Book Review
Schizophrenia
The Early Stages of Schizophrenia. Robert B Zipursky, S Charles Schulz, editors. Washington (DC): American Psychiatric Publishing Inc; 2002. 259 p. US$43.00.
Reviewer
rating*: Good
Review by Mary V Seeman MD
Toronto, Ontario
The initial stages of schizophrenia are relevant to the researcher and
to the clinician. They present an opportunity to study the patient early
in the process of developing the disorder, prior to the cumulative sequelae
of distress, alienation, social deterioration, stigma, and the potentially
toxic effects on the brain of untreated psychosis on one hand and antipsychotic
drugs on the other. In the clinic, a person not yet acculturated to the
role of invalid, and not yet disillusioned with the mental health system,
is able to form strong therapeutic alliances—fertile ground for effective
treatment.
This brief and very attractive book by international experts is superbly
edited and serves its several purposes well: to understand the concept
of schizophrenia prodromes; to understand the effect of chronological age
on the manifestation of early signs of psychosis; to differentiate early-stage
psychosis from the reaction to psychosis of an immature brain; to consider
the pros and cons of early intervention with psychological and pharmacologic
treatments; and to appreciate that very low dosages of antipsychotic drugs
work effectively at the early stage, but to know also that not everyone
responds and that relapse rates are high.
From the reader’s point of view—whether researcher, clinician, patient,
or family member—this book would have been more valuable if written by
a single person: a consistent voice is missing. The preeminent dilemma—how
best to treat someone with an at-risk-for-psychosis syndrome—is left unanswered
because different authors have tried different approaches and speak only
about their own experience. All agree that treatment staves off psychosis
and that it is better to treat than to wait and see, if only to alleviate
the considerable distress such early-stage patients experience. Low-dose
antipsychotics appear to be the favourite pharmacologic treatment, yet
safety concerns are barely mentioned, perhaps because they were not considered
important at the time of writing. Several authors comment on the safety
of the newer compounds, but the Zipursky chapter rightly points to the
weight gain and lipid and glucose dysregulation that make chronic use of
these compounds risky—and yet, the high relapse rates make anything but
chronic use unrealistic, despite faint suggestions in the book that intervening
early is akin to stopping schizophrenia in its tracks.
A sole author would have been better able to clarify this important point.
In illnesses like prostatic cancer, taking out the tumour early, before
it has permeated the capsule, means you have prevented the spread and stopped
the disease. However, this concept does not apply to schizophrenia. Intervening
early in schizophrenia is important for alleviating distress, for delaying
behaviour associated with more serious signs of psychosis, for establishing
a good therapeutic alliance, and for engaging the family. It does not prevent
the unfolding of this illness, because we do not yet know what makes it
unfold.
Many early-stage psychoses are prodromes to illnesses other than schizophrenia,
and clinicians would probably have welcomed a discussion of trials of lithium
and lamotrigine (mentioned by Kumra and others), of stress reduction, of
prevention of insomnia and substance abuse, and of the various psychotherapeutic
techniques referred to by McGorry and others as alternatives to the use
of antipsychotics. It is of course impossible to write about trials not
yet done, but expanding the theoretical horizons for both researchers and
clinicians would have been useful.
Forty years ago, early-stage psychotic prodromes were also sometimes treated
with electroconvulsive therapy (ECT), and sometimes with low-dose antipsychotics.
Haloperidol 0.5 mg twice daily was the standard dosage. Patients recovered
and were sent home with a diagnosis of “identity development disorder”
or “brink of a nervous breakdown.” It was considered very bad form to use
the word “schizophrenia,” because of its negative connotations. Not labelling
the person was, in itself, thought to be prevention; the toxic process
being prevented was not what was going on in patients’ brains but what
went on in their social network once they were stigmatized by this diagnosis.
Labelled or not, however, most patients returned with ever more serious
symptoms, and psychiatrists began to feel responsible for not having issued
a warning, for not having insisted that medications be continued.
We have gained much more knowledge since then, but our therapies are not
much improved. Early intervention, though potentially important in itself,
has a yet more important potential: it is an entry into a psychoeducational
program which ensures that treatment, once started, is not stopped and
that patients with early schizophrenia—not unlike patients with early diabetes—learn
to modify their lives, take control of their own health, establish their
own goals, and continue treatment forever. The researcher’s job is to make
that treatment safer than it currently is.
This is a very well written, error-free book. It is an excellent resource
on a topic of great current interest. I look forward to the next installment
when more is known in the area. Next time, I hope it’s a one-author book.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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