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J Am Board Fam Pract: first published as 10.3122/15572625-13-6-430 on 1 November 2000. Downloaded from First-Episode : A Clinical Approach

S. Charles Schulz, MD, Deanna Bass, MD, and Cynthia S. Vrabel, MD

Background: Psychotic illnesses, such as and bipolar illness, are relatively common and clearly devastating . Most scientific literature focuses on research and care of from psychotic illnesses in the middle age-group; subsequently, the first episode or early stages of psy­ chotic illnesses have been relatively ignored, especially the issues of early diagnosis and inten-ention. The purpose of this article is to highlight issues of first-episode schizophrenia for the family and to discuss (1) diagnosis, (2) research, (3) new medications, and (4) family issues. Methods: To approach the issues of first-episode schizophrenia, we describe a case of a young woman who suffered her first episode of psychosis. Relevant literature related to the early stages of psychosis, including new pharmacologic treatments, is addressed. Results: This report of our , a 19-year-old woman, illustrates the problems of a long prodro­ mal phase of her illness, the use of medications that might have worsened her condition, and the suc­ cessful use of new antipsychotic medications. Her family's issues as the patient went through this phase of her illness and recovery are reviewed. Conclusions: Patients at the outset of a psychotic illness are frequently first seen by a family physi­ cian. Familiarity with current diagnostic criteria and effectiveness of new treatments can lead to im­ proved detection and overall outcome. (J Am Board Fam Pract 2000;13:430-9.)

As for me, you must know, I shouldn't methods, how the works on standardized precisely have chosen madness if there had tasks. 2,3 With improved genetic methodologies, been any choice. What consoles me is that I both in molecular as well as statistical laboratories, am beginning to consider madness as an there is a greater appreciation of the locus of the illness like any other and that I accept it as genetic contribution to schizophrenia.4 such. Perhaps of greatest immediate importance has -Vincent Van Gogh been the introduction of fundamentally different, new antipsychotic medications for schizophrenia. In the last 10 years there has been a marked The first of these new medications, clozapine, was increase in the research effort to explicate the introduced in the in 1990. Kane et al 5 pathophysiology of schizophrenia and to develop showed that clozapine was effective for patients http://www.jabfm.org/ better treatments. For example, the National Plan who failed treatment with older . Cloza­ for Schizophrenia Research 1 highlighted the status pine is described as an atypical antipsychotic be­ of schizophrenia research and pointed to fruitful cause it reduces symptoms of psychosis without new opportunities. In addition, schizophrenia re­ causing -the dys­ search has been a major focus of the Decade of the tonic or parkinsonian effects that are common with th~ traditional antipsychotic medications. Unfortu­

Brain initiative. There have been exciting findings on 2 October 2021 by guest. Protected copyright. as a result of brain-imaging research, even to the nately, clozapine is associated with a 1% rate of point of visualizing through functional-imaging agranulocytosis and is not used as a front-line treat­ ment. Since the introduction of clozapine, three other atypical or new antipsychotics have been re­ Submitted, revised, 23 March 2000. leased for front-line treatment. The first was ris­ From the Department of Psychiatry (SCS, DB) and the peridone,6 a with low levels of movement Department of Family Practice & Community Health (DB), University of Minnesota School of Medicine, Minneapolisj side effects in appropriate dose ranges that is effec­ and the Department of Psychiatry (CSV), Case Western tive against symptoms of psychosis. Olanzapine was Reserve University School of Medicine, and Department of Psychiatry (CSV), University of Cleveland, Cleve­ the second, and it has been available since the land. Address reprint requests to S. Charles Schulz, MD, autumn of 1996. 7 Third was quetiapine, released in Department of Psychiatry, University of Minnesota, F28212A West, 2450 Riverside Ave, Minneapolis, MN late 1997 after two pivotal studies showed efficacy 55454. and safety.8,9

