The Schizophrenia Prodrome

Abstract

A 13-year-old girl, currently in the eighth grade and with a history of attention deficit hyperactivity disorder, was brought by her mother to a university-affiliated outpatient psychiatric clinic after a gradual decline in her academic performance was noted. She had a previous history of receiving grades of B and C in all her classes, but currently she was getting Ds and Fs. At age 8 years she had begun receiving stimulant medication, with some benefit. She had tasted alcohol in the past but denied current use. She had also used marijuana a half-dozen times. She reported having a small number of close friends. Although she said that there were no recent changes in her peer relationships, her parents claimed that she had been withdrawn and had appeared sad and that at times they needed to prompt her to take a shower. She had a maternal aunt with bipolar affective disorder and a great uncle who had been institutionalized for unknown reasons. During the clinical interview, she was dressed in Goth attire, including a black T-shirt with images of letters dripping blood; she had dyed black hair. Her affect was blunted but was slightly more animated when her parents left the room. She denied thoughts of suicide. She reported occasionally hearing whispering voices calling her name and saying that she is worthless. She also reported the belief that her friends did not like her as much as they had. Her mother, who recently met a parent of a child with schizophrenia, posed the question of whether her daughter has schizophrenia. Challenges of the Schizophrenia Prodrome The century-old term “latent schizophrenia” and the more recent term “schizophrenia prodrome” emerged from a retrospective piecing together of the early course of illness in individuals with schizophrenia. Linking the word “prodrome” with “schizophrenia,” as in the title of this article, implies that those who are identified as having symptoms of the prodrome will later develop schizophrenia. Yet the constellation of symptoms in the schizophrenia prodrome tends to be nonspecific, especially in the early stages. Thus, prodromal symptoms are not deterministic from a prospective point of view, and considerable research is directed toward identifying which patients with prodromal symptoms will later develop schizophrenia. The clinical vignette reflects these challenges. The early adolescent patient presents with a number of symptoms consistent with a schizophrenia prodrome, including a long-standing history of difficulties with attention, a recent history of cognitive decline, social withdrawal, and what appears to be psychotic symptoms. Yet these symptoms could also be explained in terms of major depression with psychotic features, bipolar affective disorder, substance use disorder, posttraumatic stress disorder (PTSD), or even an aberration in the maturation and solidification