I

“First
you tell ‘em what you’re gonna tell ‘em; then you tell ‘em; and then you tell
‘em what you told ‘em.” Those were my instructions as to how to deliver a
lecture when I first joined an American university faculty. Doctors Zipursky
and Schulz, editors of this book, follow the same order of presentation—first
an introduction; then the nine journal articles that contain the substance of
their argument; and then an “afterword.”

   
The very last
paragraph of the afterword concisely expresses their reason for putting this
book together:

“The studies and experiences
described in this book address a crucial stage of schizophrenia. We believe
that early recognition, an assertive therapeutic approach, and continued
integrated multidisciplinary treatment strategies are important for optimizing
the overall outcome for these young patients and their families.”

When I read this paragraph I experienced what Yogi
Berra called “Déjà vu all over again.” I went to one of my first psychiatric
texts—Noyes’ “Modern Clinical Psychiatry,” published by W.B. Saunders Company
in 1934, 1939 and 1948—and, sure enough, there it was, on page 386, the same
opinion about early recognition and treatment expressed by Zipursky and Schulz:

“The
treatment of schizophrenia, particularly in its early stages, is undertaken with
far less pessimism than formerly. Its success depends to no small degree upon the
therapeutic initiative, energy and effort of the physician, although the results
will be small if the psychotic methods of thinking and feeling have become
habits and established forms of adjustment….Gradually it is becoming
appreciated that the most desirable time to treat schizophrenia is before the
patient reaches the hospital for mental diseases.”

II

The credibility and readability of the book is enhanced by the
editors’ organization of their material. Each of the nine chapters is a
previously published journal article. All but three of the articles are
multi-authored, so there are nineteen contributors in all, two of whom are the
editors themselves. The book is broken down into three sections of three
articles each. The first section is entitled “Early Intervention, Epidemiology,
and Natural History of Schizophrenia;” the second “Management of the Early
Stages of Schizophrenia;” and the third “Neurobiological Investigations of the
Early Stages of Schizophrenia.”

I thought the international flavor of the book added to its
interest. The contributors and their research projects represent three
different countries: Australia, Canada, and the USA. The contributors are from
various disciplines, including psychiatry, psychology, social work and nursing.

III

The recommended interventions during the early stages of
schizophrenia are classified as prevention, treatment and maintenance. Research
results indicate that psychotic episodes are usually preceded by a prodromal
period of weeks, months, or even years. Intervention during this period may prevent
the development of frank psychosis. However, there are no reliable indicators
of the prodromal period, except retrospectively, after psychotic symptoms
develop. Poor global adjustment states in childhood and adolescence are
associated with earlier onset of schizophrenia, longer duration of psychotic
symptoms and poorer long-term outcome, but they are not specific diagnostic
indicators for schizophrenia. Bipolar disorders, psychotic depressive disorders
and some organic brain disorders have adjustment states similar to the
prodromal period of schizophrenia. With so many “false-positives,” identifying
schizophrenia during its early stages is fraught with diagnostic difficulties.

IV

Schizophrenia is conceptualized by the researchers as a
disorder with genetic, neurodevelopmental, and environmental factors
interacting from the very moment of conception. In order to differentiate
between prodromal schizophrenia and the variety of other severe psychiatric
disorders that overlap with early-stage schizophrenia, the researchers used a
number of different neurobiological studies, including neuropsycho-logical
impairments, structural brain MRI abnormalities, proton MRI abnormalities and
eye-tracking dysfunction. A number of structural brain abnormalities were identified
in patients with childhood schizophrenia, but none of them were consistently
found in all individuals diagnosed with childhood schizophrenia and for each
finding there was considerable overlap between patients and healthy control
subjects.

Ongoing studies demonstrate convincing evidence for “clinical
and biological continuity between the very-early-onset and adult-onset forms of
the disorder.” Researchers are encouraged that studies have “… provided insight
into a variety of risk factors and biological markers associated with the
disorder that can be detected during adolescence as well as neurodevelopmental
processes that may only be seen during adolescence in patients with
schizophrenia.”

Running through several of the chapters is a belief that
further research may reveal the specific genetic markers and deficits in
neuronal connections that have high predictive validity for the development of
schizophrenia, and that early treatment with psychosocial techniques or
psychotropic medication may reduce the cognitive dysfunction seen in
schizophrenic patients, prevent the development of frank psychosis and improve
long-term outcomes. On the other hand, there is also discussion of the
possibility that schizophrenia is a progressively worsening brain disease that
will ineluctably produce psychosis and disabling neurocognitive deficits in an
undetermined percentage of affected patients, despite the most expert
interventions.

V

Although
individual psychotherapy and family therapy are discussed in various chapters,
they are mostly regarded as compassionate interventions, intended to reduce the
suffering of patients and relatives who face the disadvantages of a chronic,
socially stigmatized disorder.

Chapter 4,
“Optimal Pharmacological Management of the First Episode of Schizophrenia,”
written by one of the editors, Dr. Zipursky, discusses treatment of
first-episode patients with various levels of “typical” antipsychotic
medications such as haloperidol and with the newer “atypical” agents—clozapine,
risperidone, olanzapine, quetiapine and ziprasidone. (aripiprazole had not yet
been introduced at the time the book was assembled.) Dr. Zipursky points out
the advantages of the atypical agents—they are better tolerated, associated
with a greater degree of compliance and carry a reduced risk of tardive
dyskinesia. However he goes on to say that most of the unpleasant side effects
of the typical agents are due to unnecessarily high dosage levels. 

In the studies
cited by Dr. Zipursky, patients had antipsychotic reponses to low doses of
haloperidol when the dopamine D2 receptors in the brain were 70% occupied, and
neuroleptic responses—EPS—when occupancy reached 80%. The “therapeutic window”
of 70% to 80% occupancy was reached with dosages as low as 2 mg/day.  Dr. Zipursky goes on to conclude that “There
is no evidence to date that treatment with any of the new atypical agents
results in substantial advantages in long-term outcome. Trials addressing this
question are under way.”

VII

All-in-all, “The Early Stages of Schizophrenia” is well worth
reading by all of us in the various mental health disciplines, whether in
hospitals, clinics or community programs. I have only touched on a few points
in this short review; I intend to keep the book in my library and consult it
frequently.

On the one hand I admire the scientific rigor of the studies
included in the book. On the other hand, when I remember the puzzles that still
obfuscate the concept of “mental disease,” 
I am reminded of Whitehead’s observations in “Adventures in ideas:”

“In the study of ideas, it is
necessary to remember that insistence on hard-headed clarity issues from
sentimental feeling, as if it were a mist, cloaking the perplexities of facts.
Insistence on clarity at all costs is based on sheer superstition as to the
mode in which human intelligence functions. 
Our reasonings grasp at straws for premises and float on gossamers for
deductions.”

 

 © 2003 Jack R. Anderson

 

Jack R. Anderson, M.D. is a retired
psychiatrist living in Lincoln, Nebraska.

Categories: MentalHealth