Initial Prodrome in Psychosis

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The in i t ial prodro m e in p sych osis: descr ipt iveand qu alitative aspectsAlison R. Y ung, Patrick D. McGorry

Objective: This study aimed to describe in detail, using a retrospectiveapproach, the prodromal symptoms in first-episode psychosis patients. Thisinitial prodrome, the period of disturbance preceding a first psychotic episode,is potentially important for early intervention, identification of biologicalmarkers, and understanding the process of becoming psychotic.Method: A consecutive series of 21 first-episode patients was recruited fromthe Early Psychosis Prevention and Intervention Centre, a specialised servicefor young people aged between 16 and 30 with first-episode psychosis.Subjects were interviewed in the recovery phase after the acute episode, aboutthe period leading up to the psychosis, using a combination of unstructuredand semi-structured techniques.Results: A wide variability of phenomena and sequence patterns was found,with symptoms being a mixture of attenuated psychotic symptoms, neuroticand mood-related symptoms, and behavioural changes. Symptoms were oftendisabling and some, such as suicidal thoughts, potentially life-threatening.Conclusions: The findings highlight the loss of information that has resultedfrom disregarding early phenomenological studies of the psychotic prodromeand instead focussing on behavioural features. The ground work has been laidfor the development of better methodologies for assessing and measuring firstpsychotic 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 theneurobiology of the onset of psychotic disorder.Australian and New Zealand J ournal of Psychiatry1996; 30587-599

In psychotic disorders, the term prodrome refers toa period of disturbance which represents a deviationfrom a persons previous experience and behaviourprior to the development of florid features of psy-chosis [l]. The same term has been used by someCentre for Y oung Peoples M ental Health, Parkville, Victoria,Australia

Alison R. Yung M BBS, M PM , FRA NZCP. Consultant Psychiatrist,and Lecturer, Department of Psychiatry. University of Melbourne

authors [2,3] to denote the pre-psychotic period pre-ceding a relapse in those patients with establishedpsychotic illnesses. This, then, could be called arelapse prodrome and should be distinguished fromthe pre-psychotic period preceding the first-everonsetof a psychotic i llness, 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 formof psychosis or

Patrick D. McGorry MBBS. PhD. M RCPWK ). FRAN ZCP. emergent psychosis; second, it may be Seen as aCentre. Parkville to becoming psychotic, but psychosis is notProfessor/Director, and Professor. Department of Psychiatry.University of Melbourne, and Co-Director. Early Psychosis Research syndrome which confers a heightened vulnerability

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58 8 THE INITIAL PRODROME IN PSY CHOSIS

inevitable. That is, it is a risk factor for psychosis.Regardless of which conceptualisation is used, iden-tification of the prodromal syndrome in an individualaffords the opportunity for early intervention andprevention: either primary prevention if the secondat risk conceptualisation is used, or secondary pre-vention if the first attenuated psychosis conceptual-isation is used.Past descriptions of this initial prodromal phasehave been discussed in a previous article [4]whichconsidered the symptoms and signs, patterns ofchanges and duration of this phase. What is strikingto note is the richness of early phenomenologicaldescriptions, a breadth and depth which has beenlost in more recent conceptualisations of the phase.For example, DSM-111-R [ 5 ] includes a list of nineitems purporting to be characteristic of the schizo-phrenic prodrome as its conceptualisation of thephase. One reason for the neglect of earlier descrip-tions of prodromal symptomatology is probably theanecdotal nature of these works. T he DSM-111-Rchecklist of prodromal features consists of mainlybehavioural items. This is an attempt to enhancereliability of measurement, but at the expense ofadequately describing the full range of the phenom-ena. In fact, despite this, the reliabili ty of measure-ment of these DSM-111-R cri teria is in question[6,7]. Additionally, it is not known whether theseitems are sufficiently specific for schizophrenia [8].Concerns such as these have led to this list of crite-ria being dropped from the DSM-I V [9], and theprodrome for schizophrenia has not been opera-tionalised in ICD-10 [101.Another methodologicalissue is the distinction between premorbid personal-ity and the prodrome. This distinction can be diff i-cult to make [11.12].The above highlights the need for furtherresearch. In particular there is a need for a system-atic study and methodologically sound data collec-tion in samples of first-episode psychosis with afocus on the prepsychotic period, with a wide andinclusive coverage of a range of symptomatology.This would lay the foundation for early recognitionand more accurate prediction of subsequent psy-chosis, as well as a deeper understanding of the neu-robiology of the onset of psychotic disorder. To thisend, the present study set out to describe in detail,using a retrospective approach, the prodromalperiod in a consecutive series of 21 patients withfi rst-episode psychosis.

