“We can’t always prevent psychosis. But the earlier someone gets treatment, the greater the likelihood that they’ll recover and do better in the long term.”
A college student often hears her name in the wind. A teenager starts to believe they have a special relationship with God. Another is worried that strangers are watching him. Yet they all retain insight and skepticism about the strange beliefs and perceptions they’re experiencing. They wonder: Is it just a trick of my mind?
These symptoms may indicate clinical high risk for psychosis (attenuated psychosis syndrome). In addition to suspiciousness, grandiose thoughts, and perceptual disturbances in what they see and hear, people at clinical high risk often experience social withdrawal, worsening performance in school, anxiety, and suicidal ideation. About 20% will develop psychosis within two years.
The symptoms of clinical high risk often develop in adolescence or early adulthood, and they are, unsurprisingly, alarming. “We see a lot of functional impairment and suffering in these individuals. They’re often afraid, and their families are often afraid,” says Cheryl Corcoran, MD, associate professor of psychiatry at Icahn School of Medicine at Mount Sinai and co-director of Mount Sinai’s Psychosis Risk Program. She and her colleagues are there to help.
“The goal is to catch people early to provide treatment,” says Shaynna Herrera, PhD, a clinical psychologist and instructor of psychiatry and project director at the Psychosis Risk Program. “Through education and cognitive behavioral therapy, we help them learn about the symptoms and how to manage them. We can’t always prevent psychosis. But the earlier someone gets treatment, the greater the likelihood that they’ll recover and do better in the long term.”
Interventions for Attenuated Psychosis Syndrome
The Psychosis Risk Program works with teenagers and young adults at clinical high risk for psychosis, providing evaluation, treatment, and psychoeducation to reduce the risk of psychosis and help patients manage symptoms.
For patients with high clinical risk, anti-psychotic medications aren’t recommended as a first-line therapy (though patients may take medications to address comorbid anxiety or depression). The Psychosis Risk Program offers a variety of interventions to help patients and their families. These include a structured five-session psychoeducation program that educates patients and family members about psychosis risk, called BEGIN: Brief Educational Guide for Individuals in Need. The program also offers cognitive-behavioral therapy for psychosis (CBT), which aims to decrease symptoms, provide coping skills, and prevent the development of full psychosis.
This type of CBT is adapted for people with clinical high risk, and research has shown that it can delay the progression to psychosis for at least four years, says clinical psychologist Yulia Landa, PsyD, MS, assistant professor of psychiatry, Director of Cognitive Behavioral Therapy for the Treatment and Prevention of Psychosis research and clinical program, and co-director of the Psychosis Risk Program. “We will need much longer longitudinal studies to know if CBT can really prevent psychosis, but we can delay it, and maybe prevent it,” she says.
Because most patients are adolescents and young adults who still live at home with parents, the Psychosis Risk Program also provides family-based programs. “Our group- and family-based CBT teaches family members how to interact with their loved ones who are beginning to experience psychotic-like symptoms and learn how to support them in using CBT skills at home,” Dr. Landa says.
Schizophrenia and Psychosis Research
In addition to clinical work, the Psychosis Risk Program is active in research, from mechanistic studies of biomarkers to research that evaluates diagnostic and clinical services. One recent project aims to improve early identification of patients at clinical high risk. “[Attenuated psychosis syndrome] is a newer concept, and not all clinicians recognize there is this population of people at clinical high risk who don’t meet the criteria for a psychotic disorder,” says Rachel Jespersen, LMSW, a clinical social worker and coordinator of the CBT for the Treatment and Prevention of Psychosis research and clinical program. “What’s more, these are types of symptoms people don’t spontaneously disclose, so it can be difficult to identify patients at clinical high risk.”
To improve identification, she and her colleagues recently conducted a pilot screening program in Mount Sinai’s outpatient clinics. They asked providers to use a brief screening tool for all patients between 12 and 30. Those who screened positive received further evaluation, and patients identified as clinical high risk were referred to the program for symptom monitoring and adjunctive treatment. The screening pilot identified 3.5 times as many patients at clinical high risk of psychosis compared to the standard referral model, Dr. Landa says.
She and her colleagues are also evaluating interventions such as CBT-based programs for individuals, groups, and families. “Eventually we want to establish solid interventions that could be disseminated across Mount Sinai and integrated into community practice,” Dr. Landa says.
Meanwhile, Dr. Corcoran and colleagues are actively involved in research to better understand biomarkers for schizophrenia. The Accelerating Medicines Partnership: Schizophrenia, spearheaded by the National Institutes of Mental Health, is collecting information on biomarkers such as MRI and EEG data, cognition, fluid biomarkers such as inflammatory and genetic markers, daily diary studies and biosensors that may predict behavioral patterns, even subtle patterns of language and facial expression that could predict the transition to psychosis. Mount Sinai is one of the study’s data processing centers, responsible for collecting and analyzing data from across the consortium. “We’ve identified a number of biomarkers that are predictive of psychosis,” Dr. Corcoran says. “We want to understand how they relate to each other, to better understand the causes of psychosis and ultimately to develop new pharmacological treatments.”
In addition, one of Dr. Corcoran’s abiding research interests involves collaborating with physicists, engineers, and computer scientists to use artificial intelligence to analyze speech, language, and face expression. Language disturbance (particularly complexity and coherence) is common in psychotic disorders, and often appears at the initial onset of symptoms. Using natural language processing, Dr. Corcoran and her collaborators were able to predict psychosis onset in clinically high risk patients with an 83% accuracy rate—that is, more accurate that clinician predictions. The implications of this field of study can potentially help prevent psychosis by initiating the development of treatments that address the problems with cognition that are at the root of language disturbance. Her team has focused on this as a biomarker for mechanistic studies (several currently in recruitment), and are working to include this “natural language processing” approach for services as well.
Patient Care at the Psychosis Risk Program
Running throughout all clinical and research efforts at the Psychosis Risk Program is a commitment to the well-being of patients, whose symptoms are often misunderstood and stigmatized. “We have been contributing to research on stigma and interventions to reduce stigma,” Dr. Herrera says. “And we’re committed to involving patients and their families in our work. We conduct qualitative interviews and get their feedback so that we adjust our practices and make sure that they are meeting peoples’ needs.”
The program staff also takes time in caring for patients with a challenging and frightening diagnosis. “In mental health care, there’s often not enough time to provide psychoeducation and do lengthy feedback sessions” where the evaluating therapist sits down with the patient and their family members to discuss the diagnosis, Dr. Herrera says. “One thing that makes Mount Sinai stand out is that we take our time to do thorough assessments, give feedback and write detailed reports so that families and clinicians have the information they need to seek care.”
Schizophrenia and psychosis remain challenging conditions, for the people affected and for their clinicians. But Mount Sinai’s Psychosis Risk Program is providing hope and health to the young people at clinical high risk. Learn more about their services and research, including language-based studies, at www.mountsinai.org/psychosis-risk.