Prognostic factors: UHR criteria, defined as attenuated positive psychotic symptoms (APPS), brief limited intermittent psychotic symptoms (BLIPS), and trait and state risk factors (Trait). PhD, is senior psychologist at the Basel Early Treatment Service, University Psychiatric Clinics Basel. 1 Which of the following does not count towards a diagnosis of clinical high risk for psychosis? Baseline psychosocial functioning was also assessed as a possible predictor of psychosis. She is not distressed or alarmed by this experience; on the contrary, she seems to enjoy it.  |  He dismissed his previous ideas as ‘absurd’ and was worried that they meant that he was going crazy, so he agreed to a full diagnostic evaluation. Moreover, the majority of these patients have non-psychotic psychiatric disorders such as substance-related, affective or anxiety disorders (Lin Reference Lin, Wood and Nelson2015; Michel Reference Michel, Ruhrmann and Schimmelmann2018) and exhibit long-term functional impairments compared with healthy controls (Polari Reference Polari, Lavoie and Yuen2018). Results of a prospective, naturalistic treatment study of adolescents, Lack of evidence to favor specific preventive interventions in psychosis: a network meta-analysis, Efficacy and acceptability of interventions for attenuated positive psychotic symptoms in individuals at clinical high risk of psychosis: a network meta-analysis, Attenuated psychotic symptom interventions in youth at risk of psychosis: a systematic review and meta-analysis, Early intervention for psychosis with N-methyl-d-aspartate receptor modulators, Clinical Psychopharmacology and Neuroscience, Early response to treatment predicts remission and recovery at 3 years in people with schizophrenia, The psychosis high-risk state: a comprehensive state-of-the-art review, At risk for schizophrenic or affective psychoses? 5 Which of the following is not true regarding high-risk criteria? Several atypical antipsychotics have shown efficacy in reducing conversion rates in clinical high-risk patients (Schmidt Reference Schmidt, Schultze-Lutter and Schimmelmann2015). Mike received a few psychoeducation sessions, in which a crisis plan for future episodes was developed. "lang": "en" Anna's mother reports that Anna has been withdrawn, oppositional and argumentative for the past couple of years; she does not seem to care about anything anymore, and she hardly talks to her parents. 22q11DS , D2R BPND , DA , pHVA , pPRL , SPECT , uDA AU - Nelson, Barnaby. Therefore, current international guidelines (Schmidt Reference Schmidt, Schultze-Lutter and Schimmelmann2015; Addington Reference Addington, Addington and Abidi2017) recommend the least restrictive approach, i.e. Criteria have been developed that identify individuals at high risk of developing a psychotic disorder such as schizophrenia – the Ultra High Risk (UHR) criteria. UHR+ individuals were significantly more likely to become psychotic than UHR- individuals (Odds Ratio 19.3, 95% CI 2.5, 150.5). No eLetters have been published for this article. Hence, he meets criteria for BLIPS. More than a year ago she started to experience visual disturbances. Declining transition rates to psychotic disorder in “ultra-high risk” clients: Investigation of a dilution effect . AU - Yung, Alison. She has often contemplated suicide but has never tried to harm herself. "hasAccess": "1", 2005 Nov-Dec;39(11-12):964-71. doi: 10.1080/j.1440-1614.2005.01714.x. To be rated as basic symptoms, symptoms must be experienced with full insight (i.e. [Detection and early treatment of subjects at high risk of clinical psychosis: Definitions and recommendations]. COVID-19 is an emerging, rapidly evolving situation. AU - Killackey, Eoin. a their prognostic usefulness is dependent on referral practices, b the diagnostic instruments have a low sensitivity and high specificity and, hence, they are good predictors of a future transition to psychosis, c most patients who develop a psychotic disorder meet criteria for high risk in the prodromal phase, d patients meeting high-risk criteria often exhibit long-term functional impairments. a yes, because visual perception disturbances are one of the COPER criteria, b yes, because psychosis screening in adolescents should always be carried out by trained professionals, c no, not before you establish whether the time criterion for COPER (at least 12 months) is met, d no, because there is no subjective distress and therefore the general criteria for basic symptoms are not met. e no, not before you establish whether the symptom is substance-related. Although a causal relationship has not been conclusively established, several epidemiological studies suggest that regular or heavy cannabis use may increase the risk for the development of psychotic disorders over and above the effects of acute intoxication, especially in predisposed individuals, users of potent strains of cannabis or those with an early onset of use (Gage Reference Fusar-Poli, McGorry and Kane2016; Murray Reference Murray, Quigley and Quattrone2016). "subject": true, 2017 May;43(3):292-297. doi: 10.1016/j.encep.2017.01.005. abstract = "Introduction: The ultra high risk (UHR) for psychosis criteria have been validated in a number of studies. After reading this article you will be able to: • recognise signs and symptoms indicating increased psychosis risk, • understand uses and limitations of screening for high psychosis risk, and interpretation of results. Select the single best option for each question stem. After seeing a stranger on the bus, who appeared at his place of work to visit his manager 2 days later, he started noticing people on the street and being convinced that they were following him and talking about him. TABLE 1 Ultra-high-risk criteria and comparison of the Structured Interview for Prodromal Syndromes (SIPS) and Comprehensive Assessment of At-Risk Mental States (CAARMS). Two sets of criteria are used for diagnosis: ultra-high-risk and basic symptom criteria (Schultze-Lutter Reference Schultze-Lutter, Michel and Schmidt2015). Mike reported that he had fled home 3 days ago because he thought he was being persecuted. So far, there are no published studies on the clinical efficacy of CBD in high-risk or first-episode patients; however, a recent neuroimaging study of single-dose CBD in high-risk patients suggested a positive effect on the function of brain regions associated with the clinical high-risk state, such as the parahippocampal area, striatum and midbrain (Bhattacharyya