East Asian Arch Psychiatry 2015;25:35-41

ORIGINAL ARTICLE

Ms Elaine Yee-Ning Ching, MSc, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China.
Dr Edwin Ho-Ming Lee, MRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China.
Dr Christy Lai-Ming Hui, PhD, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China.
Dr Jing-Xia Lin, PhD, Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China.
Dr Wing-Chung Chang, MRCPsych, FHKCPsych, FHKAM (Psychiatry), Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China.
Dr Sherry Kit-Wa Chan, MRCPsych, FHKCPsych, FHKAM(Psychiatry), Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China.
Prof. Eric Yu-Hai Chen, MA, MBChB, MD, FRCPsych, FHKAM (Psychiatry), Department of Psychiatry, The University of Hong Kong, Hong Kong SAR, China.

Address for correspondence: Dr Edwin Ho-Ming Lee, Department of Psychiatry, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong SAR, China.
Tel: (852) 2255 4486; Fax: (852) 2855 1345; Email: edwinlhm@hku.hk

Submitted: 8 August 2014; Accepted: 11 September 2014

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Introduction

With the advance of early intervention, the number of people seen who are at risk of developing psychosis has been increasing, drawing the attention of both clinical research and mental health services.^1-3 It is thought that, as with other medical conditions, intervening at an early stage can prevent the onset of full-blown illness and its associated complications. There has been growing evidence to support potential preventive interventions,^1,4-8 but the high false- positive rate calls for a more in-depth understanding of the condition to assist in deciding on appropriate treatment.^9,10

To better identify cases of prodromal psychosis, researchers have sought to pinpoint common symptoms that may arise during this stage. McGorry et al¹¹ proposed the clinical staging model for psychosis, a current conceptualisation of prodromal psychosis which specifies the condition throughout a progression from healthy to psychotic state, using stages 0 to 2. The initial stage identifies adolescent or emerging adults of first-degree relatives with psychosis as having an increased risk of developing a psychotic disorder. The model progresses forward to the presentation of neurocognitive deficits and functional decline. Specific or non-specific changes may both occur during all these stages.12,13 Non-specific changes or symptoms refer to hypofunctioning behaviours, such as withdrawal, or hyperfunctioning behaviours such as anxiety. Specific changes or symptoms are attentional and perceptual disturbances, which are thought to predict latter interruptions in thinking, speech, and motor abilities.

The next stage involves individuals at ultra-high risk who present with subthreshold symptoms before reaching the cutoff for prodrome — the onset of first-episode psychosis. Prior to this onset, neurotic symptoms may be present as a reaction to preceding specific or non-specific symptoms. These could be beliefs used to make sense of their disturbances, or emotional reactions, such as anxiety. In the final stage of onset of psychosis, symptoms will be further exacerbated, reaching criteria for the diagnosis of psychosis. However, some episodes do not progress into psychosis, as observed symptoms may simply be ‘prodrome-like’ and mirror true symptoms.¹⁴ Due to the lack of specificity in many of these prodromal symptoms, there is a high chance that such presentations represent co- morbidity of other psychiatric disorders.¹⁵

Differentiating between prodrome-like and actual symptoms poses a significant challenge for the field. This has raised concerns over the clarity of the definition and validity of prodromal psychosis as a diagnosis, which has in turn influenced major diagnostic tools, namely the latest DSM-IV. Researchers have long stated the need to better understand the condition through qualitative methodologies involving small groups of patients during the development of psychosis. In Hong Kong, the EASY (Early Assessment Service for Young People with Psychosis) programme was implemented more than 10 years ago.¹⁶ The advantage of the programme’s open referral system has allowed the identification of some patients with prodromal psychosis. This report highlights the symptoms presented over the course of 12 months by 10 patients with prodromal psychosis in Hong Kong. In particular, we describe the unfolding of symptoms and changes in functioning with reference to the clinical staging model by McGorry et al.¹¹ This allows comparison of current understanding through such a model with actual observations in Asian populations.

Case Series

A total of 10 Chinese patients between the ages of 16 and 35 years diagnosed with prodromal psychosis were observed monthly for 12 months between December 2012 and July 2014 at psychiatric outpatient clinics of Queen Mary Hospital, Kwai Chung Hospital, and Pamela Youde Nethersole Eastern Hospital in Hong Kong. The criteria for the 3 ultra-high risk groups from the Comprehensive Assessment of At-Risk Mental States (CAARMS)¹⁷ was used for diagnosis of prodromal psychosis by the psychiatrist. Use of the Structured Clinical Interview for DSM Disorders (SCID) was an additional assessment tool used to identify any co-morbid illnesses. Presenting symptoms and functioning during clinical sessions conducted by their attending psychiatrist were noted. Detailed vignettes of patients are included in Appendices 1 to 4. One patient transitioned into psychosis at month 1. Observations were categorised into 4 main groups: no change, improvement, transition into psychosis, and fluctuations.

