Validating the Dsmiiir Prodromal Symptoms

Listed in the DSM-IIIR were nine prodromal symptoms of schizophrenia, generated by consensus and not empirically 167 social isolation or withdrawal marked impairment in role functioning markedly peculiar behaviour marked impairment in personal hygiene blunted, flat or inappropriate affect dissociative or metaphoric speech odd or bizarre ideation unusal perceptional experiences marked lack of initiative, interests or energy. The first attempt at cross-sectionally validating these prodromal signs...

Timing and Location of Assessment

Preliminary assessment will be required when a young person first presents with a suspected psychosis. The extent of the initial assessment will be influenced by factors such as the urgency of intervention (based on the severity of symptoms and safety issues) and the extent to which the person and family can be engaged. It might be impossible to safely and effectively assess people in an acute psychotic state until they have been adequately contained, perhaps in an emergency department or...

Homebased Treatment In Early Psychosis Choice of Treatment Setting

Patients should be cared for in the least restrictive setting that is likely to be safe and to allow for effective treatment 11 . It should not be assumed that every patient with a first episode of psychosis will require admission to hospital. Hospital admission is indicated for patients who are thought to pose a serious threat of harm to themselves or others, who are unable to care for themselves, or who have general medical or psychiatric problems that are not safely or effectively treated in...

Models of Inpatient Care

EPPIC has a 16-bed inpatient unit devoted to the treatment of young people with early psychosis. Such a unit is unusual, being one of a handful of such specialized facilities around the world. As with other components of the EPPIC model, the principles adopted within the unit are not unique and can be applied in other less specialized inpatient settings, including the treatment of patients with early psychosis as part of a general psychiatric service. This is generally facilitated by physically...

Favourable Hospital Environment

Attention to the hospital environment can make the period of hospitalization a more positive experience for patients. For example, flexible visiting times will encourage continued contact between the patient, family and friends. Personal comfort and respect for individual privacy should be encouraged, with an emphasis on small but important details such as diet, access to and safety of personal possessions, access to phones, and provision of accurate information about the expected length of...

Further Syndromes of the Prodromal Phase

Less frequent than depressive symptoms in the early course of schizophrenia are manic and hypomanic symptoms. In studies their frequencies range from 3 to 10 of cases depending on the symptoms defined. They are in part associated with other bipolar symptoms and primarily have episodic or intermittent courses 99 . The catatonic syndrome, which was fairly frequent before the advent of neuroleptics and still is in some developing countries, has become rare in Western Europe and the USA. Only...

Instruments Developed by the McGlashan Group

Researchers at the Prevention through Risk Identification, Management, and Education (PRIME) Research Clinic of Yale University developed the Structured Interview for Prodromal Syndromes (SIPS) 161 and, to assess the severity of prodromal symptoms, the Scale of Prodromal Symptoms (SOPS) 162 . The SIPS is a diagnostic interview, the SOPS an associated severity scale. The aim of these instruments is to help to exclude current or previous psychosis, to diagnose one of three types of prodromal...

Family Support and Intervention

It is essential to attend to the immediate needs of family and friends of young people with a first episode of psychosis. Many young people with early psychosis still live with their parents, and families are the main source of their care during the prodromal and early acute phases. Families require an accessible and flexible service, which acknowledges their role and contribution to care. A crisis intervention model can be used, based on education, to reduce carers' stress and confusion while...

Goals of Inpatient Care in Early Psychosis

Treatment in hospital aims to reduce the severity of psychotic symptoms, and promote the remission of psychosis through the use of thorough Table 2.16 Some goals of inpatient care in first-episode psychosis Provide comprehensive assessment. Provide effective treatment with the lowest possible doses of medication to minimize the side effects. Minimize the trauma of admission to a psychiatric unit. Instil hope and an expectation of recovery. Provide counselling and support to assist the patient...