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Despite the research focus on schizophrenia and At the end of her freshman year, her family the introduction of new treatments, less attention noted the gradual onset of symptoms and has been paid to the early stages of the illness. As mild suspiciousness (feeling that her friends had this case presentation and discussion are intended changed and no longer liked her because she was to illustrate, however, first-episode schizophrenia too popular). She was fired from her job at a local can be objectively and reliably distinguished from retailer after her boss observed that she would often other conditions, and new medications can lead to "stand around staring and doing nothing." These improved outcomes. These new treatments have symptoms prompted a visit to her pediatrician, who focused attention on the importance of early detec­ was concerned about the possibility of tion and initiation of . We believe it is versus seizures. Her carbamazepine level measured important that family be alert to and at that time was therapeutic. recognize psychotic symptoms in adolescents and During the next month the patient became more young adults. We also believe it is important that preoccupied and withdrawn, often to the point of family physicians treat such symptoms using the being unable to engage in conversation. She re­ new antipsychotic medications, alone or in combi­ ported auditory with religious con­ nation with other medications, as described below. tent. Her paranoid progressed to the Furthermore, especially for primary care physi­ point where she frequently did not feel safe and was cians, there is an increasing awareness of the special unable to trust her family. Her behavior became needs of the whole family. driven by the (barricading herself in the basement, placing marbles on the stairs to stop Methods intruders, and telephoning 911 with of some­ We describe a case of a young woman who suffered one being "after me"). During this period she was her first episode of psychosis. Relevant literature evaluated by neurologist, who ordered a magnetic related to the early stages of psychosis, including resonance imaging scan (MRI) and an electroen­ new pharmacologic treatments, was researched us­ cephalogram (EEG), the results of which were nor­ ing the key words "schizophrenia," "schizo affec­ mal. She was also evaluated by a and a tive," and "antipsychotics," and is addressed. . The month culminated in an admis­ sion to the psychiatric unit of a local after the patient ran away from home and was missing Case Report for 36 hours (behavior quite uncharacteristic for An IS-year-old single woman came to the inpatient her). psychiatric unit at University Hospitals of Cleve­ When admitted to the psychiatric unit, the pa­ land complaining of depressed mood, blunted af­ tient refused all medications and was discharged http://www.jabfm.org/ fect, , , after 24 hours. She remained agitated and paranoid. auditory hallucinations, and delusions of paranoia The auditory hallucinations became more promi­ and thought control. Her chief complaint was "I nent (derogatory accusations and two voices com­ feel like I don't have a brain inside my head." menting on her behavior). On the day after she left the hospital, she was readmitted to the psychiatric

History oftbe Present/lIne,. unit of another local hospital after running to a on 2 October 2021 by guest. Protected copyright. It appeared that the first symptoms of illness oc­ police station to report that she was being abused. curred 7 months before her admission. At that time The admitting diagnosis was "paranoid disorder, she had just completed her first year of college. In possibly schizophrenia." She was given a typical high school she had been a gifted athlete, a talented antipsychotic (haloperidol), with some improve­ musician, and an excellent student. She did not use ment; however, she subsequently refused medica­ alcohol or drugs. Her psychiatric history was nota­ tions and was discharged after a 2-week hospital­ ble only for an acute disorder, which oc­ ization. curred after a bicycle accident and responded to During the next several weeks the patient . Her was notable for showed progressively worsening agitation, insom­ two nonfebrile generalized seizures in childhood, nia, paranoia, and bizarre behavior. Her third ad­ which were treated with carbamazepine. She did mission to the psychiatric unit occurred after she not suffer from temporal lobe . ran away from home, discarded her personal be-

