Incidences of Transition to Psychosis

Valarie Nikaido
Professor Hill-Clark
March 20, 2013
Currently the best regarded strategy to debilitate, stall and revert
psychosis. To maximize the efficiency and accuracy of predictions of
psychosis with sufficient specificity and sensitivity which provides
individualistic risk differentiation in terms of duration and degree of
condition? The UN –identified relation between psychosis and social
anxiety is cardinal focus in indicative preventive strategy. It is
ambiguous as to take social anxiety preliminary symptoms or as an
epiphenomenon of psychosis. In order to investigate the connection
between social anxiety and occurrence first episode psychosis
comparative phenomenology was conducted between a group of social first
episode psychosis (FEP group) with that in a group of social anxiety
without psychosis (SaD group). It is significant to predict the symptoms
and identify signs as indicative prevention in containment of psychosis.
The importance of early diagnoses of a psychosis and its symptom’s
realization in a patient plays a fundamental role in the prevention of
disease. In this regard, the ‘incidence of transition to psychosis’
has been a major topic of research for both the identification and the
intervention of psychosis. Moreover, the measure of these incidences is
also helpful to take the prompt actions in response to psychotic
disorders as well as to characterize the behavioral aspects of the
suffering individuals. The subject matter of this research paper is
therefore to address the reduction of incidences of transition to
psychosis. It analyzes three case studies including the research work
done by Ruhrmann, S. Schultze-Lutter F, Salokangas RR, et al(2010),
Hann, L. Linszen, D. Lenior, M, et al(2003) and Michail, M. and
Birchwood, M. (2009) on psychosis. This paper highlights the several
aspects involved in the assessment of patients with psychotic disorders
as discussed in these research studies.
Ruhrmann et al. (2010) research work, which is based on the ‘European
prediction of psychosis study’, has emphasized on how indicated
prevention and early prediction of psychosis is the most useful method
of reducing incidences of psychosis. In this study, it is predicted that
by adapting the early detection criterion of UHR (ultra-high risk),
which include three different syndromes and the symptom criterion based
on cognitive disturbances (COGDIS), the indicated prevention of
psychosis is significantly improved. Therefore, the study is aimed at
detecting early signs of individuals suffering from psychosis. At this
stage, these individuals do not require a clinical diagnosis since the
early intervention approach allows for prevention of the progression of
the psychosis disorder. In Hann et al. (2003) the authors identified the
relation between the schizophrenia and the delay in psychosis treatment.
Disorders Depression and anxiety are common in patients in the clinical
risk for psychosis growing, but do not appear to influence the
transition to true psychosis, say UK researchers.
In a study of 509 individuals in a mental state in danger (ARMS), people
found that almost three quarters had a diagnosis of comorbid axis I,
with 40% having depression alone (26%) or in association with disorders
anxiety (14%).
Furthermore, the presence of depression and / or anxiety was associated
with increased psychopathology and reduced function in patients of
weapons, but not with the transition to psychosis true for an average
period of 3.65 years continued.
The high incidence of these comorbidities on arms issues can
phenomenologically reflect delusional mood and emotional dysregulation
processes that precede the onset of attenuated positive symptoms,”
writes Paul Fusar-Poli (King`s College London) and colleagues in
Bulletin of Schizophrenia. Aged between 14 and 35 years and were
assessed to all participants for signs and symptoms in danger in the
baseline using the Comprehensive Assessment of Mental State Endangered
(CAARMS). During the continuation period, 14.9% of patients experienced
a true psychotic episode. Depression and / or anxiety at baseline were
associated with disorganized behavior / odd / stigmatizing highest
notches CAARMS subscale for the sociality and self-harm, and a volition
/ apathy.
The beginning of psychotic symptoms and the onset of treatment with
antipsychotic medication can be termed as Duration of Untreated
Psychosis (DUP).  Long DUP in schizophrenia is associated with less
remission (Loebel et al., 1992) and a higher relapse in psychosis (Crow
et al., 1986). It is hypothesized that Delay in Intensive Psychosocial
Treatment (DIPT) is the predictor of outcome. Furthermore, for the long
term prognosis, early intervention of psychosis aiming at boosting
self-functioning and self-esteem is considered important. The DIPT is
also characterized by long periods of hospitalization. In the third
study (Michail & Birchwood, 2009) the relationships between the social
anxiety disorder and symptoms of psychosis are investigated with special
emphasis on its relation and prevalence with paranoia. Social anxiety is
a developmental disorder characteristic of schizophrenia.
