The Prodromal Stage of Schizophrenia

Schizophrenia is a mental health disorder characterized by continuous or relapsing episodes of psychosis. “When schizophrenia is active, symptoms can include delusions, hallucinations, disorganized speech, trouble with thinking, and lack of motivation,” according to the American Psychiatric Association. “With treatment, most symptoms of schizophrenia will greatly improve and the likelihood of a recurrence can be diminished.”

As the late Colorado Recovery founder Richard Warner made clear in The Environment of Schizophrenia, the popular view that “schizophrenia has a progressive and downhill course with universally poor outcome is a myth. Over the course of months or years, about 20 to 25 percent of people with schizophrenia recover completely from the illness—all their psychotic symptoms disappear and they return to their previous level of functioning.”

As Dr. Warner explained, there is wide variation in the course of schizophrenia. In some cases the onset is gradual, “extending over the course of months or years; in others it can begin suddenly, within hours or days. Some people have episodes of illness lasting weeks or months with full remission of symptoms between each episode; others have a fluctuating course in which symptoms are continuous; others again have very little variation in their symptoms of illness over the course of years.”

Schizophrenia symptoms often only emerge well into adulthood, typically from the late teens to early 40s. The actual onset of psychosis is frequently preceded by a prodromal stage, wrote Michelle Pugle in a recent article on Verywellhealth.com, “where people (often still in adolescence) begin experiencing pre-psychotic mild or moderate disturbances in everyday functioning, including speech and movement difficulties. These changes can be attributed to heredity, genetic, environmental, and other causes.” 

“Psychosis is preceded by a 3–4-year prodromal phase characterized by non-specific symptoms and deficits in approximately 75 percent of patients with a first episode of psychosis (FEP),” according to Michael First, Professor of Clinical Psychiatry at Columbia University in New York. 

Since the prodromal phase is the earliest phase and schizophrenia symptoms are absent, it’s commonly diagnosed only after a person has entered the active phase of the disorder.

“Prodromal symptoms are generally seen as unspecific symptoms of schizophrenia (those involving an absence of normal interactions and functioning) that evolve over time,” wrote Pugle. “They can fluctuate in intensity, severity, and length of time. Such symptoms can begin in adolescence and the teenage years, although they aren’t likely to be seen as such unless a future diagnosis of schizophrenia is made later in life (a retrospective diagnosis).”

Early indicators are easy to miss. Small changes to personality and behavior or normal routine could be some of the first signs of prodromal phase schizophrenia. As we reported on this blog, researchers recently found new clues in young adults that could help predict the severity of symptoms later in life. According to their study published in the Journal of Abnormal Psychology, “Early detection of subtle, nonpsychotic forms of perceptual disturbance may aid in identifying individuals at increased risk for nonaffective psychosis outcomes in adulthood. Perceptual aberrations may constitute a useful endophenotype for genetic, neurobiological, and cognitive neuroscience investigations of schizophrenia liability.” 

Early signs and symptoms of schizophrenia may include:

  • Nervousness and/or restlessness
  • Depression
  • Anxiety
  • Thinking or concentration difficulties
  • Worrying
  • Lack of self-confidence
  • Lack of energy and/or slowness
  • A significant drop in grades or job performance
  • Social isolation or uneasiness around other people
  • Lack of attention to or care for personal hygiene 

“Some of the prodromal signs, such as a significant change in personal hygiene and a worrisome drop in grades or job performance, can also be early warning signs of other issues, including psychosis or detachment from reality,” explained Pugle in the article. 

If your child or teen starts showing the above signs and symptoms, talk to a pediatrician or mental health professional as soon as possible. Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses which are specific to each individual. About half of our clients are under 35 years of age and we expect good outcomes regardless of the duration of the disorder. Clients of any age will feel comfortable in our program. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

Assessing Cognitive Symptoms in Schizophrenia

Cognitive dysfunction is a core feature of schizophrenia, wrote Christopher Bowie and Philip Harvey in their study “Cognitive deficits and functional outcome in schizophrenia.”

“Deficits are moderate to severe across several domains, including attention, working memory, verbal learning and memory, and executive functions. These deficits pre-date the onset of frank psychosis and are stable throughout the course of the illness in most patients.” 

