Course of Illness

The typical course of the initial psychotic episode can be conceptualised as occurring in three phases. Once an episode has happened, when the course of the illness is reviewed, we can often see that there was a prodromal phase, an active phase and a recovery phase.

The At-Risk or Prodrome Phase – ‘Something is not quite right’

Psychotic illnesses rarely present out of the blue. Almost always, these disorders are preceded by a gradual change in psychosocial functioning, often over an extended period. This is the period during which the individual may start to experience a change in themselves, but have not yet started experiencing clear-cut psychotic symptoms. This is the prodromal phase of the illness, which is known as the “at risk mental state” phase.

Changes in this phase vary from person to person and the duration of this phase is also quite variable, although it is usually over several months. In general, the at risk phase is a fluctuating and fluid process, with symptoms gradually appearing and changing over time.

Some of the changes seen during this phase include:

• Changes in affect such as anxiety, irritability and depression

• Changes in cognition such as difficulty in concentration or memory

• Changes in thought content, such as a preoccupation with new ideas often of an unusual nature

• Physical changes such as sleep disturbance and loss of energy

• Social withdrawal and impairment of role functioning, which can include deterioration in school or work performance

The person may also experience some attenuated positive symptoms such as mild thought disorder, ideas of reference, suspiciousness, odd beliefs and perceptual distortions which are not quite of psychotic intensity or duration.

These may be brief and intermittent at first, escalating during times of stress or substance abuse and then perhaps subsiding, before eventually becoming sustained with the emergence of clear-cut psychosis.

Clearly many of these changes are quite non-specific and can result from a number of psychosocial difficulties, physical disorders and psychiatric syndromes. However, it is clear that persistent or worsening psychological changes in an adolescent or young adult may herald the development of a mental health disorder such as psychosis and this possibility needs to be kept in mind, particularly if other risk factors are present.