Academic journal article South African Journal of Psychiatry

First-Episode Psychosis: An Update

Academic journal article South African Journal of Psychiatry

First-Episode Psychosis: An Update

Article excerpt

Schizophrenia is a devastating illness for the majority of its sufferers. Despite many years of research, it remains one of the most burdensome and costly illnesses worldwide. (1) In addition to direct treatment costs, patients' families have to deal with many further burdens. During the last two decades, interest in first-episode psychosis has increased dramatically. Studying this population has not only allowed researchers to study the illness relatively free of confounders, (2) but has also renewed hope that the outcome of the illness can be positively influenced by early intervention. (3)

The clinical picture of schizophrenia is complex; factor analysis has shown it to comprise various symptom complexes or domains, each of which is clinically relevant and may require different treatment strategies. These domains include positive symptoms, negative symptoms, mood symptoms and cognitive symptoms, and it is postulated that there are specific pathophysiological processes underlying each domain. (4) These processes may be present to a greater or lesser degree from the first episode.

The prodromal phase

Most patients with schizophrenia experience a period of disturbance before the onset of florid psychotic symptoms, which has come to be called the prodromal phase. Typically, the prodrome is characterised by nonspecific mood and anxiety symptoms, negative symptoms (such as poor drive, low energy and poor interpersonal skills) and attenuated positive symptoms (e.g. hallucinations and odd thinking). (5) More often than not, there is marked deterioration in social and occupational functioning. (6) Owing to its insidious nature, however, the prodrome is commonly only identified retrospectively at the onset of psychosis. Recently, a number of researchers have tried to identify the prodrome premorbidly in young people seeking medical assistance. (7-11) Accurate identification of patients during the prodromal phase may allow opportunities for intervention before the onset of psychosis. This is important in the context of the 'critical period hypothesis', which emphasises the importance of early intervention as a means of minimising further deterioration in function, and optimising outcome. (12)

However, identification of the prodrome is not straightforward as symptoms are nonspecific, and many young people seem to experience quasi-psychotic symptoms without going on to develop schizophrenia. (5) This raises important ethical concerns regarding prodromal phase interventions. As the prodromal period at this point can only truly be identified in retrospect, we need to be cautious in identifying candidates for early intervention. The concerns raised include stigma, confidentiality and issues of autonomy. There is also a risk of committing falsely positive individuals to long-term treatment. (13) These ethical concerns have been addressed at specialised early psychosis centres. (14) However, individual clinicians must take cognisance of the ethical issues involved when dealing with people at risk for psychosis, especially since the absolute benefits of early intervention have yet to be proven in a rigorous and convincing manner. One approach to resolving this clinical dilemma is the development of diagnostic criteria for the prodromal phase. For example, the Ultra High Risk Criteria developed by McGorry's group, attempt to predict the experiencing of a true prodrome and thus the likelihood of developing a first episode of psychosis in the near future. Patients must have either (a) the presence of attenuated (subthreshold) psychotic symptoms, or (b) a history of brief self-limited psychotic symptoms, or (c) a family history of psychosis and deteriorating social function. (15) When these criteria are applied to young people seeking help, they are effective in identifying the majority of patients likely to develop a first episode of psychosis within a year. …

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