However, prior work carried out in Pallanti et al. (2004) has dismissed
any links existing between depression and social anxiety disorder.
Hence, work done by Michail, M. (2009) is a qualitative analysis to
investigate the difference between patients with social anxiety disorder
with psychosis and those with social anxiety disorder without psychosis.
Psychosis is a generic term used in psychiatry and psychology to refer
to a mental state described as a division or loss of contact with
reality. People who have it are called psychotic. Today, the term
“psychotic” is often incorrectly used as a synonym for psychopathic.
People experiencing psychosis may have hallucinations or delusions, and
may exhibit personality changes and disorganized thinking. These
symptoms may be accompanied by unusual or bizarre behavior, as well as
difficulty interacting socially and inability to perform activities of
daily living.
A wide variety of elements of the nervous system, both organic and
functional, can cause psychotic reactions. This has led to the belief
that psychosis is like the “fever” of mental illness, a serious but
nonspecific indicator. However, many people have unusual experiences and
distortion of reality at some point of their lives, without becoming
disabled or even distressed by these experiences. As a result, it is
argued that psychosis is not fundamentally separate from a normal
consciousness, but rather is a continuum with normal consciousness.
There are many classifications historically, some of which will be
established according delusional-hallucinatory frames (e.g.
schizophrenia) or delusional (e.g. paranoia), in delusional psychosis
plausible or implausible, good or bad systematized in connection its
emergence as a process or development, etc. Today, globally accepted as
ontological classification system to DSM-IV, and as psychiatric clinical
description still weight the German school of Bleuler, Kraepelin and
Kleist, and as for the description of delusions, the school-reviewed
French (with Gaetan of Clerembault as best example). Usually the subject
lacks introspection about strange or bizarre nature that can adopt their
behavior or thoughts, which eventually cause severe social dysfunction.
Psychosis does not affect the intrinsic relation to language, where it
leaves even a construction site – the psyche – however it results in
alterations in thought processes. There are mental over activity as well
as difficulties in collecting his thoughts. The subject may show a
diminished capacity to be in the present, in a relationship
indescribable passing time (loss of sense of times, so for example). The
person is confined in a restricted world of assumptions, which
One can observe a tachypsychie (flight of ideas), a wordy, the
digressions (leakage ideas, cock ass), a influence (or loosening of
associations), obsessive questioning, of circumlocution, of neologisms,
a morbid rationalism and, unlike the latter, poverty of speech
spontaneous dams (stop and resume spontaneous speech), the fading’s
(progressive decrease in the loudness of speech) … One of the
important characteristics of the psychotic state is denial disorders.
Classically, patients, during these episodes, believe that their
behavior, the content of their thoughts and hallucinatory experiences
are real and they live are in no way strange, unusual or strange.
However, the more time passes, the more awareness – partial – symptoms
The inclusion criterion was composed of cognitive disorder (COGDIS) and
assessed by The Bonn Scale for the Assessment for Basic
Symptoms-Prediction List (BSABS-P). Which required presence of at least
two out of nine of basic symptoms with moderate severity? Occurrence of
symptoms before one year of intake. Inability to divide attention during
interference, pressure and blockade and disturbance of receptive and
expressive speech disturbance of abstract thinking unstable ideas of
reference and captivation of attention by visual field was included as
basic symptoms. The ultra high risk (UHR) criterion was assessed by
Structural Interview for Prodromal Syndromes (SIPS). The ultra high risk
approach constituent of three alternative criteria. The attenuated
positive symptoms of unusual delusional thought content,
suspicious/persecutory ideas, grandiosity, perceptual
abnormalities/hallucinations, disorganized communication and odd
appearance. Appearance of at least one symptom from above defined as
positive symptom with frequency several times a week and one week for
last three months with moderate to severe but not psychotic.