First-Episode Psychosis 431 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-430 on 1 November 2000. Downloaded from

longings, and was found wet and dishev­ her make decisions regarding education and em­ eled 15 miles from her home. On the day after ployment. admission she was transferred to a state psychiatric Eight months after the onset of her symptoms, facility. The admitting diagnosis was "major de­ our patient was discharged from partial hospitaliza­ pressive disorder with psychotic features." She was tion to the outpatient of one of the authors given an antidepressant (nefazodone hydrochlo­ (CSV). Her mental status remained stable on anti­ ride) with some improvement in concentration. depressant (sertraline 150 mg/d), atypical antipsy­ She was discharged after a 2-week hospitaliza­ chotic (risperidone 6 mg/d), and anticonvulsant tion and immediately discontinued her medication. (sodium divalproex 1,000 mg/d) medications. She One week later she took a multiple- continued to improve during the course of treat­ in a psychotically motivated attempt ("I felt ment. She resumed her studies at a local university like the chemicals in my brain were crazy ... like (achieving As and Bs) and worked part time at a too many personalities were trying to get out; I was local retailer. controlled by them"). She was briefly cared for in In summary, this IS-year-old woman sought the medical intensive care unit and subsequently treatment for an initial onset of a 7-month course transferred back to the state psychiatric facility. of progressively worsening psychosis and intermit­ During a 9-week hospital stay, she was given tent depression, which responded to definitive several antidepressants (selective serotonin re­ treatment with atypical antipsychotic and antide­ pressant medications. uptake inhibitors) and several typical antipsychotics for brief periods without improvement. The pro­ gression of her psychiatric illness was apparent as evidenced by continued delusional thinking, audi­ Discussion tory hallucinations involving commands from the This case was chosen because it illustrates many voice of Satan, poor hygiene, blunted affect, and early-stage issues of schizophrenia. Our discussion social withdrawal. Concerned by the obvious de­ will focus on the following: (1) the symptomatology and diagnosis of psychosis at the outset of the cline in their daughter's condition, her parents con­ illness, (2) the of early-stage schizo­ tacted University Hospitals of Cleveland for a sec­ phrenia, (3) a brief description of studies investi­ ond opinion. gating biologic findings at the outset of the illness At that time we admitted the patient to the showing that early stages of schizophrenia are part inpatient psychiatric unit and were told she had an of the adult , (4) treatment with new agents initial diagnosis of based on and use of augmenting medications, and (5) ap­

prominent affective and psychotic symptoms that http://www.jabfm.org/ proaches to families' concerns. We feel these five fulfilled criteria from the Dia~ostic and Statistical points are important to family physicians because Manual of Mental Disorders (ed 4) (DSM IV).1O She they are often the first physicians contacted by a began taking an antidepressant (sertraline) and an family when symptoms emerge. atypical antipsychotic (risperidone). Carbamaz­ epine was continued as an anticonvulsant. During the course of a 3-week hospitalization, the patient's Phenomenology and Diagnosis on 2 October 2021 by guest. Protected copyright. psychotic and depressive symptoms steadily im­ For many years have struggled with proved. An episode of emerged that did the phenomenology of psychosis in adolescents and not respond to benzodiazepines but was success­ young adults. Not wanting to overdiagnose schizo­ fully treated with a course of electroconvulsive phrenia or other psychotic disorders (eg, major therapy. After her discharge from the inpatient depression with psychotic features), the field has unit, she attended a daily partial hospitalization not been aggressive in recognizing psychosis at the program for 1 month. At that time she was no outset. Our research experience with adolescents longer experiencing hallucinations, delusions, or with psychosis has shown that school counselors, subjective complaints of depression. She continued primary care physicians, and church leaders are also to have a blunted affect, ambivalence, and difficulty reluctant or are not fully knowledgeable about the with complex tasks requiring sustained attention. signs of schizophrenia and their importance, as is Neuropsychologic testing was undertaken to help clearly illustrated in the case described. Our patient

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Table 1. Psychiatric Disorders With Psychotic or Mood s,mptoms.

