We introduced this series with a case study about 17 year-old Roger. If you missed that post, you can find it here. In Part 1, we reviewed base rates of psychosis and psychotic-like experiences. Based on that information, it is clear that we have a high level of concern about Roger. Let's now look at the usual course of emerging psychosis, and then turn to other risk factors he may be displaying.
In thinking about Roger, it may be helpful to compare his course to the "typical" prodromal course (as a reminder, the "prodrome" is the period of attenuated symptoms and decline in functioning that precedes overt psychosis). Of course, not all individual who develop psychosis follow this course. However, the most common pattern you see is:
Early Childhood: ASD-like symptoms emerge. Child may have trouble making friends, seem socially withdrawn or "in his own world", have difficulty separating fantasy from reality, and struggle with conversation.
Ages 12-15: Child begins experiencing more school and social failure. Increased attention problems are often seen. Child may be diagnosed with ADHD at this time if this diagnosis has not already been provided.
Next 3-5 years: There is a general decline in functioning. This is usual due to the emergence of at-least attenuated negative symptoms, such as a loss of motivation, anhedonia, and volition. The adolescent may complain of confusion or adults may notice he seems confused. Anxiety and mood issues may emerge. Atypical thinking, magical thinking, and odd perceptions may emerge. These are usually subthreshold positive symptoms.
Ages 17-23: This is the most common age range for the emergence of overt positive symptoms like hallucinations or delusions. Suicidal behavior and substance abuse are also common during this period.
Some researchers summarize this as the "CASES" symptom trajectory, with CASES standing for:
Cognitive
Affective
Social Isolation
Educational Failure
Subthreshold Positive Symptoms
Here's a nice graph of the typical prodrome from age 12 onward, from the CEDAR early intervention clinic in Massachusetts, showing the "CASES" trajectory of symptom evolution.
We can see Roger's course follows the typical "CASES" pattern. What other risk factors do we see for him?
Specifically, let's look at what the research shows are the list of risk factors for emerging thought disorders in adolescence (approximate prevalence in parentheses):
History of ADHD (very common; ADHD is often the first diagnosis)
Autism or ASD-like symptoms (present in the histories of up to 50%, especially in those with earlier onset)
OCD-like symptoms (~25-33%, usually a means of trying to organize perceptual distortions). Note: In my experience, obsessions are often uncommon ones and relate to a disturbance in what the teen would be hearing or seeing, rather than related to pure safety/cleanliness/purity/ symmetry concerns. E.g., obsessions of seeing/feeling spiders/insects are very common. Odd rituals and atypical eating behavior are also commonly reported in the research literature.
Depression (~50%) and suicidal behavior
History of trauma (~25%)
Substance abuse (at least 50%, probably much more)
History of prenatal complications, prematurity (raises risk), and vague developmental delays (extremely common)
Decline in functioning/functional impairment (required for diagnosis)
On an antipsychotic medication. [Of course, many antipsychotics are used off-label for a variety of concerns, but it is worth noting if there is a positive response to antipsychotic medication.]
Sleep difficulties (extremely common)
Psychotic-like experiences such as perceptual distortions (e.g., seeing things slightly incorrectly; over- or under-reactivity to sensory stimuli; feeling odd sensations) or magical thinking (very common prodromal symptom)
As in most cases, we also do not have any significant "red flags" suggesting that there is a medical etiology for Roger's symptoms. Routine medical work-up is recommended in all cases of suspected First Episode Psychosis. However, extensive medical work-up is generally not recommended.
