APSS (Attenuated Psychotic symptoms syndrome)

7/28/2019 APSS (Attenuated Psychotic symptoms syndrome)

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Attenuated Psychotic SymptomsSyndrome

Presented by Dr Pavan Kumar Chaired by Dr Joylin


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Introduction Schizophrenia affects 1 out of 100 people Onset during adolescence and early adulthood Personal and Societal costs are high Prevention of Schizophrenia substantial benefits

Its Prodromal phase recognised since 19th

century Psychosis is brewing long before its manifestation as a diagnostic illnessand that there are identifiable signs and symptoms that precede thedevelopment of frank psychotic symptoms. (McGlashan et al, 2003).

Over the last decade there has been a worldwide movement to developcomprehensive early intervention programs for schizophrenia.


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Introduction - contd

Schizophrenia can be divided into three phases The 1 st the premorbid phase is a period of normality for most persons

who ultimately develop schizophrenia. When deficits exist, they usuallybegin at birth and usually are subtle, stable, and asymptomatic.

In the 2 nd or prodromalphase--, symptoms occur with increasing severitybeginning after puberty. This phase lasts between 2 and 5 years onaverage. Global functioning declines in an obvious downward, usuallyaccelerating trajectory.

The 3 rd the psychotic phase is ushered in with frankly psychoticsymptoms . At this point, patients feel convinced that their hallucinationsand delusions are real. Their earlier insight in the prodromal phase,consisting of recognition of attenuated psychotic experiences as false, isnow lost.


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Prevention of schizophrenia Primary prevention tries to reduce the incidence of new cases in the

population. Refers to intervention in the premorbid phase. Ex: improving prenatal care, reducing environmental insults and reducing

mean paternal age .

Secondary prevention aims to reduce the prevalence of the disorder. Prevalence could be reduced by efforts to delay onset of early signs and

symptoms of the disorder Tertiary prevention aims to reduce morbidity, course progression , and

mortality .

Begins by treating schizophrenia as soon as possible after onset to reducethe duration of untreated psychosis and minimize the damage that activepsychosis can wreak on the patients job, social life, and familyfunctioning.


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History The prodromal phase of schizophrenia has been recognized since the early twentieth century by Bleuler. Emil Kraepelin described the onset of mostly negative and nonspecific

symptoms followed by positive symptoms and then the first psychotic

episode. According to the Kraepelinian view, the sequence of deterioration is

immutable There is proposal to include this risk syndrome in DSM V prior its

publication.


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What is Prodrome? Describes retrospective concept because until there is an established

psychotic illness such as schizophrenia it cant be defined. (Yung et al,1996).

Refers to the time period characterized by mental state features whichrepresent a change from a persons premorbid functioning up until theonset of frank psychotic features (Yung et al. 1996).


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Approximately 80-90% of pts with schizophrenia report a variety of symptoms, including changes in perception, beliefs, cognition, moodaffect, and behavior that precede psychosis, although approx 10-20%develop psychotic symptoms precipitously without any apparentsignificant prodromal period (Yung & McGorry, 1996a).

The typical pattern is that the non-specific symptoms and negativesymptoms develop first, followed by attenuated, or mild, positivesymptoms, together with distress and decreased functioning (Hafner et al,1998).


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Prodromal criteria

It has been recognized for years that some individuals who developschizophrenia have subtle social, behavioral, and intellectual deficits suchas impaired motor development and coordination, neurological soft signs,lower intelligence, and a broad range of social problems.

Yung et al (1996) in Melbourne developed a specialized clinical setting,the Personal Assistance and Crisis Evaluation Clinic (PACE) to study andtreat individuals who present for help and concerned about symptomsthat appear to be psychotic in nature.

These individuals were considered to be at ultra -high risk , the termadopted as alternative to prodromal.


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vulnerability group1. first degree relative with psychosis or patient with schizotypalpersonality disorder.2. 30% drop in Global Assessment of Function (GAF) score from

premorbid level, sustained for 1 month3. Change in functioning occurred in the last year


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Attenuated symptom group1. specified severity rating on at least one or more attenuated positivesymptoms2. specified frequency rating over a given time period

3. symptoms present in past year and for not longer than 5 years Brief Limited Intermittent Psychotic Symptoms (BLIPS) group

1. specified severity rating of brief psychotic symptoms2. specified frequency rating over a given time period3. each episode of symptoms is present for


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Almost identical criteria, the Criteria for Prodromal Syndrome (COPS) havebeen developed by Mc Glashan at Yale University.