It is now widely recognized that these deficits are among the best predictors of functional outcomes in schizophrenia. In a recent presentation for Psych Congress Network, Leslie Citrome, MD, MPH, clinical professor of psychiatry and behavioral sciences at New York Medical College, Valhalla, NY, discussed the significance of cognition in schizophrenia. 

“We’ve known for quite some time about the positive symptoms of schizophrenia, such as delusions and hallucinations, and the negative symptoms of schizophrenia, such as the lack of motivation, lack of interest, and difficulty in expressing emotion,” Dr. Citrome explained.

“We’ve also learned to acknowledge the existence of cognitive dysfunction. Problems, for example, with verbal fluency, with paying attention, with problem-solving. At the same time, we’ve also paid more attention to the affective symptoms of schizophrenia. These overlap somewhat with negative symptoms.”

Cognitive impairment is quite common in people with schizophrenia. This has been confirmed by a number of studies. For example, in a 2019 study published in the American Journal of Psychiatry, Zanelli, Mollon, et al. found that patients with schizophrenia and other psychoses had a cognitive decline in memory, verbal learning, and vocabulary over a 10-year period. 

“Cognitive impairment occurs in first-episode and chronic schizophrenia,” said Dr. Citrome. “We can observe that people with schizophrenia have a lower degree of cognitive abilities, relative to the general population, right from the beginning.” 

Cognitive dysfunction can serve as an early warning sign. “This can be apparent at the very first episode. In fact, can predate the first episode of psychosis,” said Citrome. “People who are in the prodrome, or even in their childhood or adolescence, can exhibit some degree of cognitive impairment.” 

It’s not always easy to detect cognitive impairment associated with schizophrenia. In his presentation, Citrome explained some of the diagnostic tools. “Cognition in clinical trials with schizophrenia can be formally assessed using neuropsychological testing. The standard today is to use a battery of tests called the MATRICS Consensus Cognitive Battery or MCCB.”

The MCCB consists of 10 tests that include testing the speed of processing, attention or vigilance, working memory, verbal learning, visual learning, reasoning and problem-solving, and social cognition.

Measuring cognition has an important purpose. “Cognitive deficits do predict functional outcomes,” explained Dr. Citrome. Testing cognition “helps us predict how well someone will function.” 

Current research appears to indicate that the existence of positive schizophrenia symptoms may not necessarily impair functioning, but impairment of cognition can lead to impairment in functioning, and negative symptoms may impair functioning.

That means that “hallucinations and delusions by themselves aren’t going to be the determinants whether someone can work or have social relationships,” said Citrome. “It’s going to be negative symptoms and cognitive impairment.” 

The Colorado Recovery treatment model emphasizes the experience of empowerment, the strengthening of social relationships, and overall support for people with schizophrenia to improve all aspects of their lives. “Recovery from mental illness is about more than just getting rid of the symptoms and staying out of hospital. It is about regaining a sense of identity, belonging, and meaning in life,” said the late Richard Warner, M.D. and founder of Colorado Recovery. 

Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses which are specific to each individual. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

Treehouse Planning Session at IOP Level


Colorado Recovery is now expanding services outside our signature continuum of care. We are admitting directly into our intensive outpatient program (IOP) clients who may be ready to begin their recovery at the IOP level of care, or for those in the process of stepping down from another program. Community integration and social engagement continue to be at the heart of the approach, setting the course for a life of engagement, purpose, and connection.

This non-institutional approach created by Colorado Recovery founder Richard Warner is key to outcomes associated with independence and self-respect. One of the offerings now available at the IOP level is our Treehouse Planning Session.

This group gives clients the opportunity to participate in their recovery plan and voice what they seek from the psychosocial program. We review any needs that they have toward connecting and contributing to the community or improving the space. It’s also a time for people to meaningfully get to know each other and develop friendships outside of a strictly therapeutic setting.

Dr. Warner considered schizophrenia and similar conditions bio-psycho-social disorders significantly affected by the environment surrounding the client on multiple levels. The Warner method harnesses the benefits of client empowerment to increase skills and work preparedness and assist them with social integration. 

The Treehouse planning group is an important element of that. On the one hand, it’s “a safe space to take a break and just hang out,” says Treehouse community organizer Elise Alvarez. “At the same time, it’s a great opportunity to build more comfortable relationships.” The Treehouse group highlights the value of social integration, “many people have found roommates and best friends here,” says Alvarez. “Treehouse gives a population that doesn’t have too much opportunity to socialize the chance to do just that.”

