Sie sind auf Seite 1von 13

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

The initial prodrome in psychosis: descriptive and qualitative aspects

Alison R. Yung, Patrick D. McGorry

Objective: This study aimed to describe in detail, using a retrospective approach, the prodromal symptoms in first-episode psychosis patients. This initial prodrome, the period of disturbance preceding a first psychotic episode, is potentially important for early intervention, identification of biological markers, and understandingthe process of becoming psychotic. Method: A consecutive series of 21 first-episode patients was recruited from the Early Psychosis Prevention and Intervention Centre, a specialised service for young people aged between 16 and 30 with first-episode psychosis. Subjects were interviewed in the recovery phase after the acute episode, about the period leading up to the psychosis, using a combination of unstructured and semi-structured techniques. Results: A wide variability of phenomena and sequence patterns was found, with symptoms being a mixture of attenuated psychotic symptoms, neurotic and mood-relatedsymptoms, and behavioural changes. Symptoms were often disabling and some, such as suicidal thoughts, potentially life-threatening. Conclusions: The findings highlight the loss of information that has resulted from disregarding early phenomenological studies of the psychotic prodrome and insteadfocussing on behavioural features. The ground work has been laid for the development of better methodologies for assessingand measuring first psychotic prodromes with increased emphasis on experiential phenomena. This has the potential to lead to the early recognition and more accurate pre- diction of subsequent psychosis, as well as a deeper understanding of the neurobiology of the onset of psychotic disorder.

Australian and New Zealand Journal of Psychiatry 1996; 30587-599

In psychotic disorders, the term prodrome refers to a period of disturbance which represents a deviation from a person’s previous experience and behaviour prior to the development of florid features of psy- chosis [l]. The same term has been used by some

Centre for Young People’s Mental Health, Parkville, Victoria, Australia

Alison R. Yung MBBS, MPM, FRANZCP. Consultant Psychiatrist, and Lecturer, Department of Psychiatry. University of Melbourne

Patrick D. McGorry MBBS. PhD. MRCPWK). FRANZCP. Professor/Director, and Professor. Department of Psychiatry. University of Melbourne, and Co-Director. Early Psychosis Research Centre. Parkville

authors [2,3] to denote the pre-psychotic period pre- ceding a relapse in those patients with established psychotic illnesses. This, then, could be called a ‘relapse prodrome’ and should be distinguished from the pre-psychotic period preceding the first-ever onset of a psychotic illness, the ‘initial prodrome’. As discussed in an earlier paper [4], the initial pro- drome in psychosis may be thought of in two ways:

first, as the earliest, pre-psychotic form of a psychot- ic disorder, that is, an attenuated form of psychosis or ‘emergent psychosis’; second, it may be Seen as a syndrome which confers a heightened vulnerability to becoming psychotic, but psychosis is not

it may be Seen as a syndrome which confers a heightened vulnerability to becoming psychotic, but

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

588

THE INITIAL PRODROME IN PSYCHOSIS

inevitable. That is, it is a risk factor for psychosis. Regardless of which conceptualisation is used, iden- tification of the prodromal syndrome in an individual affords the opportunity for early intervention and prevention: either primary prevention if the second ‘at risk’ conceptualisation is used, or secondary pre- vention if the first ‘attenuated psychosis’ conceptual- isation is used. Past descriptions of this initial prodromal phase have been discussed in a previous article [4] which considered the symptoms and signs, patterns of changes and duration of this phase. What is striking to note is the richness of early phenomenological descriptions, a breadth and depth which has been lost in more recent conceptualisations of the phase. For example, DSM-111-R [5] includes a list of nine items purporting to be characteristic of the schizo- phrenic prodrome as its conceptualisation of the phase. One reason for the neglect of earlier descrip- tions of prodromal symptomatology is probably the anecdotal nature of these works. The DSM-111-R checklist of prodromal features consists of mainly behavioural items. This is an attempt to enhance reliability of measurement, but at the expense of adequately describing the full range of the phenom- ena. In fact, despite this, the reliability of measure- ment of these DSM-111-R criteria is in question [6,7]. Additionally, it is not known whether these items are sufficiently specific for schizophrenia [8]. Concerns such as these have led to this list of crite- ria being dropped from the DSM-IV [9], and the prodrome for schizophrenia has not been opera- tionalised in ICD- 10 [ 101. Another methodological issue is the distinction between premorbid personal- ity and the prodrome. This distinction can be diffi- cult to make [11.12]. The above highlights the need for further research. In particular there is a need for a system- atic study and methodologically sound data collec- tion in samples of first-episode psychosis with a focus on the prepsychotic period, with a wide and inclusive coverage of a range of symptomatology. This would lay the foundation for early recognition and more accurate prediction of subsequent psy- chosis, as well as a deeper understanding of the neu- robiology of the onset of psychotic disorder. To this end, the present study set out to describe in detail, using a retrospective approach, the prodromal period in a consecutive series of 21 patients with first-episode psychosis.

Method

Aims and hypothesis

The main aim of this study was a retrospective description of the symptoms, signs and development of changes over time in the prodromal period before the first episode of psychosis, in a series of patients presenting for the first time with a psychotic illness. The hypothesis was that initial psychotic prodromes have a wide variability of phenomena and sequence patterns. A combination of unstructured and semi-structured interviews of patients and informants was used to describe the prodrome. DSM-111-R diagnoses were independently assigned using the Royal Park Multidiagnostic Instrument for Psychosis (RPMIP:,

[13,14].

Subjects

First-episode patients were recruited from the Early Psychosis Prevention and Intervention Centre (EPPIC), a specialised service for young people aged between 16 and 30 with recent onset psychosis [ 151 The service covers the inner and western suburbs 01’ Melbourne, and has likely access to a representative sample of cases. Exclusion criteria included the fol- lowing: clear-cut organic aetiology for the psychotic symptoms; intellectual disability; and non-English language speaking. Subjects were also excluded if they were actively psychotic at the time of data col- lection: that is, they were not yet eligible to participate. Twenty-one patients presenting with a first episode of psychosis were studied. Patients were interviewed consecutively in the recovery phase of their illnesses, as soon as they were able to give a reliable history and complete a lengthy interview, as assessed by their treating doctor. This allowed as brief a duration of time as possible to have elapsed between the study and the actual prodromal period in the patients. All patients gave written informed consent. These data were collected between April and August 1993. During this 5-month period, 49 first- episode psychosis patients were referred to the EPPIC. Of these 49 patients, 28 did not participate in the study. The majority of these (n = 21) were not yet eligible. There were 5 refusers, and two were not approached owing to logistic reasons. The 21 patients included in the sample did not differ signifi-

and two were not approached owing to logistic reasons. The 21 patients included in the sample

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

A.R. YUNG. P.D. MCGORRY

589

cantly from the refusers or those not approached in demographic or diagnostic characteristics, and seemed to be a representative sample of first-episode patients presenting to the EPPIC. Patients’ relatives or friends were interviewed as informants with the patients’ permission. Informants were approached if they had been in reasonably close contact with the patient during the relevant period preceding psychosis. In one case, no suitable infor- mant was available. Hence, there are 21 patients but only 20 informants in the study.

