منابع پریشانی بالینی در افراد جوان در معرض خطر فوق العاده روان پریشی

Background Substantial controversy has been generated since the proposal to include “Attenuated Psychosis Syndrome” in DSM-5, based on research criteria used to identify young people at “ultra high risk” (UHR) for psychosis. The syndrome was ultimately included in the section for further research. The criteria specified that the person experienced attenuated psychotic symptoms (APS) that were sufficiently distressing to warrant clinical attention. Although APS are the main means of determining whether a person meets UHR criteria, clinical experience suggests that such symptoms are often not the main source of clinical distress in this patient group. However, little is known about the sources of distress in the UHR group. We aimed to assess the main sources of clinical distress in UHR patients at the time of referral to a specialized UHR clinic. Method Sources and intensity of distress in 73 UHR patients were gathered from treating clinicians. The association with transition to psychosis was explored. Results Of the total sample, 89.04% fulfilled the APS UHR criteria. APS symptoms were reported to be distressing for 58.5% of this subsample, but social and functioning difficulties (78.1%) and depressive symptoms (58.9%) were the highest sources of distress leading UHR patients to seek help. Intensity of distress associated with APS, anxiety symptoms and substance use was associated with transition to psychosis. Conclusions APS were reported to be distressing for approximately half of UHR patients. The intensity of distress associated to these symptoms may be associated with increased risk for subsequent transition to full threshold psychotic disorder.

The prodromal or pre-psychotic phase of psychotic disorders has long been recognised as a period of considerable distress and psychiatric symptomatology characterized by social and functional decline (Yung and McGorry, 1996 and Fusar-Poli et al., 2012). Over the last two decades criteria have been developed to prospectively identify young people who may be in this prodromal phase of psychotic disorder (van Os et al., 2009, Yung et al., 2012a and Fusar-Poli et al., 2013), facilitating research and the development of preventative interventions (Yung and McGorry, 1996, Yung et al., 2004 and McGorry et al., 2009). These “ultra high risk” (UHR) criteria identify help-seeking young people with a significant decline in functioning presenting with either 1) attenuated psychotic symptoms (APS), 2) brief limited intermittent psychotic symptoms (BLIPS) and/or 3) trait risk factors such as a schizotypal personality disorder or a first degree relative with a psychotic disorder (Yung et al., 2003 and Yung et al., 2004). The criteria have been thoroughly validated (Yung et al., 2008) with rates of transition to full psychotic disorder ranging from 35 to 54% over a 12-month period (Yung et al., 2004 and Fusar-Poli et al., 2012) and 34.9% over a 10-year period (Nelson et al., 2013). In the development of DSM-V a new category of “Attenuated Psychosis Syndrome”, based on the UHR criteria, was proposed. This category was ultimately introduced in the section for further research (APA, 2013). The criteria stipulated that attenuated psychotic symptoms (APS) be sufficiently distressing and disabling to the individual to warrant clinical attention (Nelson and Yung, 2011 and Fusar-Poli and Yung, 2012). Although most UHR patients typically meet the APS group (about 85% of cases (Yung et al., 2006 and Nelson et al., 2013), studies in community samples report a prevalence of about 5% of APS in the general population who are not seeking clinical help and of about 25% in people with common mental health disorders such as anxiety and depression (van Os et al., 2009 and Linscott and van Os, 2013). A recent study in the general population estimated that up to 8% of adolescents in their sample (N = 212) met the APS criteria (Kelleher et al., 2012). Only 6.9% of this subsample reported distress associated with their attenuated psychotic symptoms (Kelleher et al., 2012). Other studies that explored screening strategies for detection of people at risk of developing psychosis found higher rates of transition to psychotic disorder in young people meeting UHR criteria who were seeking help for general (non-psychotic) psychiatric problems than in a UHR group referred to specialized services for psychosis (Ising et al., 2012 and Rietdijk et al., 2012). The distress associated with the APS in the former group was presumably lower than in the latter group, because these symptoms were only detected via screening and were not necessarily a significant source of distress or reason for help-seeking/referral. UHR patients are known to present with a range of non-psychotic psychopathology other than APS, including mood disturbance, anxiety symptoms, personality disturbance, and drug and alcohol problems (Yung et al., 2011 and Fusar-Poli et al., 2013). In fact, UHR patients exhibit a considerable degree of other psychiatric outcomes as well as conversion to psychosis (van Os et al., 2001, Addington et al., 2011 and Tsuang et al., 2013). The high rates of comorbidities suggest that distress in the UHR group may be associated with a range of presenting symptoms, not just APS, which is consistent with clinical impression at our UHR service and other UHR services (Yung and Nelson, 2011 and Nelson, 2014). However, there has been no data published to date on the main sources of distress in the UHR population. Researching the issue of sources of distress in UHR patients may have implications for the DSM-V “Attenuated Psychosis Syndrome” proposal (Woods et al., 2010 and Tsuang et al., 2013). Specifically, it would shed light on whether the proposed Attenuated Psychosis Syndrome would in fact pick up on patients currently seen at UHR clinics or whether the syndrome would target a slightly different group. It is also important to investigate whether distress in relation to APS corresponds to higher risk for transition to psychosis, as identifying predictors of psychosis in the UHR group remains a key research focus (Fusar-Poli et al., 2013). Therefore, in this study we aimed to 1) examine the main sources of clinical distress in UHR patients at the time of referral to our specialized UHR clinic and 2) examine the predictive value of distress associated with APS for transition to psychosis. Based on the clinical observations noted above it was hypothesised that the main source of clinical distress experienced by UHR patients would be non-specific psychopathology rather than APS. We also hypothesised, based on previous findings (Ising et al., 2012 and Rietdijk et al., 2012), that the level of distress associated with those non-psychosis related symptoms would be more predictive of transition to psychosis than distress associated to APS alone.