Clinical subtypes may provide invaluable clues for assessment, prediction, and treatment planning when working with psychosis-risk syndrome individuals and the related challenges during the COVID-19 pandemic
| Prototype clinical presentation(s) . | COVID-19/quarantine-related issue and clinical quandaries . | Relevant subtype . | Subtype clarity contributions . | Citation . |
|---|---|---|---|---|
| Case 1: An adolescent male patient treated for a CHR syndrome is able to attend remote tele-psychiatry sessions regularly, communicates clearly, and has been shown stable attenuated positive symptoms. But recently, the patient endorsed a decrease in hygiene, indicating behaviors of now showering only every other week, and not consistently wearing clean clothes for his remote classes. | During the pandemic, cultural norms about dressing, as well as other aspects of hygiene, have shifted. Risk for conversion question: A decline in self-care can be a sign of emerging psychosis, particularly in an adolescent. Should this case be prioritized for more intensive intervention at a time when resources are limited as caseloads increase? | Impaired Hygiene Subtype | In the NAPLS 1 sample, 11% of CHR participants showed poor hygiene as a defining symptom. This patient likely meets for the subtype as it is also defined by an intact communication ability such as staying on track and participating in give and take (those in this group scored among the lowest on disorganized communication). This is also consistent with the biological sex of the participant (which is more frequent in this subgroup than others). This has relevance to the clinical quandary, as although deteriorating hygiene is an important risk indicator in and of itself, trend level findings indicate that the specific hygiene subtype is at lower odds of transition than other prominent clinical subtypes among those with CHR syndromes. | Ryan et al.17 |
| Case 2: A patient successfully treated for Major Depressive Disorder is now in partial remission. However, a few months into the pandemic, the patient began sharing a theory that the government invented the pandemic because masses would eventually be susceptible to taking a vaccine that had mind-control properties. | This theory is widely circulated on the Internet, and it is possible the patient participates in sub-cultures where this is a commonly held view. Diagnostic question: What is the likelihood of a psychosis-risk syndrome diagnosis here? | Odd and Euthymic Subtype | Truly bizarre ideations are rare in the psychosis-risk stage (occurring more often in formal psychosis), but these symptoms can happen—albeit at an attenuated level. In the NAPLS 2 sample, 5% of 737 participants that fell into a subgroup defined by the marked presence of bizarre symptoms. So, the patient may be a candidate for this group. However, the other defining feature of the empirically derived subgroup is a lack of apparent distress. So, this patient would not meet criteria for this subgroup as this person indicated high levels of distress. | Ryan et al.17 |
| This would lend weight to the possibility that this patient is developing ideas that are “normative” in sub-cultures in the anti-vaccine/conspiracy culture movement. Of course, it is always possible that a person can experience bizarre symptoms without falling into a subgroup, and referral for a more formal structured assessment would also be indicated). | ||||
| Case 3: A patient diagnosed with a psychosis-risk syndrome attends a treatment planning meeting and endorses significant avolition. She has indicated she does not have time (she is looking for a new job) or resources (she was waiting tables and her restaurant is shut down, and her health insurance is canceled) to dedicate to anything but the most “essential” treatments. While it is clear she is not formally psychotic, it is difficult to get a full clinical picture of comorbidities or other clinically relevant factors. | The patient is suffering from significant avolition and has limited time and financial resources (particularly due to COVID-19 related lay-offs). The patient is very hesitant to travel for treatment given she relies on public transportation (COVID-restrictions have limited the number of seats and her local municipal guidelines have discouraged non-essential travel). Treatment planning question: What are the likely clinical needs this patient will have in coming months, and how should treatment be prioritized? | Volition Subtype | A total of 23% of 244 psychosis-risk syndrome participants met criteria for a clinical subtype that is defined by extremely low motivation as the key clinical feature. This patient would likely fall into this group, and this is informative for several reasons relating to the clinical quandary. Specifically, compared to other subgroups, those in the reduced motivation subtype endorsed elevated levels of both anxiety and depression, and deficits in social and role functioning. Plans for her clinical care should weigh this information and make provision for affective disorder pharmacotherapy, as well as social and vocational rehabilitation. | Gupta et al.19 |
