[Early detection of psychosis in children and adolescents - have developmental particularities been sufficiently considered?]

[Psychotic disorders in ICD-11: the revisions]

Psychotic disorders in ICD-11: the revisions Abstract. This article provides an overview of the main changes to the chapter "Schizophrenia or Other Primary Psychotic Disorders" (6A2) from ICD-10 to ICD-11 and compares them with the psychosis chapter of DSM-5. These changes include abandoning the classical subtypes of Schizophrenia as well as of the special significance of Schneider's first-rank symptoms, resulting in the general requirement of two key features (one must be a positive symptom) in the definition of "Schizophrenia" (6A20) and the allowance for bizarre contents in "Delusional Disorder" (6A24), which now includes "Induced Delusional Disorder" (F24). Further introduced are the focus on the current episode, the restriction of "Acute and Transient Psychotic Disorder" (6A23) to the former Polymorphic Disorder Without Schizophrenic Symptoms (F23.0), the diagnosis of delusional "Obsessive-Compulsive or Related Disorders" (6B2) exclusively as Obsessive-Compulsive Disorders, the specification of "Schizoaffective Disorder" (6A21), and the formulation of a distinct subchapter "Catatonia" (6A4) for the assessment of catatonic features in the context of several disorders. In analogy to DSM-5, ICD-11 now includes the optional category "Symptomatic Manifestations of Primary Psychotic Disorders" (6A25) for the dimensional quantification of symptoms. Again, developmental aspects remain unattended in in the ICD-11-definitions of psychotic disorders.

Duration of unspecific prodromal and clinical high risk states, and early help-seeking in first-admission psychosis patients

PURPOSE

Prevention of psychosis requires both presence of clinical high risk (CHR) criteria and early help-seeking. Previous retrospective studies of the duration of untreated illness (i.e. prodrome plus psychosis) did not distinguish between prodromal states with and without CHR symptoms. Therefore, we examined the occurrence of CHR symptoms and first help-seeking, thereby considering effects of age at illness-onset.

METHODS

Adult patients first admitted for psychosis (n = 126) were retrospectively assessed for early course of illness and characteristics of first help-seeking.

RESULTS

One-hundred and nine patients reported a prodrome, 58 with CHR symptoms. In patients with an early illness-onset before age 18 (n = 45), duration of both illness and psychosis were elongated, and CHR symptoms more frequent (68.9 vs. 33.3 %) compared to those with adult illness-onset. Only 29 patients reported help-seeking in the prodrome; this was mainly self-initiated, especially in patients with an early illness-onset. After the onset of first psychotic symptoms, help-seeking was mainly initiated by others. State- and age-independently, mental health professionals were the main first point-of-call (54.0 %).

CONCLUSIONS

Adult first-admission psychosis patients with an early, insidious onset of symptoms before age 18 were more likely to recall CHR symptoms as part of their prodrome. According to current psychosis-risk criteria, these CHR symptoms, in principle, would have allowed the early detection of psychosis. Furthermore, compared to patients with an adult illness-onset, patients with an early illness-onset were also more likely to seek help on their own account. Thus, future awareness strategies to improve CHR detection might be primarily related to young persons and self-perceived subtle symptoms.

Developing psychosis and its risk states through the lens of schizotypy

Starting from the early descriptions of Kraepelin and Bleuler, the construct of schizotypy was developed from observations of aberrations in nonpsychotic family members of schizophrenia patients. In contemporary diagnostic manuals, the positive symptoms of schizotypal personality disorder were included in the ultra high-risk (UHR) criteria 20 years ago, and nowadays are broadly employed in clinical early detection of psychosis. The schizotypy construct, now dissociated from strict familial risk, also informed research on the liability to develop any psychotic disorder, and in particular schizophrenia-spectrum disorders, even outside clinical settings. Against the historical background of schizotypy it is surprising that evidence from longitudinal studies linking schizotypy, UHR, and conversion to psychosis has only recently emerged; and it still remains unclear how schizotypy may be positioned in high-risk research. Following a comprehensive literature search, we review 18 prospective studies on 15 samples examining the evidence for a link between trait schizotypy and conversion to psychosis in 4 different types of samples: general population, clinical risk samples according to UHR and/or basic symptom criteria, genetic (familial) risk, and clinical samples at-risk for a nonpsychotic schizophrenia-spectrum diagnosis. These prospective studies underline the value of schizotypy in high-risk research, but also point to the lack of evidence needed to better define the position of the construct of schizotypy within a developmental psychopathology perspective of emerging psychosis and schizophrenia-spectrum disorders.