Depression in the Early Illness Course as a Prognostic Indicator of the Later Course

We studied the further illness course and the predictive efficiency of prodromal symptoms in 115 first illness episodes from the representative subsample of 130 first admissions at six cross-sections over five years after first admission 114 . Patients with schizophrenia who suffered from depressive mood (> 14 days) in the early illness course were compared with age- and gender-matched patients without depressive episodes. The group with depression in the early course of schizophrenia showed...

Duration Of Untreated Illness And Untreated Psychosis As Indicators Of An Unfavourable Further Illness Course

In current clinical practice, the first treatment contact of persons falling ill with schizophrenia is preceded by incipient psychosis with a mean duration of about a year or more (DUP) and a prepsychotic prodromal phase with a mean of several years (duration of untreated illness, DUI duration of the prodrome+DUP) (see Table 1.1). DUP and, in rare studies, also DUI have been described as prognostic indicators of unfavourable aspects of course and outcome in schizophrenia. The following...

Antipsychoticfree Period

Ideally, assessment of a first episode of psychosis should be completed before any antipsychotic medications are administered. Whether managed at home or in hospital, an antipsychotic-free period of at least 24 hours allows clinicians to make repeated assessment of the evolving mental state, gather further clinical information and conduct some routine biological investigations. It also reduces the potential for premature and inappropriate diagnostic interventions or treatment. An...

Docherty et als Model

Another stage model designed with the aim of enabling early recognition was published by Docherty et al. in 1978 and has been entered especially in the Anglo-American canon of knowledge 22 . The introduction to this work reads like a statement from current research efforts to improve our understanding of the early course of schizophrenia There are many reasons for wanting to know more about the period of onset of schizophrenic psychosis. The dearest benefit is in the area of preventive...

Instruments For Assessing The Onset And Early Course Of Schizophrenia

The success of early intervention programmes depends on the degree to which help-seeking can be mobilized among at-risk persons in the population, for example by carrying out awareness programmes that provide basic information on schizophrenia and its treatment 74,140 . Antistigma and information campaigns play an important role, as successfully demonstrated by the WPA Global Programme Against Stigma and Discrimination Because of Schizophrenia 141 . Another precondition is a well-functioning...

The Sequence of Firstever Onset of Symptoms

Arranging the early symptoms by their time of emergence in a time matrix of up to 60 months before first admission, we found that four depressive symptoms (depressed mood, suicide attempt, loss of self-confidence and feelings of guilt) tended to occur five to three years before first admission. In the second time window, four to two years before first admission, with a clear overlap with the depressive syndrome, all the negative symptoms appeared. After a short interval characterized by the...

Age and Gender as Risk Factors

Age and level of social development are highly significantly correlated. Men fall ill with schizophrenia 3 to 4 years earlier and, in our population of origin, married 2.5 years later than women. Their level of social development at illness onset, in the social role of marriage in particular, was therefore considerably lower than that of women. In addition, young men with schizophrenia showed a significant excess of socially adverse behaviour at first admission, e.g. self-neglect, lack of...

Differential Diagnosis Childhoodonset Psychosis

The clinical picture of childhood-onset psychosis may include a tendency towards isolation and becoming reserved and withdrawn, but also soft neurological signs, delayed language development and attention deficit. These features, which might be characteristic of children who suffer from ADHD, do sometimes cause diagnostic confusion. They raise the question of whether a child who was diagnosed with ADHD and later with schizophrenia suffered from the outset from early signs of the latter...

Diagnostic Assessment

A thorough and extensive evaluation is necessary before diagnosing bipolar disorder in a child or adolescent. Such an evaluation requires a detailed history of both mood and non-mood symptoms and an appraisal of risk factors for bipolar disorder. A comprehensive face-to-face assessment of the child, including a mental status examination, is necessary to rule out pervasive developmental disorders, language and thought disorders, and psychotic symptoms. This assessment may take several hours to...

An Integrativedynamic Model Of The Difficult Child

Our understanding of the ''difficult'' child is based on our perception of three major components (a) the integration among personality components, (b) the interaction between the child and the environment and (c) the dynamic of these processes. The development of the ''difficult'' child is based on an organic nucleus that is in constant interaction with other characteristics of the person carrying it. In addition, and important to the same degree, is the interaction that develops between the...

