Young people at ultra high risk for psychosis: research from the PACE clinic

Abstract

Over the last fifteen years, attempts have been made to prospectively identify individuals in the prodromal phase of schizophrenia and other psychotic disorders. The ultra high risk approach, based on a combination of known trait and state risk factors, has been the main strategy used. The validation of the ultra high risk criteria allowed for predictive research in this population in an attempt to identify clinical, neurocognitive and neurobiological risk factors for psychosis onset. It also led to a series of intervention studies in this population, which have included the use of low dose antipsychotic medication, cognitive therapy, and omega-3 fatty acids. Although there is moderate evidence for the effectiveness of specific intervention strategies in this population, the most effective type and duration of intervention is yet to be determined. A current controversy in the field is whether to include an adaption of the ultra high risk criteria (the attenuated psychosis syndrome) in the next version of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).

Circadian rest–activity rhythm in individuals at risk for psychosis and bipolar disorder

“…Furthermore, in the prodromal phases, definitive predictions of the clinical expression of the syndromal stage are not possible (Yung et al, 2008). Attenuated positive symptoms occur in the prodromal phases of both schizophrenia and bipolar disorder (Angst, 2002;Bechdolf et al, 2010;Yung and McGorry, 1996;Yung and Nelson, 2011), and mood symptoms can also occur in both conditions (Tohen et al, 2003). Such attenuated positive symptoms are compatible with data that support a considerable degree of overlap in the neurobiology and genetic susceptibility for both disorders (Ivleva et al, 2008).…”

Values and DSM-5: looking at the debate on attenuated psychosis syndrome

“…Thus, the new category proposal was reconsidered as a mental disorder per se. It was renamed APS, according to the term assigned to one subgroup of patients identified by the high-risk mental state research criteria [ 18 ]. Although other sets of high-risk criteria existed, most at-risk patients identified in specialized research centers presented APS as their main medical complaint.…”

“…Associated symptoms could be treated, including anxiety, depressive symptoms, social withdrawal, and academic impairment, even for those patients who would never become psychotic [ 28 ]. Also, clinical recognition of APS could hypothetically reduce the rates of misdiagnoses, improving the process of differential diagnosis, promoting better case management and providing proper reimbursement [ 18 ].…”

“…As already demonstrated by Carpenter’s quotation, some advocates of APS inclusion in DSM-5 also argued that this move could “stimulate the creative acquisition of new knowledge” in the field of high-risk mental states [ 29 ]. To them, although research on the APS concept was already steadily growing in specialized centers, making this construct an official category listed in a globally used psychiatric classification could give the proposal more visibility, fostering discoveries in the field and providing more research funding [ 18 , 31 ]. Psychiatrists in specialized centers argued that research into APS group of patients could have the potential to “ increase our understanding of psychotic-like symptoms and their trajectories and the emerging phase of psychotic disorders” [ 20 ].…”

“…On the other side of the debate, APS opponents argued that this diagnosis could undesirably stigmatize and generate unnecessary treatment to youngsters whose majority would never transition to psychosis [ 16 ]. To these critics, making APS an official diagnostic category could also promote inappropriate allocation of the already scarce resources destined to mental health and bring incalculable damages to society [ 9 , 18 , 27 ]. Potential inadequate prescription of antipsychotic medication, with their harmful effects of weight gain and increased cardiovascular risk, could cause a profound impact on the life of identified population.…”