Two patients (Appendix 1) with no change initially presented with neurotic symptoms (mood or anxiety symptoms). Symptoms remained stable throughout 12 months, and functioning was noted to have improved slightly by month 6. Insight into changes and family support were both strong. The combination of these factors, along with cognitive behavioural case management, was thought to possibly account for the functional improvement.

Three other patients (Appendix 2) with marked symptomatic improvements first presented with distress arising from perceptual disturbances (transient auditory hallucinations with content calling the patient’s name or making simple commands) or delusion-like symptoms. Co- morbid anxiety and depressive symptoms were common, as was the experience of a recent stressful life event in this patient group. Symptoms were observed to diminish gradually throughout the follow-up period. These patients had good insight in general and good social support from family.

In contrast, one patient’s (Appendix 3) condition worsened in the first month, with transition to psychosis. This patient had a family history of mental illness and had experienced delusion-like symptoms and anxiety within the previous 2 years. A rapid decline in functioning and the emergence of positive psychotic symptoms (auditory hallucinations and persecutory delusions) was noted.

Four patients (Appendix 4) with a fluctuating condition first presented with delusion-like symptoms and perceptual disturbances. These symptoms were accompanied by low mood, anxiety, and social withdrawal. Insight and family support were poorer compared with other patient groups. Some of the symptoms diminished during the follow-up period, but were substituted by other symptoms. Some of these patients reported the presence of stressful life events.

Discussion

Patterns of symptoms and their outcome as noted in these 10 patients closely reflected the milestones outlined in the clinical staging model by McGorry et al.¹¹ Patients in most groups had a combination of non-specific and specific symptoms, compatible with the initial stages of the model. The varied outcome further emphasised the possibility of prodrome-like symptoms. However, there was no clear difference observed between such symptoms and actual symptoms. The main factor in this overall patient group that appeared to be a determinant of the onset of psychosis was a family history of psychosis. Other potential determinants noted in these patients were stressful life events.

Non-specific symptoms most commonly observed in this study were mood and anxiety symptoms, which were noted in all patient groups. In particular, the group with no change presented with mood and anxiety changes only; there was a notable absence of obvious, specific symptoms, apart from unusual thought content and mild speech disturbance. According to the CAARMS assessment, these symptoms, along with a significant drop in functioning, are sufficient for a diagnosis of prodromal psychosis. However, it could be argued that these symptoms are merely mirror symptoms of other co-morbid illness, and are not sufficient to allow classification as prodromal psychosis when present alone. Of note, McGorry et al¹¹ have suggested that the emergence of neurotic symptomatic responses which occur to make sense of unusual experiences from specific changes can also present in the form of anxiety. Moreover, the noted non- specific changes in patients without change in condition and the one transitioned into psychosis did not differ. Due to the similarity between these responses and non-specific changes, one cannot confidently rule out the possibility of these patients developing psychosis in the future. Nonetheless, the fact that these symptoms occurred in all patient groups, regardless of whether a response or a non- specific change, demonstrates the role of these symptoms in the progression of prodromal psychosis, aligning with the clinical staging model.^18-20

The accompanying specific symptoms noted in patients were mainly in the form of auditory perceptual disturbances or delusion-like symptoms, which were found in all groups, except the patient group without change in condition. The noticeable difference in specific symptoms between the patient that transitioned into psychosis and patients who improved or fluctuated was the duration and speed of symptom severity. The patient that transitioned into psychosis reported non-specific changes in mood and aggression but no specific perceptual disturbances. These disturbances rapidly declined shortly prior to diagnosis of schizophrenia. Other patients had a relatively longer period of experiencing similar specific symptoms. This partially aligns with the literature that such subthreshold psychotic symptoms, which form the basis of prodrome, are predictive of transition into psychosis.¹¹ The varied outcome for differing patients may be attributed to the suggestion that psychosis progresses on a continuum based on severity, rather than a qualitative change.^11,20 Patients who improved or fluctuated may have simply acquired symptoms that were less likely to progress than those seen in the patient who transitioned into psychosis. It is also plausible that the patient who transitioned into psychosis did not report specific symptoms, which delayed the detection and diagnosis of prodromal psychosis.