Similarly basic symptom concept which originated in the observation of deficits that were perceived by individuals with schizophrenia of 10 yrsbefore the first manifestation of psychotic symptoms. (Bonn Scale for theAssessment of Basic Symptoms, BSABS)


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Using the criteria the risk of psychosis increases from approx 10% ingenetic high-risk group to approx 30-50%

Reliability of the diagnosis has shown to be excellent and studies usingthese criteria support that prodromal persons are symptomatic and athigh and imminent risk for psychosis.


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DSM V prefers a name Attenuated Psychotic Symptoms Syndrome orAPS Syndrome for prodrome

Proposed revision in DSM-5 criteria for identifying attenuated psychoticsymptoms syndrome

a) Characteristic symptoms:at least one of the following is present inattenuated form with intact reality testing but of sufficient severityand/or frequency that it is not discounted or ignored

i. Delusionsii. Hallucinationsiii. Disorganised speech


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b) Frequency/currency: Symptom or symptoms meeting criteria A must bepresent in the past month and occur at an average frequency of at leastonce per week in the past month

c) Progression : Symptoms meeting criteria A must have begun or worsenedin the past year

d) Distress/disability/treatment seeking: Symptoms meeting Criteria A aresufficiently distressing and disabling to the patient and/orparent/guardian/others to lead them to seek help

e) Symptoms meeting criterion A are not better explained by any other DSM 5 diagnosis, including substance related disorders

f) Clinical criteria for any DSM-V frank psychotic disorder have never beenmet


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Name was changed from psychosis risk syndrome to attenuated positive

symptom syndrome This emphasises that symptoms already present rather than potential for

predicting future psychosis As a result false positive diminished But new issues raised Attenuated psychosis syndrome is included in Section III of the new

manual; conditions listed there require further research before theirconsideration as formal disorders.

DSM 5 Criteria is less inclusive than research criteria


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EPIDEMIOLOGY Although meticulous epidemiological studies of the prodrome have not

yet been done, it is believed that the incidence of prodromal patients willmirror that of patients with schizophrenia (approximately 1 per 10,000)but that prodromal patients will be on average 1 2 years younger.


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Clinical rating scales for theProdrome

3 specific scales have been developed Comprehensive Assessment of At Risk Mental State (CAARMS) Scale of prodromal Symptoms (SOPS) and Structured Interview of

prodromal Symptoms (SIPS)

Schizophrenia prediction Instrument for Adults (SPI-A)


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Transition to Psychosis Two large multisite studies

North American Prodrome Longitudinal Study (NAPLS) Approx 35% converted to psychosis over 2.5 yr follow-up period and

Five features at baseline contributed uniquely to the prediction of psychosis: a genetic risk for schizophrenia with recent deterioration infunctioning, higher levels of unusual thought content, higher levels of suspicion/paranoia, greater social impairment and history of substanceabuse.

European Prediction of psychosis Study (EPOS) 62% transition to schizophrenia, 16% mood disorder with psychotic

features and the rest schizoaffective and schizophreniform disorder


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The PACE Clinic in Melbourne has shown a prospective risk of conversionor positive predictive value of 40.8% within the first 12 months in 49prodromal patients (Yung et al. 2003).

Most recently, a follow- up study of 104 ultra -high- risk patients reportedthat 34.6% of the patients developed frank psychotic symptoms within 12months (Yung et al.2004)

In the PRIME Clinic sample, most of the patients who did not progress toschizophrenia remained prodromal, and only a few experienced remissionof prodromal symptoms within 12 months.


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Predictors of Transition Unusual thought content, suspicion/paranoia and bizarre thinking

predicted transition Negative symptoms but not as strongly as positive symptoms Low functioning over last year

Street drug use (cannabis and amphetamines)


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Cognitive deficits Intermediate between healthy controls and first episode psychosis Spatial working memory, verbal declarative learning and memory and

attention

Deficits in sustained attention stable vulnerability marker Deficits in verbal declarative memory predictive of conversion to

psychosis.

Social functioning GAF score of 50 or low Facial affect recogntion deficits- vulnerability marker


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Neuro imaging cerebral gray matter volume deficits have been found in several cortical

regions on magnetic resonance imaging studies progressive reductions in gray matter in the left parahippocampal,

fusiform, orbitofrontal, and cerebellar cortices and the cingulate gyri


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Differential Diagnosisof the Prodrome

The prodrome signals the impending onset of disorders other thanschizophrenia, making the differential diagnosis of the prodrome a criticaland challenging exercise.

rule out general medical conditions that can mimic a prodromal stateand/or progress to frankly psychotic symptoms, such as Cushings disease,delirium, certain seizure disorders, lupus, and various types of drugintoxication

Drug dependence, such as chronic marijuana use in particular, may lead toamotivation, dysphoria, perceptual abnormalities, and paranoia.


