The Prodrome

The prodrome is a period of decreased functioning prior to the first psychosis. It actually signifies the beginning of illness and it usually happens in adolescence when the individual is in school. From what I've read the prodrome is usually twice as long as the DUP, the duration of the first untreated psychosis. Together the prodrome and DUP are called the DUI, the duration of untreated illness. Since the DUP is about 1-2 years around here, the DUI is probably about 3-6 years. There hasn't been a lot of research on the prodrome experience because it happens before the individual is treated for psychosis. To learn about it you have to use retrospective enquiry, asking the individual and his/her family questions about events that happened years ago. There are also some studies that follow high risk individuals from birth. These individuals have one or more parents with schizophrenia, and their risk of developing schizophrenia is ten times what it would be for other people. These two sources of information haven't led to much of a consensus yet on what the important features of prodrome are, or what happens to these people as they become ill. Researchers are currently looking for something that will reliably predict psychosis, so that they can treat people before the first psychosis. They haven't had much luck yet, and the predictive value of their assessments is about 50%. Only about half of the people they predict will have a psychosis actually do, although this work is still very young. You have to be able to recruit people and then follow them for at least five years to see if they develop psychosis.
I think the prodrome is actually much more important for other reasons, primarily because the individual is adapting to a loss in functioning years prior to treatment for psychosis. I had an insidious onset of psychosis stretching out over 8 years, and I remember what happened during my prodrome. In the prodrome the individual loses functioning ability and human relationships. The studies of high risk individuals show that first the individual has attention troubles, then loses social functioning, then academic functioning, and then experiences psychosis, and that pretty much describes what happened to me, although I can't remember having any problems with attention per se.
You do not want to lose social functioning in high school. Being accepted by your peers is pretty important to adolescents. Adults have to contend with keeping thier kids out of trouble caused by peer pressure, but having no peers at all as a teenager is almost unthinkable. In the prodrome you will have difficulty keeping these human relationships, and particularly any romantic relationships. That usually will cause a lot of emotional turmoil and stress in adolescents, an underlying anxiety that will only escalate as the untreated prodrome continues. The stress of that anxiety could eventually precipitate the first psychosis.
The prodrome is really the essence of schizophrenia, uncolored by psychotic episodes, the declining functioning probably occuring as a result of changes in prefrontal cortex functioning, although I don't know that anyone has actually put people in prodrome through MRI and PET scans to document that. From what I've seen people adapt to losing their functioning in different ways. Some become rebels and outcasts defiant of any authority, especially their parents. Some become loners. Some turn to peer groups that are held together solely by their use of marijuana and/or alcohol. This last adaptation is very common with males experiencing a prodrome, and many will be smoking marijuana regularly when they experience their first psychosis. People will tend to lose their self confidence and self esteem in the prodrome. They are losing their ability to particpate in life. Some people become very religious even if their parents weren't.
My loss of social functioning seems to have occurred before I started high school. I usually had one good friend growing up, and I remember at age 15 and 16 hanging out with some guys and we were drinking a lot and smoking a lot of marijuana. At age 17 I dropped those male relationships because they were treating me as inferior, and courted Elizabeth and we fell in love. I became very dependent on her, because of my emotional turmoil, because of the trouble I had functioning. I adopted her friends, Sally, Lisa, and Andrea. The five of us spent a lot of time together. They were all very feminist and I was the only male they ever did anything with for several years. By then I was also losing my academic functioning. I was at one time very talented in math and physics. In grade eleven I scored very high in a provincial math contest without even trying. Liz was interested in English, Feminism, and history. I adopted her interests because to her they were more important and more valuable than math and physics. There is an important lesson there that can be applied to the prodrome experience. Adolescents tend to avoid the things they can't do well, and they tend to devalue the things they can't do well. Liz had virtually no ability in math and physics and so to her math and physics were an indication of inferior intelligence.
In grade eleven I also applied to enter an experimental high school, one that didn't stress grades and regular classes. In grade twelve I lost the ability to do school work. I lost the ability to focus on the work that had to be done. I took calculus but I would have failed in a regular high school. I would have failed high school if it hadn't been in the experimental program and I certainly wouldn't have been admitted to university with real grades. I lost all interest in competitive sports, and I was aspiring to a noncompetitive life as a hippy, as a drop out of capitalism, a back to the land, counterculture hippy. I basically lost interest in pursuing a career of any sort. I was not only losing functioning ability, I lost interest.
Losing social functioning is difficult to detect but losing academic functioning is recorded every year by the school system and has serious consequences for the individual. People in the prodrome tend to fail and drop out of school. They will then struggle and lose employment, and they will fail at romance. They would probably be considered a "loser" by their peers. They lose their functioning at a critically competitive time in human development, when people are evaluating and making very competitive career and romance choices. If you can no longer get the grades you used to, and can't attract the opposite sex the way you used to, can't interact well with your peers, or authority figures, you tend to drop out. You tend to drop out of the game you always lose. You tend to devalue the game you always lose. I wasn't interested in career acquisition because I had no natural ability. When the game is life in general, and you're not really capable of playing the game, you really struggle with how you interact with the world.