| Prototype clinical presentation(s) . | COVID-19/quarantine-related issue and clinical quandaries . | Relevant subtype . | Subtype clarity contributions . | Citation . |
|---|---|---|---|---|
| Case 1: An adolescent male patient treated for a CHR syndrome is able to attend remote tele-psychiatry sessions regularly, communicates clearly, and has been shown stable attenuated positive symptoms. But recently, the patient endorsed a decrease in hygiene, indicating behaviors of now showering only every other week, and not consistently wearing clean clothes for his remote classes. | During the pandemic, cultural norms about dressing, as well as other aspects of hygiene, have shifted. Risk for conversion question: A decline in self-care can be a sign of emerging psychosis, particularly in an adolescent. Should this case be prioritized for more intensive intervention at a time when resources are limited as caseloads increase? | Impaired Hygiene Subtype | In the NAPLS 1 sample, 11% of CHR participants showed poor hygiene as a defining symptom. This patient likely meets for the subtype as it is also defined by an intact communication ability such as staying on track and participating in give and take (those in this group scored among the lowest on disorganized communication). This is also consistent with the biological sex of the participant (which is more frequent in this subgroup than others). This has relevance to the clinical quandary, as although deteriorating hygiene is an important risk indicator in and of itself, trend level findings indicate that the specific hygiene subtype is at lower odds of transition than other prominent clinical subtypes among those with CHR syndromes. | Ryan et al.17 |
| Case 2: A patient successfully treated for Major Depressive Disorder is now in partial remission. However, a few months into the pandemic, the patient began sharing a theory that the government invented the pandemic because masses would eventually be susceptible to taking a vaccine that had mind-control properties. | This theory is widely circulated on the Internet, and it is possible the patient participates in sub-cultures where this is a commonly held view. Diagnostic question: What is the likelihood of a psychosis-risk syndrome diagnosis here? | Odd and Euthymic Subtype | Truly bizarre ideations are rare in the psychosis-risk stage (occurring more often in formal psychosis), but these symptoms can happen—albeit at an attenuated level. In the NAPLS 2 sample, 5% of 737 participants that fell into a subgroup defined by the marked presence of bizarre symptoms. So, the patient may be a candidate for this group. However, the other defining feature of the empirically derived subgroup is a lack of apparent distress. So, this patient would not meet criteria for this subgroup as this person indicated high levels of distress. | Ryan et al.17 |
| This would lend weight to the possibility that this patient is developing ideas that are “normative” in sub-cultures in the anti-vaccine/conspiracy culture movement. Of course, it is always possible that a person can experience bizarre symptoms without falling into a subgroup, and referral for a more formal structured assessment would also be indicated). | ||||
| Case 3: A patient diagnosed with a psychosis-risk syndrome attends a treatment planning meeting and endorses significant avolition. She has indicated she does not have time (she is looking for a new job) or resources (she was waiting tables and her restaurant is shut down, and her health insurance is canceled) to dedicate to anything but the most “essential” treatments. While it is clear she is not formally psychotic, it is difficult to get a full clinical picture of comorbidities or other clinically relevant factors. | The patient is suffering from significant avolition and has limited time and financial resources (particularly due to COVID-19 related lay-offs). The patient is very hesitant to travel for treatment given she relies on public transportation (COVID-restrictions have limited the number of seats and her local municipal guidelines have discouraged non-essential travel). Treatment planning question: What are the likely clinical needs this patient will have in coming months, and how should treatment be prioritized? | Volition Subtype | A total of 23% of 244 psychosis-risk syndrome participants met criteria for a clinical subtype that is defined by extremely low motivation as the key clinical feature. This patient would likely fall into this group, and this is informative for several reasons relating to the clinical quandary. Specifically, compared to other subgroups, those in the reduced motivation subtype endorsed elevated levels of both anxiety and depression, and deficits in social and role functioning. Plans for her clinical care should weigh this information and make provision for affective disorder pharmacotherapy, as well as social and vocational rehabilitation. | Gupta et al.19 |
