How to Assess for Early Psychosis

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How to Assess for Early Psychosis

• Rachel Loewy, PhD
• UCSF Prodrome Assessment Research
• and Treatment (PART) Program

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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

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What do we mean by Prodromal?

• Websters 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)

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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
Treatment success
Psychotic level Sx
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Who is at ultra-high-riskfor psychosis?
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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

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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

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UHR Conversion RatesNAPLS study (N291)
Full Psychosis
Months
Cannon, et al, 2008
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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.

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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.

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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)

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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

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

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Perceptual Disturbances

• Increased sensitivity to light and
• sound
• Hearing things that other
• people dont hear
• Seeing things that others dont see
• Smelling, tasting, or feeling unusual sensations
  that other people dont experience

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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

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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

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Disorganized Symptoms

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

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Impairment in Functioning

• Decline in functioning at school or work
• Problems in relationships with friends or family

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Structured Interview for Prodromal Syndromes
(SIPS)

Positive Symptoms Scale 0 Absent 1
Questionable 2 Subthreshold 3-5 Attenuated
Range 6 Fully Psychotic
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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?

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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.

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Case Examples