Not in psychiatry. At least not yet. But the prospect of predicting the onset of psychotic illnesses like schizophrenia, and of "early intervention" to try to prevent them, is a hot topic at the moment.Schizophrenia and similar illnesses usually begin with a period of months or years, generally during adolescence, during which subtle symptoms gradually appear. This is called the "prodrome" or "at risk mental state". The full-blown disorder then hits later. If we could detect the prodromal phase and successfully treat it, we could save people from developing the illness. That's the plan anyway.
But many kids have "prodromal symptoms" during adolescence and never go on to get ill, so treating everyone with mild symptoms of psychosis would mean unnecessarily treating a lot of people. There's also the question of whether we can successfully prevent progression to illness at all, and there have been only a few very small trials looking at whether treatments work for that - but that's another story.
Stephan Ruhrmann et al. claim to have found a good way of predicting who'll go on to develop psychosis in their paper Prediction of Psychosis in Adolescents and Young Adults at High Risk. This is based on the European Prediction of Psychosis Study (EPOS) which was run at a number of early detection clinics in Britain and Europe. People were referred to the clinics through various channels if someone was worried they seemed a bit, well, prodromal
Referral sources included psychiatrists, psychologists, general practitioners, outreach clinics, counseling services, and teachers; patients also initiated contact. Knowledge about early warning signs (e.g., concentration and attention disturbances, unexplained functional decline) and inclusion criteria was disseminated to mental health professionals as well as institutions and persons who might be contacted by at-risk persons seeking help.
COGDIS: inability to divide attention; thought interference, pressure, and blockage; and disturbances of receptive and expressive speech, disturbance of abstract thinking, unstable ideas of reference, and captivation of attention by details of the visual field...
UHR: unusual thought content/delusional ideas, suspiciousness/persecutory ideas, grandiosity, perceptual abnormalities/hallucinations, disorganized communication, and odd behavior/appearance... Brief limited intermittent psychotic symptoms (BLIPS) i.e. hallucinations, delusions, or formal thought disorders that resolved spontaneously within 1 week...
What happened was that 37 of them developed full-blown psychosis: 23 suffered schizophrenia according to DSM-IV criteria, indicating severe and prolonged symptoms; 6 had mood disorders, i.e depression or bipolar disorder, with psychotic features, and the rest mostly had psychotic episodes too short to be classed as schizophrenia. 37 people is 19% of the 183 for whom full 18 month data was available; the others dropped out of the study, or went missing for some reason.
Is 19% high or low? Well, it's much higher than the rate you'd see in randomly selected people, because the risk of getting schizophrenia is less than 1% lifetime and this was only 18 months; the risk of a random person developing psychosis in any given year has been estimated at 0.035% in Britain. So the UHR and COGDIS criteria are a lot better than nothing.
On the other hand 19% is far from being "all": 4 out of 5 of the supposedly "high risk" kids in this study didn't in fact get ill, although some of them probably developed illness after the 18 month period was over.
The authors also came up with a fancy algorithm for predicting risk based on your score on various symptom rating scales, and they claim that this can predict psychosis much better, with 80% accuracy. As this graph shows, the rate of developing psychosis in those scoring highly on their Prognostic Index is really high. (In case you were wondering the Prognostic Index is [1.571 x SIPS-Positive score >16] + [0.865 x bizarre thinking score] + [0.793 x sleep disturbances score] + [1.037 x SPD score] + [0.033 x (highest GAF-M score in the past year – 34.64)] + [0.250 x (years of education – 12.52)]. Use it on your friends for hours of psychiatric fun!)