Reference Bhattacharyya, Wilson and Appia-Kusi2018). "metrics": true, Ultra High Risk (UHR) status was determined at baseline and psychosis status was assessed at 6 month follow up. The use of ultra high risk (UHR) criteria in selected help‐seeking samples is the only clinical possibility to alter the course of psychosis by preventing its onset. BOX 4 Sets of criteria for diagnosis of high-risk state using basic symptoms on the Schizophrenia Proneness Instrument. "crossMark": true, psychological interventions, as the first-line treatment, while treatment with antipsychotics is reserved for patients who do not respond to psychological interventions or who show severe and/or progressive high-risk symptoms. Published online by Cambridge University Press:  Other potential causes of this reduction in transition are also explored. It is unclear, however, whether early neurodevelopmental trajectories are altered in UHR. Ultra high risk (UHR) for psychosis criteria: Are there different levels of risk for transition to psychosis? In the sample of 292 individuals, 119 (40.7%) met UHR criteria. In older adolescents, there are more similarities to clinical presentations of high risk in adults, but with a more fluctuating course (Schimmelmann Reference Schimmelmann, Conus and Cotton2007). BOX 7 Case vignette: Claire – clinical course of basic symptoms. The terms ‘clinical high risk’ and ‘at-risk mental state’ are used to describe signs and symptoms indicative of a high risk for psychotic disorders (Fusar-Poli Reference Fusar-Poli, Bechdolf and Taylor2013a). A notable exception is operationalisation of BLIPS: the SIPS includes an urgency exclusion criterion (symptoms associated with severe disorganisation or with danger to self and others are considered to exceed the threshold for psychosis irrespective of their duration), and thus some patients meeting this criterion in the CAARMS may be categorised as exhibiting a first psychotic episode in the SIPS (Fusar-Poli Reference Fusar-Poli, Díaz-Caneja and Patel2016a). When asked what she thinks causes the appearances, she says ‘there must be something wrong with my head’. Full text views reflects PDF downloads, PDFs sent to Google Drive, Dropbox and Kindle and HTML full text views. Yung AR, Nelson B, Stanford C, Simmons MB, Cosgrave EM, Killackey E, Phillips LJ, Bechdolf A, Buckby J, McGorry PD. Claire is a 17-year-old high school pupil. Of these UHR+ people, 12 became psychotic within 6 months and 107 did not. Handbook for Diagnosis and Follow-up, Effect of ω−3 polyunsaturated fatty acids in young people at ultrahigh risk for psychotic disorders: the NEURAPRO randomized clinical trial, Cannabidiol (CBD) as an adjunctive therapy in schizophrenia: a multicenter randomized controlled trial, Using clinical information to make individualized prognostic predictions in people at ultra high risk for psychosis, Course of clinical high-risk states for psychosis beyond conversion, European Archives of Psychiatry and Clinical Neuroscience, Traditional marijuana, high-potency cannabis and synthetic cannabinoids: increasing risk for psychosis, National Institute for Health and Care Excellence, Further examination of the reducing transition rate in ultra high risk for psychosis samples: the possible role of earlier intervention, NEURAPRO: a multi-centre RCT of omega-3 polyunsaturated fatty acids versus placebo in young people at ultra-high risk of psychotic disorders – medium-term follow-up and clinical course, Can we reduce the duration of untreated psychosis? The Ultra-High Risk (UHR) Criteria To meet UHR Criteria, clients must meet one of two impaired functioning criteria, experiencing either: † A … She had an extensive diagnostic assessment in which she was relieved to talk about her problems and to obtain professional help on how to cope with her cognitive disturbances and how to understand her perceptual disturbances. In the past few weeks, she has been experiencing increasingly distressing symptoms that occur at least once a week. Schizophrenia and schizophrenia spectrum disorders are one of the worldwide leading causes of chronic disability in young people (GBD 2016 Disease and Injury Incidence and Prevalence Collaborators 2017). Nelson, B, Yuen, HP, Lin, A, et al. AU - Cosgrave, Elizabeth. "peerReview": true, Anna is 16 years old and has dropped out of high school. In young children, the prevalence of psychotic symptoms such as auditory hallucinations may be as high as 9%, but more often than not they have no clinical relevance and remit spontaneously (Schimmelmann Reference Schimmelmann, Walger and Schultze-Lutter2013). In these cases, antipsychotic medication should be used to achieve sufficient clinical stability for psychosocial interventions; long-term preventive treatment with antipsychotics is currently not recommended (Schmidt Reference Schmidt, Schultze-Lutter and Schimmelmann2015). At the time of assessment, a week after the incident, Mike did not express any ideas of reference or persecutory delusion. MD, PhD, is a consultant psychiatrist and medical director of the Basel Early Treatment Service, University Psychiatric Clinics Basel, and an associate professor at the University of Basel, Switzerland. Several studies apply machine learning algorithms to large datasets in order to provide individualised estimates of transition risk (Klosterkötter Reference Klosterkötter, Ruhrmann and Schultze-Lutter2005; Schmidt Reference Schmidt, Cappucciati and Radua2017; NAPLS 2018; PRONIA 2018) or functional outcomes (Koutsouleris Reference Koutsouleris, Kambeitz-Ilankovic and Ruhrmann2018) in high-risk individuals. Basic symptoms are assessed using the Schizophrenia Proneness Instrument, which has separate adult (SPI-A) (Schultze-Lutter Reference Schultze-Lutter, Addington and Ruhrmann2007) and child and adolescent (SPI-CY) versions (Schultze-Lutter Reference Schultze-Lutter and Koch2010). These observations are relevant to treatment. Please enable it to take advantage of the complete set of features! medwireNews: About a third of people meeting the ultra-high-risk (UHR) criteria for psychosis will go on to develop a psychotic disorder, a study suggests. and However, after missing several therapy appointments, she was started on an antidepressant. "isLogged": "0", In this article we summarise the current criteria used to identify ‘at-risk’ individuals, such as the ultra-high-risk (UHR) criteria, and the further identification of important clinical risk factors or biomarkers to improve prediction