Disorder Psychotic Symptoms Mood Symptoms

Schizophrenia DSM N 295 Psychotic symptoms present for 6 Facial expression is frequendy flat, but months. Auditory hallucinations, patient does not report . delusions, and disorganized thinking Depression frequent after resolution of are prominent psychosis DSM N 296 Psychotic symptoms are mood Prominent grandiosity, rapid , and congruent. Belief that one is God decreased when mood is elevated. during manic stage Psychomotor retardation, hopelessness, or suicidal when low Schizoaffective disorder DSM N 295.7 Same as noted for schizophrenia. Same as for bipolar disorder Diagnosis of schizoaffective disorder when criteria for both parts of the disorder are met Major depression with psychotic features Psychotic symptoms are mood Sad and helpless feelings, decreased DSM N 296.XX (code modified for congruent, eg, voices are morbidly appetite, interrupted sleep, and suicidal severity and presence of psychosis) derogatory thoughts

Note: psychosis is regarded as loss of touch with reality, characterized by hallucinations, delusions (fixed, false beliefs), disorganized thinking, and bizarre behavior. DSM N - Diagnostic rmd Statistical ManUIII of Mental Disorders, ed 4. initially had a diagnosed despite her In the case described above, a diagnosis of clear psychotic symptoms. schizoaffective disorder was delayed despite clear The 1994 DSM N, the result of substantial symptoms of the disorder, which led to delay in nosological study, has indicated that the criteria for appropriate pharmacologic intervention and a re­ schizophrenia are the same at the onset of the sulting prolonged stay in an inpatient setting. In illness as at later times. In the past, psychiatry had addition to the long time the patient suffered from been criticized for a lack of diagnostic reliability, symptoms of psychosis, a great amount of time but agreement among psychiatrists in making the passed during an important developmental phase diagnosis of schizophrenia is quite high-even in for this young woman. its early states. The work of Carlson et al,11 who have investigated diagnosis in a "first break" sam­ Epidemiology ple, shows not only high interrater reliability of Even though schizophrenia is not a rare illness (it psychotic symptoms at first assessment, but also strikes 1% of the US population 13), there is a per­ high stability of diagnosis during the first 6 months. ception that schizophrenia is mainly an adult dis­ http://www.jabfm.org/ This latter finding is important in its treatment order. This is not true. Lorangerl4 re­ implications for the early stages of schizophrenia, ported that 39% of men and 23% of women have because clinicians need not think they should wait had the onset of psychotic symptoms before 19 long periods for the diagnostic picture to unfold years of age. Studying a German catchment area, before starting treatment. It should be noted here Hafner et al 15 found that most men had onset of

that not all psychotic conditions in adolescents and schizophrenia before they were 24 years old and on 2 October 2021 by guest. Protected copyright. young adults are schizophrenia. Other disorders most women before 26 years old. include psychosis, however, they, too, can be ob­ Although this article focuses on schizophrenia, it jectively and reliably assessed. 12 should be noted that the other psychotic disorders Distinguishing among psychotic disorders that have their onset in adolescence or young adulthood appear during adolescence and young adulthood is as well. Our experience has been that initial epi­ important, but we believe the distinction can be sodes occur during the school years, work, or mil­ made by the family physician. The major categories itary service, during a time when these persons of psychotic disorders that can appear in youth and might be in contact with school counselors, family their mood and psychotic symptoms are listed in physicians, pediatricians, or other health workers. Table 1. Further information about distinguishing One factor included in making the diagnosis of these disorders can be found in the DSM N section schizophrenia at the first episode is the prodromal on algorithms. to period of nonspecific symptoms-decreased school

First-Episode Psychosis 433 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-430 on 1 November 2000. Downloaded from

Table 2. Traditional and New Antipsychotic Medications.