These kids are moving from the state of dependent adolescent to independent adult. It's a very critical developmental period, and it becomes extremely competitive. I don't think it is a coincidence that John Nash wrote his Phd thesis on noncompetitive game theory, which, according to the movie, he first thought of while competing with his male friends for female attention. In some ways life only becomes an intensely competitive game when you can't function very well. If you're fairly competent at the game you don't even notice how competitive it really is. Life just comes naturally. If you're compromised by a prodrome you can't succeed.
Most of the family members I've talked to were acutely aware that something was wrong when their kid was in the prodrome. They just didn't know what was wrong. The prodrome tends to tear families apart. Parents put more pressure on their son/daughter to function better at school, acquire better quality peers, etc. etc. and the kids rebel, and start to hate their parents. The parents start to disown their kids, etc. etc. The DUI can leave many bad memories on both sides that later interfere with recovery on medication.
I almost dropped out of school each year I attended University. My father insisted I go and for some reason I kept going. I still aspired to be a back to the land, counterculture hippy. That has a solid foundation in the economy and finances, and I didn't do well in that either. In schizophrenia employment is always a good indicator of illness. I always struggled finding summer employment in university, always ending up with very low paying jobs that nobody else wanted. If you're going to succeed in academia you need career related summer employment, or you need highly paid skill developing summer employment. I hated my summer employment. After the summer of 75 when Liz had left me, I had a very painful experience of summer employment in Hay River NWT, and I realized that university was the only way to enjoyable well paid employment.
Instead I ended up in a no man's land of marijuana, and mysticism. Nobody else at University was making those kinds of choices. It was an antithesis of competitive struggle. I identified with the Rastafarians for whom marijuana was a sacred herb. Today in first psychosis programs typically 40-50% of the patients are smoking enough marijuana to interfere with their recovery on medication. You can tell them that marijuana use will delay their recovery and reduce the effectiveness of the medication, but their marijuana use is a way of coping they learned in their prodrome. One of my favourite songs when I was smoking marijuana on a daily basis in university was from the movie "The Harder they Come" starring Jimmy Cliff, entitled simply "Sitting in Limbo". I felt almost non human, that I didn't fit in anywhere. Later on in my psychosis I just cancelled my membership in humanity altogether. I was going to become an alien and I was real glad to be leaving. Schizophrenia can do that to you.
At university I was a radical feminist, environmentalist, anarchist. In those days becoming an anarchist was almost a natural progression from conservative to socialist, to marxist, to maoist, and finally anarchist. You can't get much more idealistic about human nature than as an anarchist... Anarchism was a philosophy based on the premise that if anyone is unhappy you will also be unhappy because we are all in this together. I became convinced I was a genius, unappreciated because I was so many years ahead of my time. I expected sociobiology to become the next Copernican revolution. As I became more ill I was drawn into a higher, more esoteric path, a path beyond spoken comprehension. I was literally following the Shaman's path, learning as much as I could about shamanism, witchcraft, and alchemy with a double major in biology and anthropology. I had dreams in university that I thought foretold of my destiny.
I couldn't function well in my dreams either. I remember one dream where I was sitting on a park bench surrounded by red meat, steaks, roasts, etc. A Hindu beggar sat down beside me and asked me for some of my meat. My biology professor came by and only had a few pounds of cheap hamburger to share with his whole class. I used to think that if I had just shared some of my meat with that beggar, maybe my life would have been completely different. I didn't because I felt so poor and didn't know how much meat I would need. I was experiencing so much emotional turmoil in university. Later I became convinced that I had been poisoned by dioxin in a bad batch of Phisohex soap. My father got a case of the stuff from the drug company as a sample. The dioxin interfered with cortical hormone regulation of stress, and everything became stressful, which it was.
Graduate school was a mistake. I tried to take something practical like Environmental Studies. I began experiencing a lot of reality distortion in graduate school. I don't know how much of my experience there was real. Eventually I was kicked out of school because several courses went unfinished, and the long struggle of my prodrome became a very rude awakening. Within a year I was homeless on the streets for six months in 1980. It was still a very competitive struggle just to keep warm, eat, and sleep somewhere safe. I went without any food at all for at least ten days and could barely walk by the time I did eat again. In the ten years I was in psychosis I never became competent enough to rise above poverty, celibacy, and unemployment. Life is a competitive struggle and I simply couldn't function well.
The prodrome's impact on recovery is important. You make choices based on your strengths. In post psychosis treatment you need to ask where is your personality, your values, your ambitions, your dreams, and where has the prodrome led you to make choices, simply because you didn't function well in the intense competitive struggle. You tend to drop out of the game you always lose. You tend to devalue the game you always lose. Just because you have experienced a period of disability, doesn't mean you can't recover, and that is probably quite true for first psychosis patients.

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