of who might develop a psychotic disorder. a treatment in a specialised early intervention service. http://creativecommons.org/licenses/by/4.0/. Currently, there are two complementary approaches to characterizing the clinical-high risk state of psychosis : the ultra-high risk (UHR) and basic symptoms criteria. He reported smoking cannabis fairly regularly, about once or twice a week, but not in the week prior to the episode. Ultra-high-risk criteria require the presence of at least one of the following: (a) attenuated positive symptoms, i.e. Their frequency is sufficient for a diagnosis of attenuated psychotic symptoms, given that the symptoms have been present for less than a year. 2 The parents of a 13-year-old girl seek advice after she tells them that, if she concentrates hard, she can perceive the edges of a picture moving. The case vignettes are fictitious but based on our clinical experience. Background: The 22q11.2 deletion syndrome (22q11DS) is one of the highest known risk factors for schizophrenia. “Transition to psychosis” has been the outcome of interest in Ultra High Risk (UHR) and “prodromal” studies. Moreover, she experiences one perceptual basic symptom (visual perception disturbances). Ultra High Risk (UHR) status was determined at baseline and psychosis status was assessed at 6 month follow up. Validation of "prodromal" criteria to detect individuals at ultra high risk of psychosis: 2 year follow-up. BOX 2 Case vignette: Mike – diagnosis of brief limited intermittent psychotic symptoms (BLIPS). A few joint sessions with her parents were held to relieve family tensions. Query parameters: { Thus, low-threshold referral strategies and outreach campaigns targeting the general population may result in limited prognostic usefulness of specialised early assessment. people genuinely at risk may not be identified. Early detection is a crucial milestone in the prevention and treatment of schizophrenia spectrum psychosis, which might alter the course of schizophrenia. However, the point at which an individual crosses the line from high risk or prodromal state to psychosis threshold is arbitrary. Presence of at least one of the following symptoms for at least 12 months: • Decreased ability to discriminate between ideas and perception, fantasy and true memories. Anna reports seeing faces and shadows and hearing footsteps on the staircase, as well as a voice whispering her name, almost every day for the past 6 months. He felt threatened, especially after seeing a hearse driving by, so he went to the train station, jumped on the next departing train and spent 3 days travelling around. She is aware that her experiences are not real; she was not certain at first, but she tried to record the appearances with her mobile phone and she found out that she could not. The ultimate goal is the development of individualised ‘risk calculators’ (Cannon Reference Cannon, Yu and Addington2016; Fusar-Poli Reference Fusar-Poli, Rutigliano and Stahl2017a). Therefore, particular caution is advised when assessing children and young adolescents for early signs of psychosis, and interpretation and communication of results should be carried out by trained professionals experienced in psychosis risk screening (Schimmelmann Reference Schimmelmann, Walger and Schultze-Lutter2013). She also sometimes has the impression that people are talking about her or looking at her, although at the same time she knows that this is actually not possible. However, a recent meta-analysis (Davies Reference Davies, Cipriani and Ioannidis2018a) did not find any evidence favouring specific interventions over needs-based interventions for the prevention of transition to psychosis. Title: The Ultra High Risk Approach to Define Psychosis Risk VOLUME: 18 ISSUE: 4 Author(s):Alison R. Yung, Paolo Fusar-Poli and Barnaby Nelson Affiliation:Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Australia. Her research uses neuroimaging and pharmacological manipulations to investigate processes associated with psychotic symptom emergence and their implications for treatment. These benefits have been acknowledged by several national and international guidelines, which consider assessment by a specialised early intervention service as an integral part of early psychosis treatment (National Institute for Health and Care Excellence 2014; Schmidt Reference Schmidt, Schultze-Lutter and Schimmelmann2015; Addington Reference Addington, Addington and Abidi2017). "languageSwitch": true NLM Anna is currently being helped by a social worker to find a supported apprenticeship. UHR individuals have a risk of developing a full psychotic disorder of 15‐30% … There were no other relevant findings from his psychiatric or family history, physical examination, laboratory tests and neuropsychological evaluation. On the basis of this information only, should you refer them to a specialised early psychosis service for evaluation? "comments": true, However, it is not known whether particular UHR criteria (Attenuated Psychotic Symptoms (APS), Brief Limited Intermittent Psychotic Symptoms (BLIPS) or Trait vulnerability criteria), or combination of criteria, is associated with a higher risk of transition to psychosis. Get the latest public health information from CDC: https://www.coronavirus.gov. It should be noted that there are some differences in the way ultra-high-risk criteria are operationalised by the SIPS and CAARMS (Table 1). BOX 1 Case vignette: Anna – diagnosis of attenuated positive symptoms. "openAccess": "1", Feature Flags last update: Tue Dec 01 2020 21:06:02 GMT+0000 (Coordinated Universal Time) Because they do not necessarily coexist with ultra-high-risk symptoms, they are used in some centres, especially in German-speaking countries, to complement assessment of suspected high-risk individuals. Awareness of this fact has led to an increased focus on early detection and treatment of psychotic disorders, boosted by a seminal study that reported a prodromal phase with attenuated or unspecific symptoms and/or functional decline several years in advance of a first psychotic episode in the majority of patients (Häfner Reference Häfner, Maurer and Löffler1998). In the sample of 292 individuals, 119 (40.7%) met UHR criteria. Moreover, a recent telephone survey of adolescents reported a point prevalence for attenuated positive symptoms of around 13.8%, but in most cases these were not frequent enough to meet criteria for psychosis risk (Schultze-Lutter Reference Schultze-Lutter, Michel and Ruhrmann2017). Trials. BOX 5 Case vignette: Mike – clinical course of BLIPS. Anna suffers from visual and auditory hallucinations. Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. He returned home when he started feeling safe again. eCollection 2019. Gallinat, Jürgen Since then, she has had a few part-time jobs. 2008 Oct;105(1-3):10-7. doi: 10.1016/j.schres.2008.07.012. Mapping the onset of psychosis: the Comprehensive Assessment of At-Risk Mental States. Dimitrakopoulos S, Kollias C, Stefanis NC, Kontaxakis V. Michel C, Toffel E, Schmidt SJ, Eliez S, Armando M, Solida-Tozzi A, Schultze-Lutter F, Debbané M. Encephale. In the mid 1990 s criteria for identifying individuals at “ultra-high risk” (UHR) of psychotic disorder... 2. M. Jarrett *, L. Valmaggia, J. Parrott, A. Forrester, T. Winton-Brown, H. Maguire, D. Ndegwa, P. McGuire, T. K J Craig * Corresponding author for this work * Views captured on Cambridge Core between 06th March 2019 - 1st December 2020. It has been suggested that the declining transition risk may represent a ‘dilution effect’ due to the application of the clinical high-risk concept to unsuitable populations. It has long been acknowledged that timely treatment in the early stages of psychotic disorders can improve clinical and functional outcomes, prevent negative social consequences of psychosis such as social isolation, unemployment and homelessness, and reduce the risk of self-harm and violence (Oliver Reference Oliver, Davies and Crossland2018).  |  NCI CPTC Antibody Characterization Program. It has been established that the prognostic accuracy of high-risk criteria is strongly dependent on the pre-test risk of the population studied (Fusar-Poli Reference Fusar-Poli, Cappucciati and Rutigliano2015a), which is higher for help-seeking individuals referred to early intervention centres (15%) compared with, for example, primary care patients (0.045%) (Fusar-Poli Reference Fusar-Poli, Cappucciati and Rutigliano2015a, Reference Fusar-Poli, Cappucciati and Rutigliano2016b). 2019 Jan 25;9:758. doi: 10.3389/fpsyt.2018.00758. Subjects with ultra-high risk (UHR) states for psychosis show brain structural volume changes similar to first-episode psychosis and also elevated incidence of environmental risk factors like childhood trauma. Basic symptom criteria represent a distinct approach in the diagnosis of high psychosis risk, in that they only consider symptoms subjectively experienced (i.e. Schizophr Res. T1 - Testing the Ultra High Risk (prodromal) criteria for the prediction of psychosis in a clinical sample of young people. Although reality testing is intact, her experiences do cause some concern and have an impact on her sleep. "relatedCommentaries": true, The current study set out to test the predictive validity of these criteria in a sample of help-seeking young people aged 15-24 years who were referred to, but not necessarily treated at, a psychiatric service. Moritz, Steffen Prediction models of functional outcomes for individuals in the clinical high-risk state for psychosis or with recentonset depression: a multimodal, multisite machine learning analysis, Cannabidiol enhances anandamide signaling and alleviates psychotic symptoms of schizophrenia, Outcomes of nontransitioned cases in a sample at ultra-high risk for psychosis, The Psychosis-Risk Syndrome. He came to his follow-up appointments every 3–4 months for about a year and kept in touch over the telephone for another few months, but he did not feel the need to make any further appointments. The UHR paradigm can additionally reduce the duration of untreated psychosis 1 and provide extended benefits to patients who are experiencing a first episode of psychosis 2 . Mike, a 19-year-old apprentice carpenter with no previous psychiatric history, was referred for emergency psychiatric assessment by his general practitioner after receiving a fine for fare evasion. 2019. Introduction. Colours of objects seem brighter, and she feels that she cannot always rely on her perception of distance or movement; for example, sometimes she thinks objects are moving, although in reality they are not. Both instruments include a cut-off threshold for the definition of overt psychosis based on symptom frequency, duration and severity. }. It should always be kept in mind that the diagnostic instruments mentioned above have high sensitivity (96%) but only modest specificity (47%) (Fusar-Poli Reference Fusar-Poli, Cappucciati and Rutigliano2015a), and thus are more useful in ruling out psychosis risk than in predicting an actual future transition to psychosis (Fusar-Poli Reference Fusar-Poli, Cappucciati and Rutigliano2016b). 2019 Oct;140(4):360-370. doi: 10.1111/acps.13078. Her mood improved somewhat, suicidal ideation disappeared and she was able to keep her appointments more reliably. The most widely used psychometric instruments for diagnosis of ultra-high-risk criteria to date are the Structured Interview for Prodromal Syndromes (SIPS) (McGlashan Reference McGlashan, Walsch and Woods2010) and the Comprehensive Assessment of At-Risk Mental States (CAARMS) (Yung Reference Yung, Yung and Pan Yuen2005). The present review aims to provide a summary of major terms, concepts and recommendations with respect to diagnosis and treatment of such individuals. Long-term follow-up of a group at ultra high risk ("prodromal") for psychosis: the PACE 400 study. Reininghaus U, Klippel A, Steinhart H, Vaessen T, van Nierop M, Viechtbauer W, Batink T, Kasanova Z, van Aubel E, van Winkel R, Marcelis M, van Amelsvoort T, van der Gaag M, de Haan L, Myin-Germeys I. USA.gov. Her mother arranged an appointment at an early psychosis service, after searching information about her daughter's symptoms online. Although most studies so far have focused on transition to psychosis as the major outcome of interest in high-risk individuals, more recent research indicates that other clinical measures may also be meaningful and relevant to treatment. As detailed above, patients screening positive for clinical high risk for psychosis experience significant distress and often functional impairment as well, irrespective of whether they will convert to psychosis or not. Because she experiences these symptoms as a deviation from her usual state and they cause her distress, they meet the general criterion for basic symptoms. BOX 6 Case vignette: Anna – clinical course of attenuated positive symptoms. 