The varied outcomes seen in this case series may also be attributed to the characteristics of the patients. One possible determinant noted was a family history of mental illness. Only the patient who transitioned into psychosis had first-degree relatives with schizophrenia or other psychotic illnesses, supporting McGorry et al’s model.¹¹ The impact of other factors, such as stressful life events, insight, and social support was less clear-cut. It was noted that both the improvement and fluctuating groups experienced recent stressful life events, but the latter had poorer social support and insight. It may be that the latter group was more reluctant to approach and accept mental health services due to the lack of support, leading to a poorer outcome. Moreover, the latter group experienced more predominant specific symptoms, rather than non-specific symptoms, which may also have influenced their willingness to seek help.²¹

Our observations generally correspond to the current clinical staging model of prodromal psychosis, but further research is required to clarify and validate these observations. The small number of patients and the observational nature of this case series preclude the provision of suggestions in relation to the patient outcome. A follow-up study may shed light on outcome patterns and potential determinants of psychosis. These studies should incorporate specific assessments, in addition to CAARMS and SCID, to assist in limiting the false-positive rate.

This case series adds to the existing literature and discussion about prodromal psychosis, and reports data specific to Asian patients. With this information, we hope to inform clinical services on recognition of appropriate timeframes for applying intervention.

References

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Appendix 1. Vignettes — no change.

Patient ‘A’

A 19-year-old male met criteria for attenuated psychosis group and presented with unusual thought content and a significant drop in social and occupational functioning. ‘A’ was brought up in a middle-class family, was known to have few close friends, was an average-grade yet diligent student, and maintained a close relationship with his parents. He had no previous history of mental illness, but it was noted that his father had received treatment for anxiety. ‘A’ first experienced distressing thoughts a year before his first contact to mental health services when he was going through his final school examinations. His grades plummeted and he failed to achieve the necessary grades for university. These distressing thoughts centred on ideas of demons, and at times commands were heard which were ruminated on constantly by the patient in attempts to avoid negative consequences. During clinical sessions, he presented with circumstantial speech, appeared occupied, and often refused to talk in depth about his ruminating thoughts, although he had good insight. He was given antidepressants and cognitive behavioural case management to alleviate his distress and anxieties. Monthly observations did not note any changes since first contact.

Patient ‘B’

A 30-year-old male met criteria for attenuated psychosis group and presented with disorganised speech and a significant drop in social and occupational functioning. ‘B’ was outgoing, had an ordinary childhood with few close friends and lived with his family. He had no personal history or family history of mental illness. ‘B’ worked as a technician but was facing redundancy due to a work injury and was seeking alternative employment. His girlfriend whom he lived with had become pregnant near the time of his first contact to mental health services. He felt upset and distressed because of these recent stressful life events, and began noticing difficulties in conveying his thoughts and expressing himself to others. He spoke little due to this. He was given cognitive behavioural case management. By month 6, he had secured a new job and was raising his newborn, with support from his family and girlfriend. Symptoms, however, remained as they were when he had first contacted mental health services.

Appendix 2. Vignettes — improvement.

Patient ‘C’

A 18-year-old male met criteria for attenuated psychosis group and presented with perceptual disturbances in the form of content calling the patient’s name and non-bizarre ideas (suspiciousness), accompanied with a significant drop in social and occupational functioning. ‘C’ was raised in a middle-class family and had close ties with family members, especially his twin brother. He had average grades throughout middle school, was sociable, and had no personal history or family history of mental illness. Since the start of high school, he had had difficulties adapting and experienced the first symptoms of auditory disturbance and suspiciousness, affecting his grades and social life. He was given cognitive behavioural case management. Along with support from his family, his non-bizarre ideas diminished by the first month and his auditory hallucinations gradually diminished after 12 months. Both his symptoms and social functioning had clearly improved, almost to the level before his first symptoms.

Patient ‘D’

A 22-year-old female met criteria for attenuated psychosis group and presented with auditory disturbances of content calling patient’s name and non-bizarre ideas (suspiciousness), accompanied with a significant drop in social and occupational functioning. ‘D’ had a stable childhood and good ties with her family. There was no history of mental illness in her family. She had recently graduated from university and begun her first job, which she found difficult and struggled with. Since this change, she had begun to experience auditory disturbances of her name being called, referential ideas that she was being followed and suspiciousness towards her colleagues. She was given cognitive behavioural case management. Symptoms diminished within the first month and social functioning gradually improved over the course of 12 months. She subsequently started her second job and adapted well to it.