People are able to reach a deeper level of knowing one another while engaging in fun activities. “Hiking is always the most popular group,” reveals Alvarez. “Especially people who are not from Boulder appreciate the nature side Colorado Recovery has to offer.”

In Treehouse planning, people work out their budget, another aspect of empowerment. “It’s an important skill to come to a decision yourself and not just defer to the judgment of the coordinator. Often, I keep pushing it back to them, telling them ‘this is your space,’ so they get to make the call.”

It’s important to give clients some measure of control, to let them work out the budget and create the space the way they want it to be. “We typically start with me making announcements, and then open the floor to things they want to talk about,” explains Alvarez. “We’ve had discussions about terminology: should it be mental illness or biopsychosocial disease? Other times, we plan out dinners or days at the beach.”

For more information about direct admission to our intensive outpatient program or our other services, connect with a specialist who can answer your questions at (720) 218-4068.

 

People With Schizophrenia Have A Higher Risk of Suicide Study Confirms

The suicide risk for people with schizophrenia between the ages of 18 to 34 years is ten times higher than that for the general US population, according to a new study published in May.

The study from the Columbia University Department of Psychiatry looked at a large population of adults diagnosed with schizophrenia and found that the youngest group (18-34) had the highest suicide risk and those aged 65 and older the lowest. By comparison, in the general US population, the reverse is true: younger adults have a smaller risk and older age groups have a greater risk.

The Columbia study, published online in the journal JAMA Psychiatry also showed that people with schizophrenia, overall, have a 4.5-fold increased risk of dying from suicide, the 10th leading cause of death in the United States.

“When a person with schizophrenia is becoming suicidal, an attempt can happen with little warning,” said Mark Olfson, Elizabeth K. Dollard professor of psychiatry at Columbia and lead author of the study. “Often, suicidal behavior in schizophrenia is driven by psychotic processes. This aspect can make it difficult to anticipate and prevent.”

The study, which provides a significant amount of data on age and suicide risk, could help suicide prevention efforts for people with schizophrenia. “Knowing more about which age groups and what personal characteristics are linked to higher risk could increase attention and support for the most vulnerable patients,” Olfson said.

Colorado Recovery founder Richard Warner believed that recovery rates for schizophrenia and suicidal thoughts are also linked to the social and economic environment. 

In his classic Recovery from Schizophrenia, Dr. Warner pointed out a strong statistical correlation between lack of employment and suicidal ideation. “Work problems, economic stress, and unemployment appear to be important in precipitating suicide.” (2nd edition, 1994)

Unfortunately, discrimination and stigma prevent many people with a mental illness such as schizophrenia and bipolar disorder from finding purposeful employment. Too many of their fellow citizens believe people with such mental disorders are unable to work.

In a more recent book, The Environment of Schizophrenia, Warner wrote that “the mentally ill are among the most alienated people in our society, daily confronting the key elements of alienation—meaninglessness, powerlessness, normlessness, and estrangement from society and from work.” This induces an “existential neurosis” which in turn drives a significantly higher risk of suicide. “Many people with mental illness face lives of aimlessness and boredom,” wrote Warner.

Work can help overcome that sense of aimlessness and provide a better chance of recovery. “Productive activity is basic to a person’s sense of identity and worth. Given training and support, most people with schizophrenia can work,” Warner wrote. A productive life in recovery can also shield from suicidal ideation. 

Colorado Recovery approaches care for mental health based on a path of self-reliance through developed practiced skills. This non-institutionalized philosophy offers comprehensive levels of care supported by an expert medical and clinical team, engaging patients in increasing community participation.

Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses which are specific to each individual. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

Is It Schizophrenia? Is It Substance Use?

Around ten million adults in the United States currently experience both mental illness and a substance use disorder (SUD). It’s a well-established correlation, often complicating the treatment of both conditions. One such co-occurring disorder is schizophrenia

In a recent webinar for Harmony Foundation, Colorado Recovery’s medical director Alan Fine, M.D., talked about the symptoms of schizophrenia and substance use disorder and why it is frequently difficult to tell the two conditions apart.

