Skip to main content Accessibility help

Early intervention in psychosis: The critical period hypothesis

  • Max Birchwood (a1), Pauline Todd (a2) and Chris Jackson (a2)


Background We consider the evidence for the proposition that the early phase of psychosis (including the period of untreated psychosis) is a critical period' in which (a) long-term outcome is predictable, and (b) biological, psychological and psychosocial influences are developing and show maximum plasticity.

Method First-episode prospective studies, predictors of outcome and the genesis of patients' key appraisals of their psychosis are reviewed.

Results The data support the notion of the ‘plateau effect’, first coined by Tom McGlashan, which suggested that where deterioration occurs, it does so aggressively in the first 2-3 years; and that critical psychosocial influences, including family and psychological reactions to psychosis and psychiatric services, develop during this period.

Conclusions The early phase of psychosis presents important opportunities for secondary prevention. We outline a prototype of intervention appropriate to the critical period. The data challenge the widely held assumption that first-episode psychosis is a benign illness posing little risk.


Corresponding author

Correspondence: Professor M. Birchwood, Early Intervention Service, Harry Watton House, Northern Birmingham Mental HealthTrust, Church Lane, Aston, Birmingham B6 5UG


Hide All
American Psychiatric Association (1987) Diagnostic and Statistical Manual of Mental Disorders (3rd edn, revised) (DSM–III–R). Washington, DC: APA.
Bebbington, P. & Kuipers, L. (1995) The predictive utility of expressed emotion in schizophrenia: an aggregate analysis. Psychological Medicine, 24, 707718.
Beiser, M., Fleming, J. A., Iacono, W. G., et al (1988) Refining the diagnosis of schizophreniform disorder. American Journal of Psychiatry, 145, 695700.
Beiser, M., Iacono, W. G. & Erickson, D. (1989) Temporal stability in major mental disorders. In The Validity of Psychiatric Diagnosis (eds Robins, L. N. & Barrett, J. E.), pp. 7798. New York: Raven Press.
Biehl, H., Maurer, K., Schubart, C., et al (1986) Prediction of outcome and utilization of medical services in a prospective study of first onset schizophrenics: Results of a prospective 5-year follow-up study. European Archives of Psychiatry and Neurological Sciences, 236, 139147.
Birchwood, M. (1992) Family factors in psychiatry. Current Opinion in Psychiatry, 5, 295299.
Birchwood, M. (1995) Early intervention in psychotic relapse: cognitive approaches to detection and management. Behaviour Change, 12, 219.
Birchwood, M., Hallett, S. & Preston, M. (1988) Schizophrenia: An Integrated Approach to Research and Treatment. Harlow: Longman.
Birchwood, M., Macmillan, F. & Smith, J. (1992) Early intervention. In Innovations in the Psychological Management of Schizophrenia (eds Birchwood, M. & Tarrier, N.), pp. 58103. Chichester: Wiley.
Birchwood, M. & Macmillan, F. (1993) Early intervention in schizophrenia. Australia and New Zealand Journal of Psychiatry, 27, 374378.
Birchwood, M., Mason, R., Macmillan, F., et al (1993) Depression, demoralisation and control over psychotic illness. Psychological Medicine, 23, 387395.
Birchwood, M. & Tarrier, N. (1994) The Psychological Management of Schizophrenia. Chichester: Wiley.
Birchwood, M. & Drury, V. (1995) Using the crisis. In Emergency Mental Health Services in the Community (eds Phelan, M., Strathdee, G. & Thornicroft, G.) pp. 113159. Cambridge: Cambridge University Press.
Birchwood, M., Chadwick, P. & Trower, P. (1996) Cognitive Therapy for Hallucinations, Delusions and Paranoia. Chichester: Wiley.
Bleuler, M. (1978) The Schizophrenic Disorders: Long Term Patient and Family Studies (S. Clements, translator). New Haven, CT: Yale University Press.
Caldwell, J. & Gottesman, I. (1990) Schizophrenics kill themselves too. Schizophrenia Bulletin, 16, 571590.
Carpenter, W. & Strauss, J. (1991) The prediction of outcome in schizophrenia. V: eleven year follow-up of the IPSS cohort. Journal of Nervous and Mental Disease, 179, 517525.
Chadwick, P. & Birchwood, M. (1994) The omnipotence of voices: a cognitive approach to auditory hallucinations. British Journal of Psychiatry, 164, 190201.
