Lecture 3 Risk for Psychosis

Question 1

Define prodrome

Answer 1

A period of altered functioning or symptoms, before the onset of frank psychosis. Commonly used in clinical services with those starting to present psychotic symptoms

Question 2

What is the problem with the term prodrome

Answer 2

Prodromal symptoms tend to be non-specific and have a high false-positive rate, meaning, some people will experience the symptoms, but not go not to have a full rank psychotic episode

The notion with this is that the only outcome for an individual presenting attenuated symptoms, is a full frank episode of psychosis.

Question 3

Define ultra-high risk

Answer 3

Another way of terming ‘prodrome’. Can also say ‘at risk mental state’.
We are saying the direction of their travel and development, BUT NOT saying they will go on to develop frank psychosis. Just saying, they’re becoming unwell.

Question 4

What are the three instruments used to detect someone who is ultra high risk

Answer 4

SPI-A - developed in Germany
CAARMS- developed in Melbourne
SIPS/SOPS - developed in North America

Question 5

What are ‘basic symptoms’

Answer 5

They are separate from attenuated and psychotic symptoms. They are the very first, subtle changes that people experience.
They are subjectively experienced, and are things that the patient feels is different to their ‘normal self’.

The SPI-A uses basic symptoms as their measures for being UHR or ARMS.

Question 6

Problems with the SPI-A

Answer 6

• It is a very long measure
• Predominantly used and research in Germany, therefore some of its components and traits might be specific to the German population - population sample is very specific and distinct to other countries e.g. the UK.
• It is based on self report and subjective experience e.g. if the individual reports something, but the researcher does not observe it, they still need to note it down and vice versa (cant report something the person says isn’t a problem)
• It is usually used as a research instrument and not in clinical settings

Question 7

What are the two groups of symptoms the SPI-A argues predict psychosis

Answer 7

Cognitive-Perceptive Basic Symptoms (COPER) - 1/10 in the last 3 months. Symptoms have been around for a while but perhaps not as severe

Cognitive Disturbances (COGDIS) - 2/9 and SPI-A score of 3 in the last 3months.

Question 8

What have early studies found with the COGDIS and COPER symptoms?

Answer 8

Klosterkoetter et al - very high transition rates for psychosis with the COPER, 20% had FEP within 12 months and 50% after 3 years

Schultze-Lutter et al - even higher transition rates for COGDIS, 24% in 12m. 61% after 3 years.

Good PPV.

Question 9

What is an ARMS according to the CAARMS or SIPS/SOPS

Answer 9

The individual has:

• Presence of attenuated or sub threshold symptoms, that are not as intense, frequent or long as frank symptoms
• They must be help-seeking, i.e. have visited their GP and be concerned about themselves
• There may be a functional impairment in their life e.g. persistent low functioning

Question 10

What is the specific criteria for ARMS in the CAARMS

Answer 10

1) attenuated psychosis
2) BLIPS - brief limited intermittent psychotic symptoms i.e. frank psychotic symptoms that last less than 1 week. Short but FULL ON.
3) genetic vulnerability e.g. 1st degree relative PLUS a functional decline

Question 11

What is good about the CAARMS and SIPS/SOPS

Answer 11

Excellent psychometric properties including:

• Good inter-rater reliability
• Good PPV - those at high risk will also transition
• Good discriminant validity - the criteria and instrument is specific to psychosis.

Question 12

Findings of Yung et al (2005)

Answer 12

They looked at the psychometric properties of the CAARMS.
Found:
-CAARMS scores predicted onset of psychosis in the UHR clinic (young people who were seeking help from MH services)
-Those meeting UHR criteria had higher rate of transition to psychosis (at 6 month follow up) than those who did not meet criteria.

Question 13

What did Fusar-Poli et al (2012) find in their meta-analysis of transitions rates using the CAARMS and SIPS/SOPS

Answer 13

They analysed 27 studies, total of 2502 patients.
Found if classified as UHR or ARMS a combined transition rate of:
-22% in one year
-29% in two years
-32% in three years
No big difference between the measures and transition rates.

They noticed most transition happened early, and then flattened off after a few years.

If you are UHR - you are 20x more likely to transition to psychosis than the general population

Question 14

What were the findings of Kirkbride et al (2006)

Answer 14

They looked at FEP in three English cities (London, Bristol and Nottingham). Recruited individuals who had presented to psychiatric services with FEP

Found the highest rates of FEP in highly dense areas (London, compared to Bristol and Nottingham) - 20.1 incidence rate per 100,000, compared to 7.

Question 15

What did Kirkbride et al (2006) uncover about incidence of psychosis and ethnicity/gender

Answer 15

• Schizophrenia was more common in men

- All psychoses were more common in black and ethnic minority groups

Question 16

What did Faris and Dunham (1939) discover with the ‘downward drift’

Answer 16

EVALUATION FOR URBANICITY.
They noted a steady decrease in MH disorders from cities to residential outskirts.
The inner city appeared to be associated with a higher risk of psychosis.
The idea of a ‘downward drift’ - as people become unwell, they lose their jobs and social relations, so move to the city in hope of finding work and help. Urbanicity is not a cause for psychosis then, but the idea of a downward drift.