Instrument

The

Prodroine (MAPP)

Multidimeiisioizal

Assessment

of

Psychotic

This instrument was designed by the first author specifically for this study as no existing instrument was considered to cover in detail the experiential phenomena expected in the initial prodrome, based on the literature and clinical experience. The Early Signs Scale [3] was designed to monitor prepsycho- tic changes heralding relapse in patients with previ- ously diagnosed psychotic illnesses and does not

purport to be exhaustive nor to assess first psychotic

prodromes. The RPMIP interview

[ 13,141 contains a

section which probes the 9 items of the DSM-111-R prodromal symptoms of schizophrenia, but experien-

tial phenomena are virtually absent from this list. The

English

Retrospective Assessment of the Onset of Schizophrenia (IRAOS) [ 161 was considered not to be in a useable form at the time of this study design. The MAPP is made up of two components. The first is an unstructured component beginning, for example, with ‘When were you last perfectly well?’ and ‘What changes did you first notice?’, and attempts to define the period between normal func- tioning and frank psychosis: that is, the prodrome. The respondent is then invited to describe the changes occurring in this ‘agreed period’. The second section is a semi-structured interview in which a series of domains. derived from the literature and from the clinical experience of colleagues, is sys- tematically covered. It is weighted for experiential components. This semi-structured component was used as a ‘systems review checklist’ to assess symp- toms and behaviours not necessarily covered in the unstructured interview.

the

language

version

of

Interview

for

Procedure

Patients were interviewed by the principal investi- gator with the MAPP when they had recovered from the acute effects of psychosis. Informant interviews followed. Interviews were tape recorded with the patients’ and informants’ knowledge and consent.

Data analysis

Data reported in this paper are essentially descrip- tive.

Qualitative data analysis

Patient and informant interviews were transcribed and analysed using a computer program for qualita- tive data analysis called NUDIST (Nonnumerical Unstructured Data - Indexing, Searching and Theorising) [ 171. This process consisted of generat- ing categories and key themes from the complex interview data, and collating them. The excerpts from each interview were then read and compared with the entire interview transcript for each case to ensure that they were not taken out of context, and importantly to ensure that the symptom or behaviour being studied did actually occur within the prodrome and not after the onset of psychosis. This generated a list of prodromal symptoms and behaviours including illustrative quotes from the cases. These results form the bulk of this study and are recorded in detail in the Results section.

Quarititative data analysis

All quantitative data analysis was performed using the statistical package SPSS/PC+ [ 181.

Demographic data

Twenty-one first-episode patients were studied. Seven of the 21 cases were female, 14 were male. The mean age for all cases was 23.1 years (SD = 4.19), median age was 23.0 years, and age range of the sample was 16-30 years. Diagnoses were simpli- fied into two diagnostic groupings: (i) schizophreni- form psychosis and schizophrenia were included together in one group, ‘schizophrenia-like psy-

(i) schizophreni- form psychosis and schizophrenia were included together in one group, ‘schizophrenia-like psy-

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

590

THE INITIAL PRODROME IN PSYCHOSIS

choses’ (total of 13 cases: three females, 10 males); and (ii) mania with psychotic features and major depression with psychotic features were included together as ‘affective psychoses’ (total of eight cases:

four females, four males).

Prodromal data

The patient and informant MAPP interviews formed the main part of data collection in this study. Interviews were analysed for the following themes:

estimation of duration of prodrome; symptoms and behavioural changes occurring during the prodrome; pattern and sequence of changes during the prodro- ma1 phase; and presence of precipitating events. The results for each theme will be discussed in turn.

Duration of the prodromal phase

Onset of prodrotne

Interviews were analysed for the patient and infor- mant impressions of when the first non-psychotic changes in the patient occurred. Some patients and informants were able to give reasonably precise esti- mates of when changes occurred. For example, Case 1 said she first experienced changes (feeling that she could not cope as well as before) 2 months prior to onset of psychosis. Case 19 identified feeling differ- ent since mid-May 1992. In cases in which the pro- dromes were of longer duration, estimates of the timing of first symptoms or altered behaviours tended to be more vague. For example, Case 6 described a gradual deterioration in his wellbeing and the development of physical discomfort, and he estimated that this had been occurring, with increas-

ing intensity, since the middle of 1990. Case 5 felt different (depressed) for 1 year before psychotic symptoms began.

Of-set of prodrome

This was defined as the first experience or appear- ance of frank psychotic symptoms such as hallucina- tions or delusions. Patients tended to be more precise in dating this change than they were at dating the onset of first noticeable non-psychotic symptoms. They were also more precise than the informants at dating the start of the psychosis, and almost invari- ably dated the onset of psychosis as earlier than did informants. For example, Case 6 described a sudden realisation associated with a sense of relief, that his parents were poisoning him, on 8 January 1993. Similarly, Case 1 vividly remembered the exact time of her first hallucinatory experience. Case 19 described intense persecutory fears and hallucina- tions since January 1993, but her parents were com- pletely taken by surprise when she accused the neighbours of plotting against her in March 1993. Duration data were calculated according to what seemed to be the most accurate information in each case. This was usually carried out using patient infor- mation. Table 1 demonstrates these data for the whole sample and according to diagnostic grouping and gender. Of note is the finding that a prodrome was described in all cases. The shortest duration was of 3 days (0.43 weeks), the longest of over 6 years (317.6 weeks). As shown in Table I, the mean duration of pro- drome gives a longer estimate than the median in patient, informant and consensus groups, and the

Table 1. Duration ofpradrorne for all cmes and according to diagnostic group and gender

Consensus duration of prodromal period (weeks)

Median

Mean

SD

Range

All cases (n = 21)