Clausen, J. A. & Yarrow, M. R. (1955) The impact of mental illness on the family. Journal of Social Issues, 11, 364.
Cotton, P., Drake, R. & Gates, C. (1985) Critical treatment issues in schizophrenics. Hospital and Community Psychiatry, 365, 534536.
DeLisi, L. (ed.) (1990) Depression in Schizophrenia. Washington, DC: APA.
Drake, R., Gates, C., Cotton, P., et al (1985) Suicide among schizophrenics: who is at risk? Journal of Nervous and Mental Disease, 172, 613617.
Drury, V., Birchwood, M., Cochrane, R., et al (1996) Cognitive therapy and recovery from acute psychosis: a controlled trial. I. Impact on psychotic symptoms and II. Impact on recovery time. British Journal of Psychiatry, 169, 593–601 and 602607.
Dube, K., Kumar, N. & Dube, S. (1984) Long-term course and outcome of the Agra cases in the International Pilot Study of Schizophrenia. Acta Psychiatrica Scandinavica, 170, 170179.
Eaton, W., Thara, R., Federman, B., et al (1995) Structure and course of positive and negative symptoms in schizophrenia. Archives of General Psychiatry, 52, 127134.
Erickson, D. H., Beiser, M., Iacono, W. G., et al (1989) The role of social relationships in the course of first-episode schizophrenia and affective psychosis. American Journal of Psychiatry, 146, 14561461.
Frank, A. & Gunderson, J. (1990) The role of the therapeutic alliance in the treatment of schizophrenia: relationship to course and outcome. Archives of General Psychiatry, 47, 228236.
Garety, P., Kuipers, L. & Fowler, D. (1994) Cognitive behavioural therapy for drug-resistant psychosis. British Journal of Medical Psychology, 67, 259271.
Geddes, J. R., Black, R. J., Whalley, L. J., et al (1994) Persistence of the decline in the diagnosis of schizophrenia among first admissions to Scottish hospitals from 1969–1988. British Journal of Psychiatry, 163, 620626.
Harrow, M., MacDonald, A.W., Sands, J. R., et al (1995) Vulnerability to delusions over time in schizophrenia and affective disorders. Schizophrenia Bulletin, 21, 95109.
Herz, M., Glazer, W., Mostert, M., et al (1991) Intermittent v. maintenance medication in schizophrenia. Archives of General Psychiatry, 48, 333337.
Hirschenberg, W. (1985) Social isolation among schizophrenic out-patients. Social Psychiatry, 20, 171178.
Jablensky, A., Sartorius, N., Emberg, G., et al (1992) Schizophrenia: manifestations, incidence and course in different cultures. A World Health Organization ten-country study. Psychological Medicine, Monograph suppl. 20, 197
Jackson, J. & Edwards, J. (1992) Social networks and social support in schizophrenia. In Schizophrenia: An Overview and Practical Handbook (ed. Kavanagh, D.), pp. 275292. London: Chapman and Hall.
Johnson, D. (1981) Studies of depressive symptoms in schizophrenia. British Journal of Psychiatry, 139, 89101.
Johnstone, E. C., Crow, T. J., Johnson, A. L., et al (1986) The Northwick Park Study of first episode schizophrenia: I. Presentation of the illness and problems relating to admission. British Journal of Psychiatry, 148, 115120.
Johnstone, E. C., Macmillan, J. F., Frith, C. D., et al (1990) Further investigation of the predictors of outcome following first schizophrenic episodes. British Journal of Psychiatry, 157, 182189.
Johnstone, E. C., Frith, C., Crow, T., et al (1992) The Northwick Park Functional Psychosis Study: diagnosis and outcome. Psychological Medicine, 22, 331346.
Jones, P. B., Bebbington, P., Foerster, A., et al (1993) Premorbid social underachievement in schizophrenia: results from the Camberwell Collaborative Psychosis Study. British Journal of Psychiatry, 162, 6571.
Kane, J. M. (1989) The current status of neuroleptics. Journal of Clinical Psychiatry, 50, 322328.
Kane, J. M., Rifkin, A., Quitkin, F., et al (1982) Fluphenazine v placebo in patients with remitted, acute first-episode schizophrenia. Archives of General Psychiatry, 39, 7073.
Kavanagh, D. (1992) Recent developments in expressed emotion and schizophrenia. British Journal of Psychiatry, 160, 601620.
Kingdon, D. G. & Turkington, D. (1994) Cognitive-Behavioural Therapy of Schizophrenia. Brighton: Lawrence Erlbaum Associations.
Kraepelin, E. (1986) Dementia Praecox. In The Clinical Roots of Schizophrenia (translated into English, 1987) (eds Cutting, J. & Shepherd, M.). Cambridge: Cambridge University Press.