MethodAims and hypothesis

The main aim of this study was a retrospectivedescription of the symptoms, signs and developmentof changes over time in the prodromal period beforethe first episode of psychosis, in a series of patientspresenting for the first time with a psychotic illness.The hypothesis was that initial psychotic prodromeshave a wide variability of phenomena and sequencepatterns.A combination of unstructured and semi-structuredinterviews of patients and informants was used todescribe the prodrome. DSM-111-R diagnoses wereindependently assigned using the Royal ParkMultidiagnostic Instrument for Psychosis (RPM IP:,[13,14].Subjects

First-episode patients were recruited from the EarlyPsychosis Prevention and Intervention Centre(EPPIC), aspecialised service for young people agedbetween 16and 30 with recent onset psychosis [151The service covers the inner and western suburbs 01Melbourne, and has likely access to a representativesample of cases. Exclusion criteria included the fol-lowing: clear-cut organic aetiology for the psychoticsymptoms; intellectual disability; and non-Englishlanguage speaking. Subjects were also excluded ifthey were actively psychotic at the time of data col-lection: that is, they were not yet eligible toparticipate.Twenty-one patients presenting with a first episodeof psychosis were studied. Patients were interviewedconsecutively in the recovery phase of their illnesses,as soon as they were able to give a reliable historyand complete a lengthy interview, as assessed bytheir treating doctor. This allowed as brief a durationof time as possible to have elapsed between the studyand the actual prodromal period in the patients. Allpatients gave written informed consent.These data were collected between April andAugust 1993. During this 5-month period, 49 first-episode psychosis patients were referred to theEPPIC. Of these49patients, 28did not participate inthe study. The majority of these (n =21) were not yeteligible. There were 5 refusers, and two were notapproached owing to logistic reasons. The 21patients included in the sample did not differ signifi-

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A.R. YUNG. P.D. MCGORRY 589

cantly from the refusers or those not approached indemographic or diagnostic characteristics, andseemed to be a representative sample of fi rst-episodepatients presenting to the EPPIC.Patients relatives or friends were interviewed asinformants with the patients permission. Informantswere approached if they had been in reasonably closecontact with the patient during the relevant periodpreceding psychosis. In one case, no suitable infor-mant was available. Hence, there are 21 patients butonly 20 informants in the study.

ProcedurePatients were interviewed by the principal investi-gator with the MA PP when they had recovered fromthe acute effects of psychosis. Informant interviewsfollowed. Interviews were tape recorded with thepatients and informants knowledge and consent.

Data analysisData reported in this paper are essentially descrip-tive.Instrument Qualitative data analysisThe Multidimeiisioizal Assessment of PsychoticProdroine (MAPP)

This instrument was designed by the fi rst authorspecifically for this study as no existing instrumentwas considered to cover in detail the experientialphenomena expected in the initial prodrome, basedon the literature and clinical experience. The EarlySigns Scale [3] was designed to monitor prepsycho-tic changes heralding relapse in patients with previ-ously diagnosed psychotic i llnesses and does notpurport to be exhaustive nor to assess first psychoticprodromes. T he RPM IP interview [13,141 contains asection which probes the 9 items of the DSM-111-Rprodromal symptoms of schizophrenia, but experien-tial phenomena are virtually absent from this list. TheEnglish language version of Interview for theRetrospective Assessment of the Onset ofSchizophrenia (IRAOS) [161 was considered not tobe in a useable form at the time of this study design.

The M A PP is made up of two components. Thefirst is an unstructured component beginning, forexample, with When were you last perfectly well?and What changes did you first notice?, andattempts to define the period between normal func-tioning and frank psychosis: that is, the prodrome.The respondent is then invited to describe thechanges occurring in this agreed period. Thesecond section is a semi-structured interview inwhich a series of domains. derived from the literatureand from the clinical experience of colleagues, is sys-tematically covered. It is weighted for experientialcomponents. This semi-structured component wasused as a systems review checklist to assess symp-toms and behaviours not necessarily covered in theunstructured interview.

Patient and informant interviews were transcribedand analysed using a computer program for qualita-tive data analysis called NUDIST (NonnumericalUnstructured Data - Indexing, Searching andTheorising) [171. This process consisted of generat-ing categories and key themes from the complexinterview data, and collating them. The excerpts fromeach interview were then read and compared with theentire interview transcript for each case to ensure thatthey were not taken out of context, and importantlyto ensure that the symptom or behaviour beingstudied did actually occur within the prodrome andnot after the onset of psychosis. This generated a listof prodromal symptoms and behaviours includingillustrative quotes from the cases. These results formthe bulk of this study and are recorded in detail in theResults section.Quarititative data analysis

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

Demographic dataTwenty-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 23.0years, 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 includedtogether in one group, schizophrenia-like psy-

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590 THE INITIAL PRODROME IN PSY CHOSIS

choses (total of 13 cases: three females, 10 males);and (ii) mania with psychotic features and majordepression with psychotic features were includedtogether as affective psychoses (total of eight cases:four females, four males).Prodromal data

