Considerations in the early identification of risk for psychosis | Ohio State Medical Center

Dr. Jason Schiffman discusses early identification of psychosis risk, focusing on social, cultural, and racial considerations in assessment.

Key Takeaways

Early identification of psychosis risk is complex and requires careful differentiation from normative experiences.
Cultural, racial, and societal contexts significantly influence the assessment and understanding of psychosis risk.
There is a need to address historical and systemic biases in psychosis research and clinical practice.
Screening tools like SIPS are valuable but must be applied thoughtfully considering individual and contextual factors.
Ongoing education, self-reflection, and advocacy are essential to improve outcomes for those at risk of psychosis.

What the video covers

Introduction to the challenges of differentiating early psychosis risk from normative adolescent experiences and other mental illnesses.
Emphasis on the importance of cultural and contextual factors in assessing psychosis risk, including the impact of race and societal influences.
Discussion of the history of racism and oppression in the field of psychosis research and clinical practice.
Overview of psychosis symptoms, including positive symptoms like hallucinations and delusions, and negative symptoms.
Presentation of screening tools such as the Structured Interview for Psychosis Risk Syndromes (SIPS).
Consideration of societal and systemic factors influencing psychosis risk, especially among marginalized populations.
Highlighting the economic and personal impact of psychotic disorders on individuals and their loved ones.
Acknowledgment of the speaker's own limitations and commitment to ongoing learning and advocacy.
Discussion of research findings related to racial disparities and the importance of reducing bias in psychosis risk identification.
Q&A session addressing practical considerations and clinical implications for early psychosis assessment.

Chapters

What are the main challenges in early identification of psychosis?

The main challenges include differentiating early psychosis symptoms from normative adolescent experiences and other mental illnesses, while considering cultural and contextual factors.

How do societal and racial factors influence psychosis risk assessment?

Societal and racial factors influence psychosis risk assessment by shaping individuals' experiences and access to care, with systemic biases and marginalization affecting the accuracy and fairness of evaluations.

What screening tools are commonly used for psychosis risk?

The Structured Interview for Psychosis Risk Syndromes (SIPS) is a commonly used tool that focuses on identifying positive symptoms of psychosis risk, such as hallucinations and delusions.

Full Transcript — Download SRT & Markdown

Speaker A

Good afternoon, everyone. For those of you joining us, like Dr. Schiffman from the West Coast, good morning. It's great to see everyone here as we begin 2024 with a talk I've been looking forward to for a number of reasons. Some of you on here might already know Dr. Jason Schiffman, who

Speaker A

I will say is our first ever two-time presenter at our Epicenter Speaker Series here, which in my biased opinion is really just due to reflection of the the the quality of work that Dr schiffman and his team keep putting out here so uh uh it's his fault I keep asking him to come back here is what

Speaker A

I will say is our first ever two-time presenter at our Epicenter Speaker Series here, which in my biased opinion is really just due to a reflection of the quality of work that Dr. Schiffman and his team keep putting out here, so, uh, it's his fault I keep asking him to come back here is what

Speaker A

we differentiate these experiences from normative experiences that pop up during adolescence and early adulthood from normative experiences that may differ uh across different situations or uh different populations uh as well as from other mental illnesses and it is a a complicated and

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the message I would say here is, but, um, today we get to hear about a very important issue around the identification of risk for psychosis. Um, as we think about identifying folks we might think are experiencing signs of a burgeoning psychotic episode, the challenge often is how do

Speaker A

he leads where this is uh what is done trying to parse out uh very thoughtfully and carefully these different experiences here to truly and most accurately identify what is risk for psychosis and what is not and so I'm particularly excited today to have Dr Shipman coming back to

Speaker A

we differentiate these experiences from normative experiences that pop up during adolescence and early adulthood, from normative experiences that may differ across different situations or different populations, as well as from other mental illnesses, and it is a complicated and

Speaker A

presentation people should feel free to send their questions to me in the chat and then I'll relay them to Dr schiffman at the end uh close captioning as always is available by clicking on the CC button at the bottom of the screen and with that I'm delighted to turn things over to

Speaker A

nuanced operation to pull that off right here. Um, I can say just yesterday, uh, for a study that Dr. Schiffman and I are parting on here or part of here, uh, I got to be part of a group that

Speaker A

to be the whatever the first second timer um they sent me this blue jacket as a as acknowledgement of of my second time around so uh I'm grateful for that um and uh and I couldn't be more thrilled to

Speaker A

he leads where this is, uh, what is done trying to parse out, uh, very thoughtfully and carefully these different experiences here to truly and most accurately identify what is risk for psychosis and what is not, and so I'm particularly excited today to have Dr. Schiffman coming back to

Speaker A

own identities my privilege and my awareness of the fact that I don't know what I don't know um so as much as I strive to be an advocate there are sizable limits to my understanding and I continue to grow and learn from the literature and also specifically from my colleagues of color and

Speaker A

uh, continue to talk about this for our group here about better understanding cultural and contextual considerations as we work to assess and identify folks who might be at risk for developing a psychotic disorder. As always, we will have a Q&A session, uh, with Dr. Schiffman at the end of today's

Speaker A

describe scientifically established corelates of race implied in the link for me is the societal not necessarily the biological factors that are driving the relation so in other words I believe it's society's influence or the experiences associated with marginalized identities

Speaker A

presentation. People should feel free to send their questions to me in the chat, and then I'll relay them to Dr. Schiffman at the end. Uh, closed captioning, as always, is available by clicking on the CC button at the bottom of the screen, and with that, I'm delighted to turn things over to

