Waterloo Lutheran Seminary
April 4th, 2017.
A female adolescent declared her imminent suicide attempt via private messaging to a woman. The woman informed the adolescent’s parents immediately after further communication was disengaged. This decision was hardly a momentary choice. The woman was aware of the adolescent’s self-harm history, and had familiarity with their family dynamics. The woman spoke before of these dynamics’ service as worsening the adolescent’s suffering and isolation. Cloistered for her virtues and the desires of the parents to protect their sole child, the adolescent was separated from the woman. Influences of outsiders upon the adolescent’s nuclear family were placed under stricter control than before and more rigorous scrutiny. Months later, the woman heard that the adolescent was referred for a psychiatric evaluation. She retains concerns, due to her experiences in a family that rejected individual consideration for a person with mental illness.
In recent years, the call for prodromal treatment of psychiatric disorders beckoned louder (McGorry, Yung, & Phillips, 2003). While genotypes have long been under investigation in search of hereditary predispositions, it is the phenotypes that were of more interest. A predisposition for cardiovascular disease does not guarantee myocardial infarction. Such a relationship is correlational, albeit stronger as positive. Yet, the relationship is not enough to warrant causality. The same reasoning was applied to research in this domain as well, with reams of twin studies and retrospective designs in earlier literature (Salokangas & McGlashan, 2008).
The focus of psychiatric diagnostics research shifted to prospective designs in order to assess probable patients at different levels of risk for developing a psychiatric disorder. There is a consistent finding that in general; disorders of this nature are best attended to as early in development as possible (Rosen, Woods, Miller, & McGlashan, 2002). Such research is referred to as prodromal research, with various labels used to classify samples under study. These labels include UHR (ultra high risk), ARMS (at risk mental state), CHR (clinical high risk), prepsychotic, and prodrome. Cornblatt, Lencz, and Kane (2001) differentiated between prodromes at genetic risk from those at clinical risk. The definition separates the immediate relatives of identified individuals from other prodromes who may or may not have family history of mental illnesses. This illustration is analogous to the difference between the genotype and phenotype for those at genetic risk, and relies on empirical observation for those at clinical risk.
Prodromal research tends to aim for samples considered under the age of majority. Schizophrenia spectrum disorders presume to emerge in late adolescence to young adulthood, therefore it is assumed to find the vulnerable and deliver treatment and resources before psychosis emerges into a fully realized condition that is chronic and may have powerful effects upon persons within (i.e., cognitive impairment) and without (i.e., social isolation). Samples range from children to adolescents in typical prodromal studies for schizophrenia. Recruitment is done with mental health clinics (McGlashan et al., 2007), online, informal procedures, and highly arousing environments such as emergency rooms (DeGrazia, 2001). DeGrazia (2001) sketches many ethical issues regarding recruit of minors for psychiatric research of this particular nature, although other authors state that basic knowledge outweighs the potentials for risk of harm (McGlashan, 2001; Rosen et al., 2002). Salokangas and McGlashan (2008) noted that prodromal symptoms are commonly found in adolescents, adding to the questionability of which individuals would qualify as at imminent risk of developing schizophrenia or if their symptoms are a general observation of adolescent behaviours. Bechdolf et al. (2010) contributed to caution with “people with a history of childhood trauma have more psychotic-like symptoms” (p. 378) in both the general and psychiatric populations that have been under study. A possible counterpoint to these signals for increased risk of harm was posited by Kane, Krystal, and Correll (2003) as a clustering of prodromal symptoms would have improved search criteria for prodromal patients that may benefit from study participation.
Prodrome symptoms are dependent on timing, though these are considered as prodromal if occurrence is before a psychotic episode. This may refer to any psychotic episode, from first to relapse. In the context of the research examined in this paper, prodrome is defined as before onset of schizophrenia, i.e. before the diagnosis is warranted by clinical standards. Symptoms include milder appearances of what are considered typical for schizophrenia (Gottesman & Erlenmeyer-Kimling, 2001), yet the strength of prodromal identification is most apparent in functional decline, an increase in negative symptoms, and either lack of or decreased ability for participation in social settings.