27.3

62.9

90.5

0.43 -

317.6

Schizophrenia and schizophreniform (n = 13)

52.1

89.9

106.5

0.57 - 317.6

Affective disorders (n = 8)

14.6

18.9

19.5

0.43 - 61.1

Females (n = 7)

8.6

14.2

13.8

0.43 - 35.1

Males (n = 14)

56.6

87.2

102.9

3.4 - 317.6

Females (n = 7) 8.6 14.2 13.8 0.43 - 35.1 Males (n = 14) 56.6 87.2

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

A.R. YUNG, P.D. MCGORRY

59 1

Table 2. Prodromal svnzptoiiis and sigris in the sample

~

Symptoms and signs found in

All cases (n = 21)

 

the prodrome

n

%

‘Neurotic’ symptoms

Physical symptoms

Anxiety

18

85.7

Somatic complaints

10

47.6

Anger, irritability

18

85.7

Loss of weight

12

57.1

Obsessive compulsive features

4

19.0

Poor appetite, not eating

10

47.6

Mood-related symptoms

Sleep disturbance

21

100

Depressed mood

16

76.2

Speech abnormalities

12

57.1

Guilt

8

38.1

Perceptual abnormalities

13

61.9

Suicidal ideas

5

23.8

Change in sense of self, others or

13

61.9

Dissatisfaction

2

9.5

the world

Loss of control, feeling powerless

3

14.3

Suspiciousness

15

71.9

Mood swings

9

42.9

Change in motility

13

61.9

Elevated mood Changes in volition

5

23.8

Change in affect Behavioural changes

1

4.8

Apathy, loss of drive

14

66.7

Deterioration in role functioning

16

76.2

Fatigue, loss of energy

13

61.9

Social withdrawal

15

71.9

Increased energy

8

38.1

Impulsivity, disinhibition

5

23.8

Sognitive changes

Odd behaviour

2

9.5

Disturbance of attention, inability

15

71.4

Aggressive, disruptive behaviour

10

47.6

to concentrate, memory problems

Doing nothing

12

57.1

Preoccupation, daydreaming

9

42.9

Increased activities

5

23.8

Thought blocking

5

23.8

Self-harm

3

14.3

Indecisiveness

4

19.0

Self-neglect

7

33.3

Racing thoughts

6

28.6

Increase in substance use

4

19.0

standard deviations are high. The means are affected by outliers, such as those with very long durations of prodrome. The median may. therefore, be a better estimate of ‘usual duration’ of prodrome. The con- sensus figure is 27.3 weeks. or about 6.5 months for all cases. Patients in the schizophrenia-like group tended to have longer prodromes than those in the affective group, with a median figure of 52.1 weeks

(about

Gust over 12 months)

3.5 months) for the affective psychoses. There were more outliers in the schizophrenic group compared to the affective group. Females tended to have shorter prodromes than males, although this may be a result

of the relatively few females with schizophrenia in the sample compared to the males.

compared to 14.6 weeks

Prodromal symptoms and signs

Forty-one different symptoms and changes in behaviour were described by either patients, infor- mants or both as occurring during the prodromal period. These are shown according to type of phe- nomena in Table 2, and in order of frequency in Table

3. Table 3 also breaks down the data according to diagnostic grouping and gender. Some of these symptoms and signs are considered in more detail below.

Classical rieitrotic symptoms

Arzxiety Anxiety was a frequently occurring symptom in the prodrome, found in 18 of the 2 1 cases, and was often described as the first noticeable change by both patients and informants. Some patients described anxiety secondary to other prepsychotic symptoms. For example, Case 3 was frightened about her sense that ‘something was happening’.

Obsessive-conzpulsive pheriomeria Obsessive- compulsive phenomena were described in four cases, all of which had schizophrenia. For example, Case 4 began to think the house was dirty and began repeat- edly showering. Case 12 developed the feeling that she was dirty all the time which led to excessive washing. These phenomena were described as occur- ring late in the prodrome. just before frank psychosis.

excessive washing. These phenomena were described a s occur- ring late in the prodrome. just before

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

592

THE INITIAL PRODROME IN PSYCHOSIS

Table 3. Symptoms and signs occurring during the prodromal period in order of frequency

Patient & informant data (n = 21)

 

n

Yo

Sleep disturbance

21

100

Anxiety

18

85.7

Angedirritability

18

85.7

Depressed mood

16

76.2

Deterioration in role functioning

16

76.2

Social withdrawal

15

71.4

Poor concentration

15

71.4

Suspiciousness Loss of drivel

15

71.4

motivation

14

66.7

Perplexity

14

66.7

Low energy/fatigue

13

61.9

Motor changes

13

61.9

Change in sense of self/ otherdthe world

13

61.9

Perceptual changes

13

61.9

Doing nothing Abnormalities in

12

57.1

speech production

12

57.1

Weight loss

12

57.1

Poor appetitehot eating

10

47.6

Somatic complaints

10

47.6

Preoccupation

10

47.6

Aggressive behaviour

10

47.6

Mood swings

9

42.9

Guilt

8

38.1

Increased energy

8

38.1

Self neglect

7

33.3

Racing thoughts

6

28.6

Elevated mood

5

23.8

Increased activities

5

23.8

Suicidal thoughts

5

23.8

Thought blocking

5

23.8

Impulsivity/disinhibition

5

23.8

Indecisiveness Obsessive-compulsive

4

19.0

phenomena Increase in substance

4

19.0

use

4

19.0

Self-harm

3

14.3

Loss of control/ powerlessness

3

14.3

Dissatisfaction

2

9.5

Odd behaviour

2

9.5

Change in affect Decrease in substance

1

4.8

use

1

4.8

All cases

 

By diagnosis

 

By gender

 

Patient

informant

Schizo-

Female

Male

data (n = 21)

data (n = 20)

phrenia & schizo- phreniform psychosis (n = 13)

Affective psychosis (n = 8)

(n = 7)