1. The intervention period was 12 weeks. Methods: We conducted a post hoc subgroup analysis of a double-blind, randomized controlled trial. Clipboard, Search History, and several other advanced features are temporarily unavailable. full-blown positive symptoms that spontaneously remit after a short time (case vignette: Box 2); and (c) genetic high risk accompanied by functional decline (see Table 1 for detailed definitions and criteria). Mike suffered from full-blown psychotic symptoms (complete loss of reality testing) but they lasted less than a week and remitted spontaneously and fully without antipsychotic treatment. 2020 May 26:10.1007/s00406-020-01143-w. doi: 10.1007/s00406-020-01143-w. Online ahead of print. Almost three decades have passed since the introduction of operationalised criteria for the identification of individuals at high risk for psychosis. A number of studies investigating the clinical course of high-risk patients who do not transition to psychosis indicate that at least a third of these individuals persistently or recurrently experience attenuated psychotic symptoms in the long term (Simon Reference Simon, Borgwardt and Riecher-Rössler2013; Michel Reference Michel, Ruhrmann and Schimmelmann2018). Reference Jaaskelainen, Juola and Hirvonen, Reference Fusar-Poli, Bechdolf and Taylor, Reference Schultze-Lutter, Michel and Schmidt, Reference Fusar-Poli, Díaz-Caneja and Patel, Reference Klosterkötter, Schultze-Lutter and Bechdolf, Reference Schultze-Lutter, Addington and Ruhrmann, Reference Fusar-Poli, Borgwardt and Bechdolf, Reference Fusar-Poli, Cappucciati and Rutigliano, Reference Schimmelmann, Walger and Schultze-Lutter, Reference Schultze-Lutter, Michel and Ruhrmann, Reference Ruhrmann, Schultze-Lutter and Salokangas, Reference Klosterkötter, Ruhrmann and Schultze-Lutter, Reference Koutsouleris, Kambeitz-Ilankovic and Ruhrmann, Reference Fusar-Poli, Rutigliano and Stahl, Reference Studerus, Ramyead and Riecher-Rössler, Reference Simon, Borgwardt and Riecher-Rössler, Reference Michel, Ruhrmann and Schimmelmann, Reference Schmidt, Schultze-Lutter and Schimmelmann, Reference van der Gaag, Smit and Bechdolf, Reference Bhattacharyya, Wilson and Appia-Kusi, Reference Fusar-Poli, Frascarelli and Valmaggia, Reference Amminger, Schäfer and Papageorgiou, Reference Amminger, Schäfer and Schlögelhofer, Canadian treatment guidelines for individuals at clinical high risk of psychosis, Long-chain omega-3 fatty acids for indicated prevention of psychotic disorders: a randomized, placebo-controlled trial, Longer-term outcome in the prevention of psychotic disorders by the Vienna omega-3 study, Effect of cannabidiol on medial temporal, midbrain, and striatal dysfunction in people at clinical high risk of psychosis: a randomized clinical trial, The effects of cannabidiol (CBD) on cognition and symptoms in outpatients with chronic schizophrenia a randomized placebo controlled trial, An individualized risk calculator for research in prodromal psychosis, Can antidepressants be used to treat the schizophrenia prodrome? C.A. For example, it has been suggested that attenuated psychotic symptoms may also occur in the context of other clinical disorders, such as depressive and anxiety disorders, as a sign of increased severity (van Os Reference van Os and Guloksuz2017); in such patients, treatment of the primary disorder might lead to remission from the high-risk state. Yung AR, Yuen HP, McGorry PD, Phillips LJ, Kelly D, Dell'Olio M, Francey SM, Cosgrave EM, Killackey E, Stanford C, Godfrey K, Buckby J. Aust N Z J Psychiatry. The Royal College of Psychiatrists 2019. In the past few months, she has been spending most of her time at home watching TV and sleeping. While reading books, for example, she noticed that she does not understand the meaning of words and passages as effortlessly as before and needs to reread them. Although individual results vary, greater severity of psychosis risk symptoms at baseline appears to be a consistent predictor of increased transition risk (Mechelli Reference Mechelli, Lin and Wood2017). a prodromal phase of attenuated psychotic symptoms and functionalimpairment(2).Individualsmeetingstandardized criteria for this phase have an ultra high risk for developing a psychotic disorder, in most cases schizophrenia (3). She agreed on regular monthly follow-ups in order to reassess her disturbances. Early Identification and Intervention of Schizophrenia: Insight From Hypotheses of Glutamate Dysfunction and Oxidative Stress. A systematic review and meta-analysis of controlled interventional studies, Clinical trajectories in the ultra-high risk for psychosis population, Prediction of psychosis in adolescents and young adults at high risk: results from the prospective European prediction of psychosis study, Pre-treatment, baseline, and outcome differences between early-onset and adult-onset psychosis in an epidemiological cohort of 636 first-episode patients, The significance of at-risk symptoms for psychosis in children and adolescents, EPA guidance on the early intervention in clinical high risk states of psychoses, Improving prognostic accuracy in subjects at clinical high risk for psychosis: systematic review of predictive models and meta-analytical sequential testing simulation, Schizophrenia Proneness Instrument, Adult Version, Früherkennung und Frühbehandlung von Psychosen, Schizophrenia Proneness Instrument, Child & Youth Version (SPI-CY), EPA guidance on the early detection of clinical high risk states of psychoses, Prevalence and clinical relevance of interview-assessed psychosis-risk symptoms in the young adult community, Moving beyond transition outcomes: meta-analysis of remission rates in individuals at high clinical risk for psychosis, Prediction of transition to psychosis in patients with a clinical high risk for psychosis: a systematic review of methodology and reporting, Preventing a first episode of psychosis: meta-analysis of randomized controlled prevention trials of 12 month and longer-term follow-ups, A critique of the “ultra-high risk” and “transition” paradigm, NMDAR-based treatments for patients at clinical high risk for psychosis, Mapping the onset of psychosis: the comprehensive assessment of at-risk mental states, Australian and New Zealand Journal of Psychiatry. 