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UNIT 3 ■ Care of Patients With Psychiatric Disorders
active psychotic (acute schizophrenic episode), and residual phases. Phase I: The Premorbid Phase Premorbid signs are those that occur before there is clear evidence of illness and may include distinctive personality traits or behaviors. Premorbid person- ality and behavioral measurements that have been noted include being very shy and withdrawn, having poor peer relationships, doing poorly in school, and demonstrating asocial behavior. Boland and Verduin (2022) stated: In the typical, but not invariable, premorbid history of schizophrenia, patients had schizoid or schizo- typal personalities characterized as quiet, passive, and introverted; as children, they had few friends. Preschizophrenic adolescents may have no close friends and no dates and may avoid team sports. They may enjoy [solitary activities] to the exclusion of social activities. (p. 349) Current research is focused on the premorbid stage in hopes that identifying biomarkers and at-risk indi- viduals may prevent transition to illness and provide greater opportunity for early intervention (Clark et al., 2016). Phase II: The Prodromal Phase Prodromal signs are differentiated from premorbid signs in that prodromal symptoms more clearly mani- fest as signs of developing schizophrenia than do pre- morbid signs. The prodromal phase of schizophrenia begins with a change from premorbid functioning and extends until the onset of frank psychotic symp- toms. This phase can be as brief as a few weeks or months but for some it may last several years. During this phase, the individual begins to show signs of significant deterioration in function. Fifty percent complain of depressive symptoms (APA, 2022). Social withdrawal is not uncommon, and signs of cognitive impairment may begin to emerge. Some adolescent patients develop sudden onset of obsessive-compulsive behavior during the prodromal phase (Boland & Verduin, 2022). Recognition of the behaviors associated with the prodromal phase provides an opportunity for early intervention with a possibility for improvement in long-term outcomes. Current treatment guidelines suggest therapeutic interventions that offer support with identified problems, cognitive therapies to min- imize functional impairment, family interventions to improve coping, and involvement with the schools to reduce the possibility of failure. Some controversy
exists about the benefits of pharmaceutical therapy during the prodromal phase; however, evidence sup- ports that comprehensive treatment begun at the time of the first psychotic episode is associated with better outcomes (Kane et al., 2015). Phase III: Active Psychotic Phase (Acute Schizophrenic Episode) Schizophrenia is a chronic illness that is character- ized by acute episodes in which symptoms are more pronounced. During acute episodes, psychotic symp- toms are typically prominent. Box 15–1 describes the DSM-5-TR (APA, 2022) diagnostic criteria for schizophrenia. Phase IV: Residual Phase Schizophrenia is characterized by periods of remis- sion and exacerbation. A residual phase usually follows an active phase of the illness (symptoms described in Phase III). During the residual phase, symptoms of the acute stage are either absent or no longer prominent. Positive symptoms (like delu- sions and hallucinations) are often ameliorated, but negative symptoms (see Box 15–2) may remain. Flat affect and impairment in role functioning are common in this phase. It has long been thought that these negative symptoms are pervasive and sta- ble, but current research has challenged that belief with evidence that negative symptoms can improve over time (Savill et al., 2015), although admittedly they are difficult to treat. Residual impairment often increases with additional episodes of active psychosis. Prognosis Outcomes in schizophrenia are difficult to predict and are highly variable, but long-term follow-up studies indicate that significant clinical improvement occurs in about 44% of patients with schizophrenia (Os & Reininghaus, 2017). Several factors have been associated with a more positive outcome. These fac- tors include good premorbid functioning, later age at onset, female sex, abrupt onset of symptoms with an obvious precipitating factor (as opposed to grad- ual, insidious onset of symptoms), lower depression scores, low baseline levels of aggression, rapid reso- lution of active-phase symptoms, minimal residual symptoms, absence of structural brain abnormal- ities, ability to live independently at baseline, no family history of schizophrenia and good family sup- port (Boland & Verduin, 2022; Frankenburg, 2020; Shrivastava et al., 2010).
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