Risk Factors for Psychosis

Paradigms, Mechanisms, and Prevention

Andrew Thompson, Matthew Broome

• Publisher: Academic Press
• Year: 2020
• Print ISBN: 9780128132012
• eBook ISBN: 9780128132029
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Risk Factors for Psychosis: Paradigms, Mechanisms, and Prevention combines the related, but disparate research endeavors into a single text that considers all risk factors for psychosis, including biological, psychological and environmental factors. The book also introduces the ethics and current treatment evidence that attempts to ameliorate risk or reduce the number of individuals with risk factors developing a psychotic disorder. Finally, the book highlights new research paradigms that will further enhance the field in the future.Psychotic disorders affect more than 50 million people worldwide, creating a devastating effect on lives and causing major financial and emotional impact on families and on society as a whole. The search for risk factors for psychosis has developed rapidly over the past decades, invigorated by changes in the thinking about the malleability and treatability of psychotic disorders. The paradigms for investigating psychosis risk have developed, often in parallel, but there has been no book to date that has summarized and synthesized the current approaches.- Integrates research from biological, psychological and environmental factors into a single resource- Offers insight into at-risk paradigms, biomarkers, and the current state of research on treatment option for psychosis- Presents a holistic and dynamic look at risk syndromes and how they can be measured through neuroimaging, neuropsychology and other methods

Chapter 1

Historical perspectives on psychosis risk

Cristina Mei ^{1 , 2} , and Patrick D. McGorry ^{1 , 2 1} Orygen, Parkville, VIC, Australia ² Centre for Youth Mental Health, The University of Melbourne, Parkville, VIC, Australia

Abstract

Almost a century ago, the notion of early detection and preventive intervention for schizophrenia and psychotic disorders was introduced. To achieve this aspiration, the prodrome of psychosis was seen as a key target. A number of seminal works attempted to reconstruct the prodromal period to identify the earliest symptoms of psychotic disorders, particularly schizophrenia. Key learnings from these retrospective studies revealed that the prodrome of psychosis was characterized by a range of mostly nonspecific signs and symptoms that had limited power to accurately predict the onset of a psychotic disorder. Thus, the prodrome concept could only be applied with certainty once a frank psychotic episode had been experienced, limiting its preventive utility. The prospective identification of individuals within the putative prodromal phase remained essentially stagnant until the 1980s and 1990s. During this period, at-risk approaches were introduced, leading to a new research paradigm. In this chapter, we summarize the historical origins of psychosis risk that have led to contemporary approaches.

Keywords

At-risk mental state; Prodrome; Psychosis; Schizophrenia; Ultra high risk

Introduction

Early detection and prevention of potentially serious medical conditions, such as cancer and cardiovascular disease, have long been strongly advocated to improve patient outcomes and survival. Achieving this endeavor for psychotic disorders has lagged considerably in comparison, despite their potentially devastating impacts and high burden of disease (Rössler et al., 2005; Morgan et al., 2012). Although a preemptive psychiatry was aspired to almost a century ago (Sullivan, 1927), it was not until decades later that this potential gained momentum. A significant barrier to progress was the early conceptualization of psychotic disorders, particularly schizophrenia, which were viewed with pessimism, with an inevitable deteriorating course and largely palliative treatment focus that offered limited hope and opportunity for recovery. The current conceptualization of psychotic disorders is more optimistic, with the course of illness understood to be modifiable and not restricted to an inevitable poor prognosis and decline in social and functional outcomes (Henry et al., 2010; McGorry et al., 1990; McGorry, 1992; Killackey et al., 2019; Anderson et al., 2018; Correll et al., 2018).

This more positive outlook is largely due to the research and early intervention efforts in the 1980s and 1990s that focused on the timely recognition and phase-specific treatment of first-episode psychosis (McGorry, 2015). This early intervention model represented a form of secondary prevention, with the target being psychosis (rather than schizophrenia) across three stages: prepsychotic, first-episode, and recovery. These stages represented key differences in the timing and duration of antipsychotic medication as well as the underlying risk of chronicity (McGorry et al., 2008). The establishment of an early psychosis paradigm led to increased research and clinical efforts to identify and intervene during the earliest or prodromal stage of psychosis to prevent or at least delay the onset of psychosis. Well before this paradigm shift, a prolonged period of signs and symptoms conceptualized as a “prodrome” were known to commonly precede the onset of a frank psychotic episode (Bleuler, 1911; Kraepelin, 1919). A number of seminal works attempted to reconstruct the prodromal period to identify the earliest symptoms of psychotic disorders, particularly schizophrenia. However, these research attempts faced numerous conceptual limitations and challenges in prospectively identifying those in the prodromal phase of illness. In this chapter, we summarize the conceptual origins of the prodrome that have led to contemporary at-risk approaches.