Name (Brand) Neurologic Side Effects Nonneurologic Side Effects Dose

Haloperidol (Haldol)* Dystonia in early use Occasional sexual side effects Adult: 10-20 mg/d Parkinsonism (galactorrhea or impotence) Early-stage illness: 2-10 mg/d (5% of Sedation cases per year of treatment) Seizures (rarely) Neuroleptic malignant syndrome Risperidone (Risperdal) Extrapyramidal side effects at Sexual side effects secondary to Average adult: 4-6 mg/d doses >6 mg/d hyperprolactinemia in some Early-stage illness: 2-4 mg/d Neuroleptic malignant patients, eg, galactorrhea in syndrome reported some young patients Tardive dyskinesia < 1% per Some weight gain year Olanzapine (Zyprexa) Extrapyramidal side effects at Sedation Average adult: 12.5-70 mg/d higher doses (eg, 25 mg/d) Weight gain Early-stage illness 10-20 mg/d Tardive dyskinesia 05 1% Quetiapine (Seroquel)t Extrapyramidal side effects Sedation Adult: 400-600 mg/d rare Some weight gain Early-stage illness: 200-600 mg/d Tardive dyskinesia is rare Clozapine (Clozaril) Extrapyramidal side effects Agranulocytosis Adult: 300-600 mg/d does not occur Sedation (recessedness has Hypothermia (lOO°F) been reported) Tardive dyskinesia probably absent

Haloperidol listed as representative of a nonsedating traditional antipsychotic medication. tQuetiapine is a relatively new agent. Tardive dyskinesia frequency is not yet known. Although the Physicians Desk Reference recommends eye examination, no increased frequency of cataracts are found in studies.

or work performance, diminished attention abili­ and campaigns of education and early ties, social avoidance, and so on. The prodromal intervention to give adolescents and young adults period, which can last for 1 year or more before the greatest chance of a good outcome. specific schizophrenic symptoms emerge, is obvi­ Especially important for the early stages of http://www.jabfm.org/ ously troubling for young people and their parents. schizophrenia is the epidemiologic finding of an Looking back at our patient's history, her pro­ associated 10% rate of completed . IS This drome probably began on her return from her finding underscores the seriousness of and mortal­ freshman year, when she was anxious and suspi­ ity associated with schizophrenia, and it is hoped cious. ~at early recognition and prompt treatment can The issue of the prodromal period and treat­ lead to a decrease in the suicide rate. In our young on 2 October 2021 by guest. Protected copyright. ment lag (the time from symptoms to treatment) patient, depression had been a major factor in ad­ has been addressed in a recent study undertaken in dition to her psychosis, so that her clinicians would Vancouver. 16 The investigators found a median of need to be aware of the potential for suicide. Fur­ 8 weeks and a mean of 52 weeks of treatment lag. A thermore, follow-up studies have shown substantial long treatment lag is important because of unnec­ morbidity in schizophrenic patients suffering from essary suffering; it also is of concern because studies depression. In a follow-up study of adolescent during the last decade indicate such a lag might schizophrenic patients, Krausz and Muller-Thom­ confer poorer response to treatment as measured sen 19 reported that depression, anxiety, and suicidal by length of time to remission and level of re­ thoughts were the major concerns of the patients. sponse. 17 Restated, the longer a youngster is symp­ For this reason recognition and treatment of co­ tomatic, the longer it takes to achieve remission. morbid depression are important parts of this pa­ These recent findings have motivated programs tient's treatment.