Patient ‘E’

A 26-year-old female met criteria for attenuated psychosis group, presenting with auditory disturbances in the form of name calling, ideas of reference and non-bizarre ideas (suspiciousness), accompanied with a significant drop in social and occupational functioning. ‘E’ was a reserved and quiet individual as a child, growing up in a family with lower socio-economic status. Due to their busy work, she had loose relationships with her parents. There was no history of mental illness in the family. She first experienced ideas of reference and suspiciousness when she was unemployed, about a year prior to her first contact with mental health services, which was rapidly followed by auditory hallucinations of name calling. Signs of anxiety accompanied these episodes. She was given antidepressants and cognitive behavioural case management. Auditory disturbances diminished within the first 3 months of treatment, whereas ideas of reference, suspiciousness, and anxiety gradually decreased throughout the 12-month follow-up period. She held a part-time job as a barista and had plans to switch to full-time employment.

Appendix 3. Vignette — transition into psychosis.

Patient ‘F’

A 35-year-old female who initially met criteria for the vulnerable to developing psychosis group, presented with a history of psychotic illness in first-degree relatives (sister and mother), accompanied by a recent drop in social and occupational functioning, and mood changes. ‘F’ grew up with siblings and parents in a lower socio-economic household, but drifted away from her family when she was involved in romantic relationships during her early adulthood. During this period, she took drugs, including cocaine but eventually stopped drug taking about 5 years before her presentation. In the year preceding her presentation, she had experienced fluctuating emotions of anger and sadness, and was often involved in arguments with strangers. With good insight, she sought help from mental health services. She was initially categorised as vulnerable to developing psychosis, which was treated with observation and case management only. Within the first month of observation, she transitioned into a full-blown schizophrenia and was treated with appropriate antipsychotic medications.

Appendix 4. Vignettes — fluctuating.

Patient ‘G’

A 16-year-old female met criteria for attenuated psychosis group and presented with non-bizarre ideas and perceptual disturbances, accompanied by a drop in social and occupational functioning. ‘G’ was a quiet and creative teenager, with close relationships with family and few close friends at school. About a year prior to contact with mental health services, ‘G’ claimed to see shadows and doors closing by themselves at school. She also felt suspicious of peers. There was no family history of mental illness. Case management was provided. Non-bizarre ideas diminished within the first month of observation, whereas perceptual disturbances diminished after 6 months. These symptoms were replaced by unusual thought content in the form of ideas of reference towards strangers, which had increased at the third month follow-up but gradually decreased after 12 months. Functioning improved during the course of the 12 months’ follow-up. At the final follow-up she reported that she was attending all classes, had a very close classmate, and could walk on the street without intruding thoughts of references.

Patient ‘H’

A 16-year-old male met criteria for attenuated psychosis group, and presented with perceptual disturbances, aggression, depression and suicidal thoughts, accompanied by a drop in social and occupational functioning. ‘H’ was a quiet teenager who grew up with his brother and mother. He had low to average grades at school and had few close friends at school. He reported recent bullying by his classmates who swore at him. After this incident, he started experiencing auditory hallucinations of foul language being yelled at him. Case management was provided. After the first month, he no longer had suicidal thoughts. Perceptual disturbances re-occurred throughout the 12 months when evoked by events where he was scolded.

Patient ‘I’

A 26-year-old male met criteria for attenuated psychosis group, and presented with non-bizarre ideas, aggression and suicidal thoughts, accompanied by a drop in social and occupational functioning. ‘I’ was an outspoken young man who grew up with his parents in a low-income family. He had high grades and few close friends. Due to financial issues within the family, he had to halt his university studies. During this period, he first started experiencing his distress. Non-bizarre ideas and aggression decreased by the fifth month, whereas his depression and lack of motivation increased. He refused to take medications and received case management only as an alternative.

Patient ‘J’

A 20-year-old male met criteria for attenuated psychosis group, and presented with disorganised speech in the form of mutism, and blunted affect, accompanied by a significant drop in social and occupational functioning. ‘J’ was known to have a ‘bubbly’ and friendly personality, and was brought up in an upper middle-class family. In the 2 years prior to presentation he had begun to stop talking, resorting to mouthing, when he experienced major examinations at school. Apart from his mutism, there was a gradual increase in unusual behaviours, including drinking excessive water, refusing to wear clothes, throwing personal items out onto the street, and lack of movement. Symptom intensity gradually increased over the course of 12 months. At month 6, he was prescribed antipsychotics but was still at the threshold of meeting criteria of a full-blown psychosis.