Empirical studies focused on therapeutic methods such as cognitive therapy (Morrison et al., 2007), cognitive-behavioural therapy (Bechdolf et al., 2010), and cognitive remediation therapy (Piskulic, Barbato, Liu, & Addington, 2015). These were aimed to prevent or delay schizophrenia onset. The nature of identified prodromal symptoms permitted such therapies, as the theoretical goal was to halt psychosis. Psychosis, as a significantly altered phenomenological approach to standardized physical reality, usage of cognitive-based therapies for prepsychosis appeared to retain some promise of symptom reversal or slow further deterioration. Cornblatt et al. (2001) noted that the sample sizes are quite small, and likely non-representative (Bechdolf et al., 2010).
While the medical field is reported to be wary of assigning some mental health diagnoses to children (DeGrazia, 2001; Schaeffer & Ross, 2002), it is evident with the increasing literature that there are researchers committed to identifying future patients as early as possible (Yung et al., 2007). Before the disorder is manifest, it is the hope that increased suffering is prevented (Morrison et al., 2007) while preserving resource management for persons who do develop schizophrenia (Birchwood, 2000). Following the diagnostic observation of age range of onset, paediatric schizophrenia and assignment of specific diagnoses for developing persons is contentious. One such issue is the ethical arguments regarding psychoactive substance exposure for patients in early childhood and infancy (Gottesman & Erlenmeyer-Kimling, 2001). Although the aim of such research is for preventative measures, critics argued that exposure during the foundations of human development are not studied enough to warrant a projection of harm for long-term, possibly far-reaching, and/or pervasive effects.
Other researchers and critics raise ethical questions about the nature of such thinking and demands for prodromal research, especially when considering long-term effects upon the patients (Gottesman & Erlenmeyer-Kimling, 2001). Long-term effects are studied less as intensely as the short-term, perhaps due to prodromal research efforts as too recent in timing to conduct a longitudinal study (Cornblatt et al., 2001), and the intense pressure to treat persons before they can enter a diagnosable state of poor health is one of many forces driving proactive psychoeducation (Rosen et al., 2002). Meanwhile, persons already living with feared and troublesome diagnoses are further stigmatized and viewed as subnormal.
Is prodromal treatment most appropriate for a specific population – young persons with schizophrenia spectrum disorders? This is heavily tied into this author’s relations with various diagnosed persons; especially poignant are the effects upon couples and families as concerns. Implicated in this question are potentially traumatic effects, and the patients’ ability to respond to therapies. Patients and clients frequent mental health discussions, reporting how their capacities to trust professionals in medical and service fields is highly dependent on their interactions and treatments (K. Tejai, personal communication, 2015). It is an unlikely testimony to witness a patient or client communicating feelings of genuine safety and security with care providers. Persons with schizophrenia spectrum disorders may suffer from stigmatization due to the complicit interactions of internal and external loci of control, discrimination, prejudice, impairment from treatments, negative reactions towards side effects, behaviour judged as maladaptive, and (self) isolation.
Frequently, reports of mental health concerns are brought to increasing awareness. In the more heart wrenching cases, tragedies and horrors of the limits in human suffering are testimonies for the public. Here the profound difficulties that persons who carry mental illnesses can struggle with or face are harder to sweep aside, and awareness campaigns reignite. Despite the increases in awareness, individuals continue to be stigmatized and traumatized within the couples and families context. In this field of psychotherapy, screening is valued and mental illness serves as a qualifier for termination of therapy and subsequent referrals (Long & Young, 2007). It is assumed that the individual must be treated before deemed fit for interpersonal therapy. Doherty (2008) wrote of the push of psychotherapy as a field to place most importance on a single person rather than consider interpersonal, broader contexts beyond the enclosed self. With systemic theories’ increasing prominence (K. Tejai, personal communication, 2016), perhaps mental illness, no matter how severe or threatening, can be addressed beyond an individual isolated by the professionals who claim to place persons foremost.
It is this author’s sincere hope that the female adolescent referenced in the opening case story will be seen as both herself and as a member of a family. This adolescent continues to inspire this author throughout her mental health journey, for a human, no matter the age or circumstance, is human.
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