The Prodrome of Schizophrenia

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The Prodrome of Schizophrenia

• Professor Max Marshall

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Overview

• What is the prodrome?
• How can it be detected?
• What do we do in the LEAD clinic?
• Development of LEAD clinics

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Prodromal Symptoms

• Two phases in emergence
• Pre-psychotic
• Non- specific dep/anx/restless/conc/worry/self
  conf/energy
• Specific basic symptoms
• Sub-psychotic
• BLIPS and Attenuated Symptoms

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Social Deterioration

• Social Deterioration is a key aspect of the
  prodrome
• If there is no social deterioration it is
  questionable whether the prodrome is present
• Decay not drift - social deterioration
  follows symptoms

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Onset of Social Disabilities (from IRAOS scale)
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How do we detect it?

• State-Trait Approaches
• i.e. Risk factors plus deterioration
• Specific non-psychotic symptoms
• Basic symptoms
• Sub-psychotic symptoms
• Brief limited psychotic symptoms
• Attenuated psychotic symptoms

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STATE-TRAIT APPROACHES

• Genetic loading
• Soft signs
• Schizotypy
• PLUS
• Social deterioration

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Soft Neurological Signs

• Neurological soft signs (NSS) are minor
  neurological signs indicating non-specific
  cerebral dysfunction.
• Patients with first-episode psychosis show an
  excess of NSS, particularly in motor coordination
  and sequencing, sensory integration and in
  developmental reflexes.

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Soft Neurological Signs
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Schizotypy

• DSM IV Axis II disorder
• Present in 1-3 of population
• Associated increased rate schizophrenia (20-40)
• Present in families of people with psychosis
• Some traits analogous to psychotic symps
• Assessed by SPQ (Raine)

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Elements of Schizotypy

• Cognitive Perceptual
• magical thinking, unusual perceptual experiences,
  ideas of reference, paranoid ideation
• Interpersonal
• no close friends, constricted affect, undue
  social anxiety
• Disorganised
• odd/eccentric behaviour, odd speech

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Basic Symptoms (Huber)

• Subtle, sub-clinical, subjective disturbances in
  drive, stress tolerance, affect, thinking,
  speech, perception motor actions
• Phenomenologically distinct from psychotic
  symptoms
• An early expression of somatic disturbance
  underlying development of psychosis
• Measured using SPI-A (Schizophrenia Proneness
  Instrument Adult version)

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Thought Perseveration
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Disturbance of Receptive Language
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Unstable Ideas of Reference
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Acoustic Perception Disturbances
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ROC curves of ten best symptoms in a model
validation sample (n80 / 80)
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At Risk Mental States

• Alison Yung Pat McGorry
• Comprehensive Assessment of At Risk Mental States
  (CAARMS)
• SIPS/SOPS
• Brief Limited Intermittent Psychotic Symptoms
  (BLIPS)
• Of psychotic intensity but limited duration
• Attenuated Psychotic Symptoms
• Of sub-psychotic intensity

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Effectiveness of Early Detection

• State-Trait Approaches
• Not all patients have them if no deterioration
  does not predict immediate risk
• ARMS
• Short range prediction only already almost
  psychotic
• SPI-A long range
• Promising, but no gold standard study
• No formal synthesis of diagnostic studies

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The LEAD Clinic

• Mike Fitzsimmons, Kishen Neelan, Caroline
  Johnson, myself
• Running for 18 ms, Daisyfield CMHT
• Assess service users who are not psychotic but
  might have prodromal symptoms

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Purpose of the clinic

• To see if it was feasible
• To assess demand and service user and carers
  reactions
• To train ourselves and refine our assessments
• To understand how it might contribute to the EIS

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The LEAD Assessment

• Genetic Risk
• Schizotypy (SPQ)
• Deterioration (Cornblatt scales)
• Soft Signs (Neurological Rating Scale)
• Basic Symptoms (SPI-A)
• Attenuated/BLIPS (CAARMS)

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Findings so far

• So far seen 34 service users
• About half are clearly prodromal, though to
  different degrees of risk
• Although the assessments takes 3 hours no one has
  yet failed to complete it

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Why bother?

• Access
• We need a quick process for identifying people in
  the prodrome
• Safety
• We have to show that decisions not to accept have
  a sound/defensible basis
• Resource Management
• We need to match the level of input to the level
  of risk
• We need to be able to discharge

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Why have a clinic?

• Efficiency
• More than one person is required
• The assessments are difficult and highly
  structured
• Supervision and quality control is essential
• Accuracy
• Requires a quiet and controlled ambience
• Training and development
• Easier to bring in new or techniques

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How could we make it better?

• Should embed clinics in the service
• We should extend the clinic to assess all
  non-psychotic service users
• Should do follow up at one year and discharge if
  improved
• Should have a stepped care model so only highest
  risk are taken on by service
• Should extend remit to assess all complex cases

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Working group

• Set up a LEAD clinic working group
• Warren, Jeff, Faith, Alison, Mike, Imran
• Agreed to roll out LEAD clinics across EIS
• Developing an operational policy
• Training program
• IT support
• Service Evaluation
• Examining Admin Support

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The End