However they came up with the algorithm by putting all of their dozens of variables into a big mathematical model, crunching the numbers and picking the ones that were most highly correlated with later psychosis - so they've specifically selected the variables that best predict illness in their sample, but that doesn't mean they'll do so in any other case. This is basically the "voodoo" non-independence problem that has so troubled fMRI, although the authors, to their credit, recognize this and issue the appropriate cautions.So overall, we can predict psychosis, sometimes, but far from perfectly. More research is needed. One of the proposed additions to the new DSM-V psychiatric classification system is "Psychosis Risk Syndrome" i.e. the prodrome; it's not currently a disorder in DSM-IV. This idea has been attacked as an invitation to push antipsychotic drugs on kids who aren't actually ill and don't need them. On the other hand though, we shouldn't forget that we're talking about terrible illnesses here: if we could successfully predict and prevent psychosis, we'd be doing a lot of good.
Ruhrmann, S., Schultze-Lutter, F., Salokangas, R., Heinimaa, M., Linszen, D., Dingemans, P., Birchwood, M., Patterson, P., Juckel, G., Heinz, A., Morrison, A., Lewis, S., Graf von Reventlow, H., & Klosterkotter, J. (2010). Prediction of Psychosis in Adolescents and Young Adults at High Risk: Results From the Prospective European Prediction of Psychosis Study Archives of General Psychiatry, 67 (3), 241-251 DOI: 10.1001/archgenpsychiatry.2009.206
10 comments:
Part of that good would be partly demystifying psychosis, so that it was something that, like other illnessess, was in part predictable and followed certain rules, as opposed to the scary thing that kids get locked up for getting.
I've made a comment on this post, but left it at the post below. Sorry.
Good post - speaking as someone engaged in the research (in Melbourne, Australia), I agree with you about the voodoo correlations aspect. One thing to bear in mind is that although only 19% of this sample became psychotic, it's likely that at least half of them had a poor outcome from a psychiatric point of view (whether that be persistent depression, bipolar etc etc). The question is whether the focus of this research should be expanded to 'risk for worsening' rather than risk for a specific syndrome that may or may not represent some objective reality.
We have two papers coming out soon in Schizophrenia Research, one arguing for the study of outcomes other than transition, and another that argues against the inclusion of the risk syndrome in the DSM-V. Both proofs have just gone back, so they should be available online in the next couple of weeks.
Stephan: Thanks for the comments. You make a good point that some of the "non-psychotic" people may have been equally unwell as the psychotic ones, and worsening would be an important thing to measure.
On the other hand I feel risk for specific symptoms is also important because if you decided someone was going to get depressed, the preventative intervention would presumably be different to if you thought they were at risk for psychosis. Ultimately we should probably try to do both...
I'll make sure to take a look at those papers when they're out.
Kind of rediclous to me. Medicating ap erson because they appear to be at risk might not be the answer. What if the person was normal but was diagnosed (whether intentionally or not intentionally) and that messes them up? Tis almost sounds like an excuse by the DSM to put poeple on medications they might not even need and make their lives even worse.
On the other hand, it could save somep opel...but being biased and overdiagnosing is risky. It could be all too easy form the to "point fingers" and claim one to have sai condition when they don't.
Bipolar disorder is a prime example. My sisters' boyfriedn was diagnosed with bipolar disorder and he was given medication. When I asked him of his symptoms, they were not matched to the true nature of bipolar disorder at all! So the medication might as well be harming him rather than "helping" him.
To me, the DSM coming up with new "synromes" and "disoder" sounds far too much like a plot to take away our free will and put us on medication we might not need anyway. Sorry, but that's how this sounds to me. That and I read something about the DSM coming up with new "disorders" and their "symptoms" that souded WAY too much like a scam and an excuse to medcate people for useless things...
I HAVE a psychotic disorder, but I use amino acids to help. Too much of the medicatin they give people are addicting (how they deplete brains' supply of said neurotransmitter by not allowing the brain to suck it bakc up to store and reuse it) bu all of those lousy side effects and not to mention the prices! I think that 1. the DSM better not step into our lives and say poeple have a disorder 9misdiagnose especially if it's intended which I have heard does happen!) or 2. find ways to treat illnesses and mental disorders without having to ruin our brains, via more like amino acids, or an amino acid like medication instead of a blocker or stimulator that depletes a brains supply. This is why some poeple who take SSRIs or antideprssant medications have their conditions get worse by their use, not better. It doesn't help the brain make more and depletes the brains' supply by not allowing it to usck it back up to store it and use it again (reupatake INHIBITOR!) Even stimulant meds cna do that.
