J Am Board Fam Pract: first published as 10.3122/15572625-13-6-430 on 1 November 2000. Downloaded from First-Episode Psychosis: A Clinical Approach S. Charles Schulz, MD, Deanna Bass, MD, and Cynthia S. Vrabel, MD Background: Psychotic illnesses, such as schizophrenia and bipolar illness, are relatively common and clearly devastating diseases. Most scientific literature focuses on research and care of patients suffering 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 physician and to discuss (1) diagnosis, (2) neuropsychiatry 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 patient, 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 brain 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 United States 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 medicines. 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 movement disorder side effects-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 medicine 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 Hospitals 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.8,9 430 JABFP November-December 2000 Vol. 13 No. 6 J Am Board Fam Pract: first published as 10.3122/15572625-13-6-430 on 1 November 2000. Downloaded from 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 anxiety 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 depression tion and initiation of therapy. We believe it is versus seizures. Her carbamazepine level measured important that family physicians 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 hallucinations with religious con­ nation with other medications, as described below. tent. Her paranoid delusions 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 paranoia (barricading herself in the basement, placing marbles on the stairs to stop Methods intruders, and telephoning 911 with fears 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 psychiatrist and a tive," and "antipsychotics," and is addressed. psychologist. The month culminated in an admis­ sion to the psychiatric unit of a local hospital 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, psychomotor retardation, suicidal ideation, 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 stress disorder, which oc­ ization. curred after a bicycle accident and responded to During the next several weeks the patient psychotherapy. Her medical history 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 epilepsy. 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 wandering wet and dishev­ her make decisions