Exclusion criterion required having a psychotic episode more than one
week fulfilling the DMS-VI criteria for having the brief psychotic
episode not only for more than one day but for more than seven days.
These symptoms were assessed by Structural Clinical Interview for DMS-VI
having symptoms familiar to inclusion arising from a known general
medical disorder or drug or alcohol dependency.
A sample of first episode psychosis (FEP) indicating social anxiety
disorder were compared with a group of social anxiety disorder(SaD)
patients without psychosis. First episode psychosis group included basic
positive symptoms with condition falling in moderate to severe with age
bracket 16 a 35. Group with social anxiety consisted of patients with
diagnosed ICD-10 social anxiety disorder. Inclusion criteria were
assessed by Schedules for Clinical Assessment in Neuropsychiatry (SCAN).
SCAN trainees and trainers were responsible for reliability check. Early
Intervention Service (EIS) contained Positive and Negative Syndrome
Scale (PANSS).
All three studies are conducted with a focus on first-episode psychosis
patients’ sample population. In Ruhrmann et al. (2010), 245
help-seeking patients in a supposedly prodromal state of psychosis are
considered according to either UHR criteria or the basic symptom-based
criterion cognitive disturbances (COGDIS). More specifically, the
inclusion criteria in Ruhrmann et al. (2010) are entailed to the
Cognitive Disturbances criterion (COGDIS) where at least two basic
symptoms of COGDIS of moderate severity that manifested within the last
three months had to be present. With the Ultra High Risk Criteria,
positive symptoms that had already weakened could be defined by at least
one of the symptoms that fell within the moderate to severe scale and
manifested several times in a week for at least one week within the last
three months. In the exclusion criteria, patients underwent psychosis
for a period not less than a week and were assessed with the Structured
Clinical Interview. While in Hann et al. (2003) patients along with
their parents are examined with an inventory concerning DIPT, DUP and
various aspects of outcome. By using a chart review, psychotic relapse
during the initial year after hospitalization was evaluated. The
DSM-III-R criteria were used to treat 88 patients where they were
referred to the program by both inpatient and outpatient care facilities
and each patient was required to be checked whether they were suffering
from schizophrenia or a related disorder. Several parameters are used
during the diagnosis involving direct interviews with the patients,
interviews with parents and a spot check on their medical history.
Finally, in the 3rd case study Michail, M. (2009), patients considered
on the basis of age group of 16 to 35. First-episode psychosis (FEP
group) sample group was compared with a sample group of social anxiety
disorder without psychosis (SaD group). Using the inclusion criteria an
assessment was made using the Schedules for Clinical Assessment in
Neuropsychiatry (SCAN). Reliability monitoring was done between SCAN
trainees and trainers. The PANSS was available at the Early Intervention
Service (EIS). Several kinds of variable including neuro-cognitive,
neurobiological, socio-biological and environmental variables are used
in conducting these research studies.
The mean observation period in Ruhrmann et al. (2010) was averaged to be
431.3 days and the mean time right from initial examination to the
transition was 496.8 days. The diagnoses of psychosis were short-spell
psychotic disorder, schizophrenia disorder, schizophrenia,
schizoaffective disorder and mood disorder with characteristics of
psychosis being evident. By combining UHR and COGDIS results yields the
best sensitivity and 19% incidence rate for transition to psychosis was
observed. By using 4-level prognostic index to further classify the
general risk of the whole sample, the predicted instantaneous incidence
rates of up to 85% is calculated. In the 2nd case study, Hann et al.
