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...

Residual Symptoms as Prodromal Signs

Because of the great difficulty in obtaining information on the onset and early course of schizophrenia prospectively, due to the low incidence rate and a frequent onset with uncharacteristic symptoms, prodromal signs usually go unheeded when they appear. In traditional clinical settings, first contact with mental health services in most cases takes place during the first psychotic episode. Help-seeking is usually precipitated by a loss of working ability and the distress caused by psychosis to...

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...

Highrisk Studies

Longitudinal investigations of children who are statistically more likely to develop schizophrenia became popular during the 1950s and continue to offer rich clinical data today. In 1952, Barbara Fish launched the New York Infant High-risk Study, the first formal investigation of children born to schizophrenic mothers 22 . Based on her work, Fish theorized that the vulnerability seen in children of schizophrenic mothers was related to defective neural integration, which could be detected in...

Premorbid Personality Traits

Indicators more closely related with the disorder that have been reported from the recent prospective epidemiological cohort studies seem to offer prospects of identifying at-risk persons. The Swedish conscript study 138 of 50084 young men aged 18 to 20 years showed that four items (having fewer than two friends, preference for socializing in small groups, feeling more sensitive than others, and not having a steady girlfriend) were associated with a high relative risk (odds ratio 30.7) of being...

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,...

The Hypothesis of the Neurotoxicity of Psychotic Episodes

In his early writings, Kraepelin 2 had presumed that the ''florid bouts of illness'' - psychotic episodes - lead to a certain amount of irreversible consequences he called ''defects''. This model, implying that schizophrenia shows a deteriorating course in the form of steps, as depicted in the trajectory proposed by Breier et al. 75 , has been revived by Wyatt 76,77 , Loebel et al. 14 and Lieberman et al. 78,79 ''The illness gets gradually worse during that period indicating that untreated...

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...

Attention Deviance and Other Cognitive Markers

Attention deficits have been shown to be highly characteristic of schizophrenic patients and their relatives. According to data gathered from the New York High-risk Project, attention deviance can be reliably detected in preschizophrenic children, and these deficits are stable and enduring over time 43 . In a 1992 review of attentional findings from the New York High-risk Project 42 , the authors indicate that by at least the age of 7 more than a quarter of the high-risk sample had attention...

Assessing Prodromal Symptoms Before Psychotic Relapses

The first attempts at systematically assessing prodromal signs retrospectively were made in the context of targeted antipsychotic therapy of relapses. The advantages of this procedure are that the prodromal symptoms of relapses are not as remote in time as those of the first episode and that their prognostic efficiency can be prospectively validated 100105 . The results obtained were valuable, but of insufficient predictive power, presumably due to differences in the type of prodromal signs...

Developing Criteria for Atrisk Mental States and Ultrahigh Risk

The ideas expressed by Bell 23 were first translated into practice in Melbourne, Australia in 1994 at the Personal Assessment and Clinical Evaluation PACE Clinic 24 . This approach has now been adopted in a number of other clinical research programmes across the world e.g. 25-27 . These studies have been referred to as ''ultra-high-risk'' UHR studies to differentiate them from the traditional high-risk studies that rely on family history as the primary inclusion criteria. Intake criteria for...

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...