TCPR: So you followed these patients for a while. Did you find that the original diagnosis was accurate, or did you get more information over time that prompted you to change the diagnosis?
Dr. Shinn: We found that diagnostic change is common in early psychosis. Half the patients had their diagnosis change. For example, among patients we initially diagnosed with schizophrenia, 55% kept that diagnosis, 11% changed to the NOS category, and 22% changed to schizoaffective disorder.
TCPR: So let’s say we’ve diagnosed a patient with some type of psychosis. Why is early intervention thought to be so important?
Dr. Shinn: By providing intensive treatment soon after a first episode, we are trying to change the patient’s trajectory so that the patient can return to school, work, and relationships rather than down a road toward disability. Like medical conditions such as cancer and heart disease, psychosis progresses through stages of severity, and if you treat early, you may slow or prevent progression.
TCPR: That’s interesting. What are the stages of psychotic illness?
Dr. Shinn: Patrick McGorry, Michael Berk, and others developed the concept of psychiatric staging. According to their models, stage 0 is actually no illness: The individual has no symptoms and is simply at risk, possibly because there is a family history of psychosis in a first-degree relative. Stage 1 corresponds to the prodromal period, when an individual may experience nonspecific or sub-threshold symptoms, along with some decline in academic, work, or social functioning. This is where you might see attenuated positive symptoms (APS) or brief limited intermittent psychotic symptoms (BLIPS), which are recurring episodes of frank psychotic symptoms that spontaneously go away and last no more than a week. Stage 2 is full-blown psychosis, ie, the first episode. Stage 3 consists of incomplete remission from the first episode or recurrence. Stage 4 is severe, persistent, or unremitting illness. Patients usually present to our program in stage 2 or early stage 3, and we say we provide early intervention to these patients. But in actuality, the first psychotic episode, when a person has converted to full-blown psychosis, is already considered a relatively late stage.
TCPR: How would we ascertain that a patient is in a very early stage of the prodrome, even before the patient has any APS or BLIPS?
Dr. Shinn: There are symptoms more subtle than APS and BLIPS, called basic symptoms, that are among the first symptoms to appear in the schizophrenia prodrome. Unlike APS and BLIPS, which are just milder or briefer psychotic symptoms, basic symptoms are qualitatively different from hallucinations, delusions, and other full-blown psychotic symptoms.
TCPR: So if basic symptoms are not frank psychotic symptoms, how do you recognize them?
Dr. Shinn: Basic symptoms are subtle, subjective disturbances of experience, especially self-experience. Psychiatrists usually associate disorders of self with borderline personality disorder. While in borderline personality disorder, the self-disturbance tends to be in the third-person perspective or narrative sense of self, basic symptoms reflect disturbances of first-person perspective, involving more fundamental and immediate experiences like experiencing oneself as continuous in time and immersed in one’s body and the world. Thus, a person might wonder about self-evident things like why our hands have five fingers or why the grass is green. The person may experience derealization and depersonalization—these are terms that psychiatrists typically associate only with trauma spectrum disorders like PTSD, but they are very common in early psychosis. A person may perceive a subtle change in the environment, like an atmospheric shift, and experience the world as surreal or illusory.
TCPR: These sound like very subtle, even esoteric experiences. How do you ask patients about them?
Dr. Shinn: You’re right, they are subtle. Unlike frank psychotic symptoms, they are rarely observable and usually only accessible by self-report. The only way to assess if they are present is to ask patients about them. The difficulty is that patients may not always have the words to describe what they are experiencing. A person might just report feeling perplexed or anxious or say, “Something is wrong; I don’t have the words for it.” Josef Parnas and his colleagues developed a semi-structured interview called the Examination of Anomalous Self-Experiences (EASE) (Parnas J et al, Psychopathology 2005;38(5):259– 267). An interview tool like the EASE can help clinicians explore some of these very subtle experiences with patients. I provide some screening questions that your readers might find helpful (Editorial note: see accompanying table). But mere recognition by a patient is not enough. The key is to use open-ended questions and engage in a dialogue that allows patients to describe their experiences using, as much as possible, their own words.
TCPR: How do we know if patients with these experiences will develop a psychotic disorder?
Dr. Shinn: It’s hard to know, in part because adolescence, which is usually when prodromal symptoms occur, is normally a period of a lot of change. Not everyone with basic symptoms will necessarily transition to full-blown psychosis. According to one study of 160 prodromal patients, basic symptoms predicted transition to schizophrenia with a probability of 70% over almost 10 years of follow-up (Klosterkotter J et al, ArchGen Psychiatry 2001;58(2):158–164).
By providing intensive treatment soon after a first episode, we are trying to change the patient’s trajectory so that the patient can return to school, work, and relationships rather than down a road toward disability. … If you treat early, you may slow or prevent progression.
~ Ann Shinn, MD
TCPR: Is there evidence that intervening at the early stages can decrease the likelihood of developing a full-blown psychotic disorder?
Dr. Shinn: The results are mixed and depend on the intervention. CBT (eg, Ising HK et al, Psychol Med 2015;45(7):1435–1436) and intensive psychosocial treatment involving things like family education, home visits, social skills training, and help with substance abuse (Nordentoft I et al, Schizophren Res 2006;83(1):29–40) seem to reduce or at least delay conversion to full-blown psychosis. Supplementation with omega-3 fatty acids (Amminger GP et al, Arch Gen Psychiatry 2010;67920:146–154) has also been shown to help. On the other hand, there is little evidence for treating at-risk individuals with antipsychotics. At least two randomized controlled trials of atypical antipsychotics in preventing psychosis have been negative (see Preti A and Cella M, Schizophren Res 2010;123(1):30–36 for review).
TCPR: And what sort of interventions do you recommend for first-episode patients, such as those you see in your clinic?
Dr. Shinn: First, while medications are usually necessary, use “gentle” pharmacology, meaning the lowest effective dose to minimize risk of side effects. Remember that most first-episode patients are drug-naïve. You want to engage a person in treatment and not have the person’s first experience with meds be negative. We know from the CATIE trial that about 75% of patients over an 18-month period stop medications, either because of side effects or because the medications were not very effective. Second, medications are important, but not sufficient—a more integrated approach is key. A recent paper in AJP (Kane JM et al, Am J Psychiatry 2016;173(5):535–536) showed that an integrated team-based approach is more effective than treatment as usual. This includes individual therapy, family psychoeducation, and employment and education support—in addition to medication. Traditional treatment approaches focus on symptomatic recovery, using antipsychotics to target positive symptoms. But to really help patients with psychosis get back on track with their lives, we need to do more to help people develop good coping skills and social skills, and help them navigate school, work, and relationships.
TCPR: Thank you, Dr. Shinn.