Anyway, interesting read! Now I just hope they don't break down my door...yeah, that was a joke!
Hopefully, medications will become safer (and more natural) in the future. i was put on Riddalin and Adorol for my "ADHD" (which I didn't have!) and I couldn't remember ANYTHING from school! I just felt drugged out of my head and dead on the inside. Luckaly, a good stable diet and amino acids have helped me out more than anything, evne therapy.
I agree with Stephen. I think some more research needs to be done to find more clues to determining psychosis insteado of just a few, deciding osmeone has psychosis, treating them and ending up making things owrse as opposed to better because they did not have psychosis to begin with.
Aother factor to psychosis I've thought of could be diet. Our diet is made up of mostly junk food, and litte to no nutrition, not to mention the massive caffeine consumption. All of those release stress hormonesm which if kept at high evels can harm the neurons and make them work incrrrectly and misfire or not at all, leading to one chaotic brain. not to mention it can imapir the immune system!
Lucky for me, some healthy supplementation and a change in diet had done me a world of good. I no longer have paranoia (the real paranoia, not what so many of us call paranoia but is actually just a generalized anxiety disorder) nor a debilitatng fear of being lcoked up in an asylum (which might not actually be part of the psychosis) as it is something that could very likely hppen, and be put on medications that might make my life worse, not better. Being quaretined to my house was bad enough! Though, i did that.
My parasocialism is gone too.
Also, in regaurd to what Frugal Dougal said, I heard that psychosis itself is not likely to make poeple violent. In fact, these types of mental ilnesses are the least of the reasons for poeple with said condition to even BE violent.
It's linked more so to drug use and past abuse. The mental illness itself does not drive them to be the bloodthirsty criminals we claimthem (and stereotype) them to be. Manyy people with psychotic disorders are, in fact, very nice. It's the drugs and trauma that lead up to (or is negatively reacting) with their said condition.
So, I think if we would stop stereotyping poeple with said mental conditions as being violent, maybe there will be a better understanding and new shade of light for these people, one of trust, not degradation, mistrust and fear.
Frugal Dougal, your comment does offend me a little. "the scary thing that kids get locked up for getting." Nothing against you, but the fact that people have this stigma about peple with mental illnesses as being violent and who should be locked up or medicated all the time is uncalled for. It offends in the sesne yu use the term "locked up". That sounds harsh, like something outside the boundaries of what really happens more than not, they go to an intitution, there firends and fmaily are allowed to visit them. From what you're saying sounds more like a jail, prison. That is what gets me the most about your comment.
I read something a couple weeks ago about stigmas and stereotypes of poeple with mental illnesses in media and that is, we portray them as being violent poeple or poele who shouldn't be liked, befriended or trusted, which is unture. Many people with metnal illnesses are perfecty normal people, just a little different, like all of us are.
DOes that mean each nad every one of us has a mental illness that makes who we are? We don't seem to be in a hurry to treat that, do we? Oh wait...the DSM is...goodbye self!
Another thing was about the fact we think they will be locked up. We don't know for sure if they will be locked up. Another awful stereotype...
Actually, when it comes to psychosis, what does that leave dreams to be? Dreams are tchenically halucinations, after all! So...why not just say EVERYONES' psychotic for having "sleep induced psychosis"? As one can tell, I'm pretty annoyed by this.
Also ,just becasue a person has symptoms of psychosis odes not mean they have a mental illness! I have hypoglycemia, and I can hallucinate and have delsuons when my blood sugar drops too low. I don't have paranoia as the mental illness, but hallucinations and delusions are tirggered from the hypoglycemia, therfor, it's not psychosis in itself.
It's just scary how we seem to be trying to medicate everyone for anything, and just how far it may be taken.
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