(n = 14)

n

Y'

n

Yo

n%

n

YO

n

Yo

n%

18

85.7

14

70.0

13 100

8

100

7

100

14 100

17

81.0

14

70.0

12

92.3

6

75.0

6

85.7

12

85.7

15

71.4

13

65.0

12

92.3

6

75.0

6

85.7

12

85.7

15

71.4

13

65.0

11

84.6

5

62.5

4

57.1

12

85.7

13

61.9

14

70.0

10

76.9

6

75.0

4

57.1

12

85.7

14

66.7

13

65.0

12

92.3

3

37.5

3

42.9

12

85.7

14

66.7

9

45.0

11

84.6

4

50.0

5

71.4

10

71.4

10

47.6

9

45.0

12

92.3

3

37.5

4

57.1

11

78.6

12

57.1

8

40.0

11

84.6

3

37.5

4

57.1

10

71.4

14

66.7

5

25.0

9

69.2

5

62.5

5

71.4

9

64.3

10

47.6

7

35.0

10

76.9

3

37.5

4

57.1

9

64.3

11

52.4

8

40.0

8

61.5

5

62.5

4

57.1

9

64.3

13

61.9

3

15.0

6

46.2

7

87.5

3

42.9

10

71.4

12

57.1

3

15.0

7

53.9

6

75.0

6

85.7

7

50.0

8

38.1

11

55.0

11

84.6

1

12.5

1

14.3

11

78.6

9

42.9

8

40.0

7

53.9

5

62.5

4

57.1

8

57.1

10

47.6

9

45.0

7

53.8

5

62.5

3

42.9

9

64.3

9

42.9

7

35.0

7

53.8

3

37.5

3

42.9

7

50.0

9

42.9

5

25.0

7

53.8

3

37.5

4

57.1

6

42.9

9

42.9

4

20.0

7

53.8

3

37.5

4

57.1

6

42.9

4

19.0

8

40.0

7

53.8

3

37.5

1

14.3

9

64.3

3

14.3

6

30.0

7

53.8

2

25.0

2

28.6

7

50.0

8

38.1

4

20.0

4

30.8

4

50.0

2

28.6

6

42.9

8

38.1

4

20.0

2

15.4

6

75.0

3

42.9

5

35.7

6

28.6

4

20.0

5

38.5

2

25.0

1

14.3

6

42.9

6

28.6

1

5.0

3

23.1

3

37.5

4

57.1

2

14.3

5

23.8

4

20.0

0

0.0

5

62.5

3

42.9

2

14.3

3

14.3

3

15.0

0

0.0

5

62.5

2

28.6

3

21.4

5

23.8

1

5.0

4

30.8

1

12.5

0

0.0

5

35.7

4

19.0

1

5.0

4

30.8

1

12.5

2

28.6

3

21.4

4

19.0

3

15.0

0

0.0

5

62.5

2

28.6

3

21.4

3

14.3

1

5.0

4

30.8

0

0.0

3

42.9

1

7.1

2

9.5

2

10.0

4

30.8

0

0.0

1

14.3

3

21.4

4

19.0

4

20.0

4

30.8

0

0.0

0

0.0

4

28.6

2

9.5

1

5.0

3

23.1

0

0.0

0

0.0

3

21.4

3

14.3

0

0.0

2

15.4

1

12.5

0

0.0

3

21.4

2

9.5

1

5.0

1

7.7

1

12.5

0

0.0

2

14.3

2

9.5

2

10.0

2

15.4

0

0.0

0

0.0

2

14.3

0

0.0

1

5.0

1

7.7

0

0.0

0

0.0

1

7.1

1

4.8

1

5.0

1

7.7

0

0.0

0

0.0

1

7.1

1 7.7 0 0.0 0 0.0 1 7.1 1 4.8 1 5.0 1 7.7 0 0.0

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

A.R. YUNG, P.D. MCGORRY

593

Mood related symptoms

Depressed mood Depressed mood was reported in the prodromal period in 16 of the 21 cases. In some cases patients andor informants attributed to the lowered mood some cause or meaning, for example, explaining it as a reaction to stress. It is of course unclear how much such attribution is an ‘effort after meaning’. In other cases. there was no apparent reason for the depression identified. Depressed mood was also described by patients as occurring secon- darily, in response to other experiences, particularly predelusional feelings of a change in the sense of self, others and the world.

Suicidal thoughts Five patients described having thoughts of suicide in the prodrome. For example, Case 7 described this after he failed Year 10 at school, and later, when psychotic, made two unsuc- cessful suicide attempts.

Physical symptoms

Ten patients in this study described having physical symptoms in the prodrome. Some examples include Case 4, who stated that he ‘just didn’t feel well’ and felt ‘physically sick in the stomach’ 4 months prior to becoming psychotic. For over 2 years before becom- ing psychotic Case 6 described aches and pains, malaise and gastric discomfort. He explained: ‘I was

I also had some problems with my

digestion. I was hungry all the time. I didn’t get any satisfaction from anything. I would get a stomach upset every time. (Food) would just give me some stomach aches and bloating and whatever.’ He also described increased sensitivity to the cold. His phys- ical discomfort progressed, and he recalled: ‘It got to the point in ’91/92 when I said to myself, “I have got to lie down, lie through this heat and not eat at all”.’ His mother described him as ‘weak’ and she remem- bered that he had complained that his ‘stomach was not all right’. In addition, several patients, along with their infor- mants, described reduced appetite, poor food intake and weight loss during the prodrome. Sleep disturbance was found in all 21 cases. Ten had decreased sleep, five had altered sleep patterns with a change to sleeping during the day and being awake at night, and the remaining six had hyper- somnia.

always tired

Cognitive changes

Poor concentration, distractibilty and memory distur- bance were found in 15 of the cases studied, indeci- siveness was described in four cases and preoccupation

in 10. Another cognitive

was found in five cases in this sample. Case 5 described this phenomenon: ‘It was just like it was my head went blank - like there was an empty space in the head. It was black’. At another time he made the analogy: ‘It was like I had been hit in the head with a

sledge hammer. I felt like I was numb in the head’. He described this trouble thinking as causing him difficul- ties in trying to communicate with others. Case 16 described brief periods of thinking nothing, and he discussed how this made it difficult to understand what others were trying to say to him:

I don’t know. Just

sometimes I didn’t know what they were talking

I was

about. I thought I didn’t hear or something

not really thinking about anything. Just daydream- ing’. These episodes lasted for a couple of minutes,

he would then wonder what people had been talking about. This worried him ‘because I couldn’t think straight. I knew something was going on’.

symptom, thought blocking,

‘I thought I was missing pieces

Perceptual clianges

Changes in perception during the prodrome were described in 13 patients in this study. These did not include frank hallucinations, which indicate actual psychosis, rather than prodrome. This alteration in perception was generally described by patients but not informants. For example, Case 3 thought that her husband’s laugh sounded different: ‘He was just

laughing really peculiar

The laugh just didn’t

seem the same to me. It was actually coming out in a funny way. It sounded really weird. It was like someone else laughing. A different laugh altogether’. She also noticed a reduction in her sense of smell, and described the sensation of feeling that time had slowed down. Case 10 described altered perception 2 weeks before his psychotic episode: ‘It seemed like everyone I was talking to was crying. They had tears in their eyes’. He also noted increased intensity of perceptions:

‘Everything was heightened, sound, the birds. It was really acute. I could feel where the world was Colours were amazing! I remember looking at a cap- sicum, and the colour, the red - it was just like blood!

was Colours were amazing! I remember looking at a cap- sicum, and the colour, the red

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

594

THE INITIAL PRODROME IN PSYCHOSIS

I had

this thing about smell. I was starting to pick all the flowers and smelling them. The smell was fantastic’. In contrast, Case 14 recalled a reduction in intensity of

And red wine, everything was really sensual

perceptions. He said that about 2 years before his psy- chosis ‘Things quietened down. Things actually got

quiet

about lost them somewhere along the line’.

everything’, and ‘My taste buds, I think I just

Change in sense of se& others and the world

Changes of this nature were described by 13 patients, but only three informants. Case 3 felt ‘very tense, frightened, worried that something was going to happen. Something weird was happening’ 1 month before her psychosis. Case 7 described himself as ‘different’ and ‘not himself’. He thought that other people and things around him had changed also: I sort of thought everything just started changing. The shopkeeper that I go to, she was serious with me, her hair colour was different, everything was just chang-

ing. Nothing was the same to me any more

were acting different. Not looked different. They were acting different’. His parents recalled: ‘He was

saying that “I am different and I don’t know what to do in the future”’.

They

PerplexiQ

A sense of confusion, perplexity, and bewilderment was described by 14 patients, and noted by three of their informants. This was generally a late phenome- non, occumng just prior to frank psychotic changes, and usually accompanied the feeling of a change in

sense of self, others or the world. For example, Case 14 found himself thinking about things more. He described

All sorts of things.

Everything! The way everything works, the way people work, even transport, nature, everything! Just too many topics all piled in on one. Without answers. And you become mumble jumbled in your brain’. Case 18 said, ‘I didn’t know what was going on’,

and Case 5 described feeling ‘Like

nothing makes

sense, so you are just looking for something that

‘working it all out in my head

patients had increased motor activity, such as moving faster and pacing. Others described moving more slowly during the prodrome, and some noticed diffi- culties with motor coordination. Some examples include Case 18, who thought he was moving differ- ently as he felt stiff in the limbs. Ifelt all tied up’, he said. He felt the need to pace to loosen his limbs. His father noted that he paced a lot about the house, and also recalled that he was moving slowly and awk- wardly, hunched over ‘like an old man about seventy or eighty years old’. Case 5 remembered: ‘I couldn’t drive a car! Normally I could drive a car all right, but when I tried to drive I felt like I lost my coordination’. His sister noticed that he was moving ‘lamely’. Case 7 also noticed problems with his coordina- tion, for example, he described his experience at

I was very

uncoordinated and everyone was just looking at me when I was playing soccer. I was dribbling the ball and not playing as well as I used to’. In two cases there were more complex motor changes. Case 11 thought his movements became

‘more gentle and delicate’ during the prodrome. His wife described echopraxia in him. She recalled: ‘He said he wanted to move like me. He wanted to breathe when I did and so on. He said he was doing the same things as me’. Case 1.5 described prominent indecisiveness and ambivalence and this was also manifested at a motor level: I was moving from one

soccer: ‘I was very different at soccer

way to another

I was twisting my body around. I

know half of me wanted to help Sally (her sister) and the other half didn’t’. Her mother noticed that her movements and gestures resembled those of her sick

sister: ‘I know it sounds weird, but she was acting a

lot like Sally

just

mannerism, conversation’.

Beliavioiiral changes

Social withdrawal This was found in 1.5 of the cases. Various different reasons were given by the patients to explain this common behaviour. Five of the patients said that they became withdrawn during the prodrome due to depression. As Case 17

makes sense

I had no idea what was going on’.

explained: ‘because I get depressed at times and I just

Motor changes

don’t feel like seeing anybody’. Two cases described social withdrawal secondary to irritability. As Case 6

explained: ‘I was just very irascible

In that kind of

Thirteen patients in this study had some form of altered motor function, varying in nature. Several

mood it’s hard to go and share company with other people’. Other cases described social isolation sec-

nature. Several mood it’s hard to go and share company with other people’. Other cases described

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

A.R. YUNG. P.D. MCGORRY

595

ondary to other feelings and experiences, such as social anxiety. In only three of the cases the patients were unable to explain why they had become with- drawn during the prodromal phase.

Deterioratiori in role fiiiictioriirig This was described in 16 of the patients, and again the reasons given for this varied from case to case. Case 2 was frequently irritable during the prodrome and recalled arguments with his boss and being late for work. Case 3, a housewife and mother of two, deteriorated in her ability to perform the housework and look after the children and attributed this to loss of interest in those things. Case 6 developed increasing fatigue and vague physical symptoms which resulted in him feeling unable to attend many lectures at University. and then his deferment from his course. Case 11 explained how initially he felt happy and ‘had lost the meaning of time’ and this resulted in him not worrying if he took longer to complete his tasks at work.

Sirbstarice use Thirteen of the 21 patients used sub- stances, either illicit drugs, alcohol or both. Four of these described increased use in the prodromal period, and stated that this was for relaxation and to reduce anxiety. In contrast, Case 18 abstained from cannabis in the 6 months prior to psychosis. No reason for this cessation was given. Both the patient and his father thought that this abstinence might have been responsible for the prodromal symptoms and eventual psychosis.

Pattern and sequence of changes

Nineteen of the 21 cases described classical neu- rotic-type symptoms, such as anxiety or depression, as occurring first with the gradual development of more marked deviations from normal following. For example, Case 5 described 1 year of increasing depressive symptoms for no apparent reason, fol- lowed by the onset of intrusive memories of an argu- ment that he had with his girlfriend, and then a vague feeling of change in himself, others and the world. In contrast, two cases (Case 9 and Case 15) described symptoms suggestive of emergent psychosis as occurring primarily, and neurotic symptoms and behavioural changes occurring as reactions to these unusual phenomena. Case 15 first noted perceptual changes, such as experiencing a fluctuating intensity

of sound and changes in her experience of time. These experiences made her feel frightened, reluctant to go out and puzzled. Case 9 became preoccupied with his appearance early in the course of his pro- drome. and began to think that he may be different from others. This led to social withdrawal and deteri- oration in his school performance. I didn’t like the way I looked, so I just withdrew’, he said.

