The Prepsychotic Phase Of Illness Conceptual Issues

The rise of the early psychosis paradigm has enabled the prepsychotic phase of schizophrenia and related psychoses to come strongly into focus for the first time. Reacting to the pessimism intrinsic to the concept of schizophrenia and also to the damage wrought by a disorder for which effective treatments were lacking, an earlier generation of psychiatrists were attracted to the notion of prepsychotic intervention [16,17]. What remained a dream for decades is now starting to become a reality. This section describes principles and progress in the prospective detection, engagement and treatment of young people with incipient psychosis.

With the advent of widespread first-episode programmes, it has become possible to detect and engage a subset of young people who are subthreshold for fully fledged psychotic disorder, yet who have demonstrable clinical needs and other syndromal diagnoses, and who appear to be at incipient risk of frank psychosis [18,19].

The prepsychotic or prodromal phase needs to be clearly distinguished from the premorbid phase on the one hand and the first episode of psychosis on the other. To understand the potential advantages of pre-psychotic intervention, it is important to explicate the concept of prodrome, a term which has only recently been widely used in schizophrenia. The period prior to clear-cut diagnosis has traditionally been referred to as the premorbid phase. However, this term has led to some confusion, because it actually covers two phases, not one, and has not been useful from a preventive perspective. Studies of the childhood antecedents of schizophrenia, while demonstrating significant but minor differences between controls and those who later developed schizophrenia, paradoxically highlighted the quiescence of the illness during this phase of life [20]. However, these studies and the findings of Hafner and colleagues [21] revealed that psychotic illnesses really begin to have clinical and social consequences after puberty, typically during adolescence and early adult life. The period of emergence of nonspecific symptoms and growing functional impairment prior to the full emergence of the more diagnosti-cally specific positive psychotic symptoms constitutes the prodromal phase.

Table 2.2 Potential advantages of prepsychotic intervention

• An avenue for help is provided, irrespective of whether transition ultimately occurs, to tackle the serious problems of social withdrawal, impaired functioning and subjective distress that otherwise become entrenched and steadily worsen prior to the onset of frank psychotic symptoms.

• Engagement and trust are easier to develop and lay a foundation for later therapeutic interventions, especially drug therapy if and when required. The family can be similarly engaged and provided with emotional support and information outside of a highly charged crisis situation.

• If psychosis develops, it can be detected rapidly and duration of untreated psychosis minimized, and hospitalization and other lifestyle disruption rarely occur. A crisis with behavioural disturbance or self-harm is not required to gain access to treatment.

• Comorbidity, such as depression and substance abuse, can be effectively treated and the patient therefore gets immediate benefits. If psychosis worsens to the point of transition, the patient enters first episode in better shape with less distress and fewer additional problems.

• The prospective study of the transition process is enabled, including neurobiological, psychopathological and environmental aspects. Patients are less impaired cognitively and emotionally, and are more likely to be fully competent to give informed consent for such research endeavours.

The fact that a very substantial amount of the disability that develops in schizophrenia accumulates prior to the appearance of the full positive psychotic syndrome and may create a ceiling for eventual recovery in young people is a key reason for attempting some form of prepsychotic intervention (Table 2.2). Other benefits include the capacity to research the onset phase of illness and examine the psychobiology of progression from the subthreshold state to fully fledged disorder. More proximal risk factors such as substance use, stress, and the underlying neurobiology can also be uniquely studied. The delineation of this discrete phase, the boundaries of which are often difficult to map precisely, is of great heuristic and practical value. Whether prodrome is the best term for it is, however, a matter for debate [10,18,22]. A number of obstacles to intervention during this phase should also be noted (Table 2.3).

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BiPolar Explained

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