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Articles: Brian V. Martindale Psychodynamic contributions to early intervention in psychosis Adv Psychiatr Treat 2007; 13: 34-42 [Abstract] [Full text] [PDF]

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"Definitions and nosology in early intervention: towards a renaissance of psychopathology?"

Massimo (aka Max) Lanzaro, Wonford House Hospital, Exeter, UK   (18 February 2007)

"Definitions and nosology in early intervention: towards a renaissance of psychopathology?" 18 February 2007
Massimo (aka Max) Lanzaro, Consultant Psychiatrist Devon Partnership Trust, Wonford House Hospital, Exeter, UK Send letter to journal: Re: "Definitions and nosology in early intervention: towards a renaissance of psychopathology?" maxlanzaro{at}btinternet.com Massimo (aka Max) Lanzaro, et al.	I should like to thank Dr B Martindale for his extremely interesting paper. The initial period has been in fact recognized as very important for early intervention programmes and understanding the process of becoming psychotic. In the UK some surveys show that it can take up to two years after the first signs of psychosis for individuals and their families to begin to seek or receive appropriate help and treatment (DH, 2000). Although further evidence is needed, pilot studies found that people with “prodromal” symptoms who received a phase-specific intervention were significantly less likely to develop psychosis at 6 months follow-up, compared to people receiving non specific care. A growing body of research also shows that the bigger the gap, the more likely patients are to have poorer outcomes across a range of measures. Reasons for delay can include: lack of awareness, reluctance to seek help, unspecific early symptoms and stigma, but also misidentification of cases by mental health services at all levels. For the purpose of diagnosis, since their official introduction, the ICD-10 and the DSM-IV classification systems have largely become an integral part of the body of knowledge of psychiatrists and instruments they constantly refer to, on the assumption that the reliability of the diagnoses therein defined was unequivocally demonstrated. They also constitute one of the main sources of knowledge for both primary care and general practitioners (GPs, in most cases, represent the main path of ensuring early detection and intervention). Unfortunately, the essence of DSM-IV concept of “prodromic” and its operative consequences raises some problems: 1. DSM-IV offers only one vague sentence about the words that other informants might use for a description of the person’s behaviour (“family members assume that he is going through a phase”); 2. The five symptoms that are mentioned and listed as examples in DSM -IV are merely residua of DSM-III-R operational criteria for the schizophrenia prodromal period, which have been dropped from the DSM-IV because of their poor reliability and validity (DSM-III defined eight features as making up the prodrome and DSM-III-R defined nine); 3. The duration criterion was dropped too and no chronological specifications are now assumed; 4. A specific list of prodromal features conflicted with ICD-10 that, on the other hand, does not describe a clustering of symptoms at all. As an alternative, some authors proposed a cluster of symptoms that confers a heightened vulnerability to becoming psychotic (McGorry’s hybrid/interactive model, 1996). McGorry’s way to envision the prodrome in psychosis is as a syndrome that confers a heightened vulnerability to becoming psychotic but does not inevitably lead to psychosis. Thus, the prodrome is seen as a state (as opposed to a trait) risk factor for psychosis. This model implies that a person with certain features may or may not develop a psychosis. In this case, the term "prodrome" is misleading, as it implies that the psychosis is inevitable (prodrome being a retrospective concept). "At-risk mental state" has been suggested as a more accurate term. An "at-risk mental state" could be combined with other known risk factors for the development of psychosis, such as the trait risk factor of family history. The main problem in such a prospective follow-up is that a (potentially stigmatising) psychiatric intervention could occur for people who will not go on to develop psychotic disorders (false-positives). Mental state changes that seem to resemble a prodrome, cross-sectionally shall or shall not progress to psychosis for two reasons. First, the mental state changes might not represent a vulnerable state at all but indicate a different underlying pathology (true false- positives). Second, the mental state change might indicate a potentially pre-psychotic at-risk mental state, but factors such as enhanced coping, increase in social support, or some other change in circumstance could prevent, delay, or modify the progression to psychosis (false-false positives). The Prevention through Risk Identification, Management, and Education (PRIME) prodromal research team at Yale University has validated the Structured Interview for Prodromal Syndromes and the Scale of Prodromal Symptoms as methods for assessment (McGlashan et al., 2003). More recently, within the German Research Network on Schizophrenia (GRNS and EPOS) awareness programmes are being carried out in several German cities, using a two step early-recognition inventory (IRAOS, ERIRAOS) with a favourable trend indicated by the preliminary data. The GRNS also pointed to integrate symptoms with neuropsychological, brain imaging and biological investigations to increase the realibility of these instruments. However, a general consensus about a valid early-recognition inventory of sufficient diagnostic and prognostic power is lacking. This complicates communication between researchers. Moreover, the resulting diagnostic heterogeneity affects the efficacy and promptness of early intervention services (EIS) and the liaison between secondary and primary care (with a possible significant delay in detection and intervention). The aim of this short contribution is to stimulate further discussions and to suggest the possible role of a renaissance of psychopatholgy in the field of prevention that may also inform criterion selection for DSM-V. Bibliography 1. Early intervention for people with psychosis. NIMHE, Department of Health , UK , 2003. 2. International Classification of Diseases, 10th Revision (ICD- 10), WHO, 2003. 3. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text revision (DSM-IV-TR). American Psychiatric Association, 2004. 4. Yung AR, McGorry PD. The prodromal phase of first-episode psychosis: past and current conceptualizations. Schizophr Bull. 22(2):353- 70, 1996. 5. McGlashan TH et al. The PRIME North America randomized double- blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. I. Study rationale and design. Schizophr Res. 1, 61(1): 19-30, 2003. Address for correspondence: Dr Max Lanzaro, Consultant Psychiatrist, Wonford House Hospital , Dryden Road , Exeter , EX2 5AF, UK, E-mail: Max.Lanzaro@DevonPtnrs.nhs.uk