Family Interaction Environment and Psychopathology

Studies provide strong evidence for family dysfunction in BN. More conflict expression without resolution and distant fathers have been found to distinguish families with a BN daughter from families of healthy controls and families with restricting AN daughters 59 . Kendler et al. 11 reported low levels of paternal care as well as parental substance abuse and parental depression associated with definite and probable cases of BN. In another analysis, Kendler et al. 53 reported that...

Pharmacological Treatment

Mania in children is not easily modified without medication. Unfortunately, there are very few treatment options that are evidence based. In general, current pharmaceutical treatment of children and adolescents with bipolar disorder is based on clinical trials in bipolar adults 79,80 . It is common clinical practice to have patients continue on medications for a period of time following remission. However, the optimal length of maintenance treatment remains unclear, and available guidelines are...

Neurobiological Aspects

The longitudinal study of a high-risk population such as bipolar offspring may help to reveal possible markers of disease which distinguish subjects who will eventually develop bipolar disorder (or other psychopathologies) from subjects who will not. Even though it may be difficult to ascertain whether these markers predispose to the disorder, or if they are the first signs of the disorder, the identification of these markers could allow earlier diagnoses and timely interventions 1 ....

Management Of Bipolar Disorder In The Youth

Management of bipolar disorder is complicated and needs to be individually tailored to the needs of the individual child and family. A treatment plan should take into account the fact that the child's symptoms will vary with developmental and environmental changes. Also, symptoms may vary due to the fluctuating nature of the disorder. Therefore, successful treatment plans for bipolarity in children require flexibility and openness by the treating clinician. Conceptualizing the child's treatment...

Can Substance Misuse Trigger a Premature Onset of the Prepsychotic Prodromal Stage

In the ABC Schizophrenia Study, the lifetime prevalence of alcohol abuse until age at first admission was 24 for the first-episode sample and 12 for matched controls from the same population 119,136,137 , and that of drug abuse 14 for patients and 7 for controls. Studies on the topic almost invariably show a preponderance of men in substance abuse. We found a cumulative prevalence (until first admission) of any type of substance abuse of 39 for men and 22 for women. Cannabis was the most...

Posttraumatic Stress Disorder

By definition, post-traumatic stress disorder (PTSD) occurs in the aftermath of a traumatic event. The characteristic symptoms of the disorder can be divided into intrusive symptoms, avoidance and numbness symptoms, and hyperarousal symptoms. Although initially conceptualized as a normal reaction to an abnormal event, PTSD is increasingly understood as a medical disorder characterized by underlying psychobiological dysfunction 36 . After a traumatic event a range of symptoms is normative in the...

Clinical Picture

The three components that constitute the basis for the diagnosis of ADHD, both at school age and earlier, are inattention, impulsiveness and hyper-activity. Nevertheless, levels of activity and attention in infancy are totally different from those at the kindergarten or school stage. In most cases, a suspicion of ADHD is not raised before the age of 2 years. When a 1-year-old baby is very active, does not sleep very much during the day, wakes up frequently at night, does not have regular...

Predictors Of Psychopathology

The majority of bipolar offspring will not develop bipolar disorder. It is therefore crucial to detect, from an early age, predictors of bipolar development in this high-risk population 1 . Early detection of a prodromal state may allow timely and specific interventions and prevention of a poorer outcome. Research on prodromal signs in this population did not give definite results. Carlson and Weintraub 19 found that attentional and behavioural problems during childhood were not more frequent...

Differential Diagnoses of ADHD in Early Childhood

ADHD in early childhood presents a slightly different and unique differential diagnosis. The conditions to be considered are the following 1. A deviation from the norm (difficult temperament), involving difficulty in regulation, much crying, difficulty in calming down, hyperactivity, etc. 2. Children who have been given no clear limits. 3. Behavioural disorder or rebellious opposition disorder. Rarer at these ages, although they exist. 4. Deviations in IQ (talented retarded). 5. Spasms of petit...

