Understanding the Predictors of Psychosis
Psychosis is a debilitating condition in which one is unable to differentiate fantasy from reality, characterized by delusions, hallucinations, disorganized thinking (speech), grossly disorganized or abnormal behavior (including catatonia), and negative symptoms (American Psychiatric Association, 2016). Those afflicted with psychosis may experience social and occupational dysfunction which can be detrimental to one’s quality of life (Domínguez-Martínez, Kwapil, & Barrantes-Vidal). On November 16, 2017, Science Magazine published an article describing the experiences of Brandon Staglin, a man diagnosed with schizophrenia. Staglin notes his first signs of an impending psychotic break that was not recognized by him or his parents; shortly after his grandfather had passed away, he had trouble differentiating if he was asleep or awake, and had felt that he could not emotionally connect to a song that he had previously felt dear to (Couzin-Frankel, 2017). Unidentified as potential prodromal symptoms of a psychotic break or schizophrenia, Staglin went onto college four years later where he began to experience auditory hallucinations and have nightmares suggesting that he was “a mixed up kid.” Later that summer, Staglin had a full-blown psychotic break, resulting in a diagnosis of schizophrenia. From the anecdotal descriptions of his prodromal symptoms, his father notes had they known the symptoms that often precede psychosis, they would have approached “his quirkiness and his behaviors” differently (Couzin-Frankel, 2017). This sentiment is not limited to Staglin’s family. Couzin-Frankel notes that physicians emphasize prevention and screenings for medical problems such as heart disease or diabetes, but rarely assess for psychiatric conditions like depression, anxiety, and schizophrenia. Because our health care professionals fail to adequately assess the psychiatric status of their patients, combined with the general stigma that comes with mental health disorders, people are not aware of these important precursors. By thoroughly understanding risk factors, methods of prevention, and addressing stigma, we can improve outcomes and potentially quality of life for those at risk for developing psychosis, among other mental health disorders.
When approaching prevention, recognizing factors that may increase one’s risk is crucial. One of these factors is an individual’s genetic and family history, which according to the literature, may be the most significant factor in one’s risk for developing a psychotic disorder. According to one study, schizophrenic spectrum disorders among other psychotic disorders pose a very high risk factor with a heritability rate of 73% (Hilker, Helenius, Fargerlund, Skytthe, Christensen, Werge, Nordentoft, Glenthøj, 2018). In this study, 31,524 twin pairs born between 1951 and 2000 were tracked using The Danish Twin Register making it possible to identify their respective ICD diagnoses related to schizophrenic spectrum disorders. Interestingly, despite the relatively high heritability rate, the concordance rate for monozygotic twins was only 33% (7% for dizygotic twins), suggesting that there are environmental factors that also influence the presentation of such disorders. Hilker et al. presented a study with a very large and representative population of twins in Denmark which helps accurately depict the general public, however, this can also manifest as a weakness as only Danish people were monitored; it is possible that other groups of people have different rates of heritability and concordance. Additionally, Stephan Heckers from the University of Maryland School of Medicine writes, “The risk [for developing a psychotic disorder] increases several folds if a person has a first-degree relative with a history of a psychotic disorder.” With evidence suggesting the high heritability of such disorders, clinicians should be assessing family history beyond just medical problems– recognizing that psychotic disorders as well as other mental health disorders are highly heritable is crucial to better provider care, and ultimately increased individual awareness of risk. In the case of Staglin, if he or his family had known about prior incidences of schizophrenia in his family, he and his parents could have been more aware of the “odd” behaviors he was exhibiting, potentially prompting them to see professional help before full blown psychosis.
