Here are the references for the two groups studying the "ultra high risk" patients…
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Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms.
by McGorry PD, Yung AR, Phillips LJ, Yuen HP, Francey S, Cosgrave EM, Germano D, Bravin J, McDonald T, Blair A, Adlard S, and Jackson H. Arch Gen Psychiatry. 2002 59(10):921-8. |
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Randomized controlled trial of interventions for young people at ultra-high risk of psychosis: study design and baseline characteristics. .
by Phillips LJ, Nelson B, Yuen HP, Francey SM, Simmons M, Stanford C, Ross M, Kelly D, Baker K, Conus P, Amminger P, Trumpler F, Yun Y, Lim M, McNab C, Yung AR, McGorry PD. Aust N Z J Psychiatry. 2009 43(9):818-29. |
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a randomized, placebo-controlled trial.
by Amminger GP, Schäfer MR, Papageorgiou K, Klier CM, Cotton SM, Harrigan SM, Mackinnon A, McGorry PD, and Berger GE. Archives of General Psychiatry. 2010 67(2):146-54. [full text on-line]
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Randomized controlled trial of interventions for young people at ultra high risk for psychosis: 6-month analysis.
by Yung AR, Phillips LJ, Nelson B, Francey SM, PanYuen H, Simmons MB, Ross ML, Kelly D, Baker K, Amminger GP, Berger G, Thompson AD, Thampi A, and McGorry PD. Journal of Clinical Psychiatry. 2011 72(4):430-40. |
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Randomised controlled trial of early detection and cognitive therapy for preventing transition to psychosis in high-risk individuals. Study design and interim analysis of transition rate and psychological risk factors.
by Morrison AP, Bentall RP, French P, Walford L, Kilcommons A, Knight A, Kreutz M, and Lewis SW. British Journal of Psychiatry Supplement 2002 43:s78-84.
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Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial.
by Morrison AP, French P, Walford L, Lewis SW, Kilcommons A, Green J, Parker S, and Bentall RP. British Journal of Psychiatry . 2004 185:291-7.
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Three-year follow-up of a randomized controlled trial of cognitive therapy for the prevention of psychosis in people at ultrahigh risk.
by Morrison AP, French P, Parker S, Roberts M, Stevens H, Bentall RP, and Lewis SW. Schizophrenia Bulletin. 2007 33(3):682-7.
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Effects of cognitive therapy on the longitudinal development of psychotic experiences in people at high risk of developing psychosis.
by French P, Shryane N, Bentall RP, Lewis SW, and Morrison AP. British Journal of Psychiatry Supplement 2007 51:s82-7.
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Early detection and intervention evaluation for peopleat risk of psychosis: multisite randomised controlled trial.
by Morrison AP, French P, Stewart SL, Birchwood M, Fowler D, Gumley AI, Jones PB, Bentall RP, Lewis SW, Murray GK, Patterson P, Brunet K, Conroy J, Parker S, Reilly T, Byrne R, Davies LM, Dunn G. British Medical Journal. 2012 Apr 5;344 [full text on-line] |
I have no credentials to say this, but I think they’re well meaning and hard-working, but on the wrong track. This is one version of their criteria for selection of pre-psychotic patients:
• Attenuated psychotic symptoms group: patients have experienced subthreshold, attenuated positive psychotic symptoms during the past year;
• Brief limited intermittent psychotic symptoms group: patients have experienced episodes of frank psychotic symptoms that have not lasted longer than a week and have spontaneously abated; or
• Trait and state risk factor group: patients have schizotypal personality disorder or have a first-degree relative with a psychotic disorder and have experienced a significant decrease in functioning during the previous year.
One of the obvious criticisms of people like me who talk about single cases is that they’re generalizing from a single instance – a perfectly valid criticism. But there’s a reason to at least consider n=1 cases, because they’re known in depth. An example is Auguste Deter, the case of Alois Alzheimer and colleague, Emil Kraepelin, that lead them to a really dramatic discovery – now called Alzheimer’s disease.
I described a case [1. from n equals one…, 2. from n equals one…, 3. from n equals one…] who definitely developed Schizophrenia, and those of us who followed her sort of knew that was what was coming. Her brother, a doctor who referred her said "she might be Schizophrenic" when he first mentioned her. Her parents joined a support group for parents of psychotic people before her break. The doctor who was taking care of her called me because he "didn’t know what [she] had." And yet she met none of those criteria listed up above. They are going for sort-of psychotic symptoms to pick their cases, and it’s "sort of" successful. Even in failure, they’re hitting at 7% or 8% and up to 30%-40% in some studies. That’s too low to use, but it’s certainly not close to the rate in the general or even psychiatric population.