Presence of precipitants

In 11 cases specific events were identified as being ‘triggers’ or the causes of changes in the patients. Such precipitants were identified by both patients and infor- mants. For example, both Case 12 and her mother identified her retrenchment from her job (through factory closure) as the precipitating factor for non-spe- cific changes. including depressed mood and poor motivation, in her. Case 7 dated changes in himself from the time he was told he had failed Year 10.

Discussion

An accurate description of the changes which occur during the period of time preceding a first- episode of psychosis, the psychotic prodrome. is increasingly being recognised as important, both clinically and for research. For example, early inter- vention strategies in the management of psychosis have received worldwide attention recently [3,19-211. The identification of prepsychotic and early psychotic changes also opens the door for research into the aetiologies and development of psy- choses and into the effect of early biopsychosocial interventions in their management [3.19-241. Recognising the importance of the prodromal period, and acknowledging the relatively little research that has been carried out in the area, this study set out to take the first step in exploring the issues: that of detailed description of the phenomenology and development of the prodrome.

Methodological issues

The saniple

The size of the sample in this study was 21 patients. This was large enough to allow meaningful qualitative and quantitative analysis of the data and to assess diversity of symptoms, signs and durations

meaningful qualitative and quantitative analysis of the data and to assess diversity of symptoms, signs and

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

596

THE INITIAL PRODROME IN PSYCHOSIS

across different diagnostic groupings. It was small enough to enable a detailed qualitative analysis to be carried out. A larger sample would have been too cumbersome to handle using the qualitative research techniques performed in this study. However, the limited sample size of 21 patients makes generalis- ability of the findings an issue. The demographic characteristics of the sample were described previ- ously. These can be compared with data available for

a consecutive series of first presentation patients

aged between 16 and 30 for the whole of the EPPIC collected over 2 years. The same diagnostic instru- ment, the RPMIP, was used. This large sample con- sisted of 154 cases. The mean age, age range and gender distribution were roughly the same in the two samples. There were some small differences in the distribution of diagnoses, as the study sample includ- ed no patients with schizoaffective disorder com- pared with 10.5% of the patients in the larger sample, but overall, the patients in this study seemed to be a reasonably representative sample of cases presenting to the EPPIC. Based on the expected incidence of psychosis in the community, it has been estimated that this larger sample is a reasonably representative sample of first-episode psychosis patients from the program’s catchment area.

Results

Duration of initial prodrome

All patients in this study had a prodrome. A com- parison with other studies which specifically exam- ined prodrome duration shows agreement with the finding that the first prodrome is highly variable in

length [ 1,Z-271. In this study, the range

to over 6 years. Beiser et al. [I] described range from

zero (i.e. no prodrome at all) to 20 years. The median finding in this study of 27.3 weeks for the whole sample was much shorter than Beiser’s finding of 37.9 weeks [I]. This may be a result of Beiser et al. excluding certain groups from their study, particular- ly those patients in whom a shorter duration of pro- drome may be expected, such as schizophreniform psychosis, brief reactive psychosis and bipolar depression. Beiser et al.’s finding in the schizophre- nia group was a median prodrome duration of 52.7 weeks, which is similar to this study’s finding of 52.1 weeks in the same group. In the Loebel ef al. study [25] the mean duration of prodrome for the sample

was 3 days

was 98.5 weeks. No median figure was given. In this study, all patients had either schizophrenia (77%) or schizoaffective disorder (23%) with other psychotic disorders excluded, thus the duration of prodrome would be expected to be longer than that found in this study. Additionally, Loebel’s mean figure may have been affected by outliers with very long durations.

Prodromnl symptom and signs

A wide variability and diversity of prodromal fea- tures were found in the sample. Sleep disturbance was universal. Anxiety, irritability, depressed mood, impaired role functioning, social withdrawal, poor concentration, suspiciousness and lack of motivation were all common, occurring in over two-thirds of the cases studied. Low energy, motor changes, perceptu- al disturbances, change in sense of self, others or the world, puzzlement, loss of interests, abnormalities in speech, and weight loss all occurred in over one-half of the sample. Poor appetite, other physical symp- toms, aggressive behaviour, mood swings, preoccu- pation, guilt, and increased energy occurred in over one-third, and self neglect was found in one-third of the cases. Blocking phenomena (thought block), described by Chapman [28] as an important early phenomenon in schizophrenia, occurred in 23.8% of the sample. Overall, the extent of prepsychotic phe- nomena found in this sample demonstrates that the prodromal period is likely to be associated with a high level of disability. The presence of suicidal thoughts (in 23.8%) and self harm (in 14.3%) in the prodromal period is also impor- tant to highlight. This indicates that in addition to psy- chosis itself being a risk factor for suicide, the prepsychotic period is also a time of increased risk. Other self-destructive behaviours, such as increased use of substances ( 19.0%) and aggressive behaviour (47.6%), are also noteworthy. This underlines the importance of early intervention in psychotic disorders, and ideally, intervention in the prepsychotic phase to reduce risk of suicide. self-harm and disability. When diagnostic groupings were compared. certain features seemed to show some specificity for mania. For instance, increased energy was present in the pro- dromes of 75% of the affective population, all of whom had mania rather than depression, compared with 15.4% of the schizophrenia-like group. Other fea- tures following this trend were elevated mood, increased activity and disinhibition. This is consistent

group. Other fea- tures following this trend were elevated mood, increased activity and disinhibition. This is