Temperament And Bipolar Vulnerability

Temperamental features can be predictors of later psychopathology 72,73 , and a difficult temperament (irregular biological rhythms, irritability, inflexibility) has been suggested to be a premorbid feature in children with bipolar disorder 74,75 . One of the authors of this chapter 76,77 described three temperamental profiles potentially predisposing to adolescent or adult-onset bipolar disorder the hyperthymic, cyclothymic and irritable types. These are characterized by excesses along the...

Prodromes Of Anorexia Nervosa Significant Weight Loss

Significant weight loss is acknowledged by patients as a critical prodromal risk factor. Patients report the appearance of the anorectic attitude around a weight loss of 15 of their previous weight 42 . A specified amount of weight loss is also a symptom of AN. The loss of weight during the prodromal phase may be induced by dieting but this is not necessarily the case. Other causes of weight loss may be fasting practices 43 , or the loss of weight might be the consequence of a physical illness...

Conrads Model

The first stage model of the early course of schizophrenia was proposed by the Marburg-based psychiatrist Conrad 21 , who studied 107 German soldiers admitted to a military hospital because of a mostly acute schizophrenic psychosis during World War II. On the basis of the symptoms and complaints reported by the patients, Conrad developed four - and a rarer fifth - stages of evolving and two stages of remitting schizophrenia. Stage 1, called trema, could last for several years. Conrad described...

Depressive Symptoms as Prodromal Signs of Schizophrenia

Several first-episode studies have consistently reported an extremely high frequency of depressive symptoms in the first psychotic episode depressive mood or at least two depressive symptoms were found in 70-75 of cases 56,57,113-115 . As shown above, depressive symptoms frequently appear long before the first positive symptom 16,114,116 . In the ABC study cohort, the lifetime prevalence of depressive mood of a duration of two or more weeks -assessed until first admission - was 81 . In 39 of...

Comparison of Prodromal Symptoms in Schizophrenia and Depression

We compared a representative subsample of 130 first admissions for schizophrenia from the ABC study with 130 age- and sex-matched ''healthy'' controls from the general population and 130 first admissions because of a depressive episode. Of the latter group, 70 suffered from a severe depressive episode. All these samples went through IRAOS interviews. Preliminary results show that DUI was significantly longer in depression (7.2 years) than in schizophrenia (5.3 years) (p< 0.05). Equal...

Differences Between Adult Adolescent And Childonset Bipolar Disorder

The DSM-IV criteria for mania were developed from data on adults with bipolar disorder and do not consider the differences between bipolar adults and bipolar children and adolescents. Paediatric bipolar disorder has been described as atypical when compared to adult bipolar disorder. The similarities in the clinical presentation of adults with mixed states and preadolescents diagnosed with mania have been noticed. Several authors have drawn a comparison between the ''virulent'' form of the...

Followup Studies

Prospective follow-up studies are rare in the literature on juvenile bi-polarity. One of the major problems in detecting bipolar disorder in children is the extent to which depressive states, temperamental moodiness, ''atypical'' mood swings with explosive moods and behaviour, and or ultra-rapid cycling represent variants and or precursors of clinically more recognizable bipolar disorder. This question cannot be resolved by cross-sectional observation. A family history of bipolar disorder may...

Age at Menarche

Menarche occurred at an earlier age in subjects with bulimia compared to psychiatric control subjects 51 . The earlier age at menarche may not be an independent factor, but very likely is weight related. Frisch and McArthur have reported that the amount of body fat is related to onset of menarche 58 . Because BN subjects have higher rates of childhood obesity, they would be expected to experience menarche at an earlier age. A tendency towards overweight and earlier exposure to the bodily...

Treatment Implications

Early detection of prodromal symptoms or signs in high-risk populations offers a window of opportunity for preventive and therapeutic interventions (psychotherapy as well as pharmacotherapy), and allows avoidance of treatments (antidepressants, stimulants) which may worsen the clinical course of the disorder 37 . Psychoeducational as well as psychotherapeutic interventions on children and their parents (either affected or not) can help them to manage life experiences or family stressors. On the...