Speaker A

part I'll try to um do that relatively quickly I also attempt to articulate that there's a history of racism and oppression embedded in this field of psychosis and and potentially early psychosis so although I have a lot more thoughts on those topics than than our time together today will for

Speaker A

our distinguished speaker today, Dr. J. Schiffman. Thank you very much, Nick. Um, I really appreciate that introduction and your thoughtfulness. You could clearly give this talk, um, and I think it would be amazing if you did, um, but I'm glad that you speak to the values of this, and I'm honored really to

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some some ideas that I have to potentially help us reduce the biases now I want to say I'm one of many people doing this type of work uh I want to highlight a few recent articles here U that I

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to be the whatever the first second timer. Um, they sent me this blue jacket as an acknowledgment of my second time around, so, uh, I'm grateful for that, um, and, uh, and I couldn't be more thrilled to

Speaker A

so our first objective provide an overview of psychosis with a focus on social and societal systematic systems influences um all right before diving into the studies I think it's important to discuss the real life effects of schizophrenia and psychosis on individuals that are experiencing

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share with you my thoughts on what I consider maybe one of the most important topics in our field, and this talk, I think, is going to cover an array of topics related to discrimination and societally influenced racialized identities. Before I begin, I want to acknowledge my awareness of my

Speaker A

population and that uh leads to two million adults approximately in the US um 100,000 adolescence and young adults develop a first episode of psychosis annually um and these conditions impact people's independent functioning quality of life and uh it impacts not just the individual but but loved ones

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own identities, my privilege, and my awareness of the fact that I don't know what I don't know. Um, so as much as I strive to be an advocate, there are sizable limits to my understanding, and I continue to grow and learn from the literature and also specifically from my colleagues of color, and

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people without um just there's things that we can do about this and I think a lot of the the work in this field is is trying to Champion some of those things it's an e uh economically costly diagnosis

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I define this broadly: academic collaborators, consumers, and friends. I also want to acknowledge that I perceive race and ethnicity as social constructs. This is a bias that I have, and oftentimes, uh, I think these constructs are used to consolidate power, uh, and therefore when I

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community um we call this recovery uh additionally many individuals who experience psychosis report positive changes as a result of their experiences that provide them purpose and meaning just like people without psychosis some of the challenges that we experience are the challenges that give

Speaker A

describe scientifically established correlates of race implied in the link, for me it is the societal, not necessarily the biological factors that are driving the relation. So, in other words, I believe it's society's influence or the experiences associated with marginalized identities,

Speaker A

screening for psychosis we roughly divide symptoms into positive and negative symptoms positive symptoms including hallucinations and delusions and negative symptoms which I'll mention in a minute but positive symptoms uh include delusions these are ideas that are held on to tenaciously

Speaker A

not something inherent to the individual, that account for many of the associations that I'll be describing today. So, learning objectives: this talk will provide information on what we know about early identification of psychosis, and this will be a review for many of you, so bear with me on that

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on a Continuum not only do I feel that this is scientifically accurate this notion of Continuum versus categories but I also contend that by highlighting continuums of experience experiences to psychosis symptoms we can create connections between those with and without challenges related

Speaker A

part. I'll try to, um, do that relatively quickly. I also attempt to articulate that there's a history of racism and oppression embedded in this field of psychosis and, and potentially early psychosis. So, although I have a lot more thoughts on those topics than our time together today will for

Speaker A

to many people and is not necessarily um an idea that's held on to tenaciously despite evidence to the contrary could actually be happening but as you walk through these examples they become more and more Uncommon and more likely to be a part of a delusional constru Building Bridges here okay

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I hope to cover at least in part all four of the objectives that we have here: overview of psychosis, value of early identification, historical and contemporary, uh, context, diagnostic assessments, and need for careful consideration and tangible recommendations. This is a part where I talk about

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they include things like blunted affect and not necessarily A blunted experience of emotion but blunted expression of emotion alosia Poverty of speech asociality social withdrawal anhedonia a lack of enjoyment of social experiences and avolition a lack of energy or will or

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some ideas that I have to potentially help us reduce the biases. Now, I want to say I'm one of many people doing this type of work. Uh, I want to highlight a few recent articles here, U, that I

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so if you think of this excuse me this point in time as the onset of psychosis and this point in time is when treatment is initiated the duration of time between these two points is referred to as the duration of untreated psychosis and in the US this time on average is roughly a little

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found particularly relevant, and I'm happy to share these resources at the end. So, if you want to copy my slides or are interested in these articles or learning more about some of the areas in which I've gained my knowledge, be happy to share with you any of that and all of that.

Speaker A

here uh and we think that if we can work with people during this risk phase we can um maybe mitigate the impact of psychosis for those destined to develop psychosis or maybe delay the the onset of psychosis for those destined to develop psychosis and maybe in some cases prevent

Speaker A

So, our first objective: provide an overview of psychosis with a focus on social and societal systematic systems influences. Um, all right, before diving into the studies, I think it's important to discuss the real-life effects of schizophrenia and psychosis on individuals that are experiencing

Speaker A

it's bad it's worse long-term outcomes more intensive needs for services negative symptoms social impairment occupational impairment neuros deficits distress and likely increased costs and burdens to the system dup is bad but we can do something about it implementation of reducing

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these challenges. Schizophrenia is perhaps the most debilitating and potentially devastating mental health condition known. Um, it can be distressing and destructive for patients or clients as well as their loved ones. Its impact is worldwide, uh, and approximately occurring around 1% of the