Beyond someone’s genetic predispositions, another risk factor that individuals generally cannot control exists when the individual is a neonate (Couzin-Frankel, 2017). In a cohort study done with nearly 2 million individuals, researchers concluded that a mother developing an infection (regardless of pathogen type) during her third trimester of pregnancy has a statistically significant increased risk of having a child who will develop a psychotic disorder, compared to no statistically significant increase in risk when infections occur in the first or second trimester (Blomström, Karlsson, Gardner, Jörgensen, Magnusson, & Dalmon, 2016). This study compared individuals diagnosed (n = 8330) and not diagnosed (n = 1,963,293) with nonaffective psychosis to understand if there is a relationship between their diagnosis/lack of diagnosis and their mother’s pregnancy infection history. Not only was it shown that infection in the 3rd trimester (HR 1.26, 95% CI: 1.05, 1.52 ) increases risk, it also revealed a synergistic relationship between mothers who have had a history of having a psychiatric disorder and having an acute infection during their third trimester. This supports the finding of another study which analyzed the synergy between family history and prenatal infection, suggesting 38% to 46% of offspring who developed schizophrenia did so because of the above risk factors (Clarke, Tanskanen, Huttumnem, Whittaker, & Cannon, 2009). A strength of this study is the large population of individuals involved, however Blomström et al. note that their study only included those who received medical care for their infections, thus excluding individuals who had less severe infections. Despite this weakness, this data can prove to be incredibly important as a soon-to-be pregnant mother may consider taking extra precautions to prevent contracting infections, ultimately decreasing risk for their offspring. Understanding this risk can potentially encourage mothers to receive an annual flu vaccination to reduce their risk of contracting influenza, practicing good hand hygiene, and other means of infection control. Providers can also implement this piece into their assessment of an individual’s risk and provide education on environmental factors relevant to increased or decreased psychotic disorder incidence.
Beyond an individual’s genetic and neonatal predispositions, it is necessary to examine other factors that precede the onset of psychotic disorders, which most commonly present between the ages of 18 and 24 (REFERENCE). One factor that can take shape in many forms is childhood trauma. In a cross-sectional study conducted with 250 participants, researchers studied the relationship between experiencing environmental adversities and psychotic symptoms (Schalinski, Breinlinger, Hirt, Teicher, Odelwald, and Rockstroh, 2017). The participants consisted of two groups; individuals who have experienced psychotic symptoms before (n = 180) and people who were part of the control group (n = 70). Researchers used a screening tool called the “Life Events Checklist” which screens for 17 different types of traumatic experiences, and categorized experiences according to the first 18 years of life, and adulthood (> 18 years). Findings reveal that risk factors are not limited to the presence of abuse, but also the age at which the traumatic event occurs. Neglect at age 10 (p = 0.002) and neglect at age 11 (p = 0.008) demonstrate a statistically significant increase in risk compared to individuals who experienced trauma or abuse at age 17 (p = 0.069) and age 18 (p = 0.057). Schalinski et al. write “Exposure to neglect at age 10 as [a] significant predictor for the severity of positive symptoms,” suggesting that high amounts of stress or trauma at a young age can precipitate more positive psychotic symptoms compared to experiencing such abuse closer to adulthood as noted above. The use of a targeted screening tool provides a large pool of traumatic experiences which participants can identify with, depicting this relationship accurately. However, though this study is suggestive of these risks, the sample size (n = 250) was limited and might not accurately depict the public. Clinical implications for this risk factor include assessing an individual’s psychosocial wellbeing, specifically for signs of a safe living situation, signs of physical or verbal abuse (bullying at school or home), and traumatic events that may cause abnormally high levels of stress (death, loss, etc.). Providers should be aware of their patients’ wellbeing beyond their physical health, evaluating the above noted risk factors. In the same way, parents can act by being aware of their children’s stress levels and taking steps to help reduce stress when in excess. However, if a child were to experience a traumatic experience, parents should seek professional help to help their child cope and process through the event.