Clinical subtypes may provide invaluable clues for assessment, prediction, and treatment planning when working with psychosis-risk syndrome individuals and the related challenges during the COVID-19 pandemic
| Prototype clinical presentation(s) . | COVID-19/quarantine-related issue and clinical quandaries . | Relevant subtype . | Subtype clarity contributions . | Citation . |
|---|---|---|---|---|
| Case 1: An adolescent male patient treated for a CHR syndrome is able to attend remote tele-psychiatry sessions regularly, communicates clearly, and has been shown stable attenuated positive symptoms. But recently, the patient endorsed a decrease in hygiene, indicating behaviors of now showering only every other week, and not consistently wearing clean clothes for his remote classes. | During the pandemic, cultural norms about dressing, as well as other aspects of hygiene, have shifted. Risk for conversion question: A decline in self-care can be a sign of emerging psychosis, particularly in an adolescent. Should this case be prioritized for more intensive intervention at a time when resources are limited as caseloads increase? | Impaired Hygiene Subtype | In the NAPLS 1 sample, 11% of CHR participants showed poor hygiene as a defining symptom. This patient likely meets for the subtype as it is also defined by an intact communication ability such as staying on track and participating in give and take (those in this group scored among the lowest on disorganized communication). This is also consistent with the biological sex of the participant (which is more frequent in this subgroup than others). This has relevance to the clinical quandary, as although deteriorating hygiene is an important risk indicator in and of itself, trend level findings indicate that the specific hygiene subtype is at lower odds of transition than other prominent clinical subtypes among those with CHR syndromes. | Ryan et al.17 |
| Case 2: A patient successfully treated for Major Depressive Disorder is now in partial remission. However, a few months into the pandemic, the patient began sharing a theory that the government invented the pandemic because masses would eventually be susceptible to taking a vaccine that had mind-control properties. | This theory is widely circulated on the Internet, and it is possible the patient participates in sub-cultures where this is a commonly held view. Diagnostic question: What is the likelihood of a psychosis-risk syndrome diagnosis here? | Odd and Euthymic Subtype | Truly bizarre ideations are rare in the psychosis-risk stage (occurring more often in formal psychosis), but these symptoms can happen—albeit at an attenuated level. In the NAPLS 2 sample, 5% of 737 participants that fell into a subgroup defined by the marked presence of bizarre symptoms. So, the patient may be a candidate for this group. However, the other defining feature of the empirically derived subgroup is a lack of apparent distress. So, this patient would not meet criteria for this subgroup as this person indicated high levels of distress. | Ryan et al.17 |
| This would lend weight to the possibility that this patient is developing ideas that are “normative” in sub-cultures in the anti-vaccine/conspiracy culture movement. Of course, it is always possible that a person can experience bizarre symptoms without falling into a subgroup, and referral for a more formal structured assessment would also be indicated). | ||||
| Case 3: A patient diagnosed with a psychosis-risk syndrome attends a treatment planning meeting and endorses significant avolition. She has indicated she does not have time (she is looking for a new job) or resources (she was waiting tables and her restaurant is shut down, and her health insurance is canceled) to dedicate to anything but the most “essential” treatments. While it is clear she is not formally psychotic, it is difficult to get a full clinical picture of comorbidities or other clinically relevant factors. | The patient is suffering from significant avolition and has limited time and financial resources (particularly due to COVID-19 related lay-offs). The patient is very hesitant to travel for treatment given she relies on public transportation (COVID-restrictions have limited the number of seats and her local municipal guidelines have discouraged non-essential travel). Treatment planning question: What are the likely clinical needs this patient will have in coming months, and how should treatment be prioritized? | Volition Subtype | A total of 23% of 244 psychosis-risk syndrome participants met criteria for a clinical subtype that is defined by extremely low motivation as the key clinical feature. This patient would likely fall into this group, and this is informative for several reasons relating to the clinical quandary. Specifically, compared to other subgroups, those in the reduced motivation subtype endorsed elevated levels of both anxiety and depression, and deficits in social and role functioning. Plans for her clinical care should weigh this information and make provision for affective disorder pharmacotherapy, as well as social and vocational rehabilitation. | Gupta et al.19 |