 

 

First off, Dr. Fine presented a diagnostic flowchart to illustrate where SUD and schizophrenia can be found in the mental healthcare realm. If the symptoms are acute and were caused by taking drugs or drinking alcohol then we’re looking at substance misuse and a possible addiction scenario. If the diagnosis is psychosis without a physical cause, the condition is often diagnosed as schizophrenia or bipolar disorder. 

The diagnosis of schizophrenia itself is complicated and based on the work of three trailblazers in the field whose impact can still be felt today: Emil Kraepelin (1856–1926), Eugen Bleuler (1857–1939), and Kurt Schneider (1887–1967). 

Kraepelin is considered one of the founders of modern scientific psychiatry. His views dominated the field at the start of the 20th century. Bleuler renamed Kraepelin’s “dementia praecox” schizophrenia and established the classic four As of the condition: ambivalence, affect, alogia, and autism (preoccupation with self). Schneider in turn formulated the first-rank symptoms of schizophrenia: auditory hallucinations, feelings of external control, thoughts connected to others, and other delusions.  

In his book, The Environment of Schizophrenia, Colorado Recovery founder Richard Warner wrote that “schizophrenia is a psychosis. That is to say, it is a severe mental disorder in which the person’s emotions, thinking, judgment, and grasp of reality are so disturbed that his or her functioning is seriously impaired.”

What about substance use then?

By definition, schizophrenia is not caused by the effects of a substance or another medical condition. That, however, is not quite all. 

Mental health conditions and SUDs frequently co-occur because many people with addiction are primarily misusing addictive substances to self-medicate emotional pain caused by serious mental health disorders. 

“The proportion of schizophrenic patients of comorbidity of substance abuse varies in published studies from 10–70 percent, depending on how patients are diagnosed with schizophrenia, the types of populations studied, and the different ways of defining drug and alcohol disorders,” said Dr. Fine. “There’s a remarkable overlap in both directions.”

People with schizophrenia are at a higher risk of engaging in substance misuse because many of them will be tempted to self-medicate the severe symptoms of their mental illness as well as some of the side effects of their antipsychotic medications. At the same time, substance misuse may cause syndromes that are similar or even identical to schizophrenia.

In the short term (acute intoxication), schizophrenia-like symptoms may include delusions (stimulants and inhalants), loose associations (stimulants, alcohol, sedatives, and inhalants), and hallucinations (stimulants, alcohol, and inhalants). Both alcohol and sedative withdrawal symptoms include hallucinations and paranoia. 

In the long term (prolonged misuse), “amphetamine use is associated with long-term psychosis—thirty percent of all amphetamine-induced psychoses become chronic,” Dr. Fine explained. Chronic alcohol misuse may cause persistent dementias such as Korsakoff syndrome and delirium tremens. 

People with schizophrenia also engage in substance misuse to cope with the deterioration of their social environment, an area that Dr. Warner explored extensively

So, the answer to the question “Is It schizophrenia or is it substance misuse?” is often: both! That means, should both conditions be present, both need to be treated because they may reinforce each other. An important element in this regard is empowerment

Empowering people with schizophrenia reduces the need to self-medicate and often improves symptoms. Believing in their ability to take charge of their lives and manage the complex challenges of their illness is crucial for people with schizophrenia.

Over the course of his long professional career, the late Dr. Warner realized that social inclusion empowers people with mental illnesses and improves outcomes. “Work helps people recover from schizophrenia,” Warner concluded. “Productive activity is basic to a person’s sense of identity and worth.”

Colorado Recovery has been utilizing the Warner method to empower adults with mental illness for many years now. Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

 

Upcoming Training with Expert in Communicating with Someone Experiencing a Mental Health Challenge

Do you ever struggle to connect and communicate with a loved one who is experiencing a mental health challenge? Dr. Xavier Amador is an internationally renowned clinical psychologist, expert, and author specializing in communication tools to help support people with mental health disorders like schizophrenia or bipolar disorder. Dr. Amador developed his evidence-based techniques to help him develop a better relationship with his brother, who was diagnosed with schizophrenia. He founded the  LEAP® (Listen-Empathize-Agree-Partner) method. Many family members and caregivers have found his techniques very helpful. 