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

A.R. YUNG, P.D. MCGORRY

591

with the clinical impression that psychotic mania is preceded by hypomania. Notably, racing thoughts were not particularly more common in the affective group compared with the schizophrenia-like group. Features found more commonly in the schizophre- nia-like group compared with the affective group were poor concentration. suspiciousness, lack of motivation, low energy and loss of interests. Indecisiveness, obsessive-compulsive phenomena, increased use of substances, and forensic behaviour were all found in four patients from the schizophre- nia-like group, but none of the affective group patients. Self-harm was found in three of the schizo- phrenia-like group, but in none of the affective group. In general. findings from this study agreed with pre- vious literature on prodromal features in schizophre- nia [2.22,24,26-351 which has been reviewed recently [4]. In addition, the symptoms of increased energy. increased activities and racing thoughts, although mainly found in the affective group, were not specific for this group as they were also found in the schizophrenia-like group. These symptoms were not previously described in schizophrenic prodromes. Another major finding was that patients are often a rich source of information, providing details of pro- dromal changes that are not accessible if informant information alone is relied upon. For instance, per- ceptual changes were commonly described by patients as occurring in the prodrome. detailed by 12 out of the 21 patients, yet only three informants noted them. The predelusional experience of altered sense of self. others and the world, discussed in the litera- ture [29.30,33], is described by 13 patients but noted by only three informants. Patients as a source of information are not only relatively neglected by existing criteria. but often by clinicians as well. At the time of the patient‘s admission to hospital with acute psychosis. information is sought from relatives and other informants about the changes leading up to admission. There is a tendency then, especially in busy acute psychiatric units, to treat the patients and discharge them without ever reconstructing the patients’ experience of becoming psychotic. Another factor to highlight which emerged from this study was that behaviours are usually only rough indi- cators of a patient’s mental state. Behaviours such as poor role functioning or social withdrawal, aggression and forensic behaviour form the final common path- ways of a number of psychopathological experiences. Anxiety, fear, irritability and suspiciousness were

among the subjective experiences that patients gave as causes of the behaviour ‘social withdrawal’. Depressed mood, imtdbihty, poor concentration and fatigue were all cited by patients as causes of deterioration of role functioning. Frankly psychotic experiences can also result in these behaviours, for example, persecutory delusions and auditory hallucinations causing social withdrawal. Hence, relying on behaviours as an indica- tor of prodrome may not be a valid method of measur- ing prodrome unless some weight and attention is given to the patient’s subjective experiences and the role they have in generating such behaviours. It is important to know what symptoms and experiences underlie apparently prodromal behaviours. The issue of premorbid personality, while not direct- ly measured in this study, was addressed in the inter- views of patients and informants who were asked to describe what the individual was like normally (before the psychotic episode) and to track the development of changes. In two cases, informants described the patients as always having had some problems, but in both cases a clear change was noted prior to the onset of psychosis indicating the presence of a prodrome.

Patteni aiid seqireiice of chaiiges in the prodlniiie

This study found that the majority of patients (19 out of 2 1) first experienced non-specific neurotic symptoms, then gradually developed more marked deviations from normal, and then experienced psy- chosis. Two patients, however, seemed to follow that pattern described by Chapman 1281 in first experi- encing unusual symptoms such as a feeling of change in sense of self or perceptual distortion, developing symptoms as reactions to this, such as anxiety or social withdrawal, and then becoming psychotic. Many of the patients described reactive symptoms, such as feeling depressed, anxious or confused about the changes that were taking place in them. Hence, prodromal features consist of a mixture of the fol- lowing: (i) attenuated psychotic symptoms, such as perceptual changes and suspiciousness; (ii) non-spe- cific neurotic and mood-related symptoms, some of which are reactions to other symptoms: and (iii) behavioural changes, which are frequently in response to other experiential phenomena, both neu- rotic and attenuated psychotic symptoms. Thus, the prodromal phase, like psychosis itself, is a complex and dynamic period, with individuals responding to their own changing internal worlds as well as react-

is a complex and dynamic period, with individuals responding to their own changing internal worlds as

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

598

THE INITIAL PRODROME IN PSYCHOSIS

ing to those around them. Feedback loops exist as well, for example, with the family responding to the individual’s altered behaviour in certain ways, which in turn affects the individual and so on. A model for understanding these complex interactions can be hypothesised which we have called the hybridlinter- active model of the prepsychotic phase, described in a previous paper [4]. Figure 1 illustrates this model for conceptualising the prodrome. In this hybridhnteractive model, people are seen as being able to move in and out of symptomatic periods, both of the non-specific type and the attenu- ated psychosis type. Both types of symptoms may precede psychosis, and either may occur primarily. Symptoms are also due to the person’s reaction to his or her experiences or to others.

Presence of precipitants

The issue of ‘effort after meaning’ [36-381 becomes important when considering the presence of precipitat- ing events in the sample. This refers to the situation when patients and families look for an event which seemed to start all the changes, and date their histories from that point. This may not always be how things actually evolved. As this was a retrospective study it was a difficult issue to clarify, and a prospective approach would be needed to examine the issue.

Conclusion

This paper has reported on the findings of the qual- itative part of a retrospective study into the initial prodromes of a series of patients with first episode psychosis. Twenty-one patients and their informants were interviewed using unstructured and semi-struc- tured interview techniques. Using this method, rich descriptions of prodromal phenomena and sequence of events were gained, along with estimations of the duration of these changes in each case. The descrip- tive data agree with earlier ‘lost’ characterisations of schizophrenic prodromes recorded in the literature and reviewed elsewhere [4]. This highlights the loss of information that has resulted from disregarding these studies, as has been done with the DSM-111-R conceptualisation of schizophrenic prodrome, which instead focuses on behavioural features. This strate- gy is part of a more general trend which aims to increase reliability as a priority, at the cost of reduced validity [394 I 1.

Reactive symptoms

and

behavioural changes

Figure 1. The hvbridhiteractive nioclel of prodrornal chariges

In addition this study examined prodromal features of affective disorders and found phenomena consis- tent with attenuated forms of the affective psychoses, such as hypomanic features preceding mania. A range of other features were also found in these affective prodromes. including neurotic symptoms. motor changes, perceptual disturbances and change in sense of self, others or the world. Through detailed description of prodromal fea- tures, this study has demonstrated the need and laid a foundation for the development of better methodolo- gies for assessing and measuring first psychotic pro- dromes. In particular, more emphasis is needed on experiential phenomena. Given the diversity of pro- dromal features found, perhaps there is also a corre- sponding need to re-examine relapse prodromes in the same light.

References

I.

Beiser M, Erickson D, Fleming JA, Iacono WG. Establishing the onset of psychotic illness. American Journal of Psychiatry 1993; 150:1349-1354.

2.

Herz MI, Melville C. Relapse in schizophrenia. American Journal of Psychiatry 1980; 137:801-805.

3.

Birchwood M. Smith J, Macmillan F et ol. Predicting relapse in schizophrenia: the development and implementa- tion of an early signs monitoring system using patients and families as observers: a preliminary investigation. Psychological Medicine 1989; 19:649-656.

4.

Yung AR, McGorry PD. The prodromal phase of first episode psychosis: past and current conceptualisations. Schizophrenia Bulletin 1996; 22:353-370.