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awareness of cultural and contextual factors and potentially an understanding of of History that's created as systematically marginalizing mental health care system and and it's these latter points that I want to spend our time together discussing um to help contextualize the rest of my

Speaker A

population, and that, uh, leads to two million adults approximately in the US. Um, 100,000 adolescents and young adults develop a first episode of psychosis annually. Um, and these conditions impact people's independent functioning, quality of life, and, uh, it impacts not just the individual but loved ones

Speaker A

one that is influenced by combination of both biology and social determinance and uh and that will kind of that that mentality frames a lot of my sentiments and what I want to share today um okay so thinking about the history of these things um marginalized racial ethnic minority

Speaker A

as well. Um, you know, a couple points of emphasis here is the risk of death by suicide, which is a contributor to reduced expectancy, but that's not the only, um, contributor to that appalling statistic that people with schizophrenia, um, can expect a life expectancy of 20 years less than

Speaker A

professions uh during the time of slavery uh and it's called drop it to drop to Mania and it's referred to as runaway slave syndrome and it's this belief that an enslaved person who um was escaping or attempting to escape enslavement was uh was having some sort of biologically medical

Speaker A

people without. Um, just there's things that we can do about this, and I think a lot of the work in this field is trying to champion some of those things. It's an economically costly diagnosis

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the least of the white community and not seeing or some of the members of the white community and not seeing how enslaved people would want to leave what they themselves experienced to be a wonderful safe and nurturing environment um in the minds of the the the white people at

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disorder as well. Um, I will say this, however, although there are negative outcomes that are associated with psychosis, it's important to keep in mind that many individuals who experience psychosis can and do lead full and successful lives, lives of their choosing, lives in the

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medicine so um as we move along further in the in sort of the history of our country um our country divided um mental health asylums into uh oftentimes black and white serving facilities and uh relative to the white serving facilities black asylums had uh were more likely to overdiagnose

Speaker A

community. Um, we call this recovery. Uh, additionally, many individuals who experience psychosis report positive changes as a result of their experiences that provide them purpose and meaning, just like people without psychosis. Some of the challenges that we experience are the challenges that give

Speaker A

folks that have done you know um dived into this have been able to find is probably just um you know just poultry compared to what actually was going on at the time um in the 60s and 70s um uh folks you well white people oftentimes would use um mental health language

Speaker A

us most growth. Um, and one of the best ways to potentiate recovery and growth is through early intervention. Um, of course, early intervention is predicated on solid early identification, and that's what I want to focus most of my time on today. So just briefly, uh, when we're thinking about

Speaker A

and Views that they had um thereby sort of disempowering uh their their messaging today uh I think there's both over and misdiagnosis and the literature suggest that black people they're more often diagnosed with schizophrenia than their white counterparts uh who are diagnosed

Speaker A

screening for psychosis, we roughly divide symptoms into positive and negative symptoms. Positive symptoms include hallucinations and delusions, and negative symptoms, which I'll mention in a minute. But positive symptoms, uh, include delusions. These are ideas that are held on to tenaciously

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psychosis so these factors have to be considered in diagnostic evaluation we have to be careful with with this there are errors regardless of where the errors lie though the current state of affairs leads to a mismatch in treatment uh stress associated with that mismatch and a

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despite evidence to the contrary. Um, some examples here: I think people are talking about me, someone is following me, people are talking about me to plot against me, and aliens are sending me messages through the TV. I picked these.

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way so that there is a caveat there that I want to emphasize but but what they found is that folks who immigrate from subsaharan African countries who are black and they immigrate into white neighborhoods uh into Western countries like uh the Netherlands or uh England there

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is an increased risk of developing psychosis for those who are immigrating and what's particularly interesting is that um the risk for um developing psychosis is persists uh across Generations so the second generation is actually at higher risk of developing psychosis than the first

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generation of immigrants which suggests to me that there's something about the immigration process that's stress uh that's it's not about the immigration process but it's about immigrating to a new country and potentially living and growing up in a country that others are marginalizes um

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there's uh so let's see what else I want to say about this the mechanisms I guess haven't been entirely established but the fact that the finding holds us strongly if not stronger for the second generation immigrants suggests that it's not something inherent to that process but rather um

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living in a marginalized Society where among other countless issues resources and access to care are scarce and folks might be considered strangers or are othered in their own country of birth um in keeping with this motion this notion of othered versus supported there's been some evidence and

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this is kind of uh interesting as well uh that there's a protective effect for people that immigrate into communities with people of similar cultures and ethnicities so this protective effect um could uh makes further suggest that societal factors are at play here as this pertains to

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psychosis risk or uh symptoms are of psychotic like experiences we've documented that there's increased risk for psychosis like experiences among people that report police victimization and in some of the larger studies related to clinical high-risk for psychosis we find that

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trauma bullying and discrimination are all uh elevated among people at clinical high risk um and also that discrimination um that that factor in particular is linked to uh increased risk for conversion to psychosis so um something that are uh we continue to research on and uh think more

Speaker A

carefully about as this field progresses let me move into our our second learning objective this is identifying signs of psychosis or symptoms through exposure to risk assessment tools um I've already alluded to this clinical high-risk for psychosis State um but let me share a little

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more and Define it a little bit more carefully here uh it is most typically um defined by uh the charact uh the qualities of having attenuated psychosis symptoms so these are symptoms that are related in um uh in nature to psychosis but tend to be less so in their severity how formed they

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are how distressing they are and how and the level of conviction that a person has around them so attenuated not full threshold people at clinical high risk tend to have comorbid mental health concerns about 75% or so of folks that meet for clinical high risk meet

