CLINICAL HANDBOOK OF SCHIZOPHRENIA

37. Treatment of the Schizophrenia Prodrome 381ing the onset of diagnosable psychotic disorder arises. Neurobiological changes that occuraround the time of onset of full-blown psychotic disorder might also be prevented, minimized,or reversed. Thus, the prodromal phase presents two possible targets for intervention:(1) current symptoms, behavior, or disability, and (2) prevention of further declineinto frank psychotic disorder.Aside from these two treatment aims, there are a number of other benefits of treatmentof people during the prodrome. Individuals experiencing this early phase of the disordermay engage more quickly with treatment than those who present late, when psychoticsymptoms are entrenched, social networks are more disrupted, and functioninghas further deteriorated. Additionally, the individual may be more likely to accept treatmentif full-blown psychosis does emerge compared to the individual who has been unwellfor a longer time before seeking assistance. This may be especially so given that theperson is likely already to have developed a therapeutic relationship with a treating team.Effective treatment can be provided rapidly if the person does develop psychosis, possiblyavoiding the need for hospitalization and minimizing the deleterious effect of extendeduntreated psychosis. Finally, prepsychotic intervention offers the chance to research theonset phase of psychotic illness, which may provide insight into the core features of thepsychopathology and psychobiology of psychosis.However, intervention during the prodromal phase is an approach that carries risksas well as benefits. The most salient of these is the issue of false positives, which are individualswho are identified as being at risk of developing a psychotic disorder, but who infact are not destined to develop a psychotic disorder. These individuals may be harmed bybeing labeled as being at high risk of psychosis and may receive treatment unnecessarily.Clearly, it is difficult to distinguish these patients from those identified as being at risk ofdeveloping a psychotic disorder and who would indeed have developed a psychotic disorderif some alteration in their circumstances (e.g., a treatment intervention, stress reduction,cessation of illicit drug use) had not prevented this from occurring. This latter grouphas been termed the false false-positive group. These issues highlight the retrospective natureof the concept of the psychotic prodrome: Onset of frank psychosis cannot be predictedwith certainty from any particular symptom or combination of symptoms; the factthat an individual was “prodromal” can only be asserted once frank psychosis hasemerged. Thus, the PACE Clinic introduced the term at-risk mental state (ARMS) to referto the phase prospectively identified as the possible precursor to full-blown psychosis.Given the lack of specificity of many prodromal symptoms of schizophrenia andother psychotic disorders, strategies are needed to increase the accuracy of prediction ofpsychosis from the presence of an ARMS. The PACE Clinic adopted a “close-in” strategyto identify this population, using a combination of established trait and state risk factorsfor psychosis with common phenomenology from the prodromal phase of psychotic disorders,as well as narrowing identification to the age range of highest risk (late adolescenceand early adulthood). According to PACE inclusions rules, UHR individuals mustmeet criteria for at least one of the following groups: (1) attenuated psychotic symptomsgroup, individuals who have experienced subthreshold, attenuated forms of positive psychoticsymptoms during the past year; (2) brief limited intermittent psychotic symptomsgroup, individuals who have experienced episodes of frank psychotic symptoms that havelasted no longer than a week and have spontaneously abated; or (3) trait and state riskfactor group, individuals who have a first-degree relative with a psychotic disorder, orwho have a schizotypal personality disorder in addition to a significant decrease in functioningduring the previous year. The person must be between ages 14 and 30 years, andcannot have experienced a psychotic episode for longer than 1 week or receivedneuroleptic medication prior to referral to the PACE Clinic.