41 - 31.17a Attenuated Psychosis Syndrome

31.17a Attenuated Psychosis Syndrome

Pub Health. 2013;13:724–732. Winters K. Advances in the science of adolescent drug involvement: Implications for assessment and diagnosis. Curr Opin Psychiatry. 2012;318–324. Winters KC, Martim CS, Chung T. Substance use disorders in DSM-V. When applied to adolescents. Addiction. 2011;106:882–884. Yuma-Guerrero PJ, Lawson KA, Velasquez MM, von Sternberg K, Maxson T, et al. Screening, brief intervention, and referral for alcohol use in adolescents: A systematic review. Pediatrics. 2012;130:115–122. 31.17 Child Psychiatry: Other Conditions 31.17a Attenuated Psychosis Syndrome Attenuated Psychosis Syndrome (APS) is a new diagnostic category included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) as a condition for further study. It is a syndrome characterized by subthreshold psychotic symptoms, less severe than those found in psychotic disorders, but which are often present in prodromal psychotic states. Debate and controversy among clinicians and researchers have surrounded the inclusion of APS in the DSM-5. There are those who believe that the identification and treatment of a prodromal syndrome of a psychotic disorder would either delay or diminish the severity of the future psychotic illness. And, there are others who believe that identification of a prodromal syndrome, which may rarely if ever progress to a full psychotic illness, would lead to unnecessary exposure to antipsychotic agents with unpredictable and possibly harmful effects. There is agreement, however, that patients with subthreshold prodromal psychotic symptoms are often impaired and are in need of psychological and psychiatric intervention. A recent meta-analysis reported that the rate of onset of psychotic disorders in those patients with prodromal psychotic symptoms was 18 percent at 6 months, 22 percent at 1 year, 29 percent at 2 years, and 36 percent at 3 years. In a follow up study it was found that of those with prodromal symptoms who went on to develop a threshold psychotic illness, 73 percent met criteria for schizophrenia. In children and adolescents psychotic symptoms are not necessarily a hallmark of a threshold psychotic disorder compared to adults. For example, in 50 percent of children with major depressive episodes, psychotic symptoms were present. In addition, epidemiological studies have found that globally, auditory hallucinations occur in 9 percent to 21 percent of children and in 8.4 percent of adolescents. Thus, in youth, the association between subthreshold psychotic symptoms and the emergence of future psychotic illness may not be a reliable predictor. Nevertheless, identification and follow up of youth with APS may provide an increased understanding of the longitudinal significance of these symptoms. ETIOLOGY

Genetic Factors Family studies have demonstrated that genetic factors influence vulnerability for schizophrenia spectrum disorders and other psychotic disorders. To the extent that APS and schizophrenia are related, genetic contributions are likely to be significant. Adoption and twin studies have confirmed that monozygotic twins have about a 50 percent concordance rate for schizophrenia compared to dizygotic twins who have a concordance rate of about 10 percent. In addition, adopted children of parents with schizophrenia do not have higher rates of schizophrenia; but biological children of schizophrenic parents do. However, genetic factors do not account fully for the emergence of schizophrenia spectrum disorders, since there is only a 50 percent concordance of exhibiting these disorders among monozygotic twins. Environmental factors also play an important role. Environmental Factors Early environmental factors that increase the risk of developing schizophrenia include fetal malnutrition, hypoxia at birth, and possibly prenatal infections. Other environmental factors include trauma, stress, social adversity and isolation. Finally, gene–environment interactions may influence an individual’s sensitivity to adverse environmental events. DIAGNOSIS Attenuated psychosis syndrome, according to DSM-5, is based on the presence of at least one of the following: delusions, hallucinations, or disorganized speech, which causes functional impairment. Although the symptoms may not have progressed to full psychotic severity, they must have been present at least once per week for one month, and must have emerged or worsened in the past year. The symptoms must cause impairment and warrant clinical attention. Attenuated delusions are described as either suspiciousness, persecutory, or grandiose, resulting in a lack of trust in others, and a sense of danger. Attenuated delusions, in contrast to delusions of threshold illness, may lead to loosely organized beliefs about hostile intentions of others, or danger; however, the delusions are not as fixed as they become in full blown psychotic illness. Attenuated hallucinations include altered sensory perceptions such as perception of murmurs, rumblings, or shadows that are disturbing; but they can be challenged, and skepticism about their reality is likely to be present. Disorganized communication or speech may be displayed as vague, or confused explanations, or circumstantial or tangential communication. When severe, but still in the attenuated range, thought blocking or loose associations may emerge; however, in contrast to psychotic illness, redirection is possible, and a logical conversation is typically achieved. Although impairment is present in APS, the individual retains an awareness and insight into the mental changes that are occurring.