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PatbopbysloloD pitalization.33 ,34 In addition to structural changes Forty years ago American psychiatrists generally seen on imaging, first-episode young patients have agreed that schizophrenia was the result of difficul­ substantially poorer neuropsychologic function (at­ ties in early life-generally a result of relationship tention, memory, decision making) than a control or communication difficulties with parents. As population. 35,36 Our group has extended these ob­ noted earlier, substantial progress has been made to servations into the adolescent patient groUp.3 7 extend the understanding of genetic, neurodevel­ These findings are important for clinicians be­ opmental, , and cognitive aspects cause they underscore the biologic continuity be­ of schizophrenia. Specifically, reports of studies us­ tween the early stages of schizophrenia and the ing a genome scan now indicate that portions of adult stages of the illness. Furthermore, these re­ chromosomes 5, 6, 8, 10, 13 and 22 are statistically search assessments underscore the seriousness of associated with increasing the risk of schizophre­ psychosis and refute ideas of early schizophrenia as nia. 2o-24 These are exciting and interesting leads, a developmental stage or stress reaction. Our pa­ yet the amount of increased risk for anyone of the tient had many difficulties noted on her neuropsy­ chromosomal areas is small. Genetic researchers chologic assessment, ranging from difficulty with believe that identification of a gene in anyone of attention to memory loss. When the pathophysio­ these areas could lead to a better understanding of logic components are ignored, treatment planning pathophysiology of schizophrenia. is frequently inadequate. In other words, the mood Early brain-imaging studies of schizophrenia as­ and psychotic symptoms experienced by our patient sessed general measures, such as the size of the are not psychologic in nature. Instead, they result lateral ventricles.25 With the advent of MRI, which from brain structural (perhaps microstructural) and allows for excellent brain morphology analysis, it neurotransmitter disturbances. appears that the frontal lobes, along with the hip­ pocampus (medial temporal lobe), are the areas of Treatment the brain most effected.26 Recent studies measuring In our opinion, clinicians have been reluctant to be the thalamus have shown its size to be reduced in aggressive in initiating pharmacologic treatment of schizophrenic compared with control patientsY schizophrenia at the early stages. In addition to Taken as a whole, the brain-imaging studies have issues already raised, there are two more specific not shown that these structural parameters change factors. One is the lack of data on the use of anti­ with time, and thus schizophrenia is hypothesized psychotic medication in adolescent and young adult as most likely a neurodevelopmental disorder.28 patients. The other, and more important factor, has All the effective antipsychotic medications have been the substantial side effects and lack of patient dopamine-blocking action, whether as their pri­ acceptance of the traditional antipsychotic medica­ http://www.jabfm.org/ mary activity, as with the traditional antipsychotics, tions (eg, , thioridazine, and halo­ or as only a part of the activity (less than serotonin peridol). blockade), as with the new, atypical antipsychotics. Only two controlled trials have investigated tra­ The discovery of dopamine-blocking capabilities of ditional medications on schizophrenic adolescents, antipsychotic medications led to the dopamine hy­ the age-group of our patient. The placebo-controlled 38 pothesis of schizophrenia. 29 More recently, the role trial by Pool et al showed that a traditional anti­ on 2 October 2021 by guest. Protected copyright. of serotonin in the pathophysiology of schizophre­ psychotic (loxapine) was effective compared with nia has been examined. placebo and had minimal side effects. As was com­ During the last 15 years, adolescents and young mon for studies at that time, only positive psychotic adults have been studied by researchers using a symptoms ( and delusions) were as­ number of neuropsychiatric . Our work sessed. In the other controlled trial (thioridazine vs with teenagers has shown that for those with thiothixene), Realmuto et al 39 showed that both schizophrenia, findings on computed tomograms traditional medications significantly reduced symp­ (CT)30 and MRI scans 31 are different from those of toms from baseline. Interestingly, they noted in control patients, a finding similar to that of Frazier their discussion that, although the medications et al,32 who assessed adolescents with childhood­ were effective,.it was difficult to balance side effects onset schizophrenia. In young adults, MRI scan with efficacy. They frequently found that patients studies have shown enlarged ventricles at first hos- had movement disorder side effects which stood in

