Prodrome

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In medicine, a prodrome is an early sign or symptom (or set of signs and symptoms, referred to as prodromal symptoms [1] ) that often indicates the onset of a disease before more diagnostically specific signs and symptoms develop. More specifically, it refers to the period between the first recognition of a disease's symptom until it reaches its more severe form. [1] It is derived from the Greek word prodromos, meaning "running before". [2] Prodromes may be non-specific symptoms or, in a few instances, may clearly indicate a particular disease, such as the prodromal migraine aura.

Contents

For example, fever, malaise, headache and lack of appetite frequently occur in the prodrome of many infective disorders. A prodrome can be the early precursor to an episode of a chronic neurological disorder such as a migraine headache or an epileptic seizure, where prodrome symptoms may include euphoria or other changes in mood, insomnia, abdominal sensations, disorientation, aphasia, or photosensitivity. Such a prodrome occurs on a scale of days to an hour before the episode, where an aura occurs more immediate to it.[ citation needed ]

Prodromal labour, mistakenly called "false labour," refers to the early signs before labour starts. [3]

In mental health

The prodrome is a period during which an individual experiences some symptoms and/or a change in functioning, which can signal the impending onset of a mental health disorder. [4] It is otherwise known as the prodromal phase when referring to the subsyndromal stage or the early abnormalities in behavior, mood, and/or cognition before illness onset. [5] Early detection of the prodrome can create an opportunity to administer appropriate early interventions quickly to try to delay or decrease the intensity of subsequent symptoms. [6]

Schizophrenia

Schizophrenia was the first disorder for which a prodromal stage was described. [7] People who go on to develop schizophrenia commonly experience non-specific negative symptoms such as depression, anxiety symptoms, and social isolation. [7] This is often followed by the emergence of attenuated positive symptoms such as problems with communication, perception, and unusual thoughts that do not rise to the level of psychosis. [7] 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. [7] 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. [8] 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. [9] 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.[ citation needed ]

Duration

The prodromal phase in schizophrenia can last anywhere from several weeks to several years, and comorbid disorders, such as major depressive disorder, are common during this period. [10]

Identification/assessments

Screening instruments include the Scale of Prodromal Symptoms [11] [12] and the PROD-screen. [13] [14]

Signs and symptoms of the prodrome to schizophrenia can be assessed more fully using structured interviews. For example, the Structured Interview for Prodromal Syndromes, [15] [12] and the Comprehensive Assessment of At Risk Mental States (CAARMS) [16] are both valid and reliable methods for identifying individuals likely experiencing the prodrome to schizophrenia or related psychotic-spectrum disorders.

There are ongoing research efforts to develop tools for early detection of at-risk individuals. This includes development of risk calculators [17] and methods for large-scale population screening. [18]

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. [9] Interventions with evidence of efficacy include antipsychotic and antidepressant medications, which can delay conversion to psychosis and improve symptoms, although prolonged exposure to antipsychotics has been associated with adverse effects including Tardive dyskinesia, an irreversible neurological motor disorder. [9] Psychotherapy for individuals and families can also improve functioning and symptomatology; specifically cognitive behavioral therapy (CBT) helps improve coping strategies to decrease positive psychosis symptoms. [9] Additionally, omega-3 fish oil supplements may help reduce prodromal symptoms. [9] Current guidelines suggest that individuals who are at "high risk" for developing schizophrenia should be monitored for at least one to two years while receiving psychotherapy and medication, as needed, to treat their symptoms. [19]

Bipolar disorder

Symptomology

There is also growing evidence that there is a prodromal phase before the onset of bipolar disorder (BD). [20] Although a majority of individuals with bipolar disorder report experiencing some symptoms preceding the full onset of their illness, the prodrome to BD has not yet been described systematically. Descriptive reports of bipolar prodrome symptoms vary and often focus on nonspecific symptoms of psychopathology, making identification of the prodromal phase difficult. The most commonly observed symptoms are too much energy, elated or depressed mood, and alterations in sleep patterns. [21] 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, [22] approximately 23% of the sample met BD criteria at the baseline and 13% of which did not meet the criteria for BD at baseline eventually were diagnosed with BD. [23]

Duration

The reported duration of the prodrome to BD varies widely (mean = 27.1 ± 23 months); [21] for most people, evidence suggests that the prodromal phase is likely to be long enough to allow for intervention.