One reason extensive medical work-up is not usually recommended in cases of suspected psychosis is that only about 3% of psychoses are attributable to medical causes. Another reason extensive medical work-up is not recommended is because of the high risk of incidental findings. For example, half of all individuals with new-onset psychosis referred for medical work-up have EEG abnormalities of unclear significance. In addition, research suggests about 20% of individuals with new-onset psychosis show incidental and non-clinically meaningful MRI findings. Extensive medical work-up is usually only recommended if:
The individual's presentation is highly atypical - for example, organic causes are more likely when the individual has visual, olfactory, or gustatory hallucinations
Onset is very sudden onset, or
The individual does not respond to standard treatment
The potential medical causes are vast. I refer you to Algon et al (2012) for a nice review of many of these potential causes. Here's a table taken from their article as a general reference:
While the list above is relatively exhaustive, it will be helpful to keep in mind that in general, the most likely medical causes of an acute psychotic state are:
Febrile
Drug/toxicity-induced
Neoplastic
Encephalitic
The most likely causes for episodic or fluctuating PLEs are:
Epilepsy
Migraine
Sleep disorders
Let's assume that Roger has had routine medical evaluation and there is no known medical etiology for his symptoms. So far, his symptoms have followed the typical course for an emerging psychotic disorder. If this is a psychotic disorder, looking ahead, what might the future look like for him?
The first 5 years after the emergence of a psychotic disorder is called the Critical Period. Research shows (and here I'll again refer you to Chan 2011) that:
About 75% of individuals have 8 or more weeks of remission or recovery during this period - that is, remission the normal and expected outcome in psychotic disorders
About 30% of individuals only ever have one episode of psychosis in their lifetime
About 60-70% experience relapse, with first relapse usually occurring within the critical period
Negative symptoms can become more debilitating during this critical period and should be the primary focus of treatment
In the 10 years following the critical period, for the 60-70% of individuals who experience relapse, symptoms tend to plateau. In most cases, the illness does not become progressively deteriorating. About half of the individuals who experiencing symptoms during this decade have a relapsing/remitting course with periods of remission or recovery, and about half do not experience substantial periods of remission or recovery.
Altogether, that means that about 2/3 of people who experience an episode of psychosis experience temporary or permanent recovery from their illness.
When looking at outcome, let's review some of the positive and negative prognostic factors. For the favorable indicators, here's a handy table which I got from Chan (2011) and which she got from Lehman et al (2004), which saves me the trouble of having to type them up myself. That is, favorable prognostic indicators of schizophrenia include:
Based on my reading of the research, here is a list of some factors that increase the risk for a negative outcome, many of which are the opposite of the positive prognostic indicators above. Negative prognostic indicators of schizophrenia include:
Poor premorbid history
Insidious onset
No precipitating stressor
Significant negative symptoms
Earlier onset
Lower baseline premorbid functioning
Unremitting course
Immediate family member with schizophrenia
Stressful environment (e.g., urban area)
Family high in Expressed Emotion
The last item on that list, Expressed Emotion, deserves a little extra attention. Expressed Emotion (EE) is one of the most robust predictors of relapse in schizophrenia. Expressed Emotion is a pattern of family interactions that includes:
Criticism
Hostility, and
Emotional over-involvement
As summarized in Amaresha, A. C., & Venkatasubramanian, G. (2012). Expressed emotion in schizophrenia: an overview. Indian journal of psychological medicine, 34(1), 12–20:
"Like many other environmental stressors, EE behaviors are not pathological or unique to families of mental disorders, but they can cause relapse of psychiatric symptoms among people with a vulnerability to stress."
Given all this information above, it becomes clear that the most important early components of assessments of possible psychotic disorders are:
Assessment of the possible prodromal course and trajectory
Assessment of the social, emotional, neurocognitive, and other symptoms that often precede or accompany emerging psychotic disorders
Awareness of the "red flags" that should result in a medical referral
Assessment of the individual and environmental risk factors that could predict favorable or unfavorable course
Specific assessment of family functioning
Knowledge of the typical course of psychotic disorders so that you can better support the family and treatment team through the provision of clear and accurate information
Based on what you know about Roger so far, what risk factors for favorable or unfavorable prognosis are you already seeing? What do you still need to assess?
So far, we have been looking at symptoms that are common in individuals at ultra high risk for psychosis, but which are not specific to psychosis. Let's move on to Part 3, where we review the specific positive, negative, and disorganized symptoms of psychotic disorders.