Does a Shortened DUP Lead to a More Favourable Illness Course and Better Outcome

This important question stems from a hope of reducing the adverse consequences of the disorder by shortening the untreated early illness period. But objections have been raised against the implied causal association ''is the link due to a common underlying factor, such as a more severe form of the illness with functional impairment after an insidious onset, more negative symptoms, more paranoid ideation '' 74 . At any rate, it has been known since Kraepelin's days that an insidious onset with a...

Pervasive Developmental Disorders PDD

The differentiation between pervasive developmental disorders (PDD) and ADHD may appear obvious. However, many children who have these disorders in various degrees of severity also exhibit symptoms of ADHD and even respond well to psychostimulants. This is especially true of Asperger's syndrome, which is more elusive from a diagnostic point of view than the other syndromes belonging to this group. Since the main characteristics of Asperger's syndrome include severe and persistent disturbances...

Early Detection Of Eating Disorders

The value of early detection of a disorder is generally undisputed in medicine. Foremost among the benefits of early detection is the chance for early treatment, enhancing the likelihood for a shorter duration of illness and a full recovery. Commonly, heightened public awareness about medical disorders facilitates early diagnosis however, so far this has not happened in the eating disorders. Certainly one reason is that the public finds it difficult to distinguish between widespread and perhaps...

Prevalence Of Bipolarity In Children Underdiagnosis Overdiagnosis Misdiagnosis

Over the past two decades, the underdiagnosis and misdiagnosis of childhood bipolar disorder have been noted by several authors 10 . Early Detection and Management of Mental Disorders. Edited by Mario Maj, Juan Jose Lopez-Ibor, Norman Sartorius, Mitsumoto Sato and Ahmed Okasha. 2005 John Wiley & Sons Ltd. ISBN 0-470-01083-5. Gammon et al. 11 interviewed 17 adolescent inpatients and their mothers using the Schedule for Affective Disorders and Schizophrenia for School-aged Children and...

Lists of Prodromal Features of Schizophrenia

Yung and McGorry 41 and Edwards and McGorry 74 have listed the prodromal features in first-episode psychosis most commonly described in the literature. All these symptoms have also been included in the IRAOS and were assessed in the ABC Schizophrenia Study 1. reduced concentration and attention 2. reduced drive and motivation, anergia 8. deterioration in role-functioning Edwards and McGorry 74 also list the four symptom categories experienced prior to a first or current psychotic episode. They,...

Instruments Developed by the Hafner Group

The Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS) The IRAOS 24-26 is the most differentiated of the currently available retrospective early-recognition instruments. It is now available in an enlarged version 27 , applicable to all types of psychotic illness and fully compatible with the first version 24-26 . It comprises the assessment of individual biography and social development in the most important social roles, of premorbid adjustment, emergence and...

References

Chambers W.J., Puig-Antich J., Hirsch M., Paez P., Ambrosini P.J., Tabrizi M.A., Davies M. (1985). The assessment of affective disorders in children and adolescents by semistructured interview. Test-retest reliability of the Schedule for Affective Disorders and Schizophrenia for school-age children, present episode version. Arch. Gen. Psychiatry, 42, 696-702. 2. Achenbach T.M. (1991). Manual for the Child Behavior Checklist 14-18 and 1991 Profile. University of Vermont, Department of...

Interviewing Young People with Early Psychosis

Power 42 described the approach to interviewing young people suspected of having an early psychotic disorder. Establishing rapport should begin with putting the patient at ease by spending time with introductions and explanations of one's role, acknowledging, listening carefully, respecting the patient's viewpoint, and trying to identify common ground. At the same time, the patient's appearance, responsiveness, attention span, affect, level of anxiety, agitation, hostility and unpredictability...

Differential Diagnosis And Comorbidity

The differential diagnosis of a manic episode may include a broad range of psychiatric conditions depending upon the age of the child. For example, sexual abuse is especially important in the differential diagnosis during the childhood years, because manic hypersexuality is often manifested in children by self-stimulatory behaviours including frequent masturbation. Thus, obtaining a careful history of whether the child could have been abused or exposed to adult sexual behaviours is important....