(2003), the average DUP was found to be 8.6 months with the median being
3.0 months whereby the duration of the first psychotic disorder
registered a mean of 26.3 months. The average duration of treated first
psychotic disorder had a mean of 17.7 months while the average DIPT
stood at 19 months. Previous cases of hospitalizations averaged at 1.02
while the average time period between the start of psychotic symptoms
and the interview was 72 months with a standard deviation of 27.6
months. It has been figured out that both DUP and DIPT were associated
with negative symptoms at outcome but mode of onset was not. DUP was
linked with mild psychotic relapse. DIPT was associated with months of
re-hospitalization. Thus, there was no relation between DUP or DIPT and
other aspects of outcome. When controlled for age at onset, gender,
duration of treated psychotic episode, only DIPT was associated with
negative symptoms at outcome. In the work of Michail, M. (2009), 25% of
the total participants with first-episode psychosis (FEP) were diagnosed
with social anxiety disorder on the scale of ICD-10.  The levels of
social anxiety, autonomic symptoms, avoidance and depression among both
FEP and SaD groups were comparable. Social anxiety in psychosis was not
related to the positive symptoms of the Positive and Negative Syndrome
Scale (PANSS). There were negative sentiments on the screening questions
that entailed their general feelings of anxiety and fear even before
their illnesses. These individuals had difficulty in their social
interaction with their peers because of the stigma and they could rather
embrace avoidance than share their troubles and challenges even with
their closest relatives.
The prediction model used in Ruhrmann et al. (2010) identified a greater
risk of psychosis with suitable prognostic accuracy in our sample. The
co-occurrence between the Ultra High Risk Criteria and COGDIS at the
reference point was a determinant for the highest proportion of
inclusions and it demonstrated the highest rate of transition. Indeed, a
step-by-step strategy should be used by using both the COGDIS and UHR
criteria for screening in the first place and secondly classifying the
risk involved using the EPOS prediction model. In conclusion, both the
Ultra High Risk Criteria and COGDIS criteria can be regarded as the
most suitable and efficient method of the early detection intervention
of psychosis. However, the work done in this study is limited to shorter
duration and in future the validity of given model over a longer time
frame is required to be examined. In Hann et al. (2003), results show
that patients with longer periods of DIPT had a higher chance of having
negative symptoms 6 years after the onset of psychotic symptoms and this
did not depend on the impact of the DUP. If intensive psychosocial
treatment is delayed, then there is a higher probability of negative
symptoms on the outcome. DUP with a lifetime of less than a year is
not a strong indicator of psychopathological outcome. Overall, DIPT is
identified as a more significant predictor of negative symptoms at
outcome than the delay in starting antipsychotic medication. In Michail,
M. (2009) case study, it has been identified that the rate of social
anxiety disorder in any given sample of people with first-episode
psychosis is estimated to be 25%. It is not only related to psychotic
symptoms and clinical paranoia rather it has more than one underlying
grounds. In actual, these disorders varied in the complexity and scale
of their severity and ranged from grave to severe, moderate and usual
The mean observance period was 431.3 days the mean time from baseline
examination was 496.8 days. Follow-up period consisted of nine to
eighteen months from the transition point. During that period the
incident rate of psychosis was 19%. Combining cognitive disorder and
ultra high risk proved to be highly sensitive. Taking ratio of possibly
occurring symptoms of psychosis 19.9 diagnostic accuracy of positive
prediction value of 83.3% was attained.
In FEP group 11.6% individuals reported clear difficulties during social
interactions with signs of avoidance and withdrawal. Both group results
indicated comparable levels of social anxiety and autonomic symptoms.
Compared to non- socially anxious persons with psychosis, persons
socially anxious showed high rate of perceived threat from persecutor.
This indicator however, does not have apparent affect on the level of
anxiety in FEP and SaD groups. Positive and negative syndrome scale was
proven unrelated to social anxiety in psychosis inclusive of persecution
or suspiciousness.
The constructed prediction model in European Prospect of Prediction of
Psychosis (EPOS) identified increasing risk contingency of psychosis
with pertinent accuracy. Whereas first episode psychosis social anxiety
is an indicative co-morbidity. It cannot be strictly regarded as
by-product of psychotic symptoms and clinical paranoia. Results indicate
the presence of social anxiety in early stages of psychosis. It peaks at
the onset of psychosis. 25% of patients were tested positive for ICD-10
criteria for social anxiety. Emergence of social anxiety in psychosis
does not have one route. Further investigation is needed to acquire
exact reasons for presence of anticipated harm in sub group of socially
anxious individuals with psychosis. It will be advantageous for
understanding the underline mechanisms of biological and environmental
nature in progression of psychosis.

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