think that early detection or prodromal facilities should be renamed and their treatment targets reconsidered. First, the association between the duration of untreated psychosis and outcome is empirically established but has become increasingly weak over the years. Moreover, its applicability to those who are considered at risk remains elusive. Second, instruments designed to identify future psychosis are prone to many biases that are not yet sufficiently controlled. None of these instruments allows an even remotely precise prognosis. Third, the rate of transition to psychosis in at-risk patients is likely lower than initially thought, and evidence for the success of early intervention in preventing future psychosis is promising but still equivocal. Perhaps most importantly, the treatment is not hope-oriented. Patients are more or less told that schizophrenia is looming over them, which may stigmatize individuals who will never, in fact, develop psychosis. In addition self-stigma has been associated with suicidality and depression. The authors recommend that treatment of help-seeking individuals with mental problems but no established diagnosis should be need-based, and the risk of psychosis should be de-emphasized as it is only one of many possible outcomes, including full remission. Prodromal clinics should not be abolished but should be renamed and restructured. Such clinics exist, but the transformation process needs to be facilitated.