EPA guidance on the early detection of clinical high risk states of psychoses

The aim of this guidance paper of the European Psychiatric Association is to provide evidence-based recommendations on the early detection of a clinical high risk (CHR) for psychosis in patients with mental problems. To this aim, we conducted a meta-analysis of studies reporting on conversion rates to psychosis in non-overlapping samples meeting any at least any one of the main CHR criteria: ultra-high risk (UHR) and/or basic symptoms criteria. Further, effects of potential moderators (different UHR criteria definitions, single UHR criteria and age) on conversion rates were examined. Conversion rates in the identified 42 samples with altogether more than 4000 CHR patients who had mainly been identified by UHR criteria and/or the basic symptom criterion 'cognitive disturbances' (COGDIS) showed considerable heterogeneity. While UHR criteria and COGDIS were related to similar conversion rates until 2-year follow-up, conversion rates of COGDIS were significantly higher thereafter. Differences in onset and frequency requirements of symptomatic UHR criteria or in their different consideration of functional decline, substance use and co-morbidity did not seem to impact on conversion rates. The 'genetic risk and functional decline' UHR criterion was rarely met and only showed an insignificant pooled sample effect. However, age significantly affected UHR conversion rates with lower rates in children and adolescents. Although more research into potential sources of heterogeneity in conversion rates is needed to facilitate improvement of CHR criteria, six evidence-based recommendations for an early detection of psychosis were developed as a basis for the EPA guidance on early intervention in CHR states.

Neuropsychological Deficits in the Prodromal Phase and Course of an Early-Onset Schizophrenia

Objectives: Although clear advances have been achieved in the study of early-onset schizophrenia (EOS), little is known to date about premorbid and prodromal neuropsychological functioning in EOS. Method: Here, we report on a case of an adolescent male with EOS who underwent neuropsychological testing before and after illness onset. Results: Marked cognitive deficits in the domains of attention, set-shifting, and verbal memory were present both pre-onset and during the course of schizophrenia, though only deficits in verbal memory persisted after illness-onset and antipsychotic treatment. Conclusion: The findings of this case study suggest that impairments in the verbal memory domain are particularly prominent symptoms of cognitive impairment in prodromal EOS and persist in the course of the disorder, which further demonstrates the difficult clinical situation of adequate schooling opportunities for adolescent patients with EOS.

Psychotische Störungen im DSM-5

Es wird eine Übersicht über die hauptsächlichen Änderungen des Kapitels «Schizophrenie-Spektrum und andere psychotische Störungen» von DSM-IV-TR zu DSM-5 gegeben, in dem erneut etwaigen Besonderheiten von Kindern und Jugendlichen nicht Rechnung getragen wird. Diese umfassen im Haupttext den Verzicht auf die klassischen Subtypen der Schizophrenie sowie die Aufgabe des besonderen Stellenwerts der Schneider’schen Erstrangsymptome und damit verbunden die Forderung von mindestens zwei Leitsymptomen (obligatorisch mindestens ein Positivsymptom) bei der Schizophrenie sowie Zulassung bizarrer Wahninhalte auch bei Wahnhaften Störungen. Neu sind zudem die Kodierung wahnhafter Zwangs-/Körperdysmorpher Störungen ausschließlich unter den Zwangsstörungen, die Präzisierung affektiver Episoden bei der Schizoaffektiven Störung und die Einführung einer eigenen Sektion «Katatonie» zur Beschreibung katatoner Symptome innerhalb verschiedendster Krankheitsbilder. In der Sektion III (Aufkommende Messmittel und Modelle) findet sich zudem der Vorschlag einer dimensionalen Beschreibung von Psychosen. Verwirrend ist die doppelte Einführung eines «Attenuated Psychosis» Syndromes: zum einen vage umschrieben unter die «Anderen spezifizierten Schizophrenie-Spektrum und anderen psychotischen Störungen» im Haupttext, zum anderen klar definiert unter die «Bedingungen mit weiterem Forschungsbedarf» der Sektion III. Mit dieser nicht spezifizierten Aufnahme des Attenuated Psychosis Syndromes in den Haupttext ist einer befürchteten Überdiagnostizierung subschwelliger psychotischer Symptome und deren frühzeitiger psychopharmakologischer Behandlung nun doch Tür und Tor geöffnet.

Severe Affective and Behavioral Dysregulation in Youths Is Associated with a Proinflammatory State 1MH and LP contributed equally to the paper

