Onset and early course of schizophrenia
The schizophrenia begins in 75% of cases with a five-year precursor phase ( prodromal phase ). This is followed by a phase of about a year with increasing positive symptoms until an acute psychotic episode begins for the first time . This period of time is known as the early course of schizophrenia .
The prodromal phase is usually characterized by two symptom complexes: depression and negative symptoms. Often the patients suffer from a social handicap. Schizophrenia is a disease that begins chronically in 2/3 of the cases and subacute in 15% of the cases examined, with a prodromal phase of one month to one year with unspecific or negative symptoms. From this it can be concluded that schizophrenia is a disease that often goes untreated for years at the beginning. Since in most cases the social handicap already begins during this time, the question of an early diagnosis and early treatment arises as early as possible during the non-psychotic prodromal phase. Since the majority of patients become ill before the age of 30, research into the prodromal phase of schizophrenia primarily affects young adults.
Methodological considerations
For practical research reasons, the following considerations are made: Statistically speaking, young patients who first came into contact with psychiatric institutions had a psychotic episode lasting two months. This period of time together with the initial admission to a clinic is regarded as the end point of the early course of schizophrenia.
Core questions of the early course of schizophrenia
Based on the empirical assumption, the key questions are first formulated and then checked through systematic studies. The key questions relate to what happens in the early stages:
- When does schizophrenia start?
- What are the first symptoms?
- How does the disease develop before the first psychotic episode?
- When and how do social disabilities occur?
- Does the medium-term course make statements about non-starters vs. Social drift debate too?
- Can the long-term course of schizophrenia be predicted?
- How can you intervene early?
Onset of schizophrenia
Older progress studies on the prodromal phase compared with more recent results from the Central Institute for Mental Health in Mannheim show that the duration of the prodromal phase can be given as about five years. This prodromal phase is followed by a phase of about a year with psychotic symptoms, which is usually followed by hospitalization.
| author | Number of cases | Duration from 1st character (years) |
Duration from 1st psychotic. Symptom (years) |
|---|---|---|---|
| Huber et al. 1979 (FRG) Haefner et al. 1995 (FRG) |
502 232 |
3.3 5.0 |
1.1 |
Early signs and common symptoms
The ten most common early signs of schizophrenic illness are: restlessness (19%); Depression (19%); Anxiety (18%); Thinking and concentration disorders <(16%); Worries (15%); lack of self-confidence (13%); Energy loss and slowdown (12%); Problems in the workplace (11%); social withdrawal (distrust) (10%) and social withdrawal (communication) (10%). The ten most common first positive symptoms of schizophrenia are: relationship delusions (51.7%); Paranoia (41.4%); unspecific delusional symptoms (38.8%); Thought disorders (36.2%); Hallucinations (31.0%); Delusional content (27.6%); Thought input (20.3%); Delusional influence (19.8%); Delusion of being controlled (19.4%); Megalomania (17.7%).
Development of schizophrenia before the first psychotic episode
| First symptom | In front | Simultaneously | To | symptom | evaluation |
|---|---|---|---|---|---|
| Trema Trema |
76.9% |
18.2% 13.7% |
4.9% |
Apophenia |
significant |
| Subjects | First character |
First negative symptom |
First positive symptom |
Maximum positive symptoms |
Initial admission |
|---|---|---|---|---|---|
| Men | 22nd | 24 | 26th | 28 | 28.2 |
| Women | 25th | 27 | 31 | 32 | 32.2 |
| total | 24 | 25th | 29 | 30th | 30.3 |
Schizophrenia and Social Disability
When it comes to the cause of social disability in patients with schizophrenia, traditionally two theories compete. The non-starter theory postulated by Dunham that patients with schizophrenia miss a social development from the outset. The social drift theory postulates a social decline of the sick as a result of the illness. In order to determine the causes of the social handicap of schizophrenic patients, Häfner and others have carried out numerous empirical studies. Patients from the so-called IRAOS study were examined. The studies on the early phase of schizophrenia showed that social disability occurs even before the onset of the psychotic phase of the disease in the early stages.
This leads to a methodological problem: 2/3 of all patients develop schizophrenia before the age of 30 and thus during the time when people are consolidating their social position and their perspective on life. If you divide patients with schizophrenia into age groups and review their social status, you can see that those with the earliest onset of the disease have the lowest social status. This made it necessary to make statements about the relationship between social status and illness in the case of schizophrenia only in the form of an age-adjusted comparison with a healthy control group.