Identification/assessments

Symptoms consistent with the prodrome to BD can be identified through semi-structured interviews such as The Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P), [24] and the Semi-structured Interview for Mood Swings [25] and symptom checklists like the Young Mania Rating Scale (YMRS) [26] and the Hamilton Depression Scale (HAM-D). [27] [21] [20]

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. [28] 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. [29] Psychoeducational Psychotherapy (PEP) may be protective in individuals at risk of developing bipolar disorder and are associated with a four-fold reduction in risk for conversion to BD. [30] This research needs to be explored further, however, it is currently thought to produce improvements in decreased stress due to social support and improved functioning through the skills developed in PEP. PEP can prove especially beneficial for individuals presenting transitional mania symptoms as it can assist caregivers in recognizing prodromal mania symptoms and knowing the next steps towards early intervention. [30] 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. This research is in its infancy, further investigations will be necessary to determine which methods lead to the best outcomes and for whom. [31]

In neurological conditions

Neurodegenerative diseases

Several neurodegenerative diseases have a prodromal phase. Early impairments in behavior, personality and language may be detected in Alzheimer's disease. [32] In dementia with Lewy bodies, there is an identifiable set of early signs and symptoms that can appear 15 years or more before dementia develops. [33] The earliest symptoms are constipation and dizziness from autonomic dysfunction, hyposmia (reduced ability to smell), visual hallucinations, and rapid eye movement sleep behavior disorder (RBD). [34] RBD may appear years or decades before other symptoms. [35] In Parkinson's disease the loss of sense of smell may aid in earlier diagnosis. [36] Multiple sclerosis may have a prodromal phase. [37] [38]

Migraine

The prodromal phase of migraine is not always present, and varies from individual to individual, but can include ocular disturbances such as shimmering lights with reduced vision, altered mood, irritability, depression or euphoria, fatigue, yawning, excessive sleepiness, craving for certain food (e.g. chocolate), stiff muscles (especially in the neck), hot ears, constipation or diarrhea, increased urination, and other visceral symptoms. [39]

See also

Related Research Articles

<span class="mw-page-title-main">Antipsychotic</span> Class of medications

Antipsychotics, previously known as neuroleptics and major tranquilizers, are a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders. They are also the mainstay, together with mood stabilizers, in the treatment of bipolar disorder. Moreover, they are also used as adjuncts in the treatment of treatment-resistant major depressive disorder.

<span class="mw-page-title-main">Bipolar disorder</span> Mental disorder that causes periods of depression and abnormally elevated mood

Bipolar disorder, previously known as manic depression, is a mental disorder characterized by periods of depression and periods of abnormally elevated mood that each last from days to weeks. If the elevated mood is severe or associated with psychosis, it is called mania; if it is less severe and does not significantly affect functioning, it is called hypomania. During mania, an individual behaves or feels abnormally energetic, happy or irritable, and they often make impulsive decisions with little regard for the consequences. There is usually also a reduced need for sleep during manic phases. During periods of depression, the individual may experience crying and have a negative outlook on life and poor eye contact with others. The risk of suicide is high; over a period of 20 years, 6% of those with bipolar disorder died by suicide, while 30–40% engaged in self-harm. Other mental health issues, such as anxiety disorders and substance use disorders, are commonly associated with bipolar disorder.

Psychosis is a condition of the mind that results in difficulties determining what is real and what is not real. Symptoms may include delusions and hallucinations, among other features. Additional symptoms are incoherent speech and behavior that is inappropriate for a given situation. There may also be sleep problems, social withdrawal, lack of motivation, and difficulties carrying out daily activities. Psychosis can have serious adverse outcomes.

<span class="mw-page-title-main">Schizophrenia</span> Mental disorder with psychotic symptoms

Schizophrenia is a mental disorder characterized by reoccurring episodes of psychosis that are correlated with a general misperception of reality. Other common signs include hallucinations, delusions, disorganized thinking, social withdrawal, and flat affect. Symptoms develop gradually and typically begin during young adulthood and are never resolved. There is no objective diagnostic test; diagnosis is based on observed behavior, a psychiatric history that includes the person's reported experiences, and reports of others familiar with the person. For a diagnosis of schizophrenia, the described symptoms need to have been present for at least six months or one month. Many people with schizophrenia have other mental disorders, especially substance use disorders, depressive disorders, anxiety disorders, and obsessive–compulsive disorder.

Schizoaffective disorder is a mental disorder characterized by abnormal thought processes and an unstable mood. This diagnosis requires symptoms of both schizophrenia and a mood disorder: either bipolar disorder or depression. The main criterion is the presence of psychotic symptoms for at least two weeks without any mood symptoms. Schizoaffective disorder can often be misdiagnosed when the correct diagnosis may be psychotic depression, bipolar I disorder, schizophreniform disorder, or schizophrenia. This is a problem as treatment and prognosis differ greatly for most of these diagnoses.