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Major depression with psychotic features : Depressive symptoms arecommon in the prodrome. Most prodromal patients, however, do notmeet full diagnostic criteria for major depression and complain of emotional numbness rather than true sadness or sustained irritability.

Schizotypal personality disorder. Distinguished mostly by course.Symptoms in the prodrome are progressive, not static.

Borderline personality disorder: BPD traits are present usually from an

early age and are unlikely to show sudden emergence in young adulthood.

Pervasive developmental disorder: may resemble the prodrome in someways, it is usually associated with mental retardationand other GMCs.


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Posttraumatic stress disorder. Unlike prodromal symptoms, PTSD developsafter a psychologically traumatic event that is generally outside the rangeof usual human experience.

Obsessive-compulsive disorder (OCD). Prodromal patients usually do notshow compulsive behaviors or preoccupation with the classic OCD themesof contamination or inadvertent harm to others, and they do notexperience OCD symptoms as ego-dystonic.

Attention-deficit/hyperactivity disorder (ADHD). Although attentiondeficits are common in the prodrome, patients with true ADHD usually areidentified before age 7 years.


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TREATMENT Two controlled studies involving treatment of prodromal symptoms with

atypical antipsychotic medications have been done. The results of 1 st study provide strong support for the ability of an atypical

antipsychotic medication in conjunction with CBT to postpone, ratherthan eliminate, progression to psychosis among prodromal patients

McGlashan et al. (2003) conducted a double-blind, placebo-controlledtrial of olanzapine in 60 prodromal patients. The 1-year results showedthat 16 patients became psychotic, including 11 (of 29) from the placebogroup and 5 (of 31) from the olanzapine group.


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TREATMENTRECOMMENDATIONS

Early identification and treatment of the prodrome at the PRIME Clinichave had several benefits, including reduced psychosocial morbidity.

Patients and their families express relief that the condition is recognized,monitored, and treated with minimal disruption of daily life and usually onan outpatient basis.

Social withdrawal and isolation are reduced, and families receiveemotional support and education about the prodrome.


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active follow-up care at frequent intervals assessment of global functioning at baseline and at periodic intervals supportive therapy for the patient, family therapy, psychoeducation, and

liaison with other treating physicians and therapists.

Safety issues, including substance abuse, poor self-care, and suicidal andhomicidal behavior, must be vigorously addressed. Comorbid disorders should be treated.


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Treatment of the prodrome with conventional antipsychotics currentlybeing used in the treatment of schizophrenia is still in its research phaseand is not recommended for standard treatment.

From a research perspective, drugs that target mechanisms of action suchas excessive oxidative stress and hypofunction of the Nmethyl- D-aspartate subtype of glutamate receptors may be beneficial, includingglycine, omega-3 fatty acid supplementation, and lamotrigine.


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Issues

Benefits of inclusion in DSM V Clinical validity of the syndrome

Stigma Unnecessary treatment Ethical dilemma


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Benefits of inclusion of a new APSsyndrome category in DSM 5

Widespread community education about who does and does not meetrisk syndrome criteria

Promotion of more rapid and larger scale treatment research


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Risk of inclusion are

Stigma Overmedication of false positive patients

=both of these can be overcome by education=also DSM 5 diagnosis are not necessarily greater than those with DSM

IV diagnosis these patients now receive, such as psychosis NOS


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If use of antipsychotic treatment becomes standard in absence of clinicaltrials and patients improve than assumption will be that it was due tomedication and it will increase overmedication


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False-positive diagnoses are likely to occur with disorders such as majordepression, bipolar disorder, OCD, and schizotypal personality disorder

Although false-negative diagnoses are also likely to occur, PRIME Clinicsample found that patients who had not initially met prodromal criteriadid not progress to psychosis within the next year.

Also lack of information about conversion rates . It keeps changing quitesubstantially with 50% in early studies to 20% in current studies.


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Conclusion Identification of individuals at the prodromal stage of illness would offer

clinicians the oppurtunity to provide preventive interventions But evidence for efficacy of pharmacological and psychosocial

intervention needs to be strengthened New changes are difficult to be accepted at the very onset, with passage

of time, experience and constructive discussion, opinions change. We hope the change would be for benefit of people suffering from

schizophrenia and psychotic disorders


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THANK U

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APSS (Attenuated Psychotic symptoms syndrome)