| Prototype clinical presentation(s) . | COVID-19/quarantine-related issue and clinical quandaries . | Relevant subtype . | Subtype clarity contributions . | Citation . |
|---|---|---|---|---|
| Case 1: An adolescent male patient treated for a CHR syndrome is able to attend remote tele-psychiatry sessions regularly, communicates clearly, and has been shown stable attenuated positive symptoms. But recently, the patient endorsed a decrease in hygiene, indicating behaviors of now showering only every other week, and not consistently wearing clean clothes for his remote classes. | During the pandemic, cultural norms about dressing, as well as other aspects of hygiene, have shifted. Risk for conversion question: A decline in self-care can be a sign of emerging psychosis, particularly in an adolescent. Should this case be prioritized for more intensive intervention at a time when resources are limited as caseloads increase? | Impaired Hygiene Subtype | In the NAPLS 1 sample, 11% of CHR participants showed poor hygiene as a defining symptom. This patient likely meets for the subtype as it is also defined by an intact communication ability such as staying on track and participating in give and take (those in this group scored among the lowest on disorganized communication). This is also consistent with the biological sex of the participant (which is more frequent in this subgroup than others). This has relevance to the clinical quandary, as although deteriorating hygiene is an important risk indicator in and of itself, trend level findings indicate that the specific hygiene subtype is at lower odds of transition than other prominent clinical subtypes among those with CHR syndromes. | Ryan et al.17 |
| Case 2: A patient successfully treated for Major Depressive Disorder is now in partial remission. However, a few months into the pandemic, the patient began sharing a theory that the government invented the pandemic because masses would eventually be susceptible to taking a vaccine that had mind-control properties. | This theory is widely circulated on the Internet, and it is possible the patient participates in sub-cultures where this is a commonly held view. Diagnostic question: What is the likelihood of a psychosis-risk syndrome diagnosis here? | Odd and Euthymic Subtype | Truly bizarre ideations are rare in the psychosis-risk stage (occurring more often in formal psychosis), but these symptoms can happen—albeit at an attenuated level. In the NAPLS 2 sample, 5% of 737 participants that fell into a subgroup defined by the marked presence of bizarre symptoms. So, the patient may be a candidate for this group. However, the other defining feature of the empirically derived subgroup is a lack of apparent distress. So, this patient would not meet criteria for this subgroup as this person indicated high levels of distress. | Ryan et al.17 |
| This would lend weight to the possibility that this patient is developing ideas that are “normative” in sub-cultures in the anti-vaccine/conspiracy culture movement. Of course, it is always possible that a person can experience bizarre symptoms without falling into a subgroup, and referral for a more formal structured assessment would also be indicated). | ||||
| Case 3: A patient diagnosed with a psychosis-risk syndrome attends a treatment planning meeting and endorses significant avolition. She has indicated she does not have time (she is looking for a new job) or resources (she was waiting tables and her restaurant is shut down, and her health insurance is canceled) to dedicate to anything but the most “essential” treatments. While it is clear she is not formally psychotic, it is difficult to get a full clinical picture of comorbidities or other clinically relevant factors. | The patient is suffering from significant avolition and has limited time and financial resources (particularly due to COVID-19 related lay-offs). The patient is very hesitant to travel for treatment given she relies on public transportation (COVID-restrictions have limited the number of seats and her local municipal guidelines have discouraged non-essential travel). Treatment planning question: What are the likely clinical needs this patient will have in coming months, and how should treatment be prioritized? | Volition Subtype | A total of 23% of 244 psychosis-risk syndrome participants met criteria for a clinical subtype that is defined by extremely low motivation as the key clinical feature. This patient would likely fall into this group, and this is informative for several reasons relating to the clinical quandary. Specifically, compared to other subgroups, those in the reduced motivation subtype endorsed elevated levels of both anxiety and depression, and deficits in social and role functioning. Plans for her clinical care should weigh this information and make provision for affective disorder pharmacotherapy, as well as social and vocational rehabilitation. | Gupta et al.19 |
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