<span class="mw-page-title-main">Thought disorder</span> Disorder of thought form, content or stream

A thought disorder (TD) is a disturbance in cognition which affects language, thought and communication. Psychiatric and psychological glossaries in 2015 and 2017 identified thought disorders as encompassing poverty of ideas, neologisms, paralogia, word salad, and delusions—all disturbances of thought content and form. Two specific terms have been suggested—content thought disorder (CTD) and formal thought disorder (FTD). CTD has been defined as a thought disturbance characterized by multiple fragmented delusions, and the term thought disorder is often used to refer to an FTD: a disruption of the form of thought. Also known as disorganized thinking, FTD results in disorganized speech and is recognized as a major feature of schizophrenia and other psychoses. Disorganized speech leads to an inference of disorganized thought. Thought disorders include derailment, pressured speech, poverty of speech, tangentiality, verbigeration, and thought blocking. One of the first known cases of thought disorders, or specifically OCD as it is known today, was in 1691. John Moore, who was a bishop, had a speech in front of Queen Mary II, about "religious melancholy."

<span class="mw-page-title-main">Mood swing</span> Extreme or rapid change in mood

A mood swing is an extreme or sudden change of mood. Such changes can play a positive part in promoting problem solving and in producing flexible forward planning, or be disruptive. When mood swings are severe, they may be categorized as part of a mental illness, such as bipolar disorder, where erratic and disruptive mood swings are a defining feature.

Schizophreniform disorder is a mental disorder diagnosed when symptoms of schizophrenia are present for a significant portion of time, but signs of disturbance are not present for the full six months required for the diagnosis of schizophrenia.

The emphasis of the treatment of bipolar disorder is on effective management of the long-term course of the illness, which can involve treatment of emergent symptoms. Treatment methods include pharmacological and psychological techniques.

Psychoneuroendocrinology is the clinical study of hormone fluctuations and their relationship to human behavior. It may be viewed from the perspective of psychiatry, where in certain mood disorders, there are associated neuroendocrine or hormonal changes affecting the brain. It may also be viewed from the perspective of endocrinology, where certain endocrine disorders can be associated with negative health outcomes and psychiatric illness. Brain dysfunctions associated with the hypothalamus-pituitary-adrenal axis HPA axis can affect the endocrine system, which in turn can result in physiological and psychological symptoms. This complex blend of psychiatry, psychology, neurology, biochemistry, and endocrinology is needed to comprehensively understand and treat symptoms related to the brain, endocrine system (hormones), and psychological health..

<span class="mw-page-title-main">Bipolar disorder in children</span>

Bipolar disorder in children, or pediatric bipolar disorder (PBD), is a rare mental disorder in children and adolescents. The diagnosis of bipolar disorder in children has been heavily debated for many reasons including the potential harmful effects of adult bipolar medication use for children. PBD is similar to bipolar disorder (BD) in adults, and has been proposed as an explanation for periods of extreme shifts in mood called mood episodes. These shifts alternate between periods of depressed or irritable moods and periods of abnormally elevated moods called manic or hypomanic episodes. Mixed mood episodes can occur when a child or adolescent with PBD experiences depressive and manic symptoms simultaneously. Mood episodes of children and adolescents with PBD are different from general shifts in mood experienced by children and adolescents because mood episodes last for long periods of time and cause severe disruptions to an individual's life. There are three known forms of PBD: Bipolar I, Bipolar II, and Bipolar Not Otherwise Specified (NOS). The average age of onset of PBD remains unclear, but reported age of onset ranges from 5 years of age to 19 years of age. PBD is typically more severe and has a poorer prognosis than bipolar disorder with onset in late-adolescence or adulthood.

Early intervention in psychosis is a clinical approach to those experiencing symptoms of psychosis for the first time. It forms part of a new prevention paradigm for psychiatry and is leading to reform of mental health services, especially in the United Kingdom and Australia.

Barbara A. Cornblatt is Professor of Psychiatry and Molecular Medicine at Hofstra Northwell School of Medicine. She is known for her research on serious mental disorders, with a specific focus on psychosis and schizophrenia. Her efforts to find treatments to help youth with mental illness led to the development of the Recognition and Prevention Program, which she founded in 1998.

Childhood schizophrenia is similar in characteristics of schizophrenia that develops at a later age, but has an onset before the age of 13 years, and is more difficult to diagnose. Schizophrenia is characterized by positive symptoms that can include hallucinations, delusions, and disorganized speech; negative symptoms, such as blunted affect and avolition and apathy, and a number of cognitive impairments. Differential diagnosis is problematic since several other neurodevelopmental disorders, including autism spectrum disorder, language disorder, and attention deficit hyperactivity disorder, also have signs and symptoms similar to childhood-onset schizophrenia.

