Barcelona snapshots

Prof. Alison R. Yung

Alison R. Yung psiquiatra Controversias Psiquiatria Barcelona
University of Manchester, Regne Unit
Ponència Estats pre-psicòtics en la persona jove
Data Divendres, 20 d'Abril 2018
Hora 14:30 a 15:15
Taula rodona Complexitats en Psiquiatria: psicosi i trastorns bipolars

BIOGRAFIA

Alison Yung is Professor of Psychiatry at the University of Manchester and Honorary Consultant Psychiatrist at Greater Manchester Mental Health NHS Foundation Trust.

After graduating from The University of Melbourne in 1986, she trained in psychiatry, and has been involved in early psychosis, in both clinical and research fields, since 1993. In 1994, she established the Personal Assessment and Crisis Evaluation (PACE) Clinic, a clinical and research centre that manages young people at incipient risk of developing psychosis. This was the first clinic of its type in the world.

Prior to moving to the UK in 2012, she was a Professor and Consultant Psychiatrist at Orygen Research Centre and the Centre for Youth Mental Health at the University of Melbourne, and an NHMRC Senior Research Fellow. She was Head of the Psychosis Research at Orygen.

Professor Yung received the Lilly Oration Award for prominence in psychiatric research in 2009, and the Richard J Wyatt Award in 2010, for exceptional contributions to the area of early intervention in psychosis. In 2014 and 2016 she was named as one of the “world’s most influential scientific minds” by Thomson Reuters.

RESUM

It is now possible to identify individuals at high and imminent risk of developing a first episode of psychosis through using the "At Risk Mental State" (ARMS) criteria. These criteria, also known as the "Ultra High Risk" (UHR) or Clinical High Risk (CHR) criteria, consist of three groups:(1) attenuated psychotic symptoms (APS) (subthreshold positive psychotic symptoms), (2) brief limited intermittent psychotic symptoms (BLIPS)(short episodes of frank psychotic symptoms that have resolved without treatment), and (3) trait and state risk factor (Trait) (presence of a presumed genetic vulnerability due to having a schizotypal personality disorder, or a first-degree relative with a psychotic disorder, combined with chronic low or a significant decrease in functioning).

About 15 - 22% of ARMS individuals develop a full psychotic disorder such as schizophrenia within 12 months. ARMS individuals are also at risk for chronic poor functioning and non-psychotic disorders.

Identification of ARMS individuals therefore presents the opportunity for early intervention to prevent of onset of full psychotic disorder and other poor outcomes. However the idea of preventive treatment for this group is not straightforward. While cognitive behavior therapy has been found to be effective in reducing the risk of psychosis in this group in clinical trials, it has no effect on functioning. A recently completed large trial of omega 3 fatty acids failed to replicate initial promising findings of the treatment’s ability to reduce psychosis risk and improve functioning. Antipsychotics have also been trialed, and although they seem to reduce risk for psychosis they are associated with side effects and high rates of treatment discontinuation.

One problem is that we lack understanding of the factors that predict these different outcomes, including underlying biological mechanisms. There is a need for investigation into factors that predict different outcomes, so that the field can move towards stratification of the ARMS group according to underlying pathological processes and targeted treatment.

Meanwhile, clinicians and policy makers have moved the field towards treating more ARMS individuals without clear knowledge of who is most at risk of which poor outcomes and which treatments should be used.

For example, it is estimated that over 12,000 people in England per year present to clinical services with distressing psychotic-like ARMS symptoms. Assessment and management of ARMS individuals is included in NICE guidelines, and since April 2016, NHS England has required clinical services to treat people with ARMS. The only recommended treatment at present is cognitive behavior therapy, which is costly and may not work for all people.

Furthermore, recently the ARMS criteria were used as the basis for a new condition included in the DSM5. This "diagnosis", the "Attenuated Psychosis Syndrome", is based on the ARMS APS group and listed in the “Schizophrenia Spectrum and Other Psychotic Disorders” Section – diagnostic code (298.8). This has led to concern that what was originally conceived as a method for identifying individuals at high risk of disorder is now seen as an actual disorder. One issue is that individuals with this diagnosis may be prescribed antipsychotic medication to prevent psychotic disorder. This is despite the majority of individuals meeting the ARMS APS criteria not developing psychosis. Many may therefore be receiving unnecessary treatment.

We need to be able to improve the prediction of different outcomes in individuals with ARMS and refine treatments accordingly. This presentation will summarise current knowledge and examine future directions for research.

REFERÈNCIES

[pdf] Yung AR et al (2015). Childhood maltreatment and transition to psychotic disorder independently predict long-term functioning in young people at ultra-high risk for psychosis, Psychol Med. 2015 Dec;45(16):3453-65. doi: 10.1017/S003329171500135X.

[web] Nelson B et al (2013). Long-term Follow-up of a Group at Ultra High Risk (“Prodromal”) for Psychosis, JAMA Psychiatry. 2013;70(8):793-802. doi:10.1001/jamapsychiatry.2013.1270

[web] Yung AR et al (2012). Whither the Attenuated Psychosis Syndrome?, Schizophr Bull. 2012 Nov; 38(6): 1130–1134.

[pdf] Yung AR et al (2010). The psychosis threshold in Ultra High Risk (prodromal) research: is it valid?, Schizophr Res. 2010 Jul;120(1-3):1-6. doi: 10.1016/j.schres.2010.03.014. Epub 2010 Apr 8.