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for things like depression anxiety substance use uh attention challenges uh It's associated with impaired Social and occupational functioning and it warrants treatment the risk state is distressing and impairing in and of itself that that's suggested by it it it warranting

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treatment so we think about Folks at risk for psychosis as a group of people that would May benefit from Care at the same time we also think uh well care for their existing circumstances but we also think about how might progress and if if their symptoms might get worse and they

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might head towards developing psychosis um and so even though I don't just think about excuse me conversion to psychosis it is an important uh outcome variable and what you see here is excuse me um a summary of uh a variety of randomized control trials that involve people at risk for

Speaker A

psychosis and the folks that got some sort of Specialized Care designed to prevent psychosis were about 50% less likely to develop psychosis than the folks that were also at clinical highrisk for psychosis but got some treatment as usual or weightless control um after after one year

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so good intervention all this is to say is that um Folks at risk for psychosis um would benefit from treatment for a variety of different reasons and one of those reasons is potentially to um prevent the development of psychosis in the future now how do we recognize risk for psychosis

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there's some general symptoms or signs that we could think about like feeling like something's not quite right or jumbled thoughts and confusion declining interest in people activities self-care deterioration and functioning but as you could rightly see these are very non-specific symptoms

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so we want to get a little bit more deeper um and try to understand context that might be influencing um our our interpretation of how some of these or the the meaning behind um the manifestation of some of these symptoms and other symptoms as well there is a gold standard

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interview that's used in predominantly well the most like uh common used tool in in the North America is called the structured interview for psychosis risk syndromes the sips many of you may be familiar with this but it focuses in on five positive symptoms of psychosis risk um and

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its job is really to distinguish whether or not a person has low risk for psychosis high risk for psychosis or has crossed the threshold for psychosis it does so by focusing in on these five symptoms unusual thought content suspiciousness grandiose ideas perceptual abnormalities and

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disorganized communication and I want to spend a couple minutes just talking about um two of these symptoms unusual thought content are positive symptom one H and then I I'll talk touch on suspiciousness positive symptom two for unusual thought content these are some questions directly

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from the sips to orient you as to what we're we're thinking about here have you have the feeling that something odd is going on that you can't explain or been confused at times whether something you experienced uh is real or imaginary do you ever feel like your thoughts are being said out loud

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so that others can hear them now the questions around suspiciousness um uh are worth additional thought in in the context of a talk like this so do you ever feel that people around you are thinking about you in a negative way have you ever found yourself feeling mistrustful or suspicious

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of other people do you ever feel that you have to pay close attention to what's going on around you in order to feel safe people that answer these questions in by and large uh are probably going to answer these questions for reasons other than psychosis RIS certainly some people at psychosis

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will say yes to these questions but we need to be very mindful about why the person is answering uh affirmatively to questions such as these I'll give you an a quick vignette that we'll walk through quick briefly together so Michael often feels that people are out to get him he describes

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being watchful in public and worries about someone jumping him he's not sure but he sometimes thinks that he's being targeted he reports feeling like the world is out to get him and he's pretty much on his own although he says he's always been a little mistrustful Michael noted that his feelings

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of being targeted have gotten worse over the past six months now the sips interview encourages us to think about uh these experiences in Greater depth to give us more context to be able to to parse apart what might be um psychosis risk versus um some other reason why someone would say yes to

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these questions the first thing that the sips encourages us to think about is the experience itself so what is it that Michael's going through well he feels that people are out to get him he worries that someone's uh might jump him he thinks he's being targeted and feels like the world is

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out to get him and pretty much that he's on his own so those are the things that we would want to like learn more about and ask like tell me more about that as we dive more into the experiences

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that Michael might be having the next thing that the sips wants us to think about is are these experiences associated with uh Behavior change are they distressing and how intense are they because these factors will give us a sense as to whether or not this is pathological uh in terms of

Speaker A

Psychopathology or pathological in terms of some other um explanation so uh in terms of behavior change he's being watchful and then um maybe an indication of some distress is that he worries that someone's going to jump him I'd like to probe more this is opportunity that the sips gives us to

Speaker A

ask questions that can give us more information uh to to have an accurate conceptualization of what's going on for Michael the sips also wants us to think about the novelty is this something that's new or is it um long-standing and stable if it's longstanding and stable it gives us a different

Speaker A

sense if it's novel then either something something may have changed something may have changed within the person or maybe externally to the person again more information for us to learn when we're thinking about the cap towards whether or not something is at risk for psychosis

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versus crossing a threshold for psychosis the construct of Doubt comes into play so in this case Michael reports he's not sure that these things are happening and the fact that he has some level of Doubt is indicative of of this idea that if this were to meet risk for psychosis or

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excuse me if this were on the psychosis continue it would be in the risk phase and not the full threshold because he still has Insight he doesn't have psychosis levels of conviction there are many alternative explanations to why Michael might have been experiencing the things um or saying

Speaker A

yes to those questions cultural and contextual factors might influence how a person responds we need aw awareness and this is one of the F the focuses of of what I want to spend our time talking about today so I'm going to circle back to that in a minute um I just want to um couch all of

Speaker A

this work in the context of the DSM if you use a DSM or you use use it for billing the attenuated psychosis risk syndrome can be found under 2988 um three here tenuate psychosis syndrome and it's by and large defined similar to what I I just of described with more details in in the

Speaker A

DSM which has a great definition actually um the sips interview if you're interested in more about the sips you can find the Sip training.com has some information about trainings and the sips itself is a great tool although of course it has its limitations one of its limitations is

