1. health and fitness
2. disorders

The Prodrome of
Schizophrenia
Professor Max Marshall
Overview
 What is the prodrome?
 How can it be detected?
 What do we do in the LEAD
clinic?
 Development of LEAD clinics
Prephases of schizophrenia
from first sign of mental disorder to first admission
Results of the Mannheim ABC-study of 232 first admissions
6.3
6.3 years
years
22 months
months
prodromal
prodromal phase
phase
average
average
duration
duration
5.0
5.0 years
years
psychoti
psychoti
cc
prephase
prephase
1.1
1.1
years
years
negative
negative and
and
unspecific
unspecific
symptoms
symptoms
first
social deficit
first
first
(negative
(negative or
or
nonspecific)
nonspecific) sign
sign of
of
mental
mental disorder
disorder
positive
positive
symptoms
symptoms
first
maximum
maximum
positive
of
of
symptom
symptom positive
positive
symptoms
symptoms
first
first
hospitalisation
Schizophrenia
ABStudy
C
Prodromal Symptoms
 Two phases in emergence:
 Pre-psychotic
 Non- specific:
dep/anx/restless/conc/worry/self
conf/energy
 Specific: basic symptoms
 Sub-psychotic
 BLIPS and Attenuated Symptoms
Social Deterioration
 Social Deterioration is a key aspect of
the prodrome
 If there is no social deterioration it is
questionable whether the prodrome is
present
 “Decay” not “drift” - social
deterioration follows symptoms
Onset of Social Disabilities (from IRAOS scale)
Dysfunctional
general behaviour
Dysfunctional
behaviour in
social / occupational
roles
60
50
40
30
20
10
1st positive symptom
0
51
Self-care
52
Leisure activity
53
Speed of coping with daily activities
54
Communication/social withdrawal
55
Lack of consideration and friction
56
Behaviour in emergencies
57
Participation in family life
58
Marriage or equiv. - emotional
59
Marriage or equiv. - sexual
60
Parental role
61
Sexual role behaviour
62
Work relationships
63
Interest in work place
64
General responsibility / interest
months before first admission
Schizophrenia
ABStudy
C
How do we detect it?
 State-Trait Approaches
 i.e.: Risk factors plus deterioration
 Specific non-psychotic symptoms
 Basic symptoms
 Sub-psychotic symptoms
 Brief limited psychotic symptoms
 Attenuated psychotic symptoms
STATE-TRAIT APPROACHES
 Genetic loading
 Soft signs
 Schizotypy
PLUS
 Social deterioration
Soft Neurological Signs
 Neurological soft signs (NSS) are minor
neurological signs indicating non-specific
cerebral dysfunction.
 Patients with first-episode psychosis show
an excess of NSS, particularly in motor
coordination and sequencing, sensory
integration and in developmental reflexes.
Soft Neurological Signs
Schizotypy
 DSM IV Axis II disorder
 Present in 1-3% of population
 Associated increased rate schizophrenia
(20-40%)
 Present in families of people with
psychosis
 Some traits analogous to psychotic symps
 Assessed by SPQ (Raine)
Elements of Schizotypy
 Cognitive Perceptual
 magical thinking, unusual perceptual
experiences, ideas of reference, paranoid
ideation
 Interpersonal
 no close friends, constricted affect, undue
social anxiety
 Disorganised
 odd/eccentric behaviour, odd speech
Basic Symptoms (Huber)
 Subtle, sub-clinical, subjective disturbances in:
drive, stress tolerance, affect, thinking, speech,
perception & motor actions
 Phenomenologically distinct from psychotic
symptoms
 An early expression of somatic disturbance
underlying development of psychosis
 Measured using: SPI-A (Schizophrenia
Proneness Instrument – Adult version)
Thought Perseveration
Disturbance of Receptive Language
HOUSE
Unstable Ideas of Reference
Acoustic Perception Disturbances
ROC curves of ten best symptoms in a model
validation sample (n=80 / 80)
sensitivity
1.0
Hypothetical curve for an optimal
diagnostic test with an area under
the curve of 1.0
0.8
Hypothetical curve for a completely
undifferentiating test with an area
under the curve of 0.5
0.6
Diagnostic accuracy in
model development sample
area under the curve = 0.852
(se=0.045; 95% CI: 0.76-0.94)
0.4
Diagnostic accuracy in
model validation sample
area under the curve = 0.836
(se=0.047; 95% CI: 0.74-0.93)
0.2
0.0
0.0
0.2
0.4
0.6
1-specificity
0.8
1.0
CE Schizophren
R ia Project
At Risk Mental States
 Alison Yung & Pat McGorry
 Comprehensive Assessment of At Risk Mental
States (CAARMS)
 SIPS/SOPS
 Brief Limited Intermittent Psychotic
Symptoms (BLIPS)
 Of psychotic intensity but limited duration
 Attenuated Psychotic Symptoms
 Of sub-psychotic intensity
Development of psychosis
Detection
and
Intervention
Detection
and
Intervention
First
psychotic episode
climax
psychotic
onset
initial
prodrome
pre-phase
time
uncharacteristic
prodromal
symptoms with
little diagnostic
accuracy
characteristic
prodromal
symptoms with
good diagnostic
accuracy
attenuated
psychotic
symptoms
transient
psychotic
symptoms
rather
persisting
psychotic
symptoms
Effectiveness of Early Detection
 State-Trait Approaches
 Not all patients have them; if no deterioration
does not predict immediate risk
 ARMS
 Short range prediction only – already almost
psychotic
 SPI-A – long range
 Promising, but no gold standard study
 No formal synthesis of diagnostic studies
The LEAD Clinic
 Mike Fitzsimmons, Kishen Neelan,
Caroline Johnson, myself
 Running for 18 ms, Daisyfield CMHT
 Assess service users who are not
psychotic but might have prodromal
symptoms
Purpose of the clinic
 To see if it was feasible
 To assess demand and service user and
carer’s reactions
 To train ourselves and refine our
assessments
 To understand how it might contribute to
the EIS
The LEAD Assessment
 Genetic Risk
 Schizotypy (SPQ)
 Deterioration (Cornblatt scales)
 Soft Signs (Neurological Rating
Scale)
 Basic Symptoms (SPI-A)
 Attenuated/BLIPS (CAARMS)
Findings so far
 So far seen 34 service users
 About half are clearly prodromal, though to
different degrees of risk
 Although the assessments takes 3 hours
no one has yet failed to complete it
Why bother?
 Access
 We need a quick process for identifying
people in the prodrome
 Safety
 We have to show that decisions not to accept
have a sound/defensible basis
 Resource Management
 We need to match the level of input to the
level of risk
 We need to be able to discharge
Why have a clinic?
 Efficiency
 More than one person is required
 The assessments are difficult and highly
structured
 Supervision and quality control is essential
 Accuracy
 Requires a quiet and controlled ambience
 Training and development
 Easier to bring in new or techniques
How could we make it better?
 Should embed clinics in the service
 We should extend the clinic to assess all
non-psychotic service users
 Should do follow up at one year and
discharge if improved
 Should have a stepped care model so only
highest risk are taken on by service
 Should extend remit to assess all complex
cases
Working group
 Set up a LEAD clinic working group
 Warren, Jeff, Faith, Alison, Mike, Imran
 Agreed to roll out LEAD clinics across EIS




Developing an operational policy
Training program
IT support
Service Evaluation
 Examining Admin Support
The End