First-Episode Psychosis 435 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-430 on 1 November 2000. Downloaded from the way of reaching an effective dose (neuroleptic mindful of antipsychotic medications side effects intolerance). There are few antipsychotic studies of that can lead to added treatment or changing med­ patients at the outset of their illness. In a major ications, and (3) being aware of potential drug-drug first-episode study by Lieberman and colleagues,4O interactions. 83 % of patients achieved a remission during the A concern for psychiatrists and family physicians first year of treatment while taking traditional an­ has been cost, as the new agents are substantially tipsychotic medications, thus indicating a good more expensive than the traditional medications. outcome for patients when they are first seen. Interestingly, studies have shown that the new For the new antipsychotic medications, case re­ medications lead to substantial decreases in hospital ports and trials involving patients at the early stage days, which more than offset medication costs.44 of illness are just now being presented and pub­ Fortunately, most state Medicaid programs have lished. In teenagers, an early report41 noted the coverage for the new, atypical medications, making usefulness and safety of risperidone for psychotic them available to young patients with a psychotic disorders. In adolescents with schizophrenia, illness. The new medications, even though more Grcevich et al42 described the cases of 16 teenagers expensive, are substantially different and superior taking risperidone who showed a significant de­ to the older medications, leading us to recommend crease in both positive and negative symptoms of them as the treatment of choice for the new patient. schizophrenia. The clinical impression was that the For our patient, we believe the new medication medication was well accepted by a young group. risperidone has offered effective and safe treatment. For the recently released new antipsychotic Although our patient represents a single case, ris­ olanzapine, an analysis of a group of first-episode peridone appears to have been better tolerated than patients who were part of a larger olanzapine-vs­ haloperidol and has led to better compliance--a haloperidol trial showed equivalent efficacy and problem that characterized her early course. Be­ fewer side effects. Negative symptoms (apathy, cause she has been able to return to school, we emotional blunting, and social isolation, for exam­ think the new medications have allowed her to ple) improved more with olanzapine.7 participate more fully. Quetiapine is the newest atypical antipsychotic This patient received an antidepressant medica­ medication. As a result of its pattern of efficacy and tion along with the new antipsychotic medication. safety in adults, clinicians can expect to see it used This combination is frequently used for schizoaf­ in young patients as a first-line treatment. A recent fective disorder or major depression with psychotic study has shown symptom reduction and few move­ features (psychotic depression). Furthermore, re­ ment side effects in adolescents with psychotic i1I­ search in the last decade has pointed to the impor­ nesses. 43 tance of using an antipsychotic-antidepressant http://www.jabfm.org/ Clinicians and researchers working with the new combination for symptoms of depression in a medications in patients at an early stage of schizo­ schizophrenic patient. Recall the high suicide rate phrenia note efficacy and few side effects. Coupled in this population. For the patient with bipolar with the impression of decreased negative symp­ di~order who has manic episodes, a mood-stabiliz­ toms, the new medications can allow clinicians to ing agent (lithium, valproate, or other) is usually

be more assertive in disease recognition and treat­ used alone. If psychotic symptoms are present, an on 2 October 2021 by guest. Protected copyright. ment. antipsychotic mediation (preferably the new atypi­ To date there are no clear guidelines for select­ cal agents) is also prescribed. ing one agent rather than another. All three of the There are at least three major reasons why a new, front-line, atypical antipsychotic medications family physician should be willing to treat psychosis are significantly more effective than placebo and in in a young person: (1) The patient might not be some studies are significantly more effective than able to see a psychiatrist for weeks, and early inter­ haloperidol. Head-to head comparisons are sparse, vention for psychosis is important. (2) The patient and the results to date are mixed. Perhaps more might be comfortable only with the family physi­ importantly, what is the role of the family physician cian and refuse to see a psychiatrist. (3) Psychiatric who is caring for a stabilized young person? We referral might not be possible, especially in a rural believe there are many important tasks, including area. For this last point, telemedicine projects (1) maintaining good physical health, (2) being might prove useful.