TREATMENT A recent review of the literature on treatment trials with patients at ultra-high-risk for psychosis found that early intervention with both psychological interventions and pharmacological agents can reduce symptoms and either delay or prevent the onset of a full psychotic illness. Other studies, however, found mixed results for early psychological or pharmacological interventions to prevent the onset of psychotic illness. One study found that most patients who became frankly psychotic did so within a few months after joining the study, making it difficult to determine if these patients were already exhibiting early signs of onset of schizophrenia when identified as prodromal. A variety of treatment approaches have been used including treatment with risperidone, olanzapine, omega-3 polyunsaturated fatty acid (w-3PUFA), cognitivebehavioral therapy (CBT), cognitive therapy (CT), and one using an integrated psychological intervention (IPI) including cognitive approaches, psychoeducation, and social skills intervention. A review of treatment effectiveness in APS found that receiving treatment was associated with lower risk of psychotic illness at 1 year, 2 years, and 3 years. Given the limited data, however, it is not clear which interventions are most efficacious. Therefore, until additional treatment trials provide efficacy data, the safest choices for treatment of APS includes psychological interventions rather than the use of antipsychotic agents. In summary, APS identifies a group of patients with psychotic-like phenomena that warrant interventions in order to improve their distress and functional levels. Further study is needed, however, to determine the relationship between APS and the development of schizophrenia and other psychotic illnesses. REFERENCES Amminger GP, Schafer MR, Papageorgiou K, Klier CM, Cotton SM. Long-chain w-3 fatty acids for indicated prevention of psychotic disorder: A randomized placebo-controlled trial. Arch Gen Psychiatry. 2010;67:146–14. Addington J, Epstein I, Liu L, French P, Boydell KM. A randomized controlled trial of cognitive behavioral therapy for individuals at clinical high risk of psychosis. Schizophr Res. 2011;125:54–61. Arango C. Attenuated psychotic symptoms syndrome: How it may affect child and adolescent psychiatry. Eur Child Adolesc Psychiatry. 2011;20:67–70. Bechdolf A, Wagner M, Ruhrman S, Harrigan S, Veith V, et al. Preventing progression to first episode psychosis in early initial prodromal states. Br J Psychiatry. 2012;200:22–29. Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rossler A, et al. The psychosis high-risk state. A comprehensive state-of-the-art review. JAMA. 2013;70:107–120. Fusar-Poli P, Bechdolf A, Taylor M, Carpenter W, Yung A, McGuire P. At risk for schizophrenia or affective psychosis? A meta-analysis of DSM/ICD diagnostic outcomes in individuals at high clinical risk. [Published online May 15, 2012]. Schizophr Bull. Doi: 10.1093/schbul/sbs060. Fusar-Poli P, Bonoldi I, Yung AR. Predicting psychosis: A meta-analysis of transition outcomes in individuals at high clinical risk. Arch Gen Psychiatry. 2012;69:220–229. Jacobs E, Kline E, Schiffman J. Defining treatment as usual for attenuated psychosis syndrome: A survey of community practitioners. Psychiatr Serv. 2012;63:1252–1256. McGlashan TH, Zipursky RB, Perkins D, Addington J, Miller T, et al. Randomized, double-blind trial of olanzapine versus