Deanna L Kelly, PharmD, BCPP
Kathleen Patchan, MD
CPNP 2015 concluded with an excellent presentation from Dr. Diana Perkins titled, “Where Do We Stand with the Psychosis Risk Syndrome?" Diana O. Perkins, MD, MPH is Profesor of Psychiatry at the University of North Carolina at Chapel Hill and the Medical Director of the Outreach and Support Intervention Services (OASIS ) Clinic. Dr. Perkins has more than 10 years of research and clinical experience in the area of early psychosis identification and treatment. She is also a Principal Investigator of the NIMH-funded “North American Prodrome Longitudinal Study” (NAPLS2), a multisite NIMH U01 grant that will examine the neurobiology of early onset schizophrenia and develop prognostic factors to improve diagnosis of psychosis.
Dr. Perkins outlined the following three learning objectives: (1) to understand the concept of psychosis risk syndrome (otherwise known as attenuated psychosis syndrome or schizophrenia prodrome) and discuss major initiatives in the U.S. and globally to identify those at risk; (2) to describe data on clinical and biological prognostic features to identify those at risk for developing psychosis; and (3) to review potential pharmacologic and psychosocial treatments.
She provided an overview of DSM-5 diagnostic criteria and the worldwide prevalence of schizophrenia. She discussed risk factors of schizophrenia including genetic predisposition, in utero exposure, and developmental factors during childhood. During gestation, maternal infection, stress, and nutritional deficiencies such as vitamin D increase the risk of schizophrenia in offspring. Developmental factors include the early and heavy use of marijuana, living in an urban environment, immigration to a new country, and exposure to childhood trauma or abuse. Dr. Perkins discussed efforts to detect psychotic symptoms and either prevent the progression to or improve the course of schizophrenia. She illustrated key points using case studies and her experiences at the OASIS Clinic.
Early detection and treatment of psychosis can have a significant impact. For example, one study found that in 207 patients with first episode psychosis, 24 (or 12%) only had a single episode over 7.5 years. Predictors of having only a single episode of psychosis included a shorter duration of untreated psychosis and rapid response to medication.
She discussed attenuated psychosis syndrome and the importance of detection in the critical early stages. In the general population, 25% of people experience attenuated psychotic-like symptoms and 10-15% experience rare and brief hallucinations at some point in their lives. These psychotic-like symptoms exist in the population as a continuum of severity rather than as an all-or-none phenomenon. Only about 5% of individuals with psychotic-like symptoms meet criteria for attenuated psychosis syndrome
Dr. Perkins discussed how attenuated psychosis syndrome was initially considered as a diagnostic category in DSM-5 but was instead included as a condition for further study. The rationale for this is because of the stigma of being diagnosed with a mental illness when many who develop attenuated psychosis syndrome will become adults without developing a chronic psychiatric condition. The graph below depicts the psychiatric diagnoses of patients one year after developing attenuated psychosis syndrome. Of those who develop attenuated psychosis syndrome, 1/3 will develop a psychotic disorder. Nearly 25% will not have a formal axis I psychiatric disorder one year after diagnosis.
Dr. Perkins concluded her lecture by detailing several multisite research initiatives that are investigating which patients may eventually develop psychosis or schizophrenia. These initiatives are focused on identifying risk factors or biomarkers to identify people who may be in the prodrome or early stages of psychosis and will go on to develop schizophrenia. Also, she discussed that a number of treatment strategies have been investigated and she recommended omega-3 fatty acid (1000-2000 mg a day of fish oil) and individual and family psychotherapy. Antipsychotics carry inherent risk and should not be considered first line treatment in patients with the psychosis risk syndrome.
Dr. Perkins offered several examples of patients in her practice and demonstrated how early intervention can have a profound impact on the lives of patients. Dr. Perkins’ experiences in identifying and treating patients with psychosis risk syndrome reinvigorated hope in many practitioners whose only experience has been with chronically ill and older populations. She left the audience with a renewed hope that early interventions can help people lead productive lives.