Conclusions

On all dimensions of the disorder we call schizophrenia - symptoms, neuropsychological changes and functional impairment - the prodromal stage and the early psychotic stage preceding the climax of the first episode constitute the most active, most rapidly progressing and hence the most decisive period in terms of the social consequences of the disorder. It may even be of far greater importance for further illness course and social outcome than any of the later stages of illness. The prodromal period usually interferes with educational and occupational career at a stage most vulnerable to influence. In accordance with results from the ABC Schizophrenia Study, Eaton and Harrison [171] describe the onset of schizophrenia as follows: ''The type of symptoms that show up first are affective, negative and cognitive and social dysfunction: depressed mood, trouble with concentration, poor work performance, subtle social deficits''.

The durations of the prodromal stages and of the psychotic episode until the climax of psychosis vary a great deal. According to studies on the topic, the mean duration of the prepsychotic prodromal stage ranges from two to five years (ABC Study: 4.8 years), and the psychotic stage until first admission currently still lasts slightly more than a year. In two thirds of cases more than a year elapses from illness onset until first admission, whereas only some 15% experience an acute type of onset of four weeks or less. Especially in patients with a chronic early course, early intervention appears promising and, since first successful results have appeared, also meaningful. The precondition is that individuals at incipient risk seek help, diagnosis can be given early and the time of onset of the psychotic episode and the future illness course are predicted with sufficient accuracy. Three quarters of all cases of schizophrenia experience a prodromal stage without specific psychotic symptoms. We must find ways of detecting and recognizing the illness and of predicting its further course earlier than is currently the case, by using appropriate instruments and designs at early-intervention centres and by increasing awareness and knowledge in the population at risk.

When prodromal signs have appeared and symptoms and/or functional impairments increase (a positive gradient), it is very likely that it will come to a full-blown psychosis. When psychotic symptoms have emerged and persisted for at least one week, a schizophrenia spectrum disorder can be diagnosed and antipsychotic therapy initiated. The validation of early recognition inventories as a basis for early intervention will be a focal point of future research.

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