In my case, the symptoms were more like a pervasive identity diffusion that interfered with each developmental stage growing up; a chameleon-like quality of copying the path or styles of others to figure out how to be; a pattern of being able to complete tasks and projects, but not being able to pick which ones to pursue; and secretive, shameful, pleasure seeking [eating, pilfering, spending] that didn’t bring pleasure and became compulsive. There was a not-knowing-how-to-be-ness that characterized her whole story. I don’t exactly know how one would screen for this kind of deficit in self-definition, but I think if they are going to pursue this research, they would do well to consider working on their selection criteria. It’s what bothers me about even their term Attenuated Psychosis Syndrome. Frankly, they were better off with Psychosis Risk Syndrome. But the DSM-5 criteria themselves are even less useful:
| Attenuated Psychosis Syndrome: Proposed Revision
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| The work group is recommending that this be included in DSM-5 but is still examining the evidence as to whether inclusion is merited in the main manual or in an Appendix for Further Research. As such, the work group strongly encourages feedback regarding this disorder.
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| All six of the following: | ||
| [a] Characteristic symptoms: at least one of the following in attenuated form with intact reality testing, but of sufficient severity and/or frequency that it is not discounted or ignored; | ||
| [i] delusions | ||
| [ii] hallucinations | ||
| [iii] disorganized speech | ||
| [b] Frequency/Currency: symptoms meeting criterion A must be present in the past month and occur at an average frequency of at least once per week in past month | ||
| [c] Progression: symptoms meeting criterion A must have begun in or significantly worsened in the past year; | ||
| [d] Distress/Disability/Treatment Seeking: symptoms meeting criterion A are sufficiently distressing and disabling to the patient and/or parent/guardian to lead them to seek help | ||
| [e] Symptoms meeting criterion A are not better explained by any DSM-5 diagnosis, including substance-related disorder | ||
| [f] Clinical criteria for any DSM-V psychotic disorder have never been met | ||
They might as well say, "sort of Schizophrenic." That’s not how Schizophrenia works. There’s a period of confusion and agita that may go on for a while, but the patients are not psychotic. The "psychotic" symptoms usually arrive in a storm – all of a sudden instead of scattered around like either one of these criteria sets suggest.
Just the thoughts of an old n=1 guy…
Very interesting. I think also that more attention could be paid to the questions that are asked to identify people at risk of psychosis. Having completed one of the questionnaires, I was struck by their insistence that [the interviewee/whatever they should be called] pays attention to the “wrong” things (ie, looking at a pillow or a part of a person instead of the interviewer). It undermines, to my mind, the ability of a person to construct meaningful experience out of their experience, further eroding a pre-existing weakness.
FYI
New View of Depression: An Ailment of the Entire Body
http://online.wsj.com/article/SB10001424052702304587704577333941351135910.html#printMode
http://psychologyofmedicine.blogspot.com/2012/04/new-view-of-depression-ailment-of.html
“People with long-term psychological stress, depression and post-traumatic stress disorder tend to develop earlier and more serious forms of physical illnesses that usually hit people in older age, such as stroke, dementia, heart disease and diabetes. Recent research points to what might be happening on the cellular level that could account for this.
Scientists are finding that the same changes to chromosomes that happen as people age can also be found in people experiencing major stress and depression. “
After the craze of Alzheimer’s died down in the media, researchers began to find that a lot of elderly people who had been diagnosed with it were actually in the advanced stages of alcoholism. Dementia is a feature of hepatic encephalopathy . “Dementia” can be oversimplified as easily as “depression”. Treating someone with drugs for Alzheimer’s while their brain is being flooded with ammonia and their liver is dying is not helpful. Medical tests before even attempting to make a psychiatric diagnosis should be required.
Since the brain and body, and individual and society are inseparable; perhaps there needs to be a diagnosis of “definite problems” that justifies treatment with a long trial and error period that includes psychological evaluations and very careful administration of drugs with very informed consent and thorough documentation of all results, including reporting all paradoxical and negative reactions to a drug to the manufacturer and the FDA.
The diagnosis, in many cases, should be tested thoroughly before it is given. Having to carry around a slew of “impressions” from various mental health professionals just adds prejudice and confusion.