Early detection of schizophrenia: a clinical-psychopathological revision of the ultra-high risk approach

V. Ramella Cravaro1, A. Raballo2

1 Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Italy; 2 Department of Mental Health, AUSL, Reggio Emilia, Italy


During the last 20 years, early phases of psychotic disorders have become one of the major clinical and research issues in psychiatry. It is well known since the last century that schizophrenia and psychotic disorders are characterised by a subclinical prodromal phase that can last weeks, months, or even years before the onset of overt psychotic symptoms. The prodromal phase is important in defining potential risk-markers of progression to psychotic illness and as a target for new biological and psychological treatments to prevent a transition to psychosis. Furthermore, the focus on early phases of psychotic disorders may improve the long term outcomes of patients by reducing the duration of untreated illness 1-3. For all these reasons, during the last two decades a clinical “At Risk Mental State” syndrome and its operational criteria have been described leading to the development of two main early detection approaches: the ultra high risk approach (UHR) and the basic symptoms (BS) approach, each with its assessing instruments. Beside these, another important research front is that of anomalous self-experiences (ASE). ASE have been already widely detailed in early phenomenological descriptions of the core features of schizophrenia that might surface in the prodromal phases. The integration of these approaches could be of great value to enrich current operational criteria with a deeper, experience-close understanding of the unique, subjective perspective of individuals at risk of developing a psychosis. However, the integration of these approaches is not a mere juxtaposition of terms. Indeed, the field of early detection is vexed by an increasing terminological confusion related to the lack of an international consensus catalogue of terms that facilitate the bibliometric proliferation of new expressions that do not allow facile comparison of results from all the early psychosis research groups worldwide 4. Likewise, to date, a diagnostic category for prodromal phases has not yet been included in DSM or ICD despite the presence of the “attenuated psychotic syndrome” in the appendix of the new DSM-5 as a condition for further study 5. From a conceptual point of view, the integration of UHR, BS and ASE approaches awaken the discussion about the existence or not of a psychotic continuum with schizophrenic and affective psychoses at the extremes. Indeed, if the former has been used for the evaluation and monitoring of individuals at high risk of developing a psychotic disorder, the latter describes and assesses a set of symptoms characteristic of schizophrenia spectrum disorders. In closing, we describe the clinical staging model as well as the clinical and research benefits and disadvantages that it could bring for early psychosis.

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