06 March 2019. Does hallucination perceptual modality impact psychosis risk? AU - McGorry, Patrick D. PY - 2006/5. Epub 2017 Mar 25. Anna was diagnosed with a major depressive episode. AU - Phillips, Lisa. Additionally, presumed genetic risk … personality disorder (BPD) who also meet ultra-high risk criteria for psychosis. BOX 3 Case vignette: Claire – diagnosis of basic symptoms. Baseline psychosocial functioning was also assessed as a possible predictor of psychosis. Although about 40% of patients can be described as having a good symptomatic outcome, impairments in everyday functioning often persist even with successful pharmacological treatment of psychotic symptoms (Emsley Reference Emsley2009); only about 1 in 7 patients experience ‘true’ recovery, i.e. Dopamine in high-risk populations: A comparison of subjects with 22q11.2 deletion syndrome and subjects at ultra high-risk for psychosis. The UHR criteria combine the risk factor of age (adoles-cence to early adulthood) with clinical, state and trait factors identified as precursors to psychotic illness [22]. They also have high rates of risk factors for psychiatric morbidity and yet they are among the populations who are less likely to seek help in the community. Prediction and prevention of schizophrenia: what has been achieved and where to go next? This data will be updated every 24 hours. National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. JAMA Psychiatry. Apart from antipsychotics, other pharmacological or neuroprotective agents have shown promise in the treatment of high-risk patients, particularly N-methyl-d-aspartate (NMDA) receptor modulators such as d-serine and glycine for the treatment of positive and negative symptoms (Woods Reference Woods, Kantrowitz and Javitt2014; Dong Reference Dong and Haschimoto2015) and antidepressants for prevention of psychotic transitions (Cornblatt Reference Cornblatt, Lencz and Smith2007; Fusar-Poli Reference Fusar-Poli, Frascarelli and Valmaggia2015b); however, further evidence is needed before a reliable recommendation can be provided. symptoms such as hallucinations and delusions that occur in the presence of more or less intact reality testing (case vignette: Box 1); (b) brief limited intermittent psychotic symptoms (BLIPS), i.e. has received non-financial support from Sunovion and Lundbeck in the past 36 months. She was prescribed quetiapine 50 mg/day 3 weeks ago, but she did not notice any improvement. Thus, the detection of 22q11DS patients at particularly high risk of psychosis is important, yet studies on the clinical significance of the widely used ultra-high risk … } The ultra‐high risk (UHR) criteria were defined to identify young people at high and imminent risk of developing a first episode of psychosis 1. He was advised to abstain from cannabis, but he continued smoking it occasionally. The criteria have now been in use worldwide for over 20 years and have shown predictive validity for psychotic disorders across different countries and service settings. At times, she loses her train of thought or her mind is flooded by insignificant thoughts, which makes it impossible to concentrate. In the sample of 292 individuals, 119 (40.7%) met UHR criteria. Close this message to accept cookies or find out how to manage your cookie settings. This site needs JavaScript to work properly. a Orygen, The National Centre of Excellence in Youth Mental Health, University of Anna dropped out of school at the age of 15 after failing eighth grade (UK year 9) twice. 4 Which of the following are evidenced-based treatments for high-risk patients? However, they make her afraid, and she cannot sleep at night. Front Psychiatry. In its guidance on the early detection of the high-risk state, the European Psychiatric Association acknowledges that substantial pre-assessment ‘risk enrichment’ is needed for early intervention services to have clinical utility, and suggests that the above criteria for assessment of high risk for psychosis should only be applied to individuals already distressed by mental problems and seeking help for them, or to those seeking clarification of their current risk in the context of, for example, a genetic predisposition for psychotic disorders (Schultze-Lutter Reference Schultze-Lutter, Michel and Schmidt2015). Anna describes a growing sense of hopelessness and worthlessness; in the past few weeks, she has had little energy and spent most of her time at home watching TV and sleeping. 2019 Dec 26;20(1):769. doi: 10.1186/s13063-019-3912-4. The UHR criteria use the risk factor of age (adolescence and young adulthood), given that this is the age range of highest incidence of psychotic disorders,20 combined with clinical risk factors, such as functional decline and prodromal symptoms, particularly those that occur close to the onset of frank psychosis, such as APS and isolated psychotic symptoms. A meta-analysis of the prognostic accuracy of psychometric interviews for psychosis prediction, Antidepressant, antipsychotic and psychological interventions in subjects at high clinical risk for psychosis: OASIS 6-year naturalistic study, Towards a standard psychometric diagnostic interview for subjects at ultra high risk of psychosis: CAARMS versus SIPS, Predicting the onset of psychosis in patients at clinical high risk: practical guide to probabilistic prognostic reasoning, Services for people at high risk improve outcomes in patients with first episode psychosis, Development and validation of a clinically based risk calculator for the transdiagnostic prediction of psychosis, Improving outcomes of first-episode psychosis: an overview, Association between cannabis and psychosis: epidemiologic evidence, GBD 2016 Disease and Injury Incidence and Prevalence Collaborators, Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016, The ABC schizophrenia study: a preliminary overview of the results, Social Psychiatry and Psychiatric Epidemiology, A systematic review of the antipsychotic properties of cannabidiol in humans, A systematic review and meta-analysis of recovery in schizophrenia. a the majority of these patients will experience a psychotic episode in the future, b psychosis risk in these patients is substantially increased compared with the general population, c many of these patients suffer from other psychiatric disorders such as depression. This article summarises criteria for a diagnosis of high psychosis risk, the implications for such a diagnosis and recommendations for treatment. Is there a role for cannabidiol in psychiatry? BOX 8 Dos and don'ts in clinical practice, • Refer for specialist assessment and treatment early when you suspect high risk for psychosis, • Offer treatment for any depression, anxiety or substance misuse, and psychosocial support, • Be optimistic – keep in mind that only about a third of high-risk patients will