Early Detection and Intervention in the Initial Prodromal Phase of Schizophrenia

 

 Buy Article Permissions and Reprints

Attenuated and transient psychotic symptoms as well as a combination of different risk indicators and a recent significant deterioration in global functioning are currently used as a preliminary definition of the initial prodromal or at-risk mental state by the vast majority of investigators in research on early psychosis detection and intervention. Recently published results demonstrated a mean progression to frank psychosis within one year in 36.7 % of cases showing emerging symptoms, indicating that these criteria already seem to provide a satisfying assessment for risk of an imminent psychosis. However, as functional decline often sets in before this time, detection in earlier prodromal stages seems necessary. In a prospective study, certain basic cognitive and perceptive symptoms showed good to excellent predictive accuracy for schizophrenic psychosis, thus potentially offering a reasonable approach for earlier detection. Early intervention is aimed at improving prodromal symptoms, avoiding functional deterioration, and suppressing or delaying transition to psychosis. Initial study results targeting an earlier or later prodromal phase are promising, but longer follow-ups and larger samples are needed.

References

• 1 Addington D, Addington J, Patten S. Depression in people with first-episode schizophrenia.  Br J Psychiatry. 1998;  172 (Suppl. 33) 90-92
  PubMedGoogle Scholar
• 2 American Psychiatric Association ( APA). Diagnostic and statistical manual of mental disorders. 3rd revised edition DSM-III-R. Washington; APA 1987
  Google Scholar
• 3 American Psychiatric Association ( APA). Diagnostic and statistical manual of mental disorders. 4th edition DSM-IV. Washington; APA 1994
  Google Scholar
• 4 Andreasen N C, Flaum M. Schizophrenia. The characteristic symptoms.  Schizophr Bull. 1991;  17 27-49
  PubMedGoogle Scholar
• 5 Bechdolf A, Wagner M, Hambrecht M. Psychological intervention in the pre-psychotic phase: preliminary results of a multicentre trial.  Acta Psychiatr Scand. 2002;  106 (Suppl. 413) 41
  CrossrefPubMedGoogle Scholar
• 6 Birchwood M, McMillan J F. Early intervention in schizophrenia.  Aust N Z J Psychiatry. 1993;  27 374-378
  PubMedGoogle Scholar
• 7 Brown S, Birtwistle J. People with schizophrenia and their families. Fifteen-year outcome.  Br J Psychiatry. 1998;  173 139-144
  PubMedGoogle Scholar
• 8 Cornblatt B, Obuchowski M, Roberts S, Pollack S, Erlenmeyer-Kimling L. Cognitive and behavioural precursors of schizophrenia.  Dev Psychopathol. 1999;  11 487-508
  CrossrefPubMedGoogle Scholar
• 9 Cornblatt B. Early pharmacotherapeutic intervention in the prodromal phase of schizophrenia: Is this a good idea?.  J Psychotic Disord. 2000;  4 3-15
  PubMedGoogle Scholar
• 10 Craig T J, Bromet E J, Fennig S, Tanenberg-Karant M, Lavelle J, Galambos N. Is there an association between duration of untreated psychosis and 24-month clinical outcome in first-admission series.  Am J Psychiatry. 2000;  157 60-67
  PubMedGoogle Scholar
• 11 Falloon I RH. Early intervention for first episodes of schizophrenia: a preliminary exploration.  Psychiatry. 1992;  55 4-15
  PubMedGoogle Scholar
• 12 Geddes J R, Verdoux H, Takei N, Lawrie S M, Bovet P, Eagles J M, Heun R, McCreadie R G, McNeil T F, O’Callaghan E, Stober G, Willinger U, Murray R M. Schizophrenia and complications of pregnancy and labor: an individual patient data meta-analysis.  Schizophr Bull. 1999;  25 413-423