Objective: A heritable behavioral phenotype, the so-called Dysregulation Profile (DP), characterized by extreme scores on the syndrome scales Anxious/Depressed (A/D), Attention Problems (AP), and Aggressive Behavior (AGG), has been identified on the Child Behavior Checklist (CBCL). It characterizes children with severe affective and behavioral dysregulation. The present study examined possible alterations of the inflammatory system in CBCL-DP using a clinical sample of n = 133 children and adolescents. Method: Participants with the CBCL-DP scoring ≥ 2.5 SDs above average constituted the CBCL-DP subgroup (n = 51). Those with CBCL-DP scores of 1 SD or less above average were regarded as controls (n = 82). Groups were compared in terms of serum levels of C-reactive protein (CRP) and albumin. Results: Participants showing the CBCL-DP exhibited increased CRP and decreased albumin levels compared to controls. CRP was correlated with AGG, AP, and the CBCL-DP total score. A negative correlation was observed between albumin and AGG, AP, the CBCL-DP score, and A/D. These associations could not be attributed to differences in age, sex, weight, socioeconomic status, global functioning, or duration of illness. Conclusions: This is the first study to demonstrate associations between the CBCL-DP and a proinflammatory state. Limitations include the lack of a healthy control group, the use of a single measurement of inflammatory markers, and the lack of follow-up data. Future research should address whether inflammatory diathesis in these children confers increased susceptibility to later development of cardiovascular disease and other medical morbidities.

Schizophrenia spectrum and other psychotic disorders

The DSM-5 list of diagnoses concerning schizophrenia spectrum and other psychotic disorders is expected to be revised and graduated from mild to severe. The proposed changes for the diagnosis of schizophrenia affect demands for characteristic symptoms, clarify relation to pervasive developmental disorders, and eliminate the classic subtypes of schizophrenia. A dimensional assessment will be measured on a 0-4 point scale. It is recommended that the concept of attenuated psychosis syndrome is further investigated. The propositions affecting characteristic symptoms of schizophrenia might increase diagnostic reliability and validity, but it is estimated to exclude about 2 % of patients currently diagnosed with DSM-IV schizophrenia from fulfilling criteria for DSM-5 schizophrenia. It might generate a problem for future young patients if the changes concerning demands on characteristic symptoms turn out to be more restrictive, leaving out a percentage of patients with psychotic symptoms from a diagnosis of schizophrenia; which in practice opens possibilities for intensive treatment options. On the other hand, not including attenuated psychosis syndrome at the present might protect patients from stigmatization and pharmacological treatment on poor indication. The introduction of dimensional assessments may make schizophrenia subtyping redundant and has the potential to enrich clinical practice and bridge communication between child and adolescent and adult psychiatry. The most recent guidelines for assessment and treatment of children and adolescents with schizophrenia are from 2001. They provide differentiated recommendations regarding diagnostics, assessment of symptoms and functioning and treatment strategies. There is an urgent need for updated guidelines in this field, especially concerning specific treatment guidelines.

The significance of at-risk symptoms for psychosis in children and adolescents

The early detection and treatment of people at risk for psychosis is currently regarded as a promising strategy in fighting the devastating consequences of psychotic disorders. Currently, the 2 most broadly used sets of at-risk criteria, that is, ultra-high risk (UHR) and basic symptom criteria, were developed mainly in adult samples. We review the data regarding the presence and relevance of at-risk symptoms for psychosis in children and adolescents. The few existing studies suggest that attenuated psychotic symptoms (APS) and brief limited intermittent psychotic symptoms (BLIPS) do have some clinical relevance in young adolescents from the general population. Nevertheless, their differentiation from atypical psychotic symptoms or an emerging schizotypal personality disorder, as well as their stability and predictive accuracy for psychosis, are still unclear. Further, standard interviews for UHR criteria do not define a minimum age for the assessment of APS and BLIPS or guidelines as to when and how to include information from parents. APS and basic symptoms may be predictive of conversion to psychosis in help-seeking young adolescents. Nevertheless, the rate and timing, and thus the required observation time, need further study. Moreover, no study has yet addressed the issue of how to treat children and adolescents presenting with at-risk symptoms and criteria. Further research is urgently needed to examine if current at-risk criteria and approaches have to be tailored to the special needs of children and adolescents. A preliminary rationale for how to deal with at-risk symptoms for psychosis in clinical practice is provided.

Neuere Entwicklungen zur Diagnostik psychischer Störungen im Jugendalter

Die vorliegende Arbeit stellt die gängigsten klinischen Interviewverfahren zur Diagnosestellung bei Jugendlichen sowie geeignete störungsspezifische Messinstrumente im deutschen Sprachraum vor. Zudem werden Besonderheiten bei der Diagnostik psychischer Störungen bei Jugendlichen erläutert sowie handlungsrelevante Hinweise gegeben. Beurteiler sind mit einer Vielzahl von Problemen konfrontiert, die eine valide Diagnosestellung erschweren. Hierbei ist die Abgrenzung von krankheitswertigem vs. jugendtypischem Verhalten, die hohe Komorbidität von psychischen Störungen im Jugendalter sowie die mangelnde Übertragbarkeit der diagnostischen Kriterien auf Jugendliche zu nennen. Zudem sind ein Einbezug verschiedener Informationsquellen und eine sorgfältige Exploration der psychosozialen Umstände des Jugendlichen erforderlich sowie eine kontinuierliche Weiterbildung über sich neu entwickelnde Störungsbilder.