make the transition to psychosis, • Screen for psychosis risk if the individual is not distressed by mental problems, unless they are seeking advice on their current risk in the context of a genetic predisposition, • Communicate suspicions of high psychosis risk to children and adolescents or their families: interpretation of screening results in this age group is complicated and should be left to trained professionals with expertise in high-risk diagnosis, • Use antipsychotics for subthreshold symptoms, or symptoms of unconfirmed severity, before exploring other options. Of these UHR+ people, 12 became psychotic within 6 months and 107 did not. Two-Year Clinical and Functional Outcomes of an Asian Cohort at Ultra-High Risk of Psychosis. Ultra High Risk (UHR) status was determined at baseline and psychosis status was assessed at 6 month follow up. Of these UHR+ people, 12 became psychotic within 6 months and 107 did not. This may be a due to the sample being a more general one, not identified as possibly "prodromal". the emphasis is on the patient's distress rather than observation by others) (case vignette: Box 3). "This is an important finding given the doubt expressed recently about the predictive value of the concept," write lead researcher Barnaby Nelson (University of Melbourne, Victoria, Australia) and colleagues in JAMA Psychiatry. 2013 Aug;70(8):793-802. doi: 10.1001/jamapsychiatry.2013.1270. Several studies have investigated whether specific combinations of prodromal symptoms are predictive of increased transition risk. Promising results that were initially obtained for omega-3 fatty acids (Amminger Reference Amminger, Schäfer and Papageorgiou2010, Reference Amminger, Schäfer and Schlögelhofer2015) could not be replicated in a larger randomised controlled trial (McGorry Reference McGorry, Nelson and Markulev2017; Nelson Reference Nelson, Amminger and Yuen2018). MD, PhD, is a senior consultant psychiatrist and head of the Basel Early Treatment Service, Professor of Neuropsychiatry at the University of Basel, and a visiting professor at the Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, UK. Prisoners have high rates of psychosis and other severe mental health (MH) problems. Younger age is included in the UHR criteria as it corre-sponds to the highest incidence for psychosis [23,24]. Render date: 2020-12-01T21:25:14.151Z Three types of psychotic-like experiences in youth at clinical high risk for psychosis. From the above figures it becomes clear that, although these patients are at considerably higher risk for the development of a psychotic disorder than the general population, approximately two-thirds of them will not develop such a disorder. Criteria for identifying individuals at imminent risk for onset of a psychotic disorder, that is "prodromal" for psychosis, have recently been described. Heinz, Andreas Background: Traditionally, research in the ultra-high risk (UHR) for psychosis population has focused on the treatment of existing symptomatology and prevention of transition to psychosis. Niles HF, Walsh BC, Woods SW, Powers AR 3rd. HHS NIH Quetiapine was discontinued, and she was offered psychoeducation about attenuated positive symptoms and cognitive–behavioural therapy. Only one person not meeting UHR criteria developed psychosis in the follow up period. for this article. Harvey, P. D. & Strassnig, M. Predicting the severity of everyday functional disability in people with schizophrenia: cognitive deficits, functional capacity, symptoms, and health status. Total loading time: 0.951 Ultra High Risk for Psychosis Led by Professor Barnaby Nelson, the Ultra High Risk (UHR) for Psychosis Research focuses on young people who may be at increased risk of going on to develop schizophrenia and other psychotic disorders. In the present study, we (1) assessed the clinical relevance of a UHR diagnosis [according to the comprehensive assessment of at-risk mental states (CAARMS) criteria] to promote the implementation of specific services for UHR adolescents into the Italian health care system; (2) described severity of positive, negative, general, and basic symptoms in UHR adolescents compared to adolescents with … Meeting criteria for brief limited intermittent psychotic symptoms at intake was associated with lower risk for persistent or recurrent disorder. duals at ‘ultra-high risk’ of developing psychosis [21,22]. (2016) Further examination of the reducing transition rate in ultra high risk for psychosis samples: the possible role of earlier intervention. In the late 1990s, operationalised criteria were developed to identify individuals at increased risk for psychotic disorders. Clinical experience and a large number of studies have established the usefulness of the concept of high psychosis risk and led to its inclusion in international guidelines. Two partially overlapping criteria sets are used for diagnosis of the high-risk state (Schultze-Lutter Reference Schultze-Lutter and Ruhrmann2008) (Box 4). Early psychotic experiences: Interventions, problems and perspectives.  |  Moreover, patients meeting both ultra-high-risk and basic symptom criteria have been reported to be at increased transition risk compared with those meeting only one set of criteria (Ruhrmann Reference Ruhrmann, Schultze-Lutter and Salokangas2010). e subjective disturbance of receptive speech. Sensitivity, specificity, positive predictive value and negative predictive value of UHR+ status for prediction of psychosis were, respectively, 0.923 (95% CI 0.621, 1), 0.616 (95% CI 0.556, 0.673), 0.101 (95% CI 0.056, 0.173) and 0.994 (95% CI 0.963, 1). Ap-proximately 35% of high-risk persons will develop a psy-chotic disorder within 24 months (4). AU - Yung, Alison R. AU - Stanford, Carrie. Baseline psychosocial functioning was also assessed as a possible predictor of psychosis. Assessment and treatment of individuals at high risk... Prognostic considerations – how to interpret a clinical high-risk diagnosis. Early detection and specialised early intervention for people at high risk for psychotic disorders have received growing attention in the past few decades, with the aim of delaying or preventing the outbreak of explicit psychotic symptoms and improving functional outcomes. However, available meta-analyses suggest that treatment with antipsychotics is not superior to psychological interventions in terms of conversion rates (Schultze-Lutter Reference Schultze-Lutter, Michel and Schmidt2015; Davies Reference Davies, Cipriani and Ioannidis2018a), reduction