The patient and informant MAPP interviewsformed the main part of data collection in this study.Interviews were analysed for the fol lowing themes:estimation of duration of prodrome; symptoms andbehavioural changes occurring during the prodrome;pattern and sequence of changes during the prodro-ma1 phase; and presence of precipitating events. Theresults for each theme will be discussed in turn.Duration of the prodromal phaseOnset of prodrotne

Interviews were analysed for the patient and infor-mant impressions of when the first non-psychoticchanges in the patient occurred. Some patients andinformants were able to give reasonably precise esti-mates of when changes occurred. For example, Case1 said she first experienced changes (feeling that shecould not cope as well as before) 2 months prior toonset of psychosis. Case 19 identified feeling differ-ent since mid-M ay 1992. In cases in which the pro-dromes were of longer duration, estimates of thetiming of first symptoms or altered behaviourstended to be more vague. For example, Case 6described a gradual deterioration in his wellbeingand the development of physical discomfort, and heestimated that this had been occurring, with increas-

ing intensity, since the middle of 1990. Case 5 feltdifferent (depressed) for 1 year before psychoticsymptoms began.Of- set of prodrome

This was defined as the first experience or appear-ance of frank psychotic symptoms such ashallucina-tions or delusions. Patients tended to be more precisein dating this change than they were at dating theonset of first noticeable non-psychotic symptoms.They were also more precise than the informants atdating the start of the psychosis, and almost invari-ably dated the onset of psychosis as earlier than didinformants. For example, Case6described a suddenrealisation associated with a sense of relief, that hisparents were poisoning him, on 8 J anuary 1993.Similarly, Case 1 vividly remembered the exact timeof her first hallucinatory experience. Case 19described intense persecutory fears and hallucina-tions since January 1993, but her parents were com-pletely taken by surprise when she accused theneighbours of plotting against her in March 1993.Duration data were calculated according to whatseemed to be the most accurate information in eachcase. This was usually carried out using patient infor-mation. Table 1 demonstrates these data for thewhole sample and according to diagnostic groupingand gender.Of note is the finding that a prodrome wasdescribed in all cases. The shortest duration was of 3days (0.43 weeks), the longest of over 6years (317.6weeks).As shown in Table I , the mean duration of pro-drome gives a longer estimate than the median inpatient, informant and consensus groups, and the

Table 1. Duration ofpradrorne for all cmes and according todiagnostic group and genderConsensus duration of prodr omal per iod (weeks)Median Mean SD Range

All cases (n =21) 27.3Schizophrenia andschizophreniform (n =13) 52.1Affective disorders (n =8) 14.6Females (n =7) 8.6Males (n =14) 56.6

62.989.918.914.287.2

90.5 0.43- 317.6106.5 0.57 -317.619.5 0.43- 61.113.8 0.43- 35.1102.9 3.4- 317.6

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A.R. YUNG, P.D. MCGORRY 591

Table 2. Prodromal svnzptoiiis and sigris in the sampleSymptoms and s igns found inthe prodrom eNeurotic symptomsAnxietyAnger, irritabilityObsessive compulsive featuresMood-related symptomsDepressed moodGuiltSuicidal ideasDissatisfactionLoss of control, feeling powerlessMood swingsElevated moodChanges in volitionApathy, loss of driveFatigue, loss of energyIncreased energy

Disturbance of attention, inabilityto concentrate, memory problemsPreoccupation, daydreamingThought blockingIndecisivenessRacing thoughts

Sognitive changes

A ll cases (n =21 )n18184

16852395

14138

159546

%

85.785.719.076.238.123.89.5

14.342.923.866.761.938.171.442.923.819.028.6

Physical symptomsSomatic complaintsLoss of weightPoor appetite, not eatingSleep disturbanceSpeech abnormalitiesPerceptual abnormalitiesChange in sense of self, others orthe worldSuspiciousnessChange in motilityChange in affectBehavioural changesDeterioration in role functioningSocial withdrawalImpulsivity, disinhibitionOdd behaviourAggressive, disruptive behaviourDoing nothingIncreased activitiesSelf-harmSelf-neglectIncrease in substance use

~

1012102112131315131

161552

10125374

47.657.147.657.161.961.971.961.94.8

76.271.923.89.5

47.657.123.814.333.319.0

100

standard deviations are high. The means are affectedby outliers, such as those with very long durations ofprodrome. The median may. therefore, be a betterestimate of usual duration of prodrome. The con-sensus figure is 27.3 weeks. or about 6.5 months forall cases. Patients in the schizophrenia-like grouptended to have longer prodromes than those in theaffective group, with a median figure of 52.1 weeksGust over 12 months) compared to 14.6 weeks (about3.5 months) for the affective psychoses. There weremore outliers in the schizophrenic group compared tothe affective group. Females tended to have shorterprodromes than males, although this may be a resultof the relatively few females with schizophrenia inthe sample compared to the males.Prodromal symptoms and signs

