Can We Predict and Prevent Schizophrenia?
Fifteen-year-old Caitlin was an excellent student with many friends when she entered the ninth grade. One year later, she suddenly became restless in school, stopped paying attention to her teachers, and eventually failed all of her subjects. At home she appeared increasingly withdrawn and isolated, spending hours sleeping or watching television. The previously even-tempered adolescent became angry, anxious, and suspicious of those around her, and was occasionally seen talking to herself while making repetitive, odd hand motions. Several years later, hearing voices and insisting that the CIA was hatching an elaborate plot to murder her and her family, she was diagnosed with schizophrenia.
If Caitlin had received help at the first sign of trouble, experts believe that her descent into psychosis might have been prevented.
Researchers around the country are now attempting to identify people who are at high risk of developing schizophrenia. As reported in several studies, they are also trying to treat at-risk people with small doses of antipsychotic medication before full-blown symptoms of this devastating psychiatric disorder have emerged.
Newer Theories on Schizophrenia
There has been a major shift in our understanding of schizophrenia in recent years. It is now believed to be a neurodevelopmental, biologically based brain disease with a strong genetic component.
According to this theory, a brain lesion of some sort occurs either before birth or shortly after. The lesion lies essentially dormant until it is triggered by various environmental stressors that typically occur during late adolescence, which is the time when schizophrenia symptoms most often appear.
The Recognition and Prevention of Psychological Problems (RAPPP) clinic focuses primarily on the detection of the prodromal features (first observable behavioral changes and symptoms) that indicate the beginning stages of severe mental illness. The clinic offers a range of treatment and early intervention strategies for young patients who demonstrate the early signs of mental illness including individual, family, and group therapy; social skills and nutrition training; and low dosages of medication.
According to one doctor, specific prodromal features associated with schizophrenia include:
- Peculiar behaviors
- Impairment in personal hygiene and grooming
- Inappropriate affect (eg, laughing when talking about something sad)
- Vague, overly elaborate, or circumstantial speech
- Poverty of speech
- Odd beliefs or magical thinking
- Unusual perceptual experiences
Non-specific prodromal features that may be significant warning signs of increased risk for schizophrenia or related disorders include:
- Gradual deterioration in functioning
- Increased social withdrawal
- Difficulties in concentration
- Reduced motivation
- Depressed mood and/or anxiety
- Sleep disturbances
The Case For Early Intervention
Evidence suggests that the earlier treatment begins after the development of actual psychosis, the more rapid the immediate recovery and the better the overall outcome. As in Caitlin’s case, a long time frequently elapses between the first manifestations of psychosis (such as hallucinations and delusions) and treatment. Reducing the time to treatment for patients with psychosis should improve prognosis.
A 1996 study at the London Health Sciences Center offered cognitive, behavioral, and pharmacological treatments to young patients who had already suffered their first psychotic episodes. Most of the deterioration in schizophrenia—the cognitive, intellectual sort of deterioration—occurs within the first 2-5 years. Without early intervention, what doctors are able to achieve is relatively limited.
Another 1996 series of articles in the Schizophrenia Bulletin reported findings by researchers who gave small doses of antipsychotic medications to patients showing "at-risk mental states" in combination with psychosocial stress management strategies and education for patients and caregivers. This approach significantly reduced the number of times during which the psychotic symptoms were more exaggerated and disabling. Studies have also been done on some persons who have many of the prodromal features noted above but who have not yet developed psychosis. Some of this research is summarized in the next section.
In November 1999, several research groups engaged in identifying and treating at-risk youngsters, presented their findings to a group of medical ethicists, psychiatric researchers, and patient advocates to discuss the complex issues raised by early intervention studies.