In individuals who are at high risk or show prodromal psychotic symptoms, treatments and therapies exist to slow the progression and possible prevent the onset of a psychotic break. Expectedly, individuals and family of individuals who are aware that they are experiencing these precursor symptoms will most likely seek help in preventing this debilitating condition– however, not all treatment options are the same, some carrying more risk and effectiveness than others. A systematic review and meta-analysis revealed highlighted cognitive behavioral therapy (CBT) informed treatment’s association “with a reduced risk of transition to psychosis at 6, 12, and 18-24 months, and [reducing] symptoms at 12 months” (Larson, Walker, Compton, 2010). This systematic review reviewed seven trials, finding that individuals who received CBT had their relative risk of developing a psychosis reduced more than 50% (calculated with 95% CIs). The effectiveness of CBT is highlighted here by not only the high rate of risk reduction, but also by the lack of adverse effects that are commonly associated with other treatments such as anti-psychotic medications. This study noted that the literature (two separate studies) concluded that CBT was not associated with increased risks of depression or social anxiety, which may occur with prodromal symptoms. CBT usually consists of talk therapy and behavioral therapy sessions that span over periods of time; some people may opt for what may seem like a simpler solution in the form of antipsychotic medications. The literature shows that antipsychotic medications can significantly decrease transition risk (prodromal symptoms to full blown psychosis). According to Liu and Demjaha, a meta-analysis (n = 2502) found that the transition risk in patients experiencing prodromal symptoms and taking antipsychotics was 22.9%, significantly lower than the prodromal group not taking antipsychotics with a transition risk rate of 36.5%. Though the decrease appears significant, this study also explains that a “specific psychological treatment” not limited to anti-psychotic medication, can lower the transitional risk to 24.9% which comes very close to the rate after taking antipsychotics. However, it is essential to question of whether the efficacy of the medication outweigh the adverse effects that users may experience. In the same meta-analysis, four drugs, risperdone, olanzapine, amisulpride, and aripipazole were noted for their adverse effects. Of the four, risperdone was the only medication with no significant adverse effects between participants’ baseline and their 6 month follow-up, though it did show an increase in weight in some (not statistically significant). The other three precipitated adverse effects that were more substantial; 56.7% of those who took olanzapine gained an average 7% of their baseline body weight versus 3.4% in the placebo group (p < 0.001); the drug also showed an increase in pulse rate (10.7 ± 15.8, p = 0.042). Amisulpride significantly increased prolactin levels by 795.4% (control group 47.2%) which was believed to contribute to menstrual disorders, fatigue, sleep problems, and weight gain. Participants taking aripiprazole experienced sedative effects and akathisia. With so many possible adverse effects, it is questionable whether the negative impacts outweigh the benefits, especially when there are other treatment options available (24.9% efficacy, as noted above). Clinicians must inform their patients about the risks of antipsychotics, and that taking or not taking antipsychotics does not concretely determine whether one will develop psychosis. As other less invasive treatment options exist, further research in the areas of treatment and prevention is needed.
Understanding the risks factors, methods of prevention, and treatment options for potential psychotic disorders is essential to approaching improving outcomes for those at risk for these debilitating, life-altering conditions. Though psychosis is not completely understood, some of the large risk factors are genetics and family history, childhood trauma and abuse, as well as a mother’s infection status during their third trimester of pregnancy. It is important for clinicians to be aware of said risks, and provide necessary screenings and education for those at risk. Moreover, clinicians should be doing their part to destigmatize mental health problems. The stigma against those with mental illness can prevent those who identify with said risks or suffer from prodromal symptoms from seeking the appropriate help and treatment they need, in term potentially creating more harm. The potential harm in reaching out and offending someone who may be experiencing prodromal symptoms pales in comparison to letting someone’s prodromal symptoms go untreated and develop into full-blown psychosis which can manifest in significantly more trauma, disability, and decreased quality of life. Treatments such as CBT and antipsychotic medications exist, though vary in effectiveness and adverse effects. Further research is required to provide more options without compromising effectiveness and the health of the individual. Through destigmatizing mental health problems and considering mental illness just as important as physical health, we can come a step closer to improving outcomes and reducing harm in those afflicted with prodromal symptoms and psychotic disorders.