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Schizophrenia and the related disorders de­ these interventions have reduced family morbidity scribed in this article have multiple possible parts. and helped the patient comply with the treatment The family physician can focus on the positive plan. Further research in this area will help guide psychotic symptoms by prescribing antipsychotic the field toward optimal interventions. medications and creating a calm and safe environ­ ment. If the family physician becomes aware of Summary cognitive difficulties, as were observed in our pa­ We have described the case of a young woman at tient, then job training, special school schedules, the onset of a schizoaffective disorder to illustrate a and social skills training can be helpful. Recent number of issues about the early stage of the illness research has drawn attention to negative symptoms and to provide an update of advances that relate to of schizophrenia-flattened affect, lack of motiva­ first-episode psychosis. Establishment of the reli­ tion, decreased pleasure-and their relation to poor ability and stability of diagnosis, improvements in outcome. Community resources, such as Depart­ pharmacologic treatment, and a greater apprecia­ ment of Rehabilitation and Case Management, tion of family issues all bode well for better out­ might help in this area. comes for these patients. In addition, recent studies showing the negative impact of a prolonged treat­ Families ofPatients wltb First-Episode Psychosis ment lag make increased awareness of the issues During the last 15 years there has been a growing surrounding schizophrenia and related disorders all collaboration between families who have a relative the more important. Many families relate the onset with schizophrenia and clinicians, mostly through of psychosis to a primary physician before seeking the National Alliance for the Mentally m(NAMI). additional care. We hope a grater appreciation of The field still has a poor understanding of the the of psychosis and the ad­ shock and grief that result from having a son, vances in treatment will allow for more assertive daughter, or sibling with a diagnosed psychotic early intervention. disorder. We have noticed in our work with teen­ ager's parents that they struggle considerably with the onset of their child's psychosis, often reacting References with and denial. Both psychiatrists and pri­ 1. Keith SJ, Regier DA, Judd LL. A national plan for mary care physicians should be sensitive to the schizophrenia research: report of the National Advi­ sory Council. Rockville, Md: Alco­ impact of the onset of psychosis on the family, hol, Drug , and Mental Health Administration, which has a burden comparable to that of other National Institute of Mental Health, Department of severe medical illnesses.45 Another reaction is that Health & Human Services. 1988. families become confused about where to turn and 2. Weinberger D, Berman KF, Zec RF. Physiologic http://www.jabfm.org/ how to get help. Many young patients have been dysfunction of dorsolateral prefrontal cortex in taken to a long series of clinicians before seeing a schizophrenia. 1. Regional cerebral blood flow evi­ psychiatrist. This pattern can lead to further con­ dence. Arch Gen Psychiatry 1986;43:114-24. fusion and delay or inappropriate treatment. The 3. Liddle PF. Functional imaging-schiwphrenia. Br Med Bull 1996;52:486-94. family physician can break this cycle of a family's 4. Kendler KS, MacLean C}, O'NeiU FA, et al. Evi­ search for answers by recognizing the symptoms of on 2 October 2021 by guest. Protected copyright. dence for a schizophrenia vulnerability locus on schizophrenia and helping the patient and family to chromosome 8p in the Irish Study of High-Density start appropriate treatment. Schizophrenia Families. Am J Psychiatry 1996;153: The main role for the family physician is to be 1534-40. aware of the phases of shock, denial, guilt, and 5. Kane J, Honigfeld G, Singer J, Meltzer H. Clozapine that many families experience. It will for the treatment-resistant schizophrenic. A double­ then be possible to help the family through under­ blind comparison with chlorpromazine. Arch Gen Psychiatry 1988;45:789-96. standing and supportive comments or referral for 6. Marder SR, Meibach RC. Risperidone in the treat­ counseling. ment of schizophrenia. Am J Psychiatry 1994; 151: Our clinical team has always included the family 825-35. in treatment planning. We offer a gradual educa­ 7. Tollefson GD, Beasley CMJr, Tran PV, et a1. Olan­ tion program about schizophrenia and medication zapine versus haloperidol in the treatment of schizo­ treatment as well as support counseling. We believe phrenia and schizoaffective and schiwphreniform

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