Forty-one di fferent symptoms and changes inbehaviour were described by either patients, infor-mants or both as occurring during the prodromalperiod. 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 todiagnostic grouping and gender. Some of thesesymptoms and signs are considered in more detailbelow.Classical rieitrotic symptomsArzxiety A nxiety was a frequently occurringsymptom in the prodrome, found in 18 of the 21cases,and was often described asthe first noticeable changeby both patients and informants. Some patientsdescribed anxiety secondary to other prepsychoticsymptoms. For example, Case 3was frightened abouther sense that something was happening.Obsessive-conzpulsive pheriomeria Obsessive-compulsive phenomena were described in four cases,all of which had schizophrenia. For example, Case4began to think the house was dirty and began repeat-edly showering. Case 12 developed the feeling thatshe was dirty all the time which led to excessivewashing. These phenomena were described asoccur-ring late in the prodrome. just before frank psychosis.

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592 THE INITIAL PRODROME IN PSYCHOSIS

Table 3.Symptoms and signs occurring during the prodromal period in orderoffrequency

Sleep disturbanceAnxietyAngedirritabilityDepressed moodDeterioration in rolefunctioningSocial withdrawalPoor concentrationSuspiciousnessLoss of drivelmotivationPerplexityLow energy/fatigueMotor changesChange in sense of self/otherdthe worldPerceptual changesDoing nothingAbnormalities inspeech productionWeight lossPoor appetitehot eatingSomatic complaintsPreoccupationAggressive behaviourMood swingsGuiltIncreased energySelf neglectRacing thoughtsElevated moodIncreased activitiesSuicidal thoughtsThought blockingImpulsivity/disinhibitionIndecisivenessObsessive-compulsivephenomenaIncrease in substanceuseSelf-harmLoss of control/powerlessnessDissatisfactionOdd behaviourChange in affectDecrease in substanceuse

Patient &informantdata (n =21 )

n Yo21 10018 85.718 85.716 76.216 76.215 71.415 71.415 71.414 66.714 66.713 61.913 61.913 61.913 61.912 57.112 57.112 57.110 47.610 47.610 47.610 47.69 42.98 38.18 38.17 33.36 28.65 23.85 23.85 23.85 23.85 23.84 19.04 19.04 19.03 14.33 14.32 9.52 9.51 4.81 4.8

All casesPatientdata(n =21 )

n Y18 85.717 81.015 71.415 71.413 61.914 66.714 66.710 47.612 57.114 66.710 47.611 52.413 61.912 57.18 38.19 42.910 47.69 42.99 42.99 42.94 19.03 14.38 38.18 38.16 28.66 28.65 23.83 14.35 23.84 19.04 19.03 14.32 9.54 19.02 9.53 14.32 9.52 9.50 0.01 4.8

informantdata(n =20 )

n Yo14 70.014 70.013 65.013 65.014 70.013 65.09 45.09 45.08 40.05 25.07 35.08 40.03 15.03 15.011 55.08 40.09 45.07 35.05 25.04 20.08 40.06 30.04 20.04 20.04 20.01 5.04 20.03 15.01 5.01 5.03 15.01 5.02 10.04 20.01 5.00 0.01 5.02 10.01 5.01 5.0

By diagnosisSchizo-phrenia& schizo-phreni formpsychos is(n =13 )n %

13 10012 92.312 92.311 84.610 76.912 92.311 84.612 92.311 84.69 69.2

10 76.98 61.56 46.27 53.911 84.67 53.97 53.87 53.87 53.87 53.87 53.87 53.84 30.82 15.45 38.53 23.10 0.00 0.04 30.84 30.80 0.04 30.84 30.84 30.83 23.12 15.41 7.72 15.41 7.71 7.7

Affectivepsychosis(n =8)

n YO8 1006 75.06 75.05 62.56 75.03 37.54 50.03 37.53 37.55 62.53 37.55 62.57 87.56 75.01 12.55 62.55 62.53 37.53 37.53 37.53 37.52 25.04 50.06 75.02 25.03 37.55 62.55 62.51 12.51 12.55 62.50 0.00 0.00 0.00 0.01 12.51 12.50 0.00 0.00 0.0

By genderFemale(n =7)

n Yo7 1006 85.76 85.74 57.14 57.13 42.95 71.44 57.14 57.15 71.44 57.14 57.13 42.96 85.71 14.34 57.13 42.93 42.94 57.14 57.11 14.32 28.62 28.63 42.91 14.34 57.13 42.92 28.60 0.02 28.62 28.63 42.91 14.30 0.00 0.00 0.00 0.00 0.00 0.00 0.0

Male(n =14)

n %14 10012 85.712 85.712 85.712 85.712 85.710 71.411 78.610 71.49 64.39 64.39 64.3

10 71.47 50.011 78.68 57.19 64.37 50.06 42.96 42.99 64.37 50.06 42.95 35.76 42.92 14.32 14.33 21.45 35.73 21.43 21.41 7.13 21.44 28.63 21.43 21.42 14.32 14.31 7.11 7.1