The prodrome concept

Within clinical medicine, the prodrome refers to the early signs of an illness that precede the emergence of specific diagnostic symptoms that denote a fully fledged illness. The development of measles is a prime example of the concept; its earliest prodromal signs and symptoms are nonspecific (fever, cough, conjunctivitis, and coryza), with a definitive diagnosis of measles possible following the appearance of a specific rash (Yung and McGorry, 1996b).

The prodrome for psychotic disorders has long been recognized. Since the early 1900s, early signs of schizophrenia had been observed prior to the onset of a clinically diagnosable psychotic disorder (Sullivan, 1927; Cameron, 1938b; Meares, 1959). This prodromal phase was characterized by a range of nonspecific signs and symptoms (e.g., mood changes, anxiety, sleep disturbance, impaired functioning) and attenuated or subthreshold psychotic symptoms that represented a change in premorbid functioning (Beiser et al., 1993; Yung and McGorry, 1996b; Loebel et al., 1992). This makes the prodrome conceptually distinct to the premorbid phase, which represents the stage prior to the onset of prodromal symptoms and functional decline. While these distinct phases exist, identifying clear-cut boundaries between the various stages of a psychotic disorder (i.e., pre-morbid, prodromal, first-episode) is challenging and often blurred (Yung and McGorry, 1996b). For instance, as the early symptoms of psychotic disorders are typically nonspecific and emerge gradually, it can be difficult to identify the precise point in which an individual's typical behavior or symptoms transition to the point of a prodrome.

Clinical implications of the prodrome

Arising from the prodrome concept was the idea of early identification and prevention of psychosis. One of the earliest notions of indicated prevention in psychiatry was described by Sullivan (1927, p. 106–107): “I feel certain that many incipient cases might be arrested before the efficient contact with reality is completely suspended, and a long stay in institutions made necessary.” This challenged deterministic 19th century notions of psychotic disorders, particularly schizophrenia, that were derived from degeneration theory, which instilled despair and stigma and were entrenched with minimal challenge for decades. This is exemplified through the phenomenon of dementia praecox, later termed schizophrenia, which connoted inevitable chronicity and deterioration, and embedded deep stigmatization. Its subsequent effect on the care of individuals with psychosis was devastating, with a largely palliative treatment focus adopted, even after effective treatments were discovered. Authors in the early 1900s questioned this early notion of schizophrenia, recognizing that treatment was often offered too late: “the psychiatrist sees too many end states and deals professionally with too few of the pre-psychotic” (Sullivan, 1927, p.106). This was echoed in the lament of McGlashan (1996, p. 198), who stated: “I remain convinced that with them [patients with schizophrenia] I came upon the scene too late; most of the damage was already done.” The prodrome was viewed as a potential solution and was identified as a key target for early detection to prevent the onset of psychosis and the loss of human potential (Cameron, 1938b; Meares, 1959; Sullivan, 1927). This was supported by the fact that much of the disability associated with psychotic disorders developed during this prepsychotic phase (Hafner et al., 1995) and was difficult to reverse even when remission of the psychotic episode was achieved (Hafner et al., 2003).

Conceptual limitations

Although intervening within the prodrome represented a potential opportunity for prevention of psychotic disorders, early obstacles, which included challenges in prospectively identifying the prodrome and the lack of effective treatments, limited the realization of this aspiration. A key component of prevention is the accurate identification of at-risk individuals. However, for psychotic disorders, the nonspecific nature of prodromal symptoms and the difficulty in differentiating these from other psychopathology (e.g., major depression) (Hafner et al., 2005) meant that the prodrome could not be accurately identified. That is, the prodrome is a retrospective concept that can only be applied after meeting diagnostic criteria for a full-threshold psychot...

Table of contents

• Cover image
• Title page
• Table of Contents
• Copyright
• Contributors
• Foreword
• Chapter 1. Historical perspectives on psychosis risk
• Chapter 2. Principles of risk, screening, and prevention in psychiatry
• I. Risk paradigms
• II. Specific areas and risk
• III. Interventions
• Index