The diagnosis of schizophrenia, a psychotic disorder, is based on criteria in either the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, or the World Health Organization's International Classification of Diseases (ICD). Clinical assessment of schizophrenia is carried out by a mental health professional based on observed behavior, reported experiences, and reports of others familiar with the person. Diagnosis is usually made by a psychiatrist. Associated symptoms occur along a continuum in the population and must reach a certain severity and level of impairment before a diagnosis is made. Schizophrenia has a prevalence rate of 0.3-0.7% in the United States.

The associated features of bipolar disorder are clinical phenomena that often accompany bipolar disorder (BD) but are not part of the diagnostic criteria for the disorder. There are several childhood precursors in children who later receive a diagnosis of bipolar disorder. They may show subtle early traits such as mood abnormalities, full major depressive episodes, and attention-deficit hyperactivity disorder. BD is also accompanied by changes in cognition processes and abilities. This includes reduced attentional and executive capabilities and impaired memory. How the individual processes the world also depends on the phase of the disorder, with differential characteristics between the manic, hypomanic and depressive states. Some studies have found a significant association between bipolar disorder and creativity.

At risk mental state is the clinical presentation of those considered at risk of developing psychosis or schizophrenia. Such states were formerly considered treated as prodromes, emerging symptoms of psychosis, but this view is no longer prevalent as a prodromal period can not be confirmed unless the emergence of the condition has occurred.

The Child Mania Rating Scales (CMRS) is a 21-item diagnostic screening measure designed to identify symptoms of mania in children and adolescents aged 9–17 using diagnostic criteria from the DSM-IV, developed by Pavuluri and colleagues. There is also a 10-item short form. The measure assesses the child's mood and behavior symptoms, asking parents or teachers to rate how often the symptoms have caused a problem for the youth in the past month. Clinical studies have found the CMRS to be reliable and valid when completed by parents in the assessment of children's bipolar symptoms. The CMRS also can differentiate cases of pediatric bipolar disorder from those with ADHD or no disorder, as well as delineating bipolar subtypes. A meta-analysis comparing the different rating scales available found that the CMRS was one of the best performing scales in terms of telling cases with bipolar disorder apart from other clinical diagnoses. The CMRS has also been found to provide a reliable and valid assessment of symptoms longitudinally over the course of treatment. The combination of showing good reliability and validity across multiple samples and clinical settings, along with being free and brief to score, make the CMRS a promising tool, especially since most other checklists available for youths do not assess manic symptoms.

A self-disorder, also called ipseity disturbance, is a psychological phenomenon of disruption or diminishing of a person's minimal self – the fundamental sense that one's experiences are truly one's own. People with self-disorder feel that their internal experiences are actually external; for example, they may experience their own thoughts as coming from outside themselves, whether in the form of true auditory hallucinations or merely as a vague sense that their thoughts do not belong to them.

<span class="mw-page-title-main">Basic symptoms of schizophrenia</span> Subjective symptoms of schizophrenia

Basic symptoms of schizophrenia are subjective symptoms, described as experienced from a person's perspective, which show evidence of underlying psychopathology. Basic symptoms have generally been applied to the assessment of people who may be at risk to develop psychosis. Though basic symptoms are often disturbing for the person, problems generally do not become evident to others until the person is no longer able to cope with their basic symptoms. Basic symptoms are more specific to identifying people who exhibit signs of prodromal psychosis (prodrome) and are more likely to develop schizophrenia over other disorders related to psychosis. Schizophrenia is a psychotic disorder, but is not synonymous with psychosis. In the prodrome to psychosis, uncharacteristic basic symptoms develop first, followed by more characteristic basic symptoms and brief and self-limited psychotic-like symptoms, and finally the onset of psychosis. People who were assessed to be high risk according to the basic symptoms criteria have a 48.5% likelihood of progressing to psychosis. In 2015, the European Psychiatric Association issued guidance recommending the use of a subscale of basic symptoms, called the Cognitive Disturbances scale (COGDIS), in the assessment of psychosis risk in help-seeking psychiatric patients; in a meta-analysis, COGDIS was shown to be as predictive of transition to psychosis as the Ultra High Risk (UHR) criteria up to 2 years after assessment, and significantly more predictive thereafter. The basic symptoms measured by COGDIS, as well as those measured by another subscale, the Cognitive-Perceptive basic symptoms scale (COPER), are predictive of transition to schizophrenia.

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