To the Editor: Several key lines of evidence support the utility of a clinical staging model to guide early interventions for patients with psychotic disorders (1,2). Such an approach defines the progression of disease in time and identifies the patient's position along this continuum of the course of illness (2). This approach integrates a variety of neurobiological, social, and personal risk factors, providing a clinical decision framework for person-tailored early intervention.
Although use of low-dose antipsychotics has shown clear-cut advantages in the treatment of fully fledged psychosis (3), there is insufficient evidence to support this pharmacologically based intervention for help-seeking patients who are in the prodromal phase or at ultra-high risk of psychotic illness but who are still below the threshold of frank psychosis. In this context, psychological interventions that address phase-specific components of the prodromal phase of psychosis are of primary importance, both as a way to control subjective distress and as an opportunity to add to the knowledge base on early intervention in psychosis in mental health services.
According to recent modeling of the progression to schizophrenia and related disorders (1,2), at least four stages along a continuum can be identified: a premorbid phase, without gross psychosocial impairment but with detectable endophenotypic vulnerability traits and risk factors; an early prodromal phase, with mostly anomalous subjective experiences (such as basic symptoms), initial psychosocial impairment, and deterioration of the quality of life and of relationships with peers; a late prodromal phase, consisting of subthreshold psychotic symptoms—that is, attenuated psychotic symptoms or brief and limited intermittent psychosis; and an overt psychotic phase that is liable to develop into schizophrenia.
Such staging indicates a continuum of increasing risk, where initially unspecific conditions that phenotypically overlap with the early stages of other disorders gradually progress to more defined clinical-diagnostic profiles. Given the heterogeneity and multidimensionality of the mental states that might indicate a risk of psychosis, psychological interventions should be individually tailored to address salient clinical and biopsychosocial features and would be better conceived as a spectrum of problem-focused techniques.
Indeed, patient and family psychoeducation, self-help (including online resources), and supportive counseling might be better suited for the initial phase, whereas other interventions, such as symptom-focused coping training, enhancement of problem-solving skills, cognitive-behavioral therapy, and interpersonal psychotherapy would become progressively more pertinent according to the incremental level of psychopathology, personal suffering, and caregivers' burden. Thus the clinical staging model can promote increasing integration of psychotherapeutic techniques, ranging from context-oriented skills training that supports specific domains of behavioral functioning to more sophisticated sociocognitive interventions (4) and even to the reestablishment of a coherent self-narrative during recovery from psychosis (5).
Mapping the "taxonomy of risk"—as reflected in the clinical staging model of psychosis—to a coherent spectrum of psychotherapeutic techniques offers clinicians a unique opportunity to move beyond the rigid geography of traditional psychotherapy "brand names" toward a more person-centered approach focused on early intervention.
Dr. Raballo is affiliated with the Center for Subjectivity Research, Danish National Research Foundation, University of Copenhagen. Dr. Larøi is with the Cognitive Psychopathology Unit, University of Liège, Belgium.
The authors report no competing interests.
Schultze-Lutter F, Ruhrmann S, Klosterkötter J: Early detection of psychosis: establishing a service for persons at risk. European Psychiatry 24:1–10, 2009
McGorry PD, Killackey E, Yung A: Early intervention in psychosis: concepts, evidence and future directions. World Psychiatry 7:148–156, 2008
Kahn RS, Fleischhacker WW, Boter H et al: Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial. Lancet 371:1085–1097, 2008
Spaulding W, Nolting J: Psychotherapy for schizophrenia in the year 2030: prognosis and prognostication. Schizophrenia Bulletin 32:94–105, 2006
Stanghellini G, Lysaker PH: The psychotherapy of schizophrenia through the lens of phenomenology: intersubjectivity and the search for the recovery of first- and second-person awareness. American Journal of Psychotherapy 61:163–179, 2007