Precursors For Bulimia Nervosa Chronic Caloric Restriction and Dieting

Food deprivation in healthy individuals, which is experienced as a stress by the organism, has been known to increase the risk of binge eating. As described by Keys et al. 50 , if normal individuals, after having undergone chronic food restriction, regain access to food, they experience food cravings and uncomfortable overeating to the point of eating ''immense'' meals. Such overeating occasionally leads to compensatory behaviours such as vomiting to relieve the discomfort. Dieting exposure has...

Why Early Psychosis

The umbrella term ''early psychosis'' has been preferred to a narrower focus such as ''first episode schizophrenia'', both for clinical and research purposes, for several reasons 7 . First, it enables the prodromal period, the first episode of psychosis and the so-called ''critical period'' 8 of the early years post-diagnosis to be included in the management focus. Second, it allows for diagnostic flux and evolution to be handled 9 . Third, the clinical needs of patients with early psychosis,...

First Episode Psychosis An Avoidable Crisis

The onset of a first episode of psychosis often represents a crisis, with the patient and family experiencing considerable trauma and multiple losses. In a small number of cases the onset is very acute and a hitherto completely well person descends into a florid phase of illness which can truly be called an ''episode''. Much more commonly, the so-called ''episode'' is largely an artefact of late presentation. The episode or crisis could have been prevented, since the patient presents after a...

Assessment Of The Difficult Child

The classical presenting picture of the ''difficult'' child is that of a parent or a teacher rushing a child with deviant behavioural symptoms to the psychiatrist, while the child himself herself is usually unaware or denying any existing problem. The first step in the assessment of the ''difficult'' child is history taking. This includes detailed medical, developmental and psychiatric history not only of the patient, but of the family as well. All sources of information must be used - the...

Posttraumatic Stress Disorder Ptsd

PTSD is an emotional and behavioural syndrome following a traumatic event in the family or outside it. In the family setting, it is the result of traumas such as physical or sexual abuse, or the loss of a parent. Outside the family, it is connected with traffic accidents, natural disasters, war or terror. In childhood PTSD, the person's subjective experience of the event is at least as important as any objective characteristics of the trauma 34 . As opposed to what was thought in the past,...

Conclusions

Almost every aspect of paediatric bipolar disorder requires more study. Many adolescents and children with bipolar disorder do not respond to current first-line pharmacological treatments. Therefore, studies with novel agents should be extended to this population. Given the poor response in many cases to available treatment, in the face of either lack of efficacy or delayed onset of efficacy of single agents, physicians will continue to use combination therapies. Therefore, the resultant...

Inpatient Treatment In Early Psychosis Criteria for Hospital Admission

Despite the best efforts of a treating team, many patients with a first episode of psychosis will be unwilling or unable to engage in a comprehensive assessment process need urgent intensive care in hospital to minimize serious risks of self-harm or violence. Criteria for admission will depend on the structure of the mental health service, including factors such as the availability of intensive outreach teams. If good outreach teams exist, then admission can be reserved primarily for risk...

Defining and Operationalizing the Prodromal Stage and the Milestones of the Early Course of Schizophrenia

The clinical end of the early illness stage first treatment contact or first admission is easy to define. But this event is determined not only by the increase in serious symptoms and impairment, but also by patients' help-seeking behaviour and the availability of adequate care. A suitable illness-related event to mark the end of the early illness stage is the climax of the first psychotic episode, operationalized as the maximum of positive symptoms 18 . Figure 1.1, based on data from the ABC...

The ABC Schizophrenia Study

Using the IRAOS interview, the ABC Schizophrenia Study examined a population-based sample of 232 first illness episodes, representing 84 of 276 first treatment episodes, and a representative subsample of 130 subjects, who were compared with two age- and gender-matched control samples -one from the ''healthy'' population n 130 , the other first hospitalized with a diagnosis of depressive episode n 130 . Survival analysis of the duration of early illness course from onset to first admission as...