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Mood related symptoms Cognitive changesDepressed mood Depressed mood was reported inthe prodromal period in 16of the 21 cases. In somecases patients andor informants attributed to thelowered mood some cause or meaning, for example,explaining it as a reaction to stress. It is of courseunclear how much such attribution is an effort aftermeaning. In other cases. there was no apparentreason for the depression identified. Depressed moodwas also described by patients as occurring secon-darily, in response to other experiences, particularlypredelusional feelings of a change in the sense ofself, others and the world.Suicidal thoughts Five patients described havingthoughts of suicide in the prodrome. For example,Case 7 described this after he failed Y ear 10 atschool, and later, when psychotic, made two unsuc-cessful suicide attempts.Physical symptoms

Ten patients in this study described having physicalsymptoms in the prodrome. Some examples includeCase 4, who stated that he just didnt feel well andfelt physically sick in the stomach 4months prior tobecoming psychotic. For over 2 years before becom-ing psychotic Case 6 described aches and pains,malaise and gastric discomfort. He explained: I wasalways tired . .. I also had some problems with mydigestion. I was hungry all the time. I didnt get anysatisfaction from anything. I would get a stomachupset every time. (Food) would just give me somestomach aches and bloating and whatever. H e alsodescribed increased sensitivity to the cold. His phys-ical discomfort progressed, and he recalled: It got tothe point in 91/92 when I said to myself, I have gotto lie down, l ie 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 wasnot all right.In addition, several patients, along with their infor-mants, described reduced appetite, poor food intakeand weight loss during the prodrome.Sleep disturbance was found in all 21 cases. Tenhad decreased sleep, five had altered sleep patternswith a change to sleeping during the day and beingawake at night, and the remaining six had hyper-somnia.

Poor concentration, distractibilty and memory distur-bance were found in 15of the cases studied, indeci-siveness was described in four cases and preoccupationin 10.Another cognitive symptom, thought blocking,was found in five cases in this sample. Case 5described this phenomenon: Itwas just like it was myhead went blank - ike there was an empty space in thehead. It was black . At another time he made theanalogy: It was like I had been hit in the head with asledge hammer. I felt like I was numb in the head. Hedescribed this trouble thinking as causing him difficul-ties in trying to communicate with others.Case 16 described brief periods of thinkingnothing, and he discussed how this made it difficultto understand what others were trying to say to him:I thought I was missing pieces . . I dont know. J ustsometimes I didnt know what they were talkingabout. I thought I didnt hear or something . . I wasnot really thinking about anything. Just daydream-ing. These episodes lasted for a couple of minutes,he would then wonder what people had been talkingabout. This worried him because I couldnt thinkstraight. I knew something was going on.Perceptual clianges

Changes in perception during the prodrome weredescribed in 13 patients in this study. These did notinclude frank hallucinations, which indicate actualpsychosis, rather than prodrome. This alteration inperception was generally described by patients butnot informants. For example, Case 3 thought that herhusbands laugh sounded different: He was justlaughing really peculiar ... The laugh just didntseem thesame to me. It was actually coming out in afunny way. It sounded really weird. It was likesomeone else laughing. A different laugh altogether.She also noticed a reduction in her sense of smell,and described the sensation of feeling that time hadslowed down.Case 10described altered perception 2 weeks beforehis psychotic episode: It seemed like everyone I wastalking to was crying. They had tears in their eyes. Healso noted increased intensity of perceptions:Everything was heightened, sound, the birds. It wasreally acute. I could feel where the world was ...Colours were amazing! I remember looking at a cap-sicum, and the colour, the red - t was just like blood!

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And red wine, everything was really sensual . . I hadthis thing about smell. I was starting to pick all theflowers and smelling them. The smell was fantastic.In contrast, Case 14recalled a reduction in intensity ofperceptions. He said that about 2 years before his psy-chosis Things quietened down. Things actually gotquiet . ..everything, and My taste buds, I think I ustabout lost them somewhere along the line.Change in sense of se& others and the world

Changes of this nature were described by 13patients, but only three informants. Case 3 felt verytense, frightened, worried that something was goingto happen. Something weird was happening 1 monthbefore her psychosis. Case 7 described himself asdifferent and not himself. He thought that otherpeople and things around him had changed also: Isort of thought everything just started changing. Theshopkeeper that I go to, she was serious with me, herhair colour was different, everything was just chang-ing. Nothing was the same to me any more . . Theywere acting different. Not looked different. Theywere acting different. His parents recalled: He wassaying that I am different and I dont know what todo in the future.PerplexiQ

