Prodromal Symptoms And Onset

It has long been known that schizophrenia does not start with first admission and not even with the first psychotic symptoms. Early manifestations of the disorder have usually been called prodromal signs and symptoms.

During the last decade, the question of when and with what symptoms schizophrenia starts and what type of course it follows until the beginning of the first psychotic episode has led to a considerable number of investigations relative to the signs and symptoms that precede the actual onset of the disorder and the time interval between the first manifestation of the disorder and the first appearance of the full picture.

In 1996, Yung and McGorry [56] published an extensive review on past and current conceptualizations of the prodromal phase of first-episode psychosis, including compilations of definitions, descriptions of symptoms and signs, and patterns and durations. ''Prodrome'' has been defined as ''a heterogeneous group of behaviours temporally related to the onset of psychosis'' [57], as the time interval from onset of unusual behavioural symptoms to onset of psychotic symptoms [58], or as the period from first noticeable symptoms to first prominent psychotic symptoms [59]. For Yung and McGorry, ''in essence, the prodrome is the period between the most valid estimates of the onset of change in the person and the onset of psychosis''. The pre-psychotic period preceding the first onset of a psychosis is sometimes referred to as ''initial prodrome'' to distinguish this period from the one preceding a relapse in patients with an established diagnosis of psychosis.

To facilitate determination of the duration of the prodromal phase, Hafner [60] distinguishes between five different definitions of onset: first sign of a disturbance, first negative symptom, first positive symptom, first episode, and first admission.

Concerning the sequence of changes that leads to psychosis over time, Yung and McGorry identify two patterns. Pattern 1 consists in non-specific changes, followed by specific pre-psychotic symptoms, then psychosis. Pattern 2 starts with specific changes, followed by neurotic symptoms as a reaction to these, then psychosis. In addition to the previous two patterns, there are variants of patterns of change called ''outpost syndromes'', that is, clusters of symptoms and behaviours that resemble prodromes but which resolve spontaneously without immediately progressing to psychosis. The symptoms of outpost syndromes have been described by Huber et al [61] under the name ''basic symptoms''.

According to Yung and McGorry, the prodromal features most commonly described in the most methodologically sound first-episode studies include, in descending order of frequency: reduced concentration and attention, reduced drive and motivation, anergia, depressed mood, sleep disturbance, anxiety, social withdrawal, suspiciousness, deterioration in role functioning and irritability.

In Loebel et al's [58] sample, the first psychotic symptoms appeared on average one year, and prodromal signs almost 3 years before first admission. In the Age, Beginning and Course of Schizophrenia (ABC) study [62, 63], the period from the first sign of a mental disturbance and the first hospital-ization averaged 4.2 years for men and 4.9 years for women. The first signs were non-specific indicators such as loss of energy and motivation, difficulty concentrating, anxiety, suspiciousness and social withdrawal. Even the first psychotic symptoms appeared on average 2 years prior to the first hospital-ization. In the Determinants of Outcome of Severe Mental Disorders or DOS study [64], negative manifestations, such as neglect of usual activities, and loss of appetite, sleep or interest in sex were frequently recognized as the first signs of the disorder.

The actual onset rate of the syndrome has been defined by Keith and Matthews [57] as the time interval between the first appearance of characteristic schizophrenic symptoms and a full picture of the syndrome. The authors define onset rates as acute (less than 3 months), subacute (less than 6 months), subchronic (less than one year) and chronic (more than one year). Hafner et al [65] adopt the following definition: acute (in less than 4 weeks), subchronic (in more than 4 weeks but less than one year), and chronic (in more than one year). According to the results of the ABC study, the chronic onset type was most frequent (68%). The subacute type was observed in 15% and the acute type in 18% of cases.

Although schizophrenia was first described as a disorder beginning in adolescence or early adult life, current investigations confirm that onset can be in childhood as well as in older subjects. According to Hafner [60] and Hafner et al [65], schizophrenia is a disorder of (almost) all ages.

In the ABC study, the prodromal phase started before age 30 in 77%, before age 20 in 41%, and before age 10 in 4% of cases. The first psychotic episode began before age 30 in 63%, before age 20 in 17%, and before age 10 in 1% of cases. The same authors report a higher mean age of onset in females, with a difference of 3 to 4 years between males and females. In addition, they describe a second peak of onsets between ages 45 and 50 in females, but not in men. In men, symptom severity decreased with increasing age of onset. In women, symptom severity remained stable except for an increase of negative symptoms with late onset. Within the group of late-onset psychoses, there was no discrimination between schizophrenia and late paraphrenia.

The term ''late-onset schizophrenia'' was introduced by Manfred Bleuler [66] to identify a form of schizophrenia with onset between the ages of 40 and 60. The concept was hardly used outside of the German-speaking community, and it was commonly admitted that the onset of schizophrenia was restricted to the first half of life. This view has been challenged in recent years. According to a review of the literature by Harris and Jeste [67], onset of schizophrenia in hospitalized patients had been after age 40 in approximately 23% of the patients. Pearlson et al [68] found no differences in the prevalence of first-rank symptoms in patients with early-onset or late-onset schizophrenia. Rabins et al [69] and Mayer et al [70] found no characteristics that clearly separated late-onset from early-onset patients with schizophrenia, but reported that late-onset patients were more frequently female. Finally, Howard et al [71], Riecher-Rossler et al [72], and Hafner et al [65] could not find discriminating empirical criteria in the spectrum of schizophrenia and paranoid disorders of old age sufficient to warrant that the two groups of disorders be separated.

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