The Prodrome of Psychotic Disorders: Identification, Prediction, and Preventive Treatment

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Key points

  • The last 25 years have seen a substantial focus on the prodromal period of psychotic disorders, triggered by the introduction of “at risk” criteria.

  • Prediction studies have identified a range of risk factors involved in the transition from “at risk” status to first episode psychotic illness, with the field now moving in the direction of dynamic and multimodal prediction approaches.

  • Treatment studies indicate that risk of transition to psychotic disorder can at least be delayed in this clinical

Identification of the prodromal phase of psychotic disorders

The early psychosis movement, starting in Melbourne in the early 1990s, initially focused on timely recognition and phase-specific treatment of first episode psychosis. Strong evidence has now accumulated for the benefit of providing comprehensive specialized treatment of the first episode of psychosis.3 However, it was also recognized that for most patients a prolonged period of nonspecific psychiatric symptoms, attenuated psychotic symptoms, and impaired functioning precedes the first

Clinical outcomes of ultra-high risk for psychosis patients

A substantial body of research has accumulated indicating that the UHR criteria have strong predictive validity for psychotic disorder when applied to a help-seeking population, with 22% progressing to psychotic disorder over a 1-year period and 36% over a 3-year period,36 which is several thousand-fold greater than the expected incidence rate for first episode psychosis in the general population.37 A long-term follow-up study of UHR patients indicated risk for psychosis onset occurring up to

Predictors of transition to psychosis

A range of variables have been identified that predict those who transition to psychosis among the group who have already been identified as being at risk (for comprehensive reviews see48 and49). In terms of clinical variables, negative symptoms, thought disorder, poor baseline social functioning, as well as decline in social functioning, and longer duration of symptoms before clinic entry have been identified as the more reliable predictors of transition to psychosis. Of environmental risk

Treatments for ultra-high-risk patients

There have been 20 randomized controlled trials (RCTs) published in the UHR population, with the primary outcome of interest generally being reduction in rate of transition to psychotic disorder. The RCTs have varied in quality and size and have consisted of a range of psychosocial, pharmacologic, and nutritional supplement interventions including cognitive behavioral therapy (CBT), family therapy, cognitive remediation, integrated psychological therapy, risperidone plus CBT, omega-3 fatty

Case example of treatment of an ultra-high-risk patient

Below, the investigators present a brief case example of a UHR young person who was assessed and treated at the authors’ UHR clinic, the PACE clinic, at Orygen in Melbourne (please see66 for further examples). Simon is a 17-year-old young man who was referred to Orygen by his General Practitioner (GP, ie, primary care doctor). Simon’s mother had made an appointment for Simon to see his GP because she was concerned that he seemed depressed, anxious, and “not quite himself.” Simon’s family is

Pluripotent risk: broadening the “at risk” approach

Over recent years, the pattern of clinical pathways to first episode psychosis and the outcomes of UHR patients described earlier (ie, heterotypic and pluripotent symptom evolution) have prompted the authors to consider a broader approach to identifying young people at risk of psychosis and other serious mental disorders, informed by the transdiagnostic clinical staging model in psychiatry.67, 68, 69 The concept of pluripotent risk is central to this thinking. “Pluripotent risk,” observed in

Summary

The last 25 years have seen substantial focus on the prodromal period of psychotic disorders, triggered by the introduction of “at risk” criteria. Prediction studies have identified a range of risk factors involved in the transition from at risk status to first episode psychotic illness, with the field now moving in the direction of dynamic and multimodal prediction approaches. Larger samples and external validation are also key requirements for this field in order to generate prediction tools

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