This comparison showed that after the onset of the disease, patients with schizophrenia in the majority suffer a stagnation of the social status they had achieved, while those in the control group developed socially. In summary, it can be said that the patient's social handicap begins in the prodromal phase of schizophrenia. Men suffer more social disabilities than women due to their lower age at first. Men are more likely to show socially negative behavior. This decreases with age. This observation is probably an epiphenomenon with regard to schizophrenia, since socially negative behavior is found in men in all population groups, regardless of disease.
This allows a theoretical conclusion. The above-mentioned theories are modified by these studies: the starting conditions determine the social course of the disease. To put it simply: the patients with an early onset of the disease do not start and stagnate (non-starter), the patients with a late onset of the disease suffer a stagnation at an advanced level (social drift). The earlier onset of the disease in men causes the less favorable social development of male schizophrenics.
Medium-term course: non-starters vs. Social drift
In order to test the theses non-starter versus social drift on the question of social disability in patients with schizophrenia, H. Häfner and others retrospectively and prospectively examined 115 patients with a schizophrenic primary illness in a study from 1998. The PSE Catego Score was used as an instrument. A DAS score of less than 2 was assumed as the overall indicator of financial independence. The investigators found that in the age group under 20 years only 20% of the patients were socially independent. They stayed that way throughout the process and will likely stay that way for a lifetime. The non-starter thesis applies to them. In the age group 20–35 years, around 40% of the patients were socially independent. Completely different conditions were found in the age group 35–60 years. They showed a steep social decline. In this age group, 85% of patients were socially independent before the onset of the disease. This proportion fell to 25% social independence after the onset of the disease. Thus, the social drift hypothesis could especially apply to patients who become ill in later life.
| Age group | |||
|---|---|---|---|
| <20 years | 21–35 years | 35–59 years | Time before and after first manifestation |
| 20th 25 |
35 40 |
85 60 |
First signs First psychotic symptoms Initial |
Long-term course
The long-term course of patients with schizophrenia has been carefully examined in several international studies with regard to the severity of symptoms and the extent of social disability. This was done as part of the so-called “WHO Disability Studies” in Groningen , Nottingham and Mannheim .
| CATEGO total score (high values = psychosis, low values = mental health) |
Time after first manifestation |
|---|---|
| 40 15 |
Initial admission ½ year |
| DAS score men (high values = pronounced negative social behavior, low values = normal social behavior) |
DAS score women (high values = pronounced negative social behavior, low values = normal social behavior) |
Time after first manifestation |
|---|---|---|
| 3.7 2.4 |
1.9 1.9 |
|
As soon as the first psychotic episode is over, in most patients the symptoms do not change significantly over a period of several years. There are hardly any differences between men and women. When measured against socially negative behavioral items, the social handicap of women is less pronounced in comparison. On the whole, the prognosis of the social course of schizophrenia is more serious in men than in women.
Further investigations
J. Rabinowitz et al. recently tested Kraepelin and Bleuer's suggestion that there are discrete signs of schizophrenia in some patients long years before the onset of the disease in the strictest sense, and that the later course of schizophrenia is related to the early signs. This assumption was tested for the first time in a cohort study . For this purpose, the data from the sampling of 17-year-old adolescents and the data from a population-wide admission register in psychiatric clinics in Israel were compared with one another. In this way, comparable data could be obtained from around 1,000 people with schizophrenia before the onset of the disease. In the male subjects, there was a connection between the number of treatment days per year and deficits in social skills. In female volunteers, there was evidence of a relationship between intellectual abilities and the severity of the disease. The authors conclude that gender- and disease-specific premorbid deficits are predictive factors in schizophrenia.
To understand the relationship between depression and schizophrenia in the early course of the disease, H. Häfner et al. recently examined risk factors and the occurrence and combination of symptoms in the untreated early course of schizophrenia. For this purpose 130 people with schizophrenia were compared with 130 depressed patients and 130 control persons. As in previous studies, it was found that the onset of schizophrenia is characterized by severe depression, followed by negative symptoms and social disability. This core syndrome of the early stage of schizophrenia becomes more evident as the disease progresses and it disappears with the onset of psychotic symptoms. The authors suspect that the depressive syndrome could be an expression of an innate reaction pattern, since the willingness to have depressive reactions is widespread in the normal population and depressive reactions belong to the prodromal stages of many different mental disorders. If brain dysfunction progresses, such a depressive syndrome can develop into a more serious illness, such as psychosis.