  PubMedGoogle Scholar
• 13 Gross G, Huber G, Klosterkötter J, Linz M. Bonner Skala für die Beurteilung von Basissymptomen (BSABS: Bonn Scale for the Assessment of Basic Symptoms). Berlin, Heidelberg, New York; Springer 1987
  Google Scholar
• 14 Haas G L, Garratt L S, Sweeney J A. Delay to first antipsychotic medication in schizophrenia: impact on symptomatology and clinical course of illness.  J Psychiatr Res. 1998;  32 151-159
  CrossrefPubMedGoogle Scholar
• 15 Häfner H, Maurer K, Löffler W, an der Heiden W, Könnecke R, Hambrecht M. The early course of schizophrenia. In Häfner H, editor Risk and protective factors in schizophrenia - towards a conceptual model of the disease process. Darmstadt; Steinkopff 2002: p. 207-228
  Google Scholar
• 16 Hambrecht M, Häfner H. Substance abuse and the onset of schizophrenia.  Biol Psychiatry. 1996;  39 1-9
  CrossrefPubMedGoogle Scholar
• 17 Heinssen R K, Perkins D O, Appelbaum P S, Fenton W S. Informed consent in early psychosis research: National Institute of Mental Health Workshop, November 15, 2000.  Schizophr Bull. 2001;  27 563-570
  PubMedGoogle Scholar
• 18 Helgason L. Twenty years’ follow-up of first psychiatric presentation for schizophrenia: What could have been prevented.  Acta Psychiatr Scand. 1990;  81 231-235
  CrossrefPubMedGoogle Scholar
• 19 Ho B C, Andreasen N C, Flaum M, Nopoulos P, Miller D. Untreated initial psychosis: its relation to quality of life and symptom remission in first-episode schizophrenia.  Am J Psychiatry. 2000;  157 808-815
  CrossrefPubMedGoogle Scholar
• 20 Hoff A L, Sakuma M, Razi K, Heydebrand G, Csernansky J G, DeLisi L E. Lack of association between duration of untreated illness and severity of cognitive and structural brain deficits at the first episode of schizophrenia.  Am J Psychiatry. 2000;  157 1824-1828
  CrossrefPubMedGoogle Scholar
• 21 Huber G. Psychiatrische Aspekte des Basisstörungskonzepts. In Süllwold L, Huber G, editors Schizophrene Basisstörungen. Berlin, Heidelberg, New York; Springer 1986: p. 39-143
  Google Scholar
• 22 Huber G, Gross G, Schüttler R. Schizophrenie. Verlaufs- und sozialpsychiatrische Langzeituntersuchungen an den 1945 - 1959 in Bonn hospitalisierten schizophrenen Kranken. Berlin, Heidelberg, New York; Springer 1979
  Google Scholar
• 23 Huber G. Reine Defektsyndrome und Basisstadien endogener Psychosen.  Fortschr Neurol Psychiatr. 1966;  34 409-426
  PubMedGoogle Scholar
• 24 Humphreys M S, Johnstone E C, MacMillan J F, Taylor P J. Dangerous behaviour preceding first admissions for schizophrenia.  Br J Psychiatry. 1992;  161 501-505
  PubMedGoogle Scholar
• 25 Jackson H J, McGorry P D, Dakis J, Harrigan S, Henry L, Mihalopoulos C. The inter-rater and test-retest reliabilities of prodromal symptoms in first-episode psychosis.  Aust N Z J Psychiatry. 1996;  30 498-504
  PubMedGoogle Scholar
• 26 Jackson H J, McGorry P D, McKenzie D. Prodromal symptoms of schizophrenia in first-episode psychosis. Prevalence and specificity.  Compr Psychiatry. 1994;  36 241-250
  PubMedGoogle Scholar
• 27 Jaeschko R, Guyatt G H, Sackett D L. User’s guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients?.  JAMA. 1994;  271 703-707
  CrossrefPubMedGoogle Scholar
• 28 Johnstone E C, Crow T J, Johnson A L, McMillan J F. The Northwick Park study of first episodes of schizophrenia: I. Presentation of the illness and problems relating to admission.  Br J Psychiatry. 1986;  148 115-120
  CrossrefPubMedGoogle Scholar