Linszen, D., Dingemans, P. & Lenior, M. (1994) Cannabis abuse and the course of schizophrenic disorders. Archives of General Psychiatry, 51, 273279.
Linszen, D., Dingemans, P., Van der Does, J., et al (1996) Treatment, expressed emotion’ and relapse in recent onset schizophrenic disorders. Psychological Medicine, 26, 333342.
Marder, S., Van Putten, T., Mintz, J., et al (1987) Low and conventional dose maintenance therapy with fluphenazine decanoate. Archives of General Psychiatry, 44, 518521.
Mason, P., Harrison, G., Glazebrook, C., et al (1995) Characteristics of outcome in schizophrenia at 13 years. British Journal of Psychiatry, 167, 596603.
McEvoy, J. P., Hogarty, E. E. & Steingard, S. (1991) Optimal dose of neuroleptic in acute schizophrenia. Archives of General Psychiatry, 48, 739745.
McGlashan, T. (1984) What has become of the psychotherapy of schizophrenia? Acta Psychiatrica Scandinavica, 90 (suppl. 384), 147152.
McGlashan, T. (1988) A selective review of North American long term follow-up studies of schizophrenia. Schizophrenia Bulletin, 259, 515542.
McGlashan, T. & Carpenter, W. (1976) Post-psychotic depression in schizophrenia. Archives of General Psychiatry, 33, 231239.
McGorry, P. D., Chanen, A., McCarthy, E., et al (1991) Post-traumatic stress disorder following recent onset psychosis. An unrecognised postpsychotic syndrome. Journal of Nervous and Mental Disease, 179, 253258.
Mortensen, P. B. & Juel, K. (1993) Mortality and the causes of death in first admitted schizophrenic patients. British Journal of Psychiatry, 163, 183189.
Mueser, K., Yarnold, P., Levinson, D., et al (1990) Prevalence of substance abuse in schizophrenia: demographic and clinical correlates. Schizophrenia Bulletin, 16, 3156.
Overall, J. E. & Gorham, D. R. (1962) The Brief Psychiatric Rating Scale. Psychological Reports, 10, 799812.
Pilowsky, L. S., Kerwin, R.W. & Murray, R. M. (1993) Schizophrenia: A neurodevelopmental perspective. Neuropsychopharmacology, 9, 8391.
Ram, R., Bromet, E. J., Eaton, W.W., et al (1992) The natural course of schizophrenia: A review of first admission studies. Schizophrenia Bulletin, 18, 185207.
Roy, A. (1986) Suicide in schizophrenia. In Suicide (ed. Roy, A.). Baltimore, MD: Williams and Wilkins.
Schubart, C., Krumm, B., Biehl, H., et al (1986) Measure of social disability in a schizophrenic patient group: Definition, assessment and outcome over 2 years in a cohort of schizophrenic patients of recent onset. Social Psychiatry, 21, 19.
Scottish Schizophrenia Research Group (1988) The Scottish first episode schizophrenia study v. one year follow-up. British Journal of Psychiatry, 152, 470476.
Shepherd, M., Watt, D., Falloon, I., et al (1989) The natural history of schizophrenia: a five year follow-up in a representative sample of schizophrenics. Psychological Medicine, Monograph suppl. 15.
Stirling, J., Tantam, D., Thonks, P., et al (1991) Expressed emotion and early onset schizophrenia. Psychological Medicine, 21, 675685.
Strauss, J. & Carpenter, W.T. (1977) Prediction of outcome in schizophrenia. Ill: Five year outcome and its predictors. Archives of General Psychiatry, 34, 159163.
Thornicroft G. & Breakey, W. (1991) The COSTAR Programme: I: Improving social networks of the long-term mentally ill. British Journal of Psychiatry, 159, 249259.
Warner, R. (1994) Recovery from Schizophrenia: Psychiatry and Political Economy (2nd edn). New York: Routledge.
Warner, R., Taylor, D., Powers, M., et al (1989) Acceptance of the mental illness label by psychotic patients: effects on functioning. American Journal of Orthopsychiatry, 59, 398409.
Westermeyer, J. F., Harrow, M. & Marengo, J.T. (1991) Risk for suicide in schizophrenia and other psychotic and non-psychotic disorders. Journal of Nervous and Mental Disease, 179, 259266.
World Health Organization (1992) The Tenth Revision of the International Classification of Diseases, Injuries and Causes of Death (ICD–10). Geneva: WHO.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *


Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Early intervention in psychosis: The critical period hypothesis

  • Max Birchwood (a1), Pauline Todd (a2) and Chris Jackson (a2)
Submit a response


No eLetters have been published for this article.


Reply to: Submit a response

Your details

Conflicting interests

Do you have any conflicting interests? *