User:Lgorelick/sandbox/prodrome

The prodrome is a period of time during which an individual experiences some symptoms and/or a change in functioning, which can signal the impending onset of a mental health disorder. Identifying symptoms of the prodrome can create an opportunity to administer appropriate interventions quickly in order to try to delay or decrease the intensity of subsequent symptoms.

Symptomology
Schizophrenia was the first disorder for which a prodromal period was described (George, Maheshwari, Chandran, Manohar, & Sathyanarayana Rao, 2017). People who go on to develop schizophrenia commonly experience non-specific negative symptoms such as depression, anxiety symptoms, and social isolation (George et al., 2017). This is often followed by the emergence of attenuated positive symptoms such as problems with communication, perception, and unusual thoughts that don't rise to the level of psychosis (George et al., 2017). Closer to the onset of psychosis, people often exhibit more serious symptoms like pre-delusional unusual thoughts, pre-hallucinatory perceptual abnormalities or pre-thought disordered speech disturbances (George et al., 2017). As positive symptoms become more severe, in combination with negative symptoms that may have begun earlier, the individual may meet the diagnostic criteria for schizophrenia (McGlashan, Miller, & Woods, 2001). Although a majority of individuals who experience some of the symptoms of schizophrenia will never meet full diagnostic criteria, approximately 20%–40% will eventually be diagnosed with schizophrenia (Larson, Walker, & Compton, 2010). One of the challenges of identifying and treating the prodrome is that it is difficult to predict who, among those with symptoms, are likely to meet full criteria later.

Duration
The prodromal period in schizophrenia can last anywhere from several weeks to several years, and comorbid disorders, such as major depressive disorder, are common during this period (Rosen, Miller, D'Andrea, McGlashan, & Woods, 2006).

Identification/Assessments
Symptoms of the prodrome to schizophrenia can be assessed using structured interviews. For example, the Structured Interview for Prodromal Syndromes (SIPS; McGlashan, 2001), and the Comprehensive Assessment of ARMS (CAARMS; McGory et al. 2003) are both valid and reliable methods for distinguishing individuals experiencing impairing positive or negative symptoms from other individuals.

Interventions
Describing the schizophrenia prodrome has been useful in promoting early intervention. Although not all people who are experiencing symptoms consistent with the prodrome will develop schizophrenia, randomized controlled trials suggest that intervening with medication and/or psychotherapy can improve outcomes (Larson, Walker, & Compton, 2010). Interventions with evidence of efficacy include antipsychotic and antidepressant medications, which can delay conversion to psychosis and improve symptoms, although prolonged exposure to antipsychotic medication has been associated with adverse effects including tardive dyskinesia, an irreversible motor disorder (Larson, Walker, & Compton, 2010). Psychotherapy for individuals and families can also improve functioning and symptomatology; specifically cognitive behavioral therapy (CBT) helps improve coping strategies to decrease ppositive psychosis symptoms (Larson et al., 2010). Additionally, omega-3 fish oil supplements may help reduce prodromal symptoms (Larson, Walker, & Compton, 2010). Current guidelinrs suggest that individuals who are at “high risk” for developing schizophrenia should be monitored for at least 1 to 2 years while receiving psychotherapy and medication, as needed, to treat their symptoms ("Clinical practice guidelines. Treatment of schizophrenia," 2005).

Symptomology
There is also growing evidence that there is a prodromal period prior to the onset of bipolar disorder (BD; Howes, 2011; Van Meter et al., 2016). Although a majority of individuals with BD report experiencing some symptoms prior to the full onset of their illness, the prodrome to BD has not yet been described in a systematic way. Descriptive reports of bipolar prodrome symptoms vary and often focus on nonspecific symptoms of psychopathology, making identification of the prodromal period difficult. The most commonly observed symptoms are too much energy, elated or depressed mood, and alterations in sleep patterns (Van Meter et al., 2016). There are no prospective studies of the prodrome to bipolar disorder, but in the Longitudinal Assessment of Manic Symptoms (LAMS) study, which followed youth with elevated symptoms of mania for ten years, approximately 13% of those who did not meet criteria for BD at baseline eventually were diagnosed with BD (note that 23% of the sample met BD criteria at baseline).

Duration
The reported duration of the prodrome to BD varies widely (mean = 27.1 +/- 23 months; (Van Meter et al., 2016); for most people, evidence suggests that the prodromal period is likely to be long enough to allow for intervention.

Identification/Assessments
Symptoms consistent with the prodrome to BD can be identified through structured interviews such as The Bipolar Prodrome Symptom Interview and Scale (BPSS-P; citation) and symptom checklists (Van Meter, Burke, Youngstrom, Faedda, & Correll, 2016) (Howes et al., 2011).

Interventions
Early intervention is associated with better outcomes for people with prodromal symptoms of BD. Interventions with some evidence of efficacy include medication (e.g. mood stabilizers, atypical antipsychotics) and psychotherapy. Specifically, family-focused therapy improves emotion regulation and enhances functioning in both adults and adolescents (Miklowitz et al., 2017). Interpersonal and Social Rhythm Therapy (IPSRT) may be beneficial for youth at risk of developing BD by helping to stabilize their sleep and circadian patterns (Goldstein, 2014). Psychoeducational Psychotherapy (PEP) is effective in children under 12 years old with a BD diagnosis. The key goals of this type of therapy are to provide psychoeducation about mood disorders and treatments, social support, and to build skills in symptom management, emotion regulation, and problem solving and communication (Fristad, 2015). This research is in its infancy, further investigations will be necessary to determine which methods lead to the best outcomes and for whom.