Australia has become a particularly active site for this type of research, and in 1996 a National Early Psychosis Project (NEPP) was launched as ‘a collaborative endeavour between the Commonwealth, State and Territory governments of Australia to develop and promote a national model of best practice for early intervention in psychosis’. This model of best practice is now embodied in the recently published Australian Clinical Guidelines for Early Psychosis. These guidelines extend the definition of psychosis to include ‘the period described as the prodrome’.[10]
The most advanced early psychosis programme in Australia, consistently cited as a model, is run by the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Victoria. EPPIC assumed a leadership role in Australia after winning the government tender to establish the NEPP. Much of the policy development embodied in the Clinical Guidelines has come out of EPPIC research programmes.
A major problem for psychiatrists researching into a prodromal phase of schizophrenia is a lack of consensus about pre-psychotic symptoms. The EPPIC team had at first intended to adopt the nine prodromal symptoms supplied in DSM-III-R.[11] However, when EPPIC conducted a community survey of Australian high school students to determine the prevalence of these symptoms in the general population of adolescents, they found that ‘nearly half the sample (49.2%) had two or more symptoms and hence met the criteria for DSM-III-R schizophrenia prodrome’. This remarkably high figure caused the researchers to adjust the threshold for diagnosis by reducing the number of possible symptoms from nine down to four. Testing the restricted criteria on ordinary high school students found that only ‘10 to 15 percent of the sample met the criteria for schizophrenia prodrome’.[12]
Satisfied that the modified criteria could be used to correctly identify their target group, the EPPIC researchers went on to implement ‘a specialised outpatient service to monitor and care for young people thought to be at high risk for psychosis’.[13] The new clinic was called PACE—Personal Assistance and Crisis Evaluation.
Initially, the PACE clinic targeted young people between sixteen and thirty years of age. These were divided into three groups. Group 1 were people who met the complete DSM-III-R criteria for schizophrenia prodrome and who also had a first or second degree relative with a history of a DSM-III-R psychotic disorder or schizotypal personality disorder. Group 2 were people who had one or more of the four DSM-III-R positive-only criteria for schizophrenia prodrome—that is, (1) markedly peculiar behaviour; (2) digressive, vague, overelaborate, or metaphorical speech; (3) odd or bizarre ideation or magical thinking; (4) unusual perceptual experiences. Group 3 were ‘young people with a history of fleeting psychotic experiences that spontaneously resolved (called brief limited intermittent psychotic symptoms, or BLIPS) within 1 week’.[14]
To detect these types of people in the community and channel them into the PACE clinic, a public education campaign was launched, aimed particularly at general practitioners and other specialised professionals—such as school counsellors, teachers and youth workers—who are frequently in contact with young people. Treatment involved psychosocial therapy or neuroleptic medication, sometimes both. Of the patients treated ‘[t]he most frequently occurring DSM-III-R prodromal symptoms were magical thinking, perceptual disturbance, and impaired role function, present in 67.7, 54.8, and 54.8 percent of the subjects, respectively’.[15]
The fact that nearly 70 per cent of these young people were treated for ‘magical thinking’ is quite extraordinary. According to a description in DSM-IV’s Glossary of Technical Terms, magical thinking is not a particularly debilitating symptom: "The erroneous belief that one’s thoughts, words, or actions will cause or prevent a specific outcome in some way that defies commonly understood laws of cause and effect. Magical thinking may be part of normal child development."[16]
The logic of schizophrenia prevention is that although some of the prodromal symptoms might not be serious handicaps in themselves, they are, all the same, signs of approaching psychosis. However, members of the EPPIC team had previously discovered in other research that 51 per cent of normal Australian sixteen-year-olds experience magical thinking.[17] The fact that magical thinking was one of the symptoms used to identify these supposed pre-psychotic young people, and that it did not have to be combined with other symptoms, means that the selection criteria were still targeting over 50 per cent of the population. Having already rejected the possibility that half of all Australian teenagers are afflicted with the prodrome for schizophrenia, why did the EPPIC team not realise that magical thinking is simply a part of normal adolescent psychology?
By 1996 the EPPIC researchers were ready to claim success for the initial PACE programme and asserted that ‘it is possible to identify and follow possibly prodromal individuals in the community’.[18] But they were concerned that many of the patients monitored during the course of the programme did not make the transition to full psychosis. The transition rate to psychosis presents an interesting problem of interpretation. On the one hand, if most of the young people fail to cross the threshold into psychosis, it can be claimed that the preventive treatment was successful. But on the other hand, it might also indicate that the prodromal indicators were not accurate, and that many of the patients had been given a false positive diagnosis.
Next: Inventing the Diagnostic Criteria
[10] National Early Psychosis Project, Australian clinical guidelines for early psychosis, p. 11.
[11] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Third Edition — Revised, (DSM-III-R), pp. 194–5.
[12] Yung et al., ‘Monitoring and care of young people at incipient risk of psychosis’, p. 289.
[13] Ibid.
[14] Ibid., p. 292.
[15] Ibid., p. 293.
[16] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM-IV), p. 768.
[17] Patrick D. McGorry and Jane Edwards, Early Psychosis Training Pack, Module 1, p. 17, cited in table adapted from McGorry et al., ‘The prevalence of prodromal features of schizophrenia in adolescence: a preliminary survey’, Acta Psychiatrica Scandanavica, 92, 1995, pp. 241–9.
[18] Yung et al., ‘Monitoring and care of young people at incipient risk of psychosis’, p. 299.