CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 37TREATMENT OF THESCHIZOPHRENIA PRODROMEBARNABY NELSONALISON YUNGTHE PRODROME, PREPSYCHOTIC INTERVENTION,AND THE PERSONAL ASSESSMENTAND CRISIS EVALUATION (PACE) CLINICThis chapter outlines a treatment approach specifically designed for young people identifiedas being at imminent or “ultra high risk” (UHR) of developing a psychotic disorder—that is, as possibly being in the prodromal phase of a psychotic disorder. This approachhas been developed at the Personal Assessment and Crisis Evaluation (PACE) Clinic inMelbourne, Australia, the first clinic to provide a clinical research service for this group.From the outset, it is important to note that although the title of this chapter refersto the “schizophrenia prodrome,” the focus of discussion is on the prevention of frank orfull-blown psychotic disorder rather than on schizophrenia as a discrete illness. The firstpsychotic episode is the target, which is regarded as a more proximal and therapeuticallysalient target than schizophrenia. Schizophrenia is a subtype of psychotic disorder towhich some individuals progress after a first psychotic episode, but it is not an inevitableresult of this first episode.The possibility of treating psychotic disorders during the prodromal phase is an alluringprospect for a number of reasons. The prodromal phase is characterized by a considerablearray of psychiatric symptoms and disability, including self-harming and otherhealth-damaging behaviors. A substantial amount of the disability that develops in psychoticdisorders accumulates prior to the appearance of the full positive psychotic syndromeand may even create a ceiling for eventual recovery. In addition, recent studieshave indicated that at some point in the transition from prodromal phase to full-blownpsychotic disorder, alterations in brain structure (and presumably function) occur. If theprodrome is recognized prospectively and treatment is provided at this stage, then existingdisability may be minimized, recovery may be possible before symptoms and poorfunctioning become entrenched, and the possibility of preventing, delaying, or ameliorat-380