Prodrome

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In medicine, a prodrome is an early sign or symptom (or set of signs and symptoms), which often indicate the onset of a disease before more diagnostically specific signs and symptoms develop. It is derived from the Greek word prodromos, meaning "running before".[1] Prodromes may be non-specific symptoms or, in a few instances, may clearly indicate a particular disease, such as the prodromal migraine aura.

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.

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

In mental health[edit]

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.[2] 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.[3] 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.[4]

In schizophrenia[edit]

Symptomology[edit]

Schizophrenia was the first disorder for which a prodromal phase was described.[5] People who go on to develop schizophrenia commonly experience non-specific negative symptoms such as depression, anxiety symptoms, and social isolation.[5] 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.[5] 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.[5] 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.[6] 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.[7] 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[edit]

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.[8]

Identification/assessments[edit]

Symptoms of the prodrome to schizophrenia can be assessed using structured interviews. For example, the Structured Interview for Prodromal Syndromes[9], and the Comprehensive Assessment of At Risk Mental States (CAARMS)[10] are both valid and reliable methods for distinguishing individuals experiencing impaired positive or negative symptoms from other individuals.

Interventions[edit]

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.[7] 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.[7] 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.[7] Additionally, omega-3 fish oil supplements may help reduce prodromal symptoms.[7] 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.[11]

In bipolar disorder[edit]

Symptomology[edit]

There is also growing evidence that there is a prodromal phase before the onset of bipolar disorder (BD).[12] 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.[13] 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.[14] 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.[15]

Duration[edit]

The reported duration of the prodrome to BD varies widely (mean = 27.1 +/- 23 months[13]); for most people, evidence suggests that the prodromal phase is likely to be long enough to allow for intervention.

Identification/assessments[edit]

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),[16] and the Semi-structured Interview for Mood Swings[17] and symptom checklists like the Young Mania Rating Scale (YMRS)[18] and the Hamilton Depression Scale (HAM-D)[19].[13][12]

Interventions[edit]

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.[20] 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.[21] 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.[22] 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.[22] 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.[23]

Prodromal phase of common diseases and conditions[edit]

  • Diverticulitis – may worsen throughout the first day, as it starts out as small pains in the torso and/or mild diarrhea, and may slowly turn into vomiting and sharp pains in the lower left quadrant of the abdomen.
  • Herpes simplex – marked by tingling (paresthesia), itching, and pain.
  • Measles – marked by fever, rhinorrhea, and conjuctivitis.
  • Migraine – 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.[24]
  • Varicella – may or may not feature a prodrome, but at least 37% of unvaccinated children who contract chickenpox do have at least a mild febrile prodrome.
  • Parkinson's diseaseloss of smell
  • Alzheimer's disease – perhaps early impairments in behavior, personality and language [25]

See also[edit]

References[edit]