A sense of confusion, perplexity, and bewildermentwas described by 14 patients, and noted by three oftheir informants. This was generally a late phenome-non, occumng just prior to frank psychotic changes,and usually accompanied the feeling of a change insenseof self, others or the world. For example, Case 14found himself thinking about things more. He describedworking it all out in my head ... All sorts of things.Everything! The way everything works, the way peoplework, even transport, nature, everything! Just too manytopics all piled in on one. Without answers. And youbecome mumble jumbled in your brain.Case 18said, I didnt know what was going on,and Case 5 described feeling L ike . .. nothing makessense, so you are just looking for something thatmakes sense .. I had no idea what was going on.Motor changes

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

patients had increased motor activity, such as movingfaster and pacing. Others described moving moreslowly during the prodrome, and some noticed diffi-culties with motor coordination. Some examplesinclude Case 18,who thought he was moving differ-ently as he felt stiff in the limbs. I feltall tied up, hesaid. He felt the need to pace to loosen his limbs. Hisfather noted that he paced a lot about the house, andalso recalled that he was moving slowly and awk-wardly, hunched over like an old man about seventyor eighty years old.Case 5 remembered: I couldnt drive a car!Normally I could drive a car all right, but when I triedto drive I felt like I lost my coordination. His sisternoticed that he was moving lamely .Case 7 also noticed problems with his coordina-tion, for example, he described his experience atsoccer: I was very different at soccer . . I was veryuncoordinated and everyone was just looking at mewhen I was playing soccer. I was dribbling the balland not playing as well as I used to.In two cases there were more complex motorchanges. Case 11 thought his movements becamemore gentle and delicate during the prodrome. Hiswife described echopraxia in him. She recalled: Hesaid he wanted to move like me. He wanted tobreathe when I did and soon. He said he was doingthe same things as me. Case 1.5described prominentindecisiveness and ambivalence and this was alsomanifested at a motor level: I was moving from oneway to another ... I was twisting my body around. Iknow half of me wanted to help Sally (her sister) andthe other half didnt. Her mother noticed that hermovements and gestures resembled those of her sicksister: I know it sounds weird, but she was acting alot like Sally .. ust mannerism, conversation.Beliavioiiral changesSocial withdrawal This was found in 1.5 of thecases. Various different reasons were given by thepatients to explain this common behaviour. Five ofthe patients said that they became withdrawn duringthe prodrome due to depression. A s Case 17explained: becauseI get depressed at times and I justdont feel like seeing anybody. Two cases describedsocial withdrawal secondary to irritability. As Case6explained: Iwas just very irascible . . In that kind ofmood its hard to go and share company with otherpeople. Other cases described social isolation sec-

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A.R. YUNG. P.D. MCGORRY 595

ondary to other feelings and experiences, such associal anxiety. In only three of the cases the patientswere unable to explain why they had become with-drawn during the prodromal phase.Deterioratiori i n role fii ii ctioriiri g This wasdescribed in 16of the patients, and again the reasonsgiven for this varied from case to case. Case 2 wasfrequently irritable during the prodrome and recalledarguments with his boss and being late for work.Case 3, a housewife and mother of two, deterioratedin her ability to perform the housework and look afterthe children and attributed this to loss of interest inthose things. Case6developed increasing fatigue andvague physical symptoms which resulted in himfeeling unable to attend many lectures at University.and then his deferment from his course. Case 11explained how initially he felt happy and had lostthe meaning of time and this resulted in him notworrying if he took longer to complete his tasks atwork.Sirbstariceuse Thirteen of the 21 patients used sub-stances, either illicit drugs, alcohol or both. Four ofthese described increased use in the prodromalperiod, and stated that this was for relaxation and toreduce anxiety. In contrast, Case 18abstained fromcannabis in the 6 months prior to psychosis. Noreason for this cessation was given. Both the patientand his father thought that this abstinence might havebeen responsible for the prodromal symptoms andeventual psychosis.Pattern and sequenceof changes

Nineteen of the 21 cases described classical neu-rotic-type symptoms, such as anxiety or depression,as occurring first with the gradual development ofmore marked deviations from normal following. Forexample, Case 5 described 1 year of increasingdepressive 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 vaguefeeling of change in himself, others and the world. Incontrast, two cases (Case 9 and Case 15) describedsymptoms suggestive of emergent psychosis asoccurring primarily, and neurotic symptoms andbehavioural changes occurring as reactions to theseunusual phenomena. Case 15 first noted perceptualchanges, such as experiencing a fluctuating intensity

of sound and changes in her experience of time.These experiences made her feel frightened, reluctantto go out and puzzled. Case 9 became preoccupiedwith his appearance early in the course of his pro-drome. and began to think that he may be differentfrom others. This led to social withdrawal and deteri-oration in his school performance. I didnt like theway I looked, so I just withdrew, he said.Presenceof precipitants

In 11 cases specific events were identified as beingtriggers or the causes of changes in the patients. Suchprecipitants were identified by both patients and infor-mants. For example, both Case 12 and her motheridentified her retrenchment from her job (throughfactory closure) as the precipitating factor for non-spe-cific changes. including depressed mood and poormotivation, in her. Case 7 dated changes in himselffrom the time he was told he had failed Y ear 10.Discuss ion

