Researchers in Hunt for Key to Preventing Schizophrenia

Call him “Sam.” He is a patient—or a“ client,” since he doesn't yet have a diagnosis—at a clinic whose purpose is not to cure him of illness, but to prevent it from happening. At 19, he looks and dresses like any of the thousands of young people at the nearby University of Toronto—jeans, T-shirt, and sneakers. There is little about him that marks him as a young man at risk for a severe mental illness; a slight nervousness maybe, as if he were watching his words or watching himself, fearful of slipping up.

On the surface, his story as he describes it is not so out of the ordinary either—a breakup with a girlfriend, spending a lot of time by himself, a sudden drop in his grades. But he also described an anomalous physical ailment, a sense of being paralyzed in his sleep.

“And then I began to feel that people were looking at me,” he said. “Like, if I was on a street corner in a crowd and I saw someone staring at me, I thought they might be watching me.”

“Sam” is a client at the PRIME (Prevention Through Risk Identification, Management and Education) Clinic in downtown Toronto, at the Centre for Addiction and Mental Health (CAMH). He agreed to share his story with Psychiatric News anonymously.

CAMH is affiliated with the University of Toronto and is Canada's leading addiction and mental health teaching hospital. Following referral by a college counselor and a lengthy battery of standardized psychological and neuropsychological tests—including the Scale of Prodromal Symptoms (SOPS), Positive and Negative Syndrome Scale (PANSS), Calgary Depression in Schizophrenia Scale (CDSS), and the Schizophrenia Predictive Instrument-Adult Version—he was found to be a risk for psychosis.

Staff at PRIME say the specificity of Sam's thoughts about who he believed was watching him and why—along with other symptoms—convinced them that he was on the verge of conversion to psychosis.

Now, he comes periodically to the clinic to talk to therapists and to psychometric “raters” who assess his progress (or his deterioration). And as a subject in a multicenter study looking at the efficacy of alternative methods for preventing or delaying the onset of schizophrenia, Sam is a participant in unique public-health initiative that is on a far frontier of schizophrenia research.

“Individuals who come to us say, 'A change has come over me, and I can't explain what it is,' ” PRIME Clinic psychiatrist Irvin Epstein, M.D., told Psychiatric News. “They are starting to feel that the whole world is strange to them, they don't feel right about themselves, they feel awkward in company or in school, and they are starting to lack focus and direction. They describe being anxious, but they don't know why, and they sense they are starting to lose their emotional connections to others.”

Today there is a growing scientific confidence in the validity of the“ prodrome,” the prepsychotic signs and symptoms that schizophrenia researchers believe precede an acute psychotic episode. As the science has progressed, identification of at-risk individuals has advanced beyond targeting those on the very cusp of psychosis to those who are even earlier in the developmental process of schizophrenia.

“The field is starting to mature,” Epstein said. “We are out of the period of infancy and uncertainty, and we now have a better idea of whom we should be targeting and what the symptoms are. Originally we were catching people on the verge of psychosis. These were people who didn't require a professional to appreciate that they were at risk of psychosis. In essence, what we were doing was trying to identify and to limit the extent of the inevitable psychosis.

“Now we are getting people who have a subjective sense that something in their world is changing, and it is really transforming the scope of what we are trying to accomplish from improving the outcome to really preventing the onset of a first episode.”