• 29 Johnstone E C, Macmillan J F, Frith C D, Benn D K, Crow T J. Further investigation of the predictors of outcome following first schizophrenic episodes.  Br J Psychiatry. 1990;  157 182-189
  PubMedGoogle Scholar
• 30 Klosterkötter J. Predicting the onset of schizophrenia. In Häfner H, editor. Risk and protective factors in schizophrenia - towards a conceptual model of the disease process. Darmstadt; Steinkopff 2002: p. 193-206
  Google Scholar
• 31 Klosterkötter J, Hellmich M, Steinmeyer E M, Schultze-Lutter F. Diagnosing schizophrenia in the initial prodromal phase.  Arch Gen Psychiatry. 2001;  58 158-164
  Google Scholar
• 32 Koreen A R, Siris S G, Chakos M, Alvir J, Mayerhoff D, Lieberman J. Depression in first-episode schizophrenia.  Am J Psychiatry. 1993;  150 1643-1648
  PubMedGoogle Scholar
• 33 Larsen T K, Johannessen J O, Opjordsmoen S. First-episode schizophrenia with long duration of untreated psychosis. Pathways to care.  Br J Psychiatry. 1998;  172 (Suppl 33) 45-52
  PubMedGoogle Scholar
• 34 Larsen T K, McGlashan T H, Moe L C. First-episode schizophrenia: I. Early course parameters.  Schizophr Bull. 1996;  22 241-256
  PubMedGoogle Scholar
• 35 Lieberman J A, Kinon B J, Loebel A D. Dopaminergic mechanisms in idiopathic and drug-induced psychoses.  Schizophr Bull. 1990;  16 97-110
  PubMedGoogle Scholar
• 36 Lieberman J A, Sheitman B B, Kinon B J. Endogenous neurochemical sensitization in the pathophysiology of schizophrenia deficits and dysfunction in neural regulation and plasticity.  Neuropsychopharmacology. 1997;  17 205-229
  CrossrefPubMedGoogle Scholar
• 37 Loebel A D, Lieberman J A, Alvir J M, Mayerhoff D I, Geisler S H, Szymanski S R. Duration of psychosis and outcome in first-episode schizophrenia.  Am J Psychiatry. 1992;  149 1183-1188
  PubMedGoogle Scholar
• 38 Malla A K, Norman R MG. Facing the challenges of intervening early in psychosis.  Annals RCPSC. 1999;  32 394-397
  PubMedGoogle Scholar
• 39 Malla A K, Norman R MG, Voruganti L P. Improving outcome in schizophrenia: the case for early intervention.  Can Med Assoc J. 1999;  160 843-846
  PubMedGoogle Scholar
• 40 McGlashan T H, Johannessen J O. Early detection and intervention with schizophrenia: rationale.  Schizophr Bull. 1996;  22 201 -222
  Google Scholar
• 41 McGlashan T H, Miller T J, Woods S W. Pre-onset detection and intervention research in schizophrenia psychoses: current estimates of benefit and risk.  Schizophr Bull. 2001;  27 563-570
  PubMedGoogle Scholar
• 42 McGorry P D, Edwards J. Early psychosis training pack. Victoria Mill; Gardiner-Caldwell Communications, Australia 1997
  Google Scholar
• 43 McGorry P D, Edwards J, Mihalopoulos S M. EPPIC: An evolving system of early detection and optimal management.  Schizophr Bull. 1996;  22 305-326
  Google Scholar
• 44 McGorry P D, McKenzie D, Jackson H J, Waddell F, Curry C. Can we improve the diagnostic efficiency and predictive power of prodromal symptoms for schizophrenia?.  Schizophr Res. 2000;  42 91-100
  CrossrefPubMedGoogle Scholar
• 45 McGorry P D, Yung A R, Phillips L J, Yuen H P, Francey S, Cosgrave E M, Germano D, Bravin J, Adlard S, McDonald T, Blair A, Jackson H. A randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms.  Arch Gen Psychiatry. 2002;  59 921-928
  Google Scholar
• 46 Miller T J, Zipursky R B, Perkins D. et al. The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being prodromally symptomatic for psychosis. II. Baseline characteristics of the ”prodromal” sample.  Schizophr Res. 2003;  61 19-30