Question 17

Why did Pederson and Mortensen (2001) discredit the idea of a downward drift.

Answer 17

Survey of ~2m Danish adults.

• Risk of psychosis was dependant on how many days and years you were exposed to the city. If you lived in a city whilst young and then moved to a rural area, the city experience still influenced the risk of later developing psychosis.
• dose-response relationships between exposure and risk of psychosis.

Question 18

The NEMESIS Study (van Os et al) also discredited the downward drift. How?

Answer 18

Found the more urban environments were associated with higher rates of subthreshold/sub clinical symptoms.
You therefore cannot claim this is a downward drift, as these people ARE NOT unwell, so why would they leave the outskirts and drift into the city?

Question 19

Findings from the UK 2000 National Survey of Psychiatric Morbidity - Johns et al (2004)

Answer 19

Large UK survey of MH in the UK population

Psychotic experiences were strongly correlated with living in cities.

Question 20

What does urbanisation lead to?

Answer 20

Urbanisation could result in complex social stressors:

• More competition for jobs, resources, there is more going on in the environment
• There might be poorer family networks and increased social isolation if you had to move away for work and to keep up with the changing times

Question 21

What mechanisms could account for the increased risk of urbanisation?

Answer 21

The increased amount of stressors due to urbanisation results in the dysregulation of the HPA axis (hypothalamic pituitary adrenal axis) and increased dopamine sensitivity.

This means there are higher levels of cortisol, with peoples stress responses becoming dysregulated when living in urban environments

Evidence of the HPA axis and activation to stress has been shown in neuroimaging studies

Question 22

Issues with studying urbanity as a risk for psychosis?

Answer 22

It is highly confound with socioeconomic adversity and ethnicity

Question 23

Findings of Wicks et al (2010)

Answer 23

Found an increased risk for psychosis in adoptees without parental history (no genetic risk) if their adoptive family was unemployed, a single-parent household or lived in an apartment.

The risk increased if there was a genetic risk as well.

Question 24

Why is socioeconomic adversity considered a risk factor for developing psychosis?

Answer 24

• Money buys you food, a varied diet, better nutrition to help brain development
• If a single-parent household, its hard for them to take time off, and attend any appointments regarding the child (health and school)

Question 25

Examples of childhood trauma

Answer 25

• Physical, sexual, emotional or psychological abuse
• Neglect
• Parental death
• Bullying

Question 26

What is an odds-ratio

Answer 26

Measure of association between an exposure and the outcome:
The ratio represents the odds that an outcome will occur (given exposure) and the odds than the outcome will occur (in the absence of exposure)

e.g. odds of psychosis developing with or without exposure to trauma.

Question 27

Methodology of Varese et al (2012)

Answer 27

Meta-analysis looking at case control studies, prospective studies and population based cross-sectional studies (good diversity and representativeness in the studies used)

Question 28

Findings of Varese et al (2012)

Answer 28

3.3x more likely to develop psychosis if you had childhood trauma.
Proportion of people who would not have become psychotic had CHT not been present was 33%.

Question 29

Findings of Shevlin et al (2007)

Answer 29

Dose-response relationship: the more childhood trauma experiences you accumulate, the increased risk you get of developing clinical psychosis.

2.5 risk for 1 type of trauma - 53.3 risk for 5 types of trauma

Question 30

Is the association with risk and trauma specific to psychosis?

Answer 30

No. Childhood trauma is associated with many mental disorders (Norman et al 2012). It IS NOT a unitary predictor of psychosis.

Question 31

What is the association between cannabis use and risk for psychosis

Answer 31

Cannabis use can produce short term PE and cause relapse in some.
Prolonged used can lead to prolonged displays of psychotic symptoms

Question 32

What do the ingredients in cannabis do?

Answer 32

THC - causes hallucinations, delusions and paranoia

CBD - can actually have anti-psychotic effects

Question 33

Cannabis and psychosis - is the use a cause or consequence of the MH disorder?

Answer 33

Some people self-medicate with cannabis to treat PE and psychotic symptoms. But can the use of the drug also cause new cases of schizophrenia?

Question 34

What is the statistic for psychosis and cannabis use?

Answer 34

Rates of cannabis use are significantly higher (2x) in schizophrenic patients.

BUT - is this cause or consequence of using the drug.

Question 35

Findings of Arsenault et al (2002) - Cannabis use

Answer 35

Prospective longitudinal study:

• Cannabis users at age 15/16, had more psychotic symptoms at age 26 than non users.
• The effect was stronger with earlier use
• Users 4x more likely to have schizophreniform disorder at age 26.
• Cannabis use seems to be specific to psychosis.

Question 36

Findings of Thompson et al (2014)

Answer 36

• Total childhood trauma WAS NOT associated with risk for psychosis
• Sexual abuse WAS associated with risk for transition to psychosis - particularly HIGH SEXUAL ABUSE

Question 37

What are the two types of risk factors for psychopathology

Answer 37

Distal risk factors: occur early on in childhood e.g. genetic risk or adversities (abuse, neglect)

Proximal risk factors: emerge later in life, influence the individuals stress response (stress, isolation)