 

Colorado Recovery encourages families and caregivers to read his book, I Am Not Sick and I Don’t Need Help, or attend an upcoming training listed below. 

Dr. Xavier Amador will be presenting an online training sessionlive with Q&A! 

Wednesday, January 13, 2021, @12:00pm-3:00 pm Eastern Time (the US and Canada)

This session is for Family Caregivers and Professionals who want to help someone with serious mental Illness and anosognosia—the neurological symptom that leaves a person unable to understand s/he is ill, resulting in conflict, isolation, and treatment refusal.

Participants will be introduced to LEAP® (Listen-Empathize-Agree-Partner), an evidence-based approach that teaches you how to create relationships that lead to treatment and recovery. Learning objectives include:

  • Identify Anosognosia vs. “Denial”
  • Lower Anger, Resistance & Defensiveness
  • Re-establish Trust & Broken Relationships

Cost

$130 Early Bird (ends Dec 11), $150 Regular

LEAP Foundation is a small nonprofit and 100% of proceeds from this session are used to fulfill the organization’s mission.

More info: https://lfrp.org/online-trainings

Readings on Schizophrenia

I have had the pleasure to discover and study some of Dr. Richard Warner’s books (The Environment of Schizophrenia, Social Inclusion of People with Mental Illness and Recovery from Schizophrenia) and they have absolutely changed my outlook on mental illness. My 20-year old son has been diagnosed with schizophrenia two years ago. The following are some of the things I have learned from Dr. Warner’s books:

1. The books have changed my mindset from the start, by stating that 25% of people with schizophrenia actually recover. Many of us know what a cloud of despair can be cast on parents and relatives of schizophrenics. When my son was first diagnosed, I was given sympathetic looks and a list of support groups. I can’t begin to tell you how many times I was told, “Good luck!” Support groups were often equally discouraging. I am sure they can be useful in some situations, but the ones I attended were full of sad people with very few answers, who desperately wanted a way out. The main question was, “How can I – as a parent – survive this?” Many were telling me to put my son in an institution or send him out on his own, but I just couldn’t do it.

Finally, my son had to be hospitalized for a month. Even there, I received no word of hope. The person who was given temporary guardianship of him at that time thought she was being reassuring when she told me that he will most likely relapse and the second time around we will have a better chance to obtain permanent guardianship. And then I read these books. There is a chance my son might recover! Finally, a ray of hope.

2. The second thing that helped me in thee books is the warm and sound approach to recovery. Having lived in many third world countries, I can see how schizophrenics can receive greater social acceptance and more opportunities for work there. Even in Italy (where I was born), medical institutions are far from the cold, sterile approach I found in this country. Here my son has been arrested three times, handcuffed twice, pepper-sprayed once. Most doctors and therapists I have seen have been distant, measuring their words as if they were following a text book. This ordeal has actually drawn me closer to my sister (who lives in Italy) because I have called her at times of crisis, finding comfort and support in the natural motherly wisdom we have both known as children and have tried to apply in our families. These books have helped me to recognize the importance of a warm family environment, which is mentioned but rarely stressed in most publications (where the emphasis seems to fall on medications).

3. I have also appreciated Dr. Warner’s insights on cigarettes and marijuana usage. My son uses both. He started smoking cigarettes at the hospital, where they gave them out like candy. About the marijuana, all the professionals I have seen have warned me that it will have terrible effects or at least will cancel out the medications he is taking. My son told me it’s the only thing that helps him. He says it simplifies his thoughts and, when he uses it, “the voices are not angry anymore.” You may wonder why he still hears voices while he takes medications. I wonder too, and I told the psychiatrist who has made no effort to change her prescription. I suppose she knows what she is doing. My son doesn’t want to change doctors and I am just happy he accepts the medications because initially he didn’t. At any rate, Dr. Warner’s books have relieved my own paranoia about my son’s marijuana usage. Now that I know the sky is not going to fall, I can concentrate on what Dr. Warner advises to do in these cases – in his words, “invest more in those programs that help a person find a place in the world, that help people make friends and fulfill useful social roles.” I have been trying to prevent his boredom, include him in engaging activities (he does pole-vaulting at a local college), encourage situations where he can meet friends, and enroll him in work-training programs sponsored by the Department of Rehab.

There is much more, and I might have to write again at a later time. For now, I am deeply grateful for Dr. Warner’s efforts to bring concrete hope and solutions to patients and their parents.