Speaker A

that it's not great at predicting who's going to develop psychosis and who's not if a person meets uh for sips criteria there about a 25% chance of developing psychosis within three years now that's much better than just a general population 1% it's better than having a first-degree relative

Speaker A

which is about like 12% or so um uh in terms of risk but this still means that three out of four people that are sips positive POS are not going to develop psychosis so we need to think about how we can improve prediction and and uh in order to do that we think about the

Speaker A

right using the right tools what strategies can we uh complement the sips with that will make the sips even more accurate and this is where risk screening comes into play um risk screening can make uh sips assessments more efficient can help find people not in services like you know doing

Speaker A

like public mental health screening or screening in schools can monitor in our clinics we use the u a screening tool weekly to assess um men uh changes in psychosis risk status um when we're working on other treatment targets um assessment itself is is treatment that's sort of an kind of

Speaker A

a cool thing about mental health and that the act of observing and learning more can be Curative in and of itself we also have clinical interviews which is the gold standard like the sips these get more um you know client input so you're able to make sure that you have a shared understanding

Speaker A

of the questions and the meanings behind their responses but they're lengthy and require lots of training if any of you maybe have gone through a sips training you know that it's like a two-day Affair um and uh and it requires a lot um so this is the the gold standard but are there things

Speaker A

within self-report that we can use to complement to make those gold standard interviews better faster easier uh self-report measures they have these advantages of being brief and the Criterion validity is pretty good um but because you're just sort of giving a you know a piece of paper or or

Speaker A

having somebody fill something out on the computer there's less opportunities for uh conversation to make sure that there's a shared understanding between what the questions were intended to mean and how the person is interpreting them um and and so more validation is required we

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need to understand moderation um and the general psychometrics and generalizability of these good first line of uh approach to screening that would then I think open the door for a full or sips evaluation now I'm going to try to share with you a series of studies that looked at the validity

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of of some of these screening tools um where the the vast majority of the methodology that I'll describe is comparing somebody's self-report to um their interview with the clinician after after they fill out the the self now first forway foray into validating screening tools was to administer

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a variety of measures SP some that were specific to clinical high-risk for psychosis and others related to constructs like anxiety and depression and others to likely unrelated constructs like perception of exercise and what we found was some evidence for convergent and discriminate validity

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with the measures of psychosis risk oops uh tending to correlate highly with each other more so than they did with measures of anxiety and depression and way more than they did with unrelated constructs like the exercise thing uh in this in this study then the next study to advance

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this line of research we compared um the screening to the gold standard clinical interviews and what we found on three different prominent risk screening tools was pretty high accuracy between screening for psychosis and uh clinician diagnosed risk for psychosis perfect but pretty good so um

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and then if you uh if you factor in distress so it's more than just more than just uh yes or no on these questions but distress then um accuracy increases even further in this study led by um my

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now colleague uh I should just say Emily um Klein was the lead on the lot of this work um she's in Boston now and um Peter failen in Baltimore um helped us divide devise a two item screening this

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is maybe the most practical uh tip that I have in my talk which is uh these two items are pretty good if you just want to have a conversation with someone about risk for psychosis so do you ever

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hear a voice of someone talking other people can't hear have you ever felt that you're that someone was playing with your mind from our IRT analyses these two items were pretty good but all this screening research left us thinking there's more that we need to do we need to get more accurate

Speaker A

and better at doing so in particular for some of our members of our community who are marginalized are not necessarily as repres presented in the research as um the majority population give me one second okay this part about Zoom is being able to mute when you have to blow your notes

Speaker A

okay learning objective three recognize how attention to cultural and contextual factors inform assessment strategies now as I was saying in that last section screening is pretty good but it can't get better and I I think we need to understand validity in context in order to do so

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so let me walk you through this little image here um there are let's see some red arrows here or these like gray arrows here they represent false links between other symptoms and experiences of CHR so it should be that symptoms of psychosis risk lead to an accurate diagnosis but there's

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all these other factors that that uh go into play here like person's race the community that that they're from uh developmental considerations uh culture and potential interview biases that feed into confounds to this like pure line from uh symptoms to risk however if we approach our

Speaker A

assessments with sensitivity uh we use measures and uh and refine our existing measures to make them better um we can sort of reduce some of these like these gray error lines here and get back to a more Pure Line Between symptoms of risk and CHR uh you know an accurate CHR clinical highrisk

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label and uh the following three studies I think sort of speak to to our our efforts to to kind of shed some light into that into that dat domain and and reduce some of the the error that I was

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talking about here and this was a study um led by my recent graduate who's also now in Boston um Zach milman uh and his question was are the screening tools that um you know these paper and pencil screening tools are they valid across race and in particular we were looking at one one item

Speaker A

or excuse me one tool called the prime screen and this is a a tool that was developed by the authors of the Sip so we like that one because of the congruence between the sips and the prime screen itself um and it's also short it's only 12 items but the question was does the prime screen

Speaker A

perform equally well for our participants who are black and our participants who are white and the answer uh was no uh if you I just highlight this little blue box here with the simple effects the this uh it was not there was not a statistically significant relation between um our self-report

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measures from our black participants and the clinical interview of those same participants with the with the clinicians gold standard sips interview the the relation that relation was significant for our white participants however leading us to believe that the prime screen screen

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doesn't adequately assess black you at least in our and potentially lacks required context there's no conversation we can't understand why they're saying yes to a particular item and as a result we uh they may not have the same understanding of an item as we intend it

Speaker A

to be interpreted and then uh over pathology May ensue um so screening alone may over pathologize I will say this for some of our participants who are black the prime screen worked just fine so it's these are averages so and no one should be no group should be considered monolithically um

