Predictors of transition of high risk state to psychosis: JAMA Psych.Jan 2013. (Part 2)


High risk state for psychosis (=at risk mental state/Ultra High Risk)   (HR)  indicate the presychotic phase when people present with potentially prodromal symptoms. ‘Prodromal’ was first introduced by Mayor-Gross. Huber and Gross first described the basic symptoms in 60s. Hafner et al (1989)  showed that 73% of all first admitted psychosis patients had a prodromal phase  that lasted up to 5 yrs in average. Establishment of clinical services for potentially prodromal individuals started in 90s. Soon , various diagnostic criteria emerged.Paolo Fusar-Poli et al review our current knowledge of HR state in this article.

Clinical characteristics of HR state : HR state is associated with anxiety, depression, substance use. impaired functioning and increased suicidality also reported.

Neuro cognition: Small-to-medium impairments across most neurocognitive domains  are observed. level of these impairments are similar to those at genetic risk of schizophrenia. HR individuals who convert to psychosis show more severe neurocognitive deficits at baseline than do non converters.

PET  studies  indicate elevated striatal dopamine synthesis in HR individuals that is greater in those who later convert to psychosis and consistent with the finding of 14% elevation in established schizophrenia .Structural imaging results show much heterogeneity.

Predictors of  Psychosis Conversion:

Clinical:  Genetic risk with functional decline, High unusual thought content scores, High suspicion/paranoia scores, Low social functioning,  History of substance abuse, High suspiciousness and High anhedonia/ asociality scores.

Neuro: Multivariate neurocognitive pattern classifications (eg executive and verbal learning impairments) has yielded accuracy of 90% (Koutsouleris et al 2011)in predicting conversion.Neuroanatomical gray matter pattern classification was 88% accurate in predicting transition (Koutsouleris 2009).

Treatment : Receiving focused treatment from specialized services was associated with lower risk of psychosis at 12 months and at 24 to 36 months. It is unclear what element of services are beneficial. Most guidelines recommend ongoing monitoring alone.

Comment: All high risk psychosis states, especially those with known risk factors need more close monitoring. Care ( possible elements being regular contact, support in socialisation and resource building) is effective in reducing transition. Ongoing trials will inform us more on what work for these individuals.

Summary of the article: (Part 2):

The Psychosis High-Risk State: A Comprehensive State-of-the-Art Review. Fusar-Poli P, Borgwardt S, Bechdolf A, Addington J, Riecher-Rössler A, Schultze-Lutter F, Keshavan M, Wood S, Ruhrmann S, Seidman LJ, Valmaggia L, Cannon T, Velthorst E, De Haan L, Cornblatt B, Bonoldi I, Birchwood M, McGlashan T, Carpenter W, McGorry P, Klosterkötter J, McGuire P, Yung A. JAMA psychiatry 2013; 70(1) :107-120.

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