Academic journal article Hong Kong Journal of Psychiatry

Conceptual Problems of Early Intervention in Schizophrenia

Academic journal article Hong Kong Journal of Psychiatry

Conceptual Problems of Early Intervention in Schizophrenia

Article excerpt

ABSTRACT

An increasing interest in early detection and treatment of schizophrenic psychoses has been emerging. Extending treatment initiatives to earlier 'disease stages' creates both diagnostic and ethical problems with current nosological concepts. In this paper, philosophically-informed conceptual analysis is used to clarify the issue. The philosophical grammar of 'premorbid symptoms of schizophrenia' is examined. The basic conceptual problem concerning the early intervention approach is that the activity has to draw on locally acceptable criteria of morbidity, even though the rationale for this activity is dependent on a generally acceptable conception of psychiatric morbidity. Consequently, 'premorbid symptoms' is not an ordinary psychiatric concept and has only limited use in ordinary clinical transactions. Preventive work has to heed these limits to ensure its legitimacy. It has been shown that in the absence of valid diagnostic criteria for prodromal symptomatology, the justification of early intervention programmes in schizophrenic psychoses lies in the professional characteristics of psychiatric institutions.

Keywords: Conceptual Analysis; Early Intervention; Prodromal Symptom; Schizophrenia

INTRODUCTION

There has been a significant upsurge in clinical research programmes focussing on early detection of and intervention in schizophrenic psychoses (McGlashan, 1996a). These programmes have been targeted towards both shortening the length of untreated psychosis and towards preventing psychotic episodes altogether (Vaglum, 1996). The following is a discussion of some of the conceptual problems relating to detection and treatment of schizophrenic patients in the 'prodromal phase', before the emergence of openly psychotic symptomatology.

THE RATIONALE OF EARLY INTERVENTION

It has long been known that, in retrospect, acute schizophrenic psychoses are usually preceded by long-standing psychiatric symptom formation. According to Hafner et al. (1992, 1997), 75% of first episode schizophrenic patients manifested the so-called prodromal symptoms of schizophrenia for a period averaging four years before the onset of the psychotic symptoms. The existence of the long prodromal period has given impetus to establishing preventive treatment strategies (Falloon, 1992; Yung et al., 1996a), with the hope of improving long-term prognosis, treatment compliance, and possibly preventing psychotic episodes altogether. Also, the demonstrated utility of prodromal symptoms in preventing psychotic relapses has created expectations for a similar development in primary prevention (Birchwood & Macmillan, 1993).

Nevertheless, there are serious problems with this endeavour, not only the clinical ones of utility or feasibility of such intervention programmes, but also theoretical ones, related to the disease concepts involved. Three conceptually distinct groups of problems emerge from current discussions on the topic in psychiatric journals:

(1) recognising prodromal schizophrenic morbidity (Falloon, 1992; Birchwood et al., 1997)

(2) identifying a valid concept of schizophrenia (Hafner, 1989; Hafner et al., 1992)

(3) dealing ethically and appropriately with 'at-risk mental states' (Yung et al., 1996a; Birchwood et al., 1997).

IS DIAGNOSING PRODROMES THE MAIN ISSUE?

When Falloon (1992) questions how to find reliable methods of distinguishing schizophrenic development, the problem of recognition is interpreted as an empirical difficulty. The same rationale is present in discussions about the risk of identifying 'false positives' (McGlashan & Johannessen, 1996b; Yung, 1996a) with the early intervention approach--thus implicitly assuming that the status of 'true positives' is not at issue.

The most widespread instrument for assessing prodromal symptoms has been the Diagnostic and Statistical Manual of Mental Disorders- (DSM-) III-R criteria (APA,1987). …

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