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A Case of a College Student Presenting With Mild Mental Health Problems

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 17-year-old boy was referred from the general practitioner to the local psychosis early-detection clinic owing to a drop in functioning and social withdrawal during the previous 6 months. He began college 6 months prior but had found the workload difficult and failed his examinations. He had no family history of mental disorders, denied any current or past use of drugs, and reported no significant medical history. He was well kempt, was quiet during his interview, and provided short answers. He reported that he no longer enjoyed his former interests and could not relate to people at college or to friends, but there were no clear signs of depressive disorders. No formal thought disorders were elicited. He was 80% convinced that random people looked and talked about him when he was out in public but was able to question it. He stated that these people were probably commenting on the way he looked, but he did not believe these individuals meant him harm. He never acted on these thoughts. He also reported a vague feeling of perplexity and derealization. These experiences began when he started college and continued to occur every day for up to an hour at a time, causing significant distress. The Structured Clinical Interview for DSM did not reveal any mental disorder.

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The designation (not properly a diagnosis) is Clinical High Risk for Psychosis (CHR-P),1 attenuated psychotic symptoms subgroup, determined using the Comprehensive Assessment of At-risk Mental States (CAARMS).2 Prognosis: The increased risk of developing psychosis is 26% at 3 years (95% CI, 23%-30%).3

C. Clinical follow-up for at least 3 years and indicated primary prevention

Children, adolescents, and young adults (aged 8-40 years) who seek help at specialized early-detection clinics have an enhanced risk of developing mental disorders, such as psychosis, compared with the local age-matched general population (15%4 vs 0.43%5 at 3 years, respectively) (Figure). Fully addressing their presenting problems requires a prognosis, which is forecasting their risk (ie, probability) of developing future outcomes. The development of semistructured psychometric interviews (prognostic tools) to assess CHR-P criteria has allowed formulating a prognosis of being at risk or not at risk for psychosis.3 The original prognostic tool in this field (CAARMS2) was developed on the basis of accumulating knowledge of the specific symptoms that may predate the onset of psychosis (defined as binary outcome). The CAARMS is transdiagnostic, allowing the presence of several comorbid mental disorders at baseline, which are frequent in these patients.6 Specific training is needed to use it, and its administration usually requires 2 hours in the context of a clinical assessment.7 Extensive international validation has confirmed that in people referred to psychosis early-detection services, the CAARMS has an adequate prognostic performance, comparable with other prognostic instruments used in medicine.3 Vice versa, it does not work well outside these samples.3 Its potentials include a good ability to rule out a state of risk for psychosis, while its limitations include only a moderate ability to rule in a state of risk for psychosis (Figure).4 This prognostic tool has allowed one of the first preventive approaches to psychotic disorders to be implemented in psychiatry.8 Several other variants of the CAARMS have been developed with almost comparable prognostic performance.3 The use of these prognostic tools in individuals seeking help at psychosis early-detection clinics can impact their clinical management by (1) informing patients about their risk of developing psychosis, (2) establishing whether clinical monitoring is required, and (3) deciding whether to initiate preventive treatments or not.

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Article Information

Corresponding Author: Paolo Fusar-Poli, MD, PhD, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, Main Building, 5th Floor, PO63, 16 De Crespigny Park, SE5 8AF London, United Kingdom (paolo.fusar-poli@kcl.ac.uk).

Published Online: October 17, 2018. doi:10.1001/jamapsychiatry.2018.2486

Conflict of Interest Disclosures: Dr Fusar-Poli has served on the advisory board for Lundbeck. No other disclosures are reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
1.
Fusar-Poli  P.  The Clinical High-Risk State for Psychosis (CHR-P), version II.  Schizophr Bull. 2017;43(1):44-47. doi:10.1093/schbul/sbw158PubMedGoogle ScholarCrossref
2.
Yung  AR, Yuen  HP, McGorry  PD,  et al.  Mapping the onset of psychosis: the comprehensive assessment of at-risk mental states.  Aust N Z J Psychiatry. 2005;39(11-12):964-971. doi:10.1080/j.1440-1614.2005.01714.xPubMedGoogle ScholarCrossref
3.
Fusar-Poli  P, Cappucciati  M, Rutigliano  G,  et al.  At risk or not at risk? a meta-analysis of the prognostic accuracy of psychometric interviews for psychosis prediction.  World Psychiatry. 2015;14(3):322-332. doi:10.1002/wps.20250PubMedGoogle ScholarCrossref
4.
Fusar-Poli  P, Schultze-Lutter  F, Cappucciati  M,  et al.  The dark side of the moon: meta-analytical impact of recruitment strategies on risk enrichment in the clinical high risk state for psychosis.  Schizophr Bull. 2016;42(3):732-743. doi:10.1093/schbul/sbv162PubMedGoogle ScholarCrossref
5.
Fusar-Poli  P, Rutigliano  G, Stahl  D,  et al.  Deconstructing pretest risk enrichment to optimize prediction of psychosis in individuals at clinical high risk.  JAMA Psychiatry. 2016;73(12):1260-1267. doi:10.1001/jamapsychiatry.2016.2707PubMedGoogle ScholarCrossref
6.
Fusar-Poli  P, Nelson  B, Valmaggia  L, Yung  AR, McGuire  PK.  Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: impact on psychopathology and transition to psychosis.  Schizophr Bull. 2014;40(1):120-131. doi:10.1093/schbul/sbs136PubMedGoogle ScholarCrossref
7.
Fusar-Poli  P, Raballo  A, Parnas  J.  What is an attenuated psychotic symptom? on the importance of the context.  Schizophr Bull. 2017;43(4):687-692.PubMedGoogle Scholar
8.
NICE. Psychosis and schizophrenia in adults: prevention and management. https://www.nice.org.uk/guidance/cg178/chapter/1-Recommendations. Accessed September 7, 2018.
9.
Fusar-Poli  P, Tantardini  M, De Simone  S,  et al.  Deconstructing vulnerability for psychosis: meta-analysis of environmental risk factors for psychosis in subjects at ultra high-risk.  Eur Psychiatry. 2017;40:65-75. doi:10.1016/j.eurpsy.2016.09.003PubMedGoogle ScholarCrossref
10.
Fusar-Poli  P, Rocchetti  M, Sardella  A,  et al.  Disorder, not just state of risk: meta-analysis of functioning and quality of life in people at high risk of psychosis.  Br J Psychiatry. 2015;207(3):198-206. doi:10.1192/bjp.bp.114.157115PubMedGoogle ScholarCrossref
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