Speaker A

moving on to the second second study I wanted to mention this was by Camille Wilson who uh is at a children's hospital in Ohio and um what camil was was thinking about was the impact of neighborhood and how might Neighborhood Impact how a person responds to the sips so in this case

Speaker A

there was no screening involved but what Kil was thinking was if a person lives in a neighborhood that has more crime then there's a good chance that they're going to say yes to symptoms those those uh positive symptoms on the sips like have you found yourself feeling mistrustful

Speaker A

or suspicious of other people do you ever feel like you have to pay close attention to what's going on around you to feel safe and sure enough that's what she found that that uh we uh we were able to partner with the Baltimore neighborhood indicators Alliance to create a uh a crime index

Speaker A

within neighborhoods we correlated that crime index with um P2 suspiciousness on the sips and we found a significant link between P2 and and neighborhood crime and then we controlled for the other uh positive symptoms to try to get a sensus to like what what if what if if we sort

Speaker A

of parsed out psychosis risk and P2 continued above and beyond so uh to predict um or you know to correlate with um yeah indices of crime so what this suggests is that neighborhood has an effect Beyond just psychosis and there's the importance of context in in individual symptom reports so

Speaker A

this is like it talkk to these concepts of healthy contextual mistrust versus labeling someone with Psychopathology now this term healthy contextual mistrust sometimes you hear it as healthy cultural mistrust but I don't think it's anyone's cultur to be mistrustful I think only when a person or

Speaker A

culture is marginalized or discriminated against or othered in some way do they become mistrustful and I think that might be what's going on here um uh but I will say this it's also very well possible that living in neighborhood that's high in crime could be a stress or risk risk factor

Speaker A

that could authentically increase the risk of of developing psychosis so we don't know exactly the implications here but we know that it's important to be mindful and thoughtful um when we're working with individuals really okay last study is um from my also recent graduate Pam Roan RAR who is now an

Speaker A

assistant professor at the University of Maryland Baltimore County and she was thinking about this the factor structures of that Prime screen measure that I mentioned before um 12 items self-report and she's saying do items mean different things for different people and different times um and

Speaker A

are some items suggestive of typical functioning and um and she did a factor analysis on those that 12 item measure and roughly found two factors one that sort of aligns with what you would expect for psychosis risk and another maybe not so much but you see here the the factor that psychosis

Speaker A

or outer unusual things going on can't explain uh thoughts being said out loud thinking that I might go crazy now whereas the second Factor had a sort of different flavor to the items predicting the future superstitions having gifts and what she did cleverly was she correlated these two

Speaker A

factors with measures of functioning and that factor one the like more Psychopathology kinds of thing my feeling you're going crazy that was uh inversely related to functioning so the higher you were on that factor the worse you were doing in terms of uh Global and social functioning

Speaker A

interestingly enough on the other Factor there were a lot of non-significant correlations but one significant one was the higher you were on like having superstitions for instance on that scale the higher you were in Social functioning and what we we think is one that scale and those

Speaker A

items within the larger scale aren't predictive of Psychopathology and two maybe it's because um these items uh are like ones that allow us to connect with people like talking about superstitions or or having you know like talking about Connections and dreams and stuff like that

Speaker A

and that this is just sort of a way in which we all relate when it's not at a Psychopathology level um I'm G to run through this pretty quickly but when she looked at the items individually and um and separated our our sample um a compartive sample between our black participants and our

Speaker A

white participants and correlated the items with mental an index of mental well-being what she found was differences in uh relations between our mental well-being and the items from our black participants and mental well-being and our items from our white participants so that in

Speaker A

short the tool is working differently within our sample for our black and white participants with only one item um predicting well-being for both groups which was I feel like I'm going crazy item item 12 all right so what does all this mean well Factor one may be or some items within the prim

Speaker A

screen may be really about attenuated psychosis others maybe about other things um and so not all questions indicate psychology and there could be some questions that are particularly questionable for participants who are black like I wonder if people maybe blame planning to hurt

Speaker A

me or even maybe about to hurt me um as an I that might not be so good for um people from marginalized groups okay uh winding down um I want to try to save some time for questions as well but let me see if I can't cover most of this so the the fourth learning objective

Speaker A

describe actions that can be taken to change the status quo with respect to potential biases um and these are just my thoughts but I think these thoughts are whether or not you agree with the the idea I think they're important um you know the understanding of integration and culture and

Speaker A

context I think is relevant I think I've made an argument that there's historical and present challenges that are um potentially making things uh unfair or different for people in one culture versus another or one group versus another uh and we need to be thinking about things like race and

Speaker A

neighborhood uh I didn't mention development but uh development is another cultural factor that I think we should bear in mind culture and then other things that I didn't talk too much about like trauma and distress are things that should I think be factored into um some of the the driving

Speaker A

science like our risk calculators that that are used to predict who may or may not develop serious mental illnesses related to psychosis um so I have some recommendations and these are just my own recommendations and thoughts so they could very well be misguided or wrong but um but I'll

Speaker A

share them with you the first is um one that may be familiar to to many folks is this idea of cultural humility um This research that we're doing in psychosis risk is one that's sort of on the you know the Forefront like I think we're on like sort of a bit of a revolution when it comes

Speaker A

to identifying people at risk for psychosis and being able to think about preventing psychosis when I started the the field in the field like 27 years ago or so people really weren't talking about this and now it's like it's mainstream almost mainstream um but there's so much that

Speaker A

we don't know and there's so much that we don't know in particular around um communities of color and so uh we should be humble and I believe and cultural humility is defined as committing to an ongoing relationship with patients communities and colleagues that requires humility as individuals

