Taxonomías Primarias (Primary Taxonomies)

Sullivan, a psychiatrist, published as early as July 1927 his article on the onset        of schizophrenia in The American Journal of Psychiatry (Sullivan, 1994). He explained                    there that two factors preliminary to schizophrenic psychoses had been identified in        male patients: the experience of ‘subjectively difficult efforts’ and a ‘sex factor’ (the        inability to ‘achieve if only for a short time a definitely satisfying adjustment to a sex        object’) (Sullivan, 1994, p.135). In addition to this, ‘cultural distortions provided by the       

11   _{I will focus almost exclusively on psychotic disorders in this chapter (and throughout this}                         

home’ were determined to be of prime importance in the onset of schizophrenia (Ibid.,        p.135). While the detection of vulnerability traits, risk factors and prodromal        symptoms has transformed considerably since then, Sullivan’s insistence on the        importance of a dynamic view rather than a static one when envisaging psychotic        disorders, so as to dedicate more efforts into the study of their prodrome, is in a quite        similar vein to what is published on the topic nowadays.  

The most recent increase in focus on the prodromal phase of mental disorders        was, in part, motivated by the aggregation of retrospective accounts from schizophrenic        patients relating their growing difficulties in thinking, in feeling and in behaving        (Addington; Heinssen, 2012). A series of studies, a number of which were not primarily        aiming to inform the definition of a prodrome, provided researchers with data about        patients’ experiences and memories before the onset of a full-threshold mental disorder.        Their narratives were recorded, analysed, combined and compared in order to try and        reach a clearer consensus in the demonstration and the definition of psychosis’        prodrome, as is shown by Loebel et al. (1992, p.1184): 

First we asked patients and their family members when the        patient (or the family member) first experienced (or noticed)        behavioral changes which, in retrospect, appear to have been        related to the patient's becoming ill. Second, after explaining        psychosis in clear language, we asked when the patient (or the        family member) first experienced (or noticed) psychotic        symptoms. 

Although the precision of such recollections is liable to questioning and might cast        doubt on the accuracy of the data thus collected, the frequency with which patients’        accounts mentioned specific symptoms across various populations allowed researchers        to reach conclusions concerning the existence of a prodromal phase for several mental        disorders. The retrospective study of the prodromal symptoms of schizophrenia headed        by Rofes, Bueno, Labad and Valero led to the discovery that several prodromal        symptoms were repeatedly reported in their sample of 689 schizophrenic patients:       

delusional ones, disorganized ones and neurotic ones ( 2003, p.35) . Up to 90% of        patients with schizophrenia have been shown to describe changes in drive, perception,        beliefs, attention, concentration, mood, affect and behaviour (Yung, McGorry, 1996,        p.353).  

As I will explain later, however, definitions of the prodrome have become        much more detailed and comprehensive with time, and they cannot be reduced to the        retrospective reports of patients who already suffer from a full-threshold mental        disorder. A large number of retrospective and prospective clinical studies focusing on        subthreshold symptoms, biomarkers and genetic markers has given rise to remarkably        thorough assessments of the prodrome. What is most noteworthy about these efforts,        though, are the reasons why the earlier phases of mental disorders have gathered        increasing attention since the 1990’s, and how pre-emptive psychiatry has recently        become an overarching issue.  

Underlying the development of pre-emptive psychiatry is the hope that it        might provide significantly better clinical and functional outcomes for patients, as        opposed to simply palliative approaches (McGorry et al., 2014, p.211). A significant link        between the Duration of Untreated Psychosis (DUP) and poorer prognoses has been        established on several occasions; and there is convincing evidence of a ‘modest        association between DUP and outcome, which supports the case for clinical trials that        examine the effect of reducing DUP’ (Marshall, 2005, p.975). Therefore, there is        considerable medical interest in being able to intervene as early as possible. According        to Singh, three emerging strands of evidence support the case for specialised Early        Intervention services: first, evidence that early trajectory and disability are strongly        predictive of long-term course and outcome, as it offers an early window of        opportunity during this period of neuronal and psychosocial plasticity; secondly, the        association between longer periods of untreated psychosis and poorer outcomes being        firmly established; and thirdly, evidence that even well-resourced community services        are not meeting the needs of young people in their first psychotic episode or who are at        risk for psychosis (Singh, 2010, p.343). Developing Early Intervention services might        thus participate in ameliorating many people’s prognosis by reducing delays in       

treatment and addressing these people’s needs more specifically than general      12      community health services; it would certainly explain the enthusiasm demonstrated by        pre-emptive psychiatry’s most fervent proponents. 

However, considering that the rest of this chapter is dedicated to explaining in        more detail what underlies and justifies the development of pre-emptive psychiatry        from a medical perspective, the consideration of its economic impact becomes a more        pressing question here. Indeed, in order to justify pursuing research on the prodrome        of mental disorders to such an extent, its relevance must be argued for in terms of both        medical results and cost-effectiveness.