Dr. Thomas H. McGlashan, director of an ongoing study at Yale University, is looking at the benefits of psychotropic medications in patients manifesting social withdrawal, changes in personality, deterioration of personal hygiene, decline in academic performance, and perceptual oddities (all prodromal symptoms of schizophrenia). In a double-blind study, 22 subjects between the ages of 12-45 are given either Zyprexa—an antipsychotic drug—or a placebo and monitored to see if the medication is able to short-circuit the development of full-blown psychotic symptoms.
Dr. Patrick D. McGorry of the University of Melbourne in Australia and author of The Recognition and Management of Early Psychosis , discussed his study of patients with pre-schizophrenic symptoms. One group was treated with low doses of Risperdal along with a specially designed form of psychotherapy (Group 1) and another group who had similar symptoms received psychotherapy alone (Group 2). Only 4 of 31 subjects in Group 1 developed psychosis within the six months after the drug was stopped. In Group 2, however, 10 of the 28 subjects became psychotic. This is a clinically and statistically significant difference, but due to the small number of people studied, further research is clearly warranted. As Dr. McGorry wrote in 2003, “the ultimate clinical utility and general safety of this approach and the range of effective treatments remain unclear, and will be determined by more extensive research.
Concerns About Early Intervention
The concept of predicting psychiatric disorders is still relatively new, which has led to abundant concerns about labeling people as "pre-schizophrenic" and medicating them when they are not showing definitive signs of the disorder. Clinicians worry about the possible stigmatization of people defined as "high risk," as well as the possibility that being treated as "at risk for mental illness" might drastically affect one's self-image.
Perhaps of more importance, drugs used to treat schizophrenia have many side effects, some which may prove life-threatening and/or may continue even after medications are stopped. Since there is no perfect test for early schizophrenia, inevitably some persons who would never have developed schizophrenia (in current studies, 20% of those identified as “prodromal”) will be labeled and treated.. Until better early diagnosis becomes possible and the benefits of treatment are better proven, intervention before the development of psychosis should be regarded as experimental. Some might be concerned that it represents a significant bioethical risk as well.
These concerns need to be weighed against the very real possibility that early diagnosis and intervention may be able to prevent a lifetime of crippling psychiatric disability. The fact remains, however, that many persons experience significant delays in treating newly developed psychosis. Many experts feel that rapid diagnosis and treatment of psychosis may be helpful in reducing long-term morbidity of schizophrenia and other psychotic disorders.
For schizophrenia, the prognosis is better than ever before. Treatment includes a combination of powerful medications to curb symptoms; family therapy to increase understanding; and social, behavioral, and possibly vocational training to improve functioning. About 80% of patients respond well to some combination of these interventions.
Furthermore, as we amass knowledge about the signs and symptoms of early schizophrenia and develop new strategies to attack the disorder at the very first signs of its appearance, researchers and clinicians are cautiously optimistic that the prognosis will soon improve.
Federation of Families for Children's Mental Health
National Alliance on Mental Illness
The National Mental Health Association
Canadian Psychiatric Association
Children's Mental Health Ontario
Catts SV. Early clinical intervention and prevention in schizophrenia. Acta Psychiatr Scand . 2005 Mar;111(3):253.
Doctors Try a Bold Move Against Schizophrenia. The New York Times . December 7, 1999.
Larsen TK, Friis S, Haahr U, et al. Early detection and intervention in first-episode schizophrenia: a critical review. Acta Psychiatr Scand . 2001 May;103(5):323-34.
McGlashan TH. Commentary: progress, issues, and implications of prodromal research: an inside view. Schizophr Bull . 2003;29(4):851-8.
McGlashan TH, Zipursky RB, 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. I. Study rationale and design. Schizophr Res . 2003 May 1;61(1):7-18.
Morrison AP, French P, Walford L, et al. Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial. Br J Psychiatry . 2004 Oct;185:291-7.
Yung AR, Phillips LJ, Yuen HP, et al. Psychosis prediction: 12-month follow up of a high-risk ("prodromal") group. Schizophr Res . 2003 Mar 1;60(1):21-32.
Last reviewed June 2008 by Jill D. Landis, MD
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