Speaker A

continually engage in self-reflection and self critique and this goes for how we develop our systems of care and and conduct our research as well um I emphasize this at the beginning but I want to come back to it which is this this idea that social and cont contextual factors make a

Speaker A

difference or matter in the field of psychosis just as I do and other mental health concerns and sometimes people need to hear that or be retrained on that um I think social mediated stress is a dynamic factor for risk um training and Trauma can be really useful obviously there's

Speaker A

a lot of attention uh rightly so to trauma but um trauma is a is a known risk factor for the development of psychosis and people at risk for psychosis are more likely than not to have had traumatic experiences in their past um and we also have literature that suggest multiple exposures

Speaker A

uh of trauma lead to greater risk for psychosis so uh contextual factors make a difference here and Trauma could extend uh or manifest itself in many different ways including neighborhood and um factors associated with low socioeconomic status and discrimination as well one tip that I

Speaker A

have that I think is a really useful one is um to Avail yourself of the tool referred to as um the clinical formulation in or excuse me the cultural formulation interview or CFI this is freely available uh it's connected to the DSM you can just Google it there's there's like a a like a

Speaker A

a broad one and then it has like subsets but it's it's um a a great interview that allows clinicians to be afforded the opportunity to read questions that will open up conversation about a person's background and culture that might be awkward for them to to raise otherwise um and it ensures

Speaker A

hopefully a shared understanding of the meaning of a person's culture and where they're coming from in one study not of risk for psychosis but of full psychosis um they they made some pretty compelling evidence that after using the culture formulation interview diagnosis like half of the diagnosis

Speaker A

within their their study would have changed from psychosis to not psychosis just by understanding the culture of the the participants better um I also alluded to this at the beginning um I haven't talked about treatment much but you there's just a lot of stuff that we know we don't know um and

Speaker A

you know sometimes I think it's great to and the right thing to do to um uh adapt existing interventions and strategies for care but there could be a whole new ways of approaching care that we just haven't imagined yet and I I just I want to be open to that and I want to invite

Speaker A

more people into that conversation I think that's a good idea regardless of whether or not you agree with my ideas uh this I think it's important to be thinking about the problem and and the challenges and I know that the federal government is thinking about this as well and so to our local

Speaker A

communities there's more and more funding um out there for risk for psychosis early intervention for psychosis um and and we have a chance we a chance to like build things in in an image that we want it you know to to help support all people all vulnerable members of our society in ways that

Speaker A

would be really inclusive um or we could kind of just sort of do status quo stuff and and end up marginalizing groups that have historically been marginalized and prioritizing others um okay so um I'm wrapping down here I think I was able to cover everything that I was hoping to you know we talked

Speaker A

about psychos the value of early identification I frame things from a historical context talked about diagnostic assessment and some some research that suggests that we have to be careful in how we assess but uh but that we can do it and uh and then there's some steps that we could take

Speaker A

to be more more inclusive in our approach to evaluation um and with that uh these are just some some pictures from my various teams that I'm very proud of being part of and uh and I'll Le I'll I'll end my formal remarks with a quote from Brandon staglin who's uh I think a thought leader

Speaker A

in our field he says enthusiasm and hope or might make the difference um thank you all for sticking with me for this uh 45 minutes or so and I'll be happy to to answer any questions that we might

Speaker A

have hi Dr schiffman it's Chris Reed from the Peaks clinic in Denver hi Chris hi nice to see you I'm such a great great presentation I know you probably remember I have a a real affinity for this topic I'm raising a black man myself who's only nine years old but that's kind of the

Speaker A

journey I'm on and I'm wondering like yesterday I was doing a sips assessment with um a young a 19-year-old man a black man who also had an overlap with AC ASD and I'm curious if you ever Envision a change to some of the sips questions especially around P2 I'm thinking especially

Speaker A

like people that not may not be familiar with the cultural formulation interview may not use those queries like may not ask about police violence may not ask about the neighborhood or overp policing of this person's experience and I just wonder I wonder what we're missing sometimes

Speaker A

if if people don't go a little deeper with those SI questions yeah I mean that like Chris is like it's like you're a plant and from the audience is exactly the the like taking what I was talking about sort of hypothetically and like bringing it into the real world into your experiences and

Speaker A

what I'm excited about is is that you were sensitive to that and and you kind of knew like this is sort of what I should be thinking about and uh you know the question is like do I mean your your real question I think one of one of your questions was like should we change the

Speaker A

sips and I I would be okay with that although I know that there's like some challenges with that as well um so so what I think I mean what I've been more mission towards um is is to like

Speaker A

help more people be more empowered like you to be aware of these factors and um and and just kind of uh get the word out to try to prevent uh like blanket evaluation without uh you know context I

Speaker A

mean the sips does empower us to ask the ask the questions uh you know about like what's really going on here tell me more about this and um you know is distressing impairing what's the root and if we do ask those questions then the sips can be uh culturally informed but it really it really is

Speaker A

incumbent upon the this the interviewer you know such as yourself um to get it to get it right um so uh so thank you for doing what you do and doing it the way you do it you're an example

Speaker A

for how I want this field to be thank you yeah so Dr Chipman we've had a couple questions come in in the chat uh first one is uh I really love this talk and thank you I'm wondering about contextual

Speaker A

differences in the kind of experiences people have versus the kind of language people use to talk about similar experiences to what extent should we think about for example different responses to Sips questions as differences in life experiences versus communication

Speaker A

Styles um read the second part again the like the question part yeah what extent should we think about different responses to Si's questions yeah as differences in life experiences versus communication Styles um communication all right so I'm not 100% that I sure that I'm going