of attenuated positive symptoms (Davies Reference Davies, Radua and Cipriani2018b; Devoe Reference Devoe, Farris and Townes2019) or functional outcomes (Schmidt Reference Schmidt, Schultze-Lutter and Schimmelmann2015). World Psychiatry 11, 73–79 (2012). Claire had an appointment with an early psychosis detection service after she talked to the school social worker about her very distressing experiences. eCollection 2018. Epub 2008 Sep 2. This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (, Copyright © The Royal College of Psychiatrists 2019, Hostname: page-component-79f79cbf67-nqzjh the time between onset of symptoms and the beginning of treatment) (Oliver Reference Oliver, Davies and Crossland2018) and reduce the need for in-patient treatment and compulsory admissions (Fusar-Poli Reference Fusar-Poli, Díaz-Caneja and Patel2016c). Presence of least two of the following symptoms in the past 3 months: • Captivation of attention by details of the visual field, Cognitive-perceptual disturbances (COPER). A meta-analysis of DSM/ICD diagnostic outcomes in individuals at high clinical risk, At risk or not at risk? Jessica A. Hartmanna, Hok Pan Yuena, Patrick D. McGorrya, Alison R. Yunga,b, Ashleigh Linc, Stephen J. Woodd,e, Suzie Lavoiea, Barnaby Nelsona . GAF, Global Assessment of Functioning; SOFAS, Social and Occupational Functioning Assessment Scale. At the heart of the UHR criteria are the presence of subthreshold psychotic symptoms and age in adolescence or young adulthood. Eur Arch Psychiatry Clin Neurosci. As in the CAARMS, the SIPS includes precisely defined criteria for the UHR state (the Criteria of Prodromal Syndromes, COPS) and for the psychosis‐threshold (Presence … Chan CT, Abdin E, Subramaniam M, Tay SA, Lim LK, Verma S. Front Psychiatry. View all Google Scholar citations Her main area of interest is the multidisciplinary assessment and treatment of young patients in the early stages of psychotic disorders, and she has worked in early psychosis projects in Switzerland, Australia and Denmark. the CAARMS before assessing psychosis risk, either through their headspace centre or through a training organisation. Efficacy of Acceptance and Commitment Therapy in Daily Life (ACT-DL) in early psychosis: study protocol for a multi-centre randomized controlled trial. Acta Psychiatr Scand. She reported feeling less frightened by her hallucinations and later that they had disappeared altogether. as a change from the individual's usual state) and cause significant subjective distress. 3 Which of the following statements regarding clinical high risk for psychosis is correct? There have been few attempts to Feature Flags: { e they should be interpreted with caution in children and adolescents. Gawęda, Łukasz However, clinicians should be aware of the limitations of psychosis risk assessment and the particularities of treatment in high-risk individuals (Box 7); early referral to a specialised early intervention service will be advantageous in most cases. Therefore, both high-risk and first-episode patients should be encouraged to reduce or abstain from cannabis use. The European Prediction of Psychosis Study (EPOS): integrating early recognition and intervention in Europe. Moreover, cannabis use has been related to worse symptomatic outcomes and accelerated loss of grey matter volume in individuals with schizophrenia (Iseger Reference Iseger and Bossong2015). The probability of psychotic transition in individuals meeting high-risk criteria has been estimated to be about 36–37% in recent meta-analyses and appears to reach its peak in the first 2–3 years of follow-up (Fusar-Poli Reference Fusar-Poli, Bechdolf and Taylor2013a; Schultze-Lutter Reference Schultze-Lutter, Michel and Schmidt2015); most of these individuals will develop a schizophrenia spectrum disorder (Fusar-Poli Reference Fusar-Poli, Borgwardt and Bechdolf2013b). Get the latest research from NIH: https://www.nih.gov/coronavirus. We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Y1 - 2006/5 Nelson B, Yuen HP, Wood SJ, Lin A, Spiliotacopoulos D, Bruxner A, Broussard C, Simmons M, Foley DL, Brewer WJ, Francey SM, Amminger GP, Thompson A, McGorry PD, Yung AR. Claire experiences several cognitive basic symptoms: disturbance of receptive and expressive speech, thought interference, thought blockage, unstable ideas of reference. Fifteen adolescents with BPD (mean age 16.2 years, [SD 2.1]) were randomized to either 1.2 g/day n-3 PUFAs or placebo. Conclusions: Individuals at ultra-high risk for psychosis who do not transition to psychosis are at significant risk for continued attenuated psychotic … Specialised early intervention services work towards these goals by adopting an integrated multidisciplinary approach that typically includes a combination of elements such as symptom monitoring and management, improvement of social skills and cognition, psychoeducation, treatment of comorbidities, crisis management, family intervention and support, and psychosocial support for housing, educational or vocational problems (case vignettes: Box 5, Box 6, Box 7). She also has difficulty finding the right words and putting them in order to make meaningful sentences. "metricsAbstractViews": false, The transition to psychosis rate was much lower than in previous samples. Schizophrenia Research , 174 : 43 –9. 2019 Feb 27;10:93. doi: 10.3389/fpsyt.2019.00093. Two small randomised controlled studies have suggested that CBD might be effective in the treatment of positive symptoms in individuals with schizophrenia (Leweke Reference Leweke, Piomelli and Pahlisch2012; McGuire Reference McGuire, Robson and Cubala2018), but a third study failed to replicate these findings (Boggs Reference Boggs, Surti and Gupta2018). All of these effects appear to be mediated by tetrahydrocannabinol (THC) (Iseger Reference Iseger and Bossong2015; Gage Reference Fusar-Poli, McGorry and Kane2016). Method. Apart from symptoms, variables such as environmental, cognitive, neuroimaging and electrophysiological measures (Fusar-Poli Reference Fusar-Poli, Borgwardt and Bechdolf2013a; Schmidt Reference Schmidt, Cappucciati and Radua2017) have also been suggested to be useful in predicting psychotic transitions. Interestingly, the observed negative consequences of THC do not extend to cannabidiol (CBD), which instead has been suggested to have antipsychotic effects (Iseger Reference Iseger and Bossong2015; Khoury Reference Khoury, Neves and Roque2017).
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