The Early Course of Schizophrenia.

Schizophrenia is a chronic psychiatric disease that represents an immense amount of individual and familial suffering and an important social burden. Early explanations involved various unique etiologies (among others: a virus, a single gene, or, unfairly, the mother), but the last decades of research have recognized schizophrenia as a multifactorial disease. The Early Course of Schizophrenia, edited by Tonmoy Sharma, M.D., and Philip D. Harvey, Ph.D., and written by experts in the field, addresses the most pressing questions in the pathogenesis and treatment of schizophrenia, focusing on the strongest evidence to date with great clarity. The first section, “Schizophrenia in the Premorbid Period,” begins with a discussion of some of the key evidence supporting the neurodevelopmental hypothesis of schizophrenia. The neurodevelopmental hypothesis distinguishes several periods of this illness, extending from vulnerability to risk factors to the definite clinical diagnosis. These include an early premorbid period, associated with nonspecific abnormalities, and the prodromal period, retrospectively assessed as a time of various symptoms and difficulties (including many that are hardly specific to schizophrenia, such as depressed mood, anxiety, social withdrawal, irritability, and aggressive behavior; suicidal ideation and attempts; and substance use). These periods precede the onset of frank psychotic symptoms (hallucinations, delirious thoughts, and negative symptoms). This widely accepted model involves a developing brain, with genetic vulnerabilities interacting with environmental insults that may occur both in early life (when risk factors may include prenatal exposure or obstetric complications) and during adolescence or early adulthood (when risk factors may include pubertal changes, substance use, or the process in adolescence that requires coping with the new identity, sexuality oriented toward other people, and autonomy from the parents). The interactions between these different kinds of internal and external risk factors are best illustrated by the example of one person's believing that others are thinking badly about or laughing at him, resulting in social withdrawal; nonattendance at school, university, or work; and suspiciousness and altered behavior toward family and friends. Precocious therapeutic interventions may permit the patient to benefit from social integration and avoid psychiatric chronicity. That outcome requires both treating the disease intensively in the early phases and respecting what may retrospectively appear as a transitory adaptation to a stressful period in the patient's life. “Schizophrenia in the Premorbid Period” provides, interestingly, a synthetic description of intellectual and cognitive functioning before and at the onset of the first episode, stressing that, for a subgroup of patients, cognitive deficits (executive functions, working memory, attention, and abstract reasoning) are already evident many years before a clinical diagnosis of schizophrenia is assigned and that they appear stable over the early years after the onset of psychotic symptoms. These cognitive abnormalities, considered as a core feature of schizophrenia, are developed in the next section, “Schizophrenia at the Time of the First Episode,” and they are the topic of the last chapter of the third section, which deals with different forms of “Treatment of Early Schizophrenia.” This last section provides an overview of a comprehensive therapeutic program, focusing on current symptoms and behavior or disability and on treatments aiming to delay, ameliorate, or even prevent the progression of the psychotic disorder. With chapters on both early-onset and late-onset (an imprecise term) schizophrenia, The Early Course of Schizophrenia is recommended to all physicians who are concerned with psychiatric disorders. Yet focusing on the early stages of the disease would miss the point if it led to the illusion that psychiatric disorders do not continue over the patients' entire life span. The Early Course of Schizophrenia does indeed approach the persisting issues of maintenance treatment, relapse prevention, and treatment adherence.