Speaker A

to answer this question as it was intended to be answered um or asked but um I think I mean I think what this speak what it's making me think about is like you know who is the person that gets

Speaker A

to determine what's Psychopathology and what's not and um and maybe that's deeper or different than what you're asking uh but I think I mean at a at like at a surface level you know if if someone answers the question uh like you know in a way that is ambiguous like and and their

Speaker A

communication style is different than what the interviewer is thinking or is accustomed to then it really is incumbent upon the interviewer to like ask more questions and and to get clarity And to clarify and tell me more about that and and and build rapport so that the person feels

Speaker A

comfortable in uh and safe in in responding um and take the time like don't think like okay well we have 45 minutes to do this sips and you know checklist so I think that covers maybe like The Superficial or like one level of of what I heard in that question and while I'm I'm talking if if

Speaker A

the person that ask that question if they want to ask more for more clarity or clarify please be by all means but the the other level is like you know like there is like a mental health Canon that defines what is Psychopathology and what's not and I think you know the sips like you know

Speaker A

you do ratings and you evaluate now the cool thing about the sips is that it really is is zeroing in on whether or not something's distressing uh interfering and uh and causes Behavior change that that might be you know maladaptive for the person and I think those factors are important to

Speaker A

bear in mind when you're thinking about like well is this Psychopathology or is this an experience I'm I'm very like adamant that we not pathologize an experience if something is different than you know than what I tend to experience or what what's uh akin to my culture whatever like that doesn't

Speaker A

mean it's psychopath ology for instance when I was in Hawaii so my first six years as a professor at the University of Hawaii and I quickly learned that there was just sort of differences in terms of uh like the Western training that I had in terms of what psychology is and and the some of

Speaker A

the the the beliefs and the um the realities that the the people in the community who I was working with who I was serving um you know experien so for instance then U my one of my very first

Speaker A

clients gave me a book it was written by Elders um and in her faith community and it said there was a chapter really on psychosis even though it didn't wasn't labeled that and it said you know if if a person hears voices and they're the only one that hears it and those voices are negative then

Speaker A

that's not consistent with our cultural values there's something a Miss there but if it's a shared experience and it's positive then that's not Psychopathology that's that's part of our community and culture and you know these it wasn't my place to pathologize one you know one side or

Speaker A

the other that I garnered and learned from the community so anyway those are like two thoughts um for I think what is a really provocative question I could probably spend another hour talking about that thank you for asking that question so there there was a clarification that or additional

Speaker A

detail that came in so I'll jump that um we know there are differences in how people talk about their experiences for example across culture some authors have suggested that people of color are more likely to be rative as aggressive due to normative cultural variation in speaking style

Speaker A

and tone I feel like two people uh who've had the same experience might use very different language to describe it based on cultural and contextual variation okay yeah and that sorry I went off on the five minute tangent although hopefully that some of that stuff was interesting um I

Speaker A

mean to me this is just like a like a not even a question so much as like something that I missed that I should include in my next talk related to this and and do some more homework in terms

Speaker A

of you know like uh making sure that people are educated uh or or comfortable or familiar with the the speaking style and the the choice of language used from you know um the the the clients that they're serving and that is a great Point um and uh and I think that probably plays a

Speaker A

role in in in subtly in some of these mismatches that we have between the screening tools and the interview itself um because with the interview you do get you get some more context like uh people will share with you what they're thinking and then and then you can kind of rate it accordingly um so

Speaker A

excellent excellent question all of that good so the next question um asked about the lower rates of psychotic disorders particularly schizophrenia that have been documented in women uh how much of that do you think is tied into lower inherent rates of schizophrenia among women versus

Speaker A

bias due to having symptoms may be attributed to mood anxiety or trauma um that's a good question um I think I think there's uh I'm not sure I think there's uh I think that the answer to that lies in in a combination of biological and also soci societal influences um and I

Speaker A

think Society in General on AG aggregate treats uh people who identify as male differently than people who identify as women differently and and that probably has some role in in the expression of psychosis symptoms I'm not an expert in that area and I don't want to say something

Speaker A

at a turn I will say this that's this is not an answer but actually just something I find interesting and that in a lot of our research our current research right now for folks at risk for psychosis so not psychosis itself which is a long you know there's long-standing

Speaker A

documentation of more like higher rates of psychosis among men than women which may or may not be true it's just the documentation of it um but in our studies of folks at risk for psychosis where our recruitment strategies are are novel relative to the old days a

Speaker A

lot of online recruitment we are finding uh a preponderance of women or young girls who are reporting as at risk for psychosis relative to to men or or boys who and so so we'll see the the question sort of um it begs to be answered I will say the the the the the conclusion I want to

Speaker A

draw from my my observation about this this new data that's coming in is that it's possible that what we think we know about psychosis and gender differences sex differences may be uh a result of of of recruitment um more than a result of you know like what is true in in reality although

Speaker A

I don't know that for sure I'm just I'm open to that possibility I'm open to change open to being wrong well Dr Shipman thank you for a wonderful talk here today um and thanks for everyone for joining us we hope you can join us next week when uh Dr Stefan borgart from the University

Speaker A

of Lubec will be presenting for our team here uh hope everyone is staying well and healthy and Dr shiffman thank you again for a wonderful presentation today thanks Nick thanks everyone bye everyone

Topics:psychosisearly identificationpsychosis riskcultural considerationsracial disparitiesmental healthpsychotic disordersSIPSsocial determinantsOhio State Wexner Medical Center

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