  1. ^ Mosby's Medical Dictionary (8th ed.). http://medical-dictionary.thefreedictionary.com/prodrome: Elsevier. 2009. ISBN 9780323049375.
  2. ^ Zeschel E, Correll CU, Haussleiter IS, Krüger-Özgürdal S, Leopold K, Pfennig A, et al. (November 2013). "The bipolar disorder prodrome revisited: Is there a symptomatic pattern?". Journal of Affective Disorders. 151 (2): 551–60. doi:10.1016/j.jad.2013.06.043. PMID 23932736.
  3. ^ Bauer M, Juckel G, Correll CU, Leopold K, Pfennig A (November 2008). "Diagnosis and treatment in the early illness phase of bipolar disorders". European Archives of Psychiatry and Clinical Neuroscience. 258 Suppl 5 (S5): 50–4. doi:10.1007/s00406-008-5009-z. PMID 18985295.
  4. ^ Meter AV, Youngstrom E (2018-10-01). "22.1 Early Identification of Bipolar Disorder: A Meta-Analytic Approach". Journal of the American Academy of Child & Adolescent Psychiatry. 57 (10): S302. doi:10.1016/j.jaac.2018.07.740.
  5. ^ a b c d George M, Maheshwari S, Chandran S, Manohar JS, Sathyanarayana Rao TS (2017). "Understanding the schizophrenia prodrome". Indian Journal of Psychiatry. 59 (4): 505–509. doi:10.4103/psychiatry.IndianJPsychiatry_464_17 (inactive 2019-10-15). PMC 5806335. PMID 29497198.
  6. ^ McGlashan TH, Miller TJ, Woods SW (2001-01-01). "Pre-onset detection and intervention research in schizophrenia psychoses: current estimates of benefit and risk". Schizophrenia Bulletin. 27 (4): 563–70. doi:10.1093/oxfordjournals.schbul.a006896. PMID 11824483.
  7. ^ a b c d e Larson MK, Walker EF, Compton MT (August 2010). "Early signs, diagnosis and therapeutics of the prodromal phase of schizophrenia and related psychotic disorders". Expert Review of Neurotherapeutics. 10 (8): 1347–59. doi:10.1586/ern.10.93. PMC 2930984. PMID 20662758.
  8. ^ Rosen JL, Miller TJ, D'Andrea JT, McGlashan TH, Woods SW (July 2006). "Comorbid diagnoses in patients meeting criteria for the schizophrenia prodrome". Schizophrenia Research. 85 (1–3): 124–31. doi:10.1016/j.schres.2006.03.034. PMID 16650735.
  9. ^ Miller TJ, McGlashan TH, Rosen JL, Cadenhead K, Cannon T, Ventura J, et al. (2003). "Prodromal assessment with the structured interview for prodromal syndromes and the scale of prodromal symptoms: predictive validity, interrater reliability, and training to reliability". Schizophrenia Bulletin. 29 (4): 703–15. doi:10.1093/oxfordjournals.schbul.a007040. PMID 14989408.
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  11. ^ Canadian Psychiatric Association (November 2005). "Clinical practice guidelines. Treatment of schizophrenia". Canadian Journal of Psychiatry. 50 (13 Suppl 1): 7S–57S. PMID 16529334.
  12. ^ a b Howes OD, Lim S, Theologos G, Yung AR, Goodwin GM, McGuire P (August 2011). "A comprehensive review and model of putative prodromal features of bipolar affective disorder". Psychological Medicine. 41 (8): 1567–77. doi:10.1017/S0033291710001790. PMC 3687203. PMID 20836910.
  13. ^ a b c Van Meter AR, Burke C, Youngstrom EA, Faedda GL, Correll CU (July 2016). "The Bipolar Prodrome: Meta-Analysis of Symptom Prevalence Prior to Initial or Recurrent Mood Episodes". Journal of the American Academy of Child and Adolescent Psychiatry. 55 (7): 543–55. doi:10.1016/j.jaac.2016.04.017. PMID 27343882.
  14. ^ Horwitz SM, Demeter CA, Pagano ME, Youngstrom EA, Fristad MA, Arnold LE, et al. (November 2010). "Longitudinal Assessment of Manic Symptoms (LAMS) study: background, design, and initial screening results". The Journal of Clinical Psychiatry. 71 (11): 1511–7. doi:10.4088/JCP.09m05835yel. PMC 3051351. PMID 21034684.
  15. ^ Findling RL, Youngstrom EA, Fristad MA, Birmaher B, Kowatch RA, Arnold LE, et al. (December 2010). "Characteristics of children with elevated symptoms of mania: the Longitudinal Assessment of Manic Symptoms (LAMS) study". The Journal of Clinical Psychiatry. 71 (12): 1664–72. doi:10.4088/JCP.09m05859yel. PMC 3057622. PMID 21034685.
  16. ^ Correll CU, Olvet DM, Auther AM, Hauser M, Kishimoto T, Carrión RE, et al. (August 2014). "The Bipolar Prodrome Symptom Interview and Scale-Prospective (BPSS-P): description and validation in a psychiatric sample and healthy controls". Bipolar Disorders. 16 (5): 505–22. doi:10.1111/bdi.12209. PMC 4160534. PMID 24807784.
  17. ^ Ozgürdal S, van Haren E, Hauser M, Ströhle A, Bauer M, Assion HJ, Juckel G (2009). "Early mood swings as symptoms of the bipolar prodrome: preliminary results of a retrospective analysis". Psychopathology. 42 (5): 337–42. doi:10.1159/000232977. PMID 19672137.
  18. ^ Young RC, Biggs JT, Ziegler VE, Meyer DA (2013). "Young Mania Rating Scale". doi:10.1037/t20936-000. Cite journal requires |journal= (help)
  19. ^ Hamilton M (February 1960). "A rating scale for depression". Journal of Neurology, Neurosurgery, and Psychiatry. 23 (1): 56–62. doi:10.1136/jnnp.23.1.56. PMC 495331. PMID 14399272.
  20. ^ Miklowitz DJ, Schneck CD, Walshaw PD, Garrett AS, Singh MK, Sugar CA, Chang KD (April 2019). "Early intervention for youth at high risk for bipolar disorder: A multisite randomized trial of family-focused treatment". Early Intervention in Psychiatry. 13 (2): 208–216. doi:10.1111/eip.12463. PMC 5797511. PMID 28776930.
  21. ^ Goldstein TR, Fersch-Podrat R, Axelson DA, Gilbert A, Hlastala SA, Birmaher B, Frank E (March 2014). "Early intervention for adolescents at high risk for the development of bipolar disorder: pilot study of Interpersonal and Social Rhythm Therapy (IPSRT)". Psychotherapy. 51 (1): 180–9. doi:10.1037/a0034396. PMID 24377402.
  22. ^ a b Nadkarni RB, Fristad MA (August 2010). "Clinical course of children with a depressive spectrum disorder and transient manic symptoms". Bipolar Disorders. 12 (5): 494–503. doi:10.1111/j.1399-5618.2010.00847.x. PMC 2924759. PMID 20712750.
  23. ^ Fristad MA, Young AS, Vesco AT, Nader ES, Healy KZ, Gardner W, et al. (December 2015). "A Randomized Controlled Trial of Individual Family Psychoeducational Psychotherapy and Omega-3 Fatty Acids in Youth with Subsyndromal Bipolar Disorder". Journal of Child and Adolescent Psychopharmacology. 25 (10): 764–74. doi:10.1089/cap.2015.0132. PMC 4691654. PMID 26682997.
  24. ^ Kelman L (October 2004). "The premonitory symptoms (prodrome): a tertiary care study of 893 migraineurs". Headache. 44 (9): 865–72. doi:10.1111/j.1526-4610.2004.04168.x. PMID 15447695.
  25. ^ Welsh-Bohmer KA (March 2008). "Defining "prodromal" Alzheimer's disease, frontotemporal dementia, and Lewy body dementia: are we there yet?". Neuropsychology Review. 18 (1): 70–2. doi:10.1007/s11065-008-9057-y. PMC 2881320. PMID 18327642.

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