What if clinicians could treat schizophrenia before it became a devastating illness? Recent research reports indicate that this may become an option.
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 At home she appeared increasingly withdrawn and isolated, spending hours sleeping or watching television.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 recent 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 the symptoms of schizophrenia most often begin to appear.
Early Detection
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 (e.g., 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
Suspiciousness
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 the enrollment in 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 two to five 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.
Research Continues
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 and 45 are given either Zyprexa—an antipsychotic drug—or a placebo and will be 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. Since there is no perfect test for early schizophrenia, inevitably some persons will be treated with drugs who would never have developed schizophrenia if untreated. Until better early diagnosis becomes possible 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.
Cautious Optimism
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.
RESOURCES:
Internet Mental Health Magazine
http://www.mentalhealth.com/
Mental Health Infosource
http://www.mhsource.com
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 recent 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 the symptoms of schizophrenia most often begin to appear.
Early Detection
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 (e.g., 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
Suspiciousness
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 the enrollment in 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 two to five 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.
Research Continues
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 and 45 are given either Zyprexa—an antipsychotic drug—or a placebo and will be 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. Since there is no perfect test for early schizophrenia, inevitably some persons will be treated with drugs who would never have developed schizophrenia if untreated. Until better early diagnosis becomes possible 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.
Cautious Optimism
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.
RESOURCES:
Internet Mental Health Magazine
http://www.mentalhealth.com/
Mental Health Infosource
http://www.mhsource.com