S.C.

People recover from schizophrenia

You won’t hear psychiatrists say this often (and I am a psychiatrist): People recover from schizophrenia.

Something that has long been accepted as a truism by psychiatrists around the world is a belief, promulgated by Emil Kraepelin, the director of a German asylum in the late 1800s, that schizophrenia has an inevitable downhill course. Kraepelin called the illness “dementia praecox” (progressive illness of early life) to hammer home this idea. The concept is reinforced for psychiatrists by the fact that they rarely see people who have recovered from the illness; the recovered patient just stops coming in to see them and returns to a normal life.

Some events transform our professional lives. The first in my career was a conference in Palo Alto in 1977. I was a raw, young psychiatrist when Loren Mosher and his colleagues presented the results of the Soteria study. At that meeting I learned a truth from which my training had protected me – that people can recover from schizophrenia without medication.

Soteria was a therapeutic milieu for young people who met criteria for schizophrenia that was designed as a gentler alternative to the psychiatric hospital. The program, established in a house on a street in San José, California, offered a calming, respectful environment that tolerated individual differences. Staff were encouraged to treat residents as peers and to share household chores, creating an ethos of shared responsibility for running the house and being part of a mutually-supportive community. AnTo post a response to this blog please visit The Recovery Trust.

The Recovery Trust, a Colorado-based nonprofit, has added a new resource for families in need of education and support. It is a free, secure, online forum through which family members can join with others in the same situation.

The forum is moderated by a team of mental health professionals, psychiatrists, family members and people who have experienced mental illness, all of whom have received extensive training in their role as facilitators. Users of the forum can access a large database of information about these illnesses, FAQs and links to other resources.tipsychotic medication was rarely used.

The Soteria project demonstrated that long-term outcome for residents of the therapeutic household was similar to that of patients admitted to standard hospital-based treatment where antipsychotic medication was routinely used. The Soteria approach has since been replicated in California, Alaska, and several countries in Europe.

Coming away from the Soteria conference, I was infused with a passion to understand the true course and outcome from schizophrenia. For months, I ferretted around in the dusty basements of medical libraries unearthing twentieth-century research studies from all over the world. Outcome from schizophrenia has been a popular topic for psychiatrists to study, in the US, Britain, Scandinavia and beyond, since the late 1800s when it was first defined as an illness by Kraepelin. I brought this analysis of over a hundred studies in schizophrenia up-to-date in 2004, incorporating results from the entire century. It demonstrated that optimism about outcome from schizophrenia is justified. Throughout the century around 20% regularly achieved “social recovery” (economic and residential independence and minimal social disruption) and another 20% achieved “complete recovery” (loss of psychotic symptoms and return to the pre-illness level of functioning). This was true for the whole century, except the Great Depression, when recovery rates were halved. Long-term outcome did not improve at all – in fact it got worse – after the introduction of antipsychotic medication in the mid-1950s.

These results aren’t just ancient history. Support for this level of recovery comes from a number of recent studies. A 2007 Chicago-based 15-year follow-up of people with schizophrenia found 19% to be in complete recovery. A 2008 study from Hamburg, Germany, found that 17% of nearly 400 patients with schizophrenia achieved complete recovery after a 3-year follow-up period, and an 8-year study of people with schizophrenia in Dublin, published in 2009, found 39% to be socially recovered. All these results are closely in line with the results of the twentieth-century studies.

It emerges that one of the most robust findings about schizophrenia is that a substantial proportion of those who present with the illness in high-income countries will recover completely or with good functional capacity. Surprisingly, outcome is even better in low- and middle-income countries. Kraepelin’s view that a deteriorating course is a hallmark of the illness proves not to be true; heterogeneity of outcome, both in terms of symptoms and functioning, is the signature feature.

Knowing what I know now, when I see a patient with a first episode of psychosis I don’t start antipsychotic medications right away, especially if the onset is very acute. I wait a few days to see what transpires. If I eventually decide that the person does suffer from schizophrenia, the first thing I tell the family is: This is an illness that generally gets milder as time passes.

Let’s put Emil Kraepelin behind us. We know what we need to know to be able to stop telling patients and families that the outlook from schizophrenia is dismal.

Dick Warner