5.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed., revised. Washington, DC: American Psychiatric Association. 1987.

and statistical manual of mental disorders. 3rd ed., revised. Washington, DC: American Psychiatric Association. 1987.

by 182.182.50.137 on 12/29/12

For informahealthcare.com

personal use only.

Aust NZ J Psychiatry Downloaded from

A.R. YUNG. P.D. MCCORRY

599

6. Jackson HJ. McCorry PD. Dakis J, Harrigan S, Henry L. Mihalopoulos C. The inter-rater and test-retest reliabilities of prodromal symptoms in first-episode psychosis. Australian and New Zealand Journal of Psychiatry 1996:

30:498-504.

7. Jackson HJ. McGorry PD, McKenrie D. The reliability of DSM-111 prodromal symptoms in first episode psychotic patients. Acta Psychiatrica Scandinavica 1994: 90:375-378.

8. Jackson HJ, McGorry PD, Dudgeon P. Prodromal symptoms of schizophrenia in first episode psychosis: prevalence and specificity. Comprehensive Psychiatry 1995; 36:241-250.

9.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington. DC:

American Psychiatric Association. 1994.

10.

World Health Organization. Manual of the international classification of diseases. injuries and causes of death. 10th

ed

revised. Geneva: World Health Organization, 1994.

II.

Jones PB, Behbington P. Foerstcr A et nl. Premorbid social underachievement in schizophrenia. Results from the Camberwell COkIbordtiVe Psychosis Study. British Journal of Psychiatry 1993; 16265-7 1.

12.

Foerster A. Lewis S. Owen M, Murray R. Pre-morbid adjustment and personality in psychosis. Effects of sex and diagnosis. British Journal of Psychiatry 1991; 158:171-176.

13.

McGorry PD. Singh BS, Copolov DL. Royal Park multi- diagnostic instrument for psychosis: Part I: rationale and review. Schizophrenia Bulletin 1990; 16:SOl-5 15.

14.

McGorry PD. Singh BS, Copolov DL. Royal Park multi- diagnostic instrument for psychosis: Part 11: development. reliability and validity. Schizophrenia Bulletin 1990;

16:s17-536.

15.

McGorry PD. Early Psychosis Prevention and Intervention Centre. Australasian Psychiatry 1993; 1:32-34.

16.

Hafner H. Riecher RA, Hambrecht M ef NI. IRAOS: an instrument for the assessment of onset and early course of schizophrenia. Schizophrenia Research 1992: 6:209-223.

17.

Richards T, Richards L, McGalliard J. Sharrock B. NUDIST 2.3 reference manual. Bundoora: Replee, 1993.

18.

Statistical Package for Social Sciences lcomputer program]. SPSS/PC+ advanced statistics 4.0. Chicago: SPSS. 1990.

19.

Birchwood M. Early intervention in schizophrenia: theoreti- cal background and clinical strategies. British Journal of Clinical Psychology 1992: 3 I :257-378.

20.

Falloon IRH. Early intervention for first episodes of schizo- phrenia: a preliminary exploration. Psychiatry 1992; 55:4-15.

21.

Birchwood M, Macmillan F. Early intervention in schizo- phrenia. Australian and New Zealand Journal of Psychiatry 1993: 27:374-378.

33

--.

Heinrichs DW. Carpenter WT. Prospective study of prodro- ma1 symptoms in schizophrenic relapse. American Journal of Psychiatry 1985: 142:371-373

23.

MacMillan F, Birchwood M. Smith J. Predicting and con- trolling relapse in schizophrenia: early signs monitoring. In:

Kavanagh DJ, ed. Schizophrenia: an overview and practical handbook. London: Chapman and Hall, I993:293-308.

34.

Subotnik KL, Nuechterlein KH. Prodromal signs and symp- toms of schizophrenic relapse. Journal of Abnormal

Psychology

1988: 97:405312.

25.

Loebel AD. Lieberman JA. Alvir JM, Maycrhoff DI, Ceisler SH. Szymanski SR. Duration of psychosis and outcome in first-episode schizophrenia. American Journal of Psychiatry

1992; 149:1183-1188.

26.

Cameron DE. Early schizophrenia. American Journal of Psychiatry 1938: 95567-578.

37.

Varsamis J. Adamson JD. Early schizophrenia. Canadian Psychiatric Association Journal 197I : 16:487397.

28.

Chapman J. The early symptoms of schizophrenia. British Journal of Psychiatry 1966; I12:225-25 1.

29.

Bowers M. The onset of psychosis: a diary account. Psychiatry 1965: 28:346-358.

30.

Bowera MB. Freedman DX. 'Psychedelic' experiences in acute psychoses. Archives of General Psychiatry 1966:

15 :340-248.

31.

Meares A. The diagnosis of prepsychotic schizophrenia. Lancet 1959: i:55-59.

31.

Pious WL. A hypothesis about the nature of schirophrenic behaviour. In: Burton A. ed. Psychotherapy of the psy- choses. New York: Basic Books. 1961.

33.

Stein WJ. The sense of becoming psychotic. Psychiatry 1967: 30:262-275.

34.

Donlon PT. Blacker KH. Stages of schizophrenic decom- pensation and reintegration. Journal of Nervous and Mental Disease 1973: 157:200b209.

35.

Docherty JP, Van Kainmen DP. Siris SG. Marder SR. Stages of onset of schizophrenic psychosis. American Journal of Psychiatry 1978: 135:420426.

36.

Henderson AS. An introduction to social psychiatry. Oxford:

Oxford University Press, 1988:69-106.

37.

Hirsch S, Cramer P, Bowen J. The triggering hypothesis of the role of life events in schizophrenia. British Journal of Psychiatry 1992; 161(Suppl. 18):8&87.

38.

Tennant CC. Stress and schizophrenia. Integrative Psychiatry 1985: 3:248-261.

39.

McGorry PD, Copolov DL, Singh BS. The validity of the assessment of psychopathology in the psychoses, Australian and New Zealand Journal of Psychiatry 1989: 23:469482.

40. Kendell RE. Clinical validity. Psychological Medicine 1989;

19:45-55.

41. Carey G, Gottesman 11. Reliability and validity in binary ratings: areas of common misunderstanding in diagnosis and symptom ratings. Archives of General Psychiatry 1978:

35: 1454-1459.

areas of common misunderstanding in diagnosis and symptom ratings. Archives of General Psychiatry 1978: 35: 1454-1459.