An accurate description of the changes whichoccur during the period of time preceding a first-episode of psychosis, the psychotic prodrome. isincreasingly being recognised as important, bothclinically and for research. For example, early inter-vention strategies in the management of psychosishave received worldwide attention recently[3,19-211. T he identification of prepsychotic andearly psychotic changes also opens the door forresearch into the aetiologies and developmentof psy-choses and into the effect of early biopsychosocialinterventions in their management [3.19-241.Recognising the importance of the prodromal period,and acknowledging the relatively little research thathas been carried out in the area, this study set out totake the first step in exploring the issues: that ofdetailed description of the phenomenology anddevelopment of the prodrome.M ethodological issuesThe saniple

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

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across different diagnostic groupings. It was smallenough to enable a detailed qualitative analysis to becarried out. A larger sample would have been toocumbersome to handle using the qualitative researchtechniques performed in this study. However, thelimited sample size of 21 patients makes generalis-ability of the findings an issue. The demographiccharacteristics of the sample were described previ-ously. These can be compared with data available fora consecutive series of first presentation patientsaged between 16and30 for the whole of the EPPICcollected 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 andgender distribution were roughly the same in the twosamples. There were some small differences in thedistribution 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 areasonably representative sample of cases presentingto the EPPIC. Based on the expected incidence ofpsychosis in the community, it has been estimatedthat this larger sample is a reasonably representativesample of first-episode psychosis patients from theprograms catchment area.ResultsDurationof 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 thefinding that the first prodrome is highly variable inlength [1,Z-271. In this study, the range was 3daysto over 6years. Beiser et al. [ I ] described range fromzero (i.e. no prodrome at all) to 20 years. The medianfinding in this study of 27.3 weeks for the wholesample was much shorter than Beisers finding of37.9 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 schizophreniformpsychosis, brief reactive psychosis and bipolardepression. Beiser et al.s finding in the schizophre-nia group was a median prodrome duration of 52.7weeks, which is similar to this studys finding of 52.1weeks in the same group. In the Loebel ef al. study[25] the mean duration of prodrome for the sample

was 98.5weeks. No median figure was given. In thisstudy, all patients had either schizophrenia (77%) orschizoaffective disorder (23%) with other psychoticdisorders excluded, thus the duration of prodromewould be expected to be longer than that found in thisstudy. Additionally, L oebels mean figure may havebeen 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 disturbancewas universal. Anxiety, irritability, depressed mood,impaired role functioning, social withdrawal, poorconcentration, suspiciousness and lack of motivationwere all common, occurring in over two-thirds of thecases studied. L ow energy, motor changes, perceptu-al disturbances, change in sense of self, others or theworld, puzzlement, lossof interests, abnormalities inspeech, and weight loss all occurred in over one-halfof the sample. Poor appetite, other physical symp-toms, aggressive behaviour, mood swings, preoccu-pation, guilt, and increased energy occurred in overone-third, and self neglect was found in one-third ofthe cases. Blocking phenomena (thought block),described by Chapman [28] as an important earlyphenomenon in schizophrenia, occurred in 23.8% ofthe sample. Overall, the extent of prepsychotic phe-nomena found in this sample demonstrates that theprodromal period is likely to be associated with ahigh level of disability.The presence of suicidal thoughts (in 23.8%) and selfharm (in 14.3%) in the prodromal period isalso impor-tant to highlight. This indicates that in addition to psy-chosis itself being a risk factor for suicide, theprepsychotic period is also a time of increased risk.Other self-destructive behaviours, such as increaseduse of substances (19.0%) and aggressive behaviour(47.6%), are also noteworthy. This underlines theimportance of early intervention in psychotic disorders,and ideally, intervention in the prepsychotic phase toreduce risk of suicide. self-harm and disability.When diagnostic groupings were compared. certainfeatures seemed to show some specificity for mania.For instance, increased energy was present in the pro-dromes of 75% of the affective population, all ofwhom had mania rather than depression, comparedwith 15.4% of the schizophrenia-like group. Other fea-tures following this trend were elevated mood,increased activity and disinhibition. This is consistent

