1 Boring Old Man

In the case I was talking about, there wasn’t any question about diagnosis. She met the criteria of the day as they changed when the manual was revised. When she was psychotic, she had it all – voices, disjointed thought, paranoia, odd affect, magical thinking, automatisms, thought broadcasting, etc. In between, she had some version of what are called "negative symptoms" most of the time. I can’t imagine treating her without medications, acutely or chronically. I tried that experiment and the results were definitive – decompensation. I think she’d say the same thing. The voice of restraint with neuroleptics was mine, not hers. She would’ve gladly up-ed the doses along the way, and there were times when I used anti-anxiety medication to keep her from using a neuroleptic like an "as needed for anxiety" drug.

Now back to the initial point – the Prodromal Risk Syndrome. I’m sure it exists, though I wouldn’t have  picked that term, at least in this case. She’d had some version of her illness from the start – and still does. So I guess I’d want the name to reflect that chronicity but I can’t think of an alternative. I don’t know what causes Schizophrenia or how the antipsychotics work. But I don’t think they work by reversing the basic problem – because the basic problem persists both during psychotic episodes and in the spaces in between. To me, however, the antipsychotics are more than just "symptomatic," because they seem to uniquely take the wind out of the sails of whatever drives active psychosis, though they’re certainly no cure. They are "anti-psychotic" but not "anti-schizophrenic" drugs. In this case, there was nothing to suggest that they were a "chemical straight jacket" or made her a "zombie." They did neither. And she was not a patient whose symptoms "melted" quickly, but rather diminished gradually over days or weeks. She always remembered her psychotic experiences, and wanted to talk about them after the fact. My impression was that she got more mileage out of looking back at the precipitating events and warning signs than at the content of her psychosis, but we talked about both – a lot.

So would preemptive treatment with antipsychotics have helped her? I doubt it. She had taken them and they didn’t help, but beyond that, neither she nor her family would’ve made the changes necessary without a cataclysmic wake-up call. At the time of her suicidal contemplations, I think she was on a neuroleptic [the same one we used later]. In her case, I don’t think the psychotic episodes hurt her long term, but that’s just an impression. Do I think psychotherapy is the treatment for Schizophrenia? Of course not. That "lecture" was about supportive psychotherapy, and that’s what it was. This patient had a supportive family, financial resources, a lot of personal internal resources, and a stick-to-it-ness that allowed her to learn how to live with the illness, not get over it. In her case, there was no attempt to uncover forces in her mind or defense mechanisms. If I had to characterize what we did, it was three things. First, we managed her medication use between the poles of "help" and "hurt." Second, she needed a person-anchor that was focused on helping her fit her life to the person she was with the illness she had – interrupting her high achievment family ideals. And finally a "learning" therapy that I’ve described above – learning to be schizophrenic. She was an atypical patient in some ways, but also instructive in general.

I’m of a mixed mind about the inclusion of the Prodromal Risk Syndrome. because I think it’s just part of the course of Schizophrenia itself [that opinion is from a lot bigger n than one]. But I don’t question that it exists, so that speaks to inclusion. I’m suspicious that including it will be followed by clinical trials that show statistical significance that will get drugs through the FDA and we’ll see a lot of people unnecessarily medicated with potentially dangerous drugs. Many such patients do not have schizophrenic breaks with reality, known since Bleuler and recently reaffirmed [Early Intervention for Schizophrenia: The Risk-Benefit Ratio of Antipsychotic Treatment in the Prodromal Phase]. I can envision creative Direct-to-Consumer medication ads in that future with their mumbled warnings in the background ["blah, blah, diabetes, blah, blah, irreversible neurological symptoms, blah, blah"]. I’d prefer to say "ask your doctor if the time-honored medical principle of ‘watchful waiting’ and informed supportive therapy is right for you" and maybe add "until the place of medication treatment is studied long term without the obvious bias of drug manufacturers."

And as for n=1 science – I’d like to see the n=30 science take the fact that it’s also 30 n=1s more into account. Similarities and differences both matter. Schizophrenia was a big determinant in the course of this woman’s life, but there were a lot of other important factors. Medication was an important part of her treatment, but there were also a lot of other important things. Psychiatry is not much different from any other medical specialty that deals with chronic disease. In medicine, it’s called "following the patient" or "management". We just use different names.