  CrossrefPubMedGoogle Scholar
• 47 Morrison T, Bentall R, French P, Kilcommons A, Green J, Lewis S. Early detection and intervention for psychosis in primary care.  Acta Psychiatr Scand. 2002;  106 (Suppl. 413) 44
  CrossrefPubMedGoogle Scholar
• 48 Norman R MG, Townsend L, Malla A K. Duration of untreated psychosis and cognitive functioning in first episode patients.  Br J Psychiatry. 2001;  179 340-345
  CrossrefPubMedGoogle Scholar
• 49 Pantelis C, Velakoulis D, McGorry P D, Wood S J, Suckling J, Phillips L J, Yung A R, Bullmore E T, Brewer W, Soulsby B, Desmond P, McGuire P. Neuroanatomical abnormalities before and after onset of psychosis: a cross-sectional and longitudinal MRI comparison.  Lancet. 2003;  361 281-288
  CrossrefPubMedGoogle Scholar
• 50 Phillips L J, Yung A, McGorry P D. Identification of young people at risk of psychosis: validation of the personal assessment and crisis evaluation clinic intake criteria.  Aust N Z J Psychiatry. 2000;  34 (Suppl.) S164-S169
  PubMedGoogle Scholar
• 51 Ruhrmann S, Kühn K U, Streit M, Bottlender R, Maier W, Klosterkötter J. Pharmakologische und psychologische Frühintervention bei Risikopersonen mit psychosenahen Prodromen: erste Ergebnisse einer kontrollierten Studie.  Nervenarzt. 2002;  73 (Suppl. 1) 9
  PubMedGoogle Scholar
• 52 Schultze-Lutter F. Prediction of psychosis is necessary and possible. In McDonald C, Schulze K, Murray R, Wright P, editors Schizophrenia: challenging the orthodox. Martin Dunitz (in press)
  Google Scholar
• 53 Stirling J. et al . Expressed emotion and early onset schizophrenia: a one-year follow-up.  Psychol Med. 1991;  21 675-685
  PubMedGoogle Scholar
• 54 Stirling J, Tantam D, Thomas P, Newby D, Montague L, Ring N, Rowe S. Expressed emotion and schizophrenia: the ontogeny of EE during an 18-month follow-up.  Psychol Med. 1993;  23 771-778
  PubMedGoogle Scholar
• 55 Strakowski S M, Keck PE J r, McElroy S L, Lonczak H S, West S A. Chronology of comorbid and principal syndromes in first-episode psychosis.  Compr Psychiatry. 1995;  36 106-112
  CrossrefPubMedGoogle Scholar
• 56 Tsuang M T, Stone W S, Seidman L J, Faraone S V, Zimmet S, Wojcik J, Kelleher J P, Green A I. Treatment of nonpsychotic relatives of patients with schizophrenia: four case studies.  Biol Psychiatry. 1999;  45 1412-1418
  CrossrefPubMedGoogle Scholar
• 57 Warner R. The prevention of schizophrenia: What interventions are safe and effective.  Schizophr Bull. 2001;  27 551-562
  PubMedGoogle Scholar
• 58 Wing J K, Cooper J F, Sartorius N. Measurement and classification of psychiatric symptoms. An Introduction manual for PSE and Catego-program. London; Cambridge Press 1974
  Google Scholar
• 59 Woods S W, Miller T J, McGlashan T H. The ‘prodromal’ patient: Both, symptomatic and at risk.  CNS Spectr. 2001;  6 223-232
  PubMedGoogle Scholar
• 60 Woods S W, Breier A, Zipursky R B, Perkins D O, Addington J, Miller T J, Hawkins K A, Marquez E, Lindborg S R, Tohen M, McGlashan T H. Randomized trial of olanzapine vs placebo in the symptomatic acute treatment of the schizophrenic prodrome.  Biol Psychiatry. 2003;  (in press)
  PubMedGoogle Scholar
• 61 Wyatt R J. Neuroleptics and the natural course of schizophrenia.  Schizophr Bull. 1991;  17 325-51
  PubMedGoogle Scholar

Stephan Ruhrmann, M.D.

Department of Psychiatry and Psychotherapy

University of Cologne

Joseph-Stelzmann-Str. 9

50924 Cologne

Germany

Phone: +49 (221) 478-40 24

Fax: +49 (221) 478-55 93

Email: stephan.ruhrmann@uni-koeln.de

URL: http://www.fetz.org