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with the clinical impression that psychotic mania ispreceded by hypomania. Notably, racing thoughtswere not particularly more common in the affectivegroup compared with the schizophrenia-like group.Features found more commonly in the schizophre-nia-like group compared with the affective groupwere poor concentration. suspiciousness, lack ofmotivation, low energy and loss of interests.Indecisiveness, obsessive-compulsive phenomena,increased use of substances, and forensic behaviourwere all found in four patients from the schizophre-nia-like group, but none of the affective grouppatients. 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 reviewedrecently [4]. In addition, the symptoms of increasedenergy. increased activities and racing thoughts,although mainly found in the affective group, werenot specific for this group as they were also found inthe schizophrenia-l ike group. These symptoms werenot previously described in schizophrenic prodromes.Another major finding was that patients are often arich source of information, providing details of pro-dromal changes that are not accessible if informantinformation alone is relied upon. For instance, per-ceptual changes were commonly described bypatients as occurring in the prodrome. detailed by 12out of the 21 patients, yet only three informants notedthem. The predelusional experience of altered senseof self. others and the world, discussed in the litera-ture [29.30,33], is described by 13patients but notedby only three informants. Patients as a source ofinformation are not only relatively neglected byexisting criteria. but often by clinicians as well. A tthe time of the patients admission to hospital withacute psychosis. information is sought from relativesand other informants about the changes leading up toadmission. There is a tendency then, especially inbusy acute psychiatric units, to treat the patients anddischarge them without ever reconstructing thepatients experience of becoming psychotic.Another factor to highlight which emerged from thisstudy was that behaviours are usually only rough indi-cators of a patients mental state. Behaviours such aspoor role functioning or social withdrawal, aggressionand 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 ascauses of the behaviour social withdrawal . Depressedmood, imtdbihty, poor concentration and fatigue wereall cited by patients as causes of deterioration of rolefunctioning. Frankly psychotic experiences can alsoresult in these behaviours, for example, persecutorydelusions and auditory hallucinations causing socialwithdrawal. 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 isgiven to the patients subjective experiences and therole they have in generating such behaviours. It isimportant to know what symptoms and experiencesunderlie 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 todescribe what the individual was like normally (beforethe psychotic episode) and to track the development ofchanges. In two cases, informants described thepatients as always having had some problems, but inboth cases a clear change was noted prior to the onsetof psychosis indicating the presence of a prodrome.Patteni aiid seqireiice o chaiiges in the prodlnii ie

This study found that the majority of patients (19out of 21) first experienced non-specific neuroticsymptoms, then gradually developed more markeddeviations from normal, and then experienced psy-chosis. Two patients, however, seemed to follow thatpattern described by Chapman 1281 in first experi-encing unusual symptoms such as a feeling of changein sense of self or perceptual distortion, developingsymptoms as reactions to this, such as anxiety orsocial withdrawal, and then becoming psychotic.Many of the patients described reactive symptoms,such as feeling depressed, anxious or confused aboutthe changes that were taking place in them. Hence,prodromal features consist of a mixture of the fol-lowing: (i) attenuated psychotic symptoms, such asperceptual changes and suspiciousness; (i i) non-spe-cific neurotic and mood-related symptoms, some ofwhich are reactions to other symptoms: and ( i i i )behavioural changes, which are frequently inresponse to other experiential phenomena, both neu-rotic and attenuated psychotic symptoms. Thus, theprodromal phase, like psychosis itself, is a complexand dynamic period, with individuals responding totheir own changing internal worlds as well as react-

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598 THE INITIA L PRODROME IN PSYCHOSIS

ing to those around them. Feedback loops exist aswell, for example, with the family responding to theindividuals altered behaviour in certain ways, whichin turn affects the individual and soon. A model forunderstanding these complex interactions can behypothesised which we have called the hybridl inter-active model of the prepsychotic phase, described ina previous paper [4].Figure 1 illustrates this modelfor conceptualising the prodrome.In this hybridhnteractive model, people are seen as

being able to move in and out of symptomaticperiods, both of the non-specific type and the attenu-ated psychosis type. Both types of symptoms mayprecede psychosis, and either may occur primarily.Symptoms are also due to the persons reaction to hisor her experiences or toothers.Presence of precipitants

The issue of effort after meaning [36-381 becomesimportant when considering the presenceof precipitat-ing events in the sample. This refers to the situationwhen patients and families look for an event whichseemed to start all the changes, and date their historiesfrom that point. This may not always be how thingsactually evolved. A s this was a retrospective study itwas a difficult issue to clarify, and a prospectiveapproach would be needed to examine the issue.Conclus ion

This paper has reported on the findings of the qual-itative part of a retrospective study into the initialprodromes of a series of patients with first episodepsychosis. Twenty-one patients and their informantswere interviewed using unstructured and semi-struc-tured interview techniques. Using this method, richdescriptions of prodromal phenomena and sequenceof events were gained, along with estimations of theduration of these changes in each case. The descrip-tive data agree with earlier lost characterisations ofschizophrenic prodromes recorded in the literatureand reviewed elsewhere [4].This highlights the lossof information that has resulted from disregardingthese studies, as has been done with the DSM-111-Rconceptualisation of schizophrenic prodrome, whichinstead focuses on behavioural features. This strate-gy is part of a more general trend which aims toincrease reliability as a priority, at the cost of reducedvalidity [394 1.

Reactive symptomsandbehavioural changes

Figure 1. The hvbridhiteractive nioclel ofprodrornal chariges

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

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Initial Prodrome in Psychosis