Therapeutic options
The empirical studies presented here show that schizophrenia is a disease that begins chronically in the majority of cases. About 75% of patients experience the first so-called outpost symptoms about five to six years before they are first admitted to a psychiatric clinic. Within the first five years, patients develop a core schizophrenic syndrome with depression, negative symptoms and a social disability. On average, the onset of the first psychotic symptoms occurs in the last year before the first admission. The social consequences of the disease usually begin in this so-called prodromal phase. In male patients in particular, schizophrenia begins around the age of 20 to 22 with a depressive mood. In women, the onset of the disease occurs only a few years later, but with the same developmental stages. The reasons for this delay are unknown.
The consequences of these studies are manifold:
- The most important early symptoms are: Depression and negative symptoms with social disabilities.
- All early symptoms can be adequately treated with conventional methods (antidepressants, cognitive behavioral therapy, psychosocial training, occupational rehabilitation).
- For ethical reasons, great caution is required with regard to early treatment of patients with neuroleptics.
- The fact that the disease follows a typical pattern in its onset supports assumptions about the biological cause of schizophrenia .
See also
- Clinical schizophrenia concepts
- Neurobiological Schizophrenia Concepts
- Symptoms and diagnosis of schizophrenia
- Subtyping of schizophrenia
- Late schizophrenia
- Course of schizophrenia
- Therapy for schizophrenia
Individual evidence
- ↑ H. Häfner et al .: Onset and early course of schizophrenic diseases . In: Joachim Klosterkötter (Ed.): Early diagnosis and early treatment of mental disorders. Springer, Berlin 1998, ISBN 3-540-64440-7
- ↑ a b c H. Häfner et al .: Onset and early course of schizophrenia. In: H. Häfner et al .: Search for the causes of schizophrenia. Vol. III. Springer, Berlin 1995, pp. 43-66.
- ↑ M. Hambrecht, H. Häfner: "Trema, Apophänie, Apocalypse" - Can Conrad's phase model be empirically justified? Progress Neurol. Psychiatr. 61 (1993) 418-423. PMID 8112705
- ^ Dunham, HW: Community and schizophrenia: an epidemiological analysis . Wayne State University Press, Detroit 1965.
- ^ H. Häfner: The epidemiology of onset and early course of schizophrenia . In: H. Häfner and others: New research in psychiatry. Hogrefe and Huber. Seattle 1996, pp. 33-61.
- ↑ a b H. Häfner et al .: Is schizophrenia a disorder of all ages? A comparison of first episodes and early course over the life cycle . In: Psychol Med , 28, 1998, pp. 357-365. PMID 9572092
- ↑ H. Häfner et al .: An instrument for the retrospective assessment of the onset of schizophrenia (Instrument for the Assessment of the Onset of Schizophrenia. - IRAOS) . In: Z Klin Psychol , 19, 1990, pp. 230-255
- ^ H. Häfner et al .: IRAOS: An instrument for the assessment of the onset and early course of schizophrenia . In: Schizophr Res , 6, 1992, pp. 209-223. PMID 1571314
- ^ H. Häfner and others: The influence of age and sex on the onset and early course of schizophrenia . In: Br. J. Psychiatry , 162, 1993, pp. 80-86. PMID 8425144
- ^ D. Wiersma et al .: Assessment of the need for care 15 years after onset of a Dutch cohort of patients with schizophrenia, and an international comparison . In: Soc Psychiatry Psychiatr Epidemiol , 31, 1996, pp. 114-121, PMID 8766456
- ^ P Mason et al .: Characteristics of outcome in schizophrenia at 13 years . In: Br. J Psychiatry , 169, 1996, pp. 580-586. PMID 8564314
- ↑ W. an der Heiden et al .: Mannheim Long-Term Study of Schizophrenia . In: neurologist , 66, 1995, pp 820-827. PMID 8532098
- ↑ W. an der Heiden et al .: A prospective study on the long-term course of schizophrenic psychoses: Results of the 14-year follow-up . In: Z. Med Psychol , 5, 1996, pp. 66-75.
- ^ J. Rabinowitz et al .: Association between functioning in adolescence prior to first admission for schizophrenia and affective disorders and patterns of hospitalizations thereafter . In: Schizophr Res. , 2005 Mar 1, 73 (2-3), pp. 185-191. PMID 15653261
- ↑ H. Häfner et al .: The early course of schizophrenia and depression . In: Eur Arch Psychiatry Clin Neurosci. , 2005 Jun; 255 (3), pp. 167-173. PMID 15995900
