M. Hambrecht

Depression, negative symptoms, social stagnation and social decline in the early course of schizophrenia.

Häfner H, Löffler W, Maurer K, Hambrecht M, an der Heiden W. Depression, negative symptoms, social stagnation and social decline in the early course of schizophrenia.

The ABC schizophrenia study: a preliminary overview of the results

Abstract The ABC Schizophrenia Study, a large-scale epidemiological and neurobiological research project commenced in 1987, initially pursued two aims: (1) to elucidate the possible causes of the sex difference in age at first admission for schizophrenia and (2) to analyse the early course of the disorder from onset until first contact and its implications for further course and outcome. First, transnational case-register data (for Denmark and Germany) were compared, second, a population-based sample of first-episode cases of schizophrenia (n = 232) were selected and third, the results obtained were compared with data from the WHO Determinants of Outcome Study by using a systematic methodology. A consistent result was a 3–4 years higher age of onset for women by any definition of onset, which was not explainable by social variables, such as differences in the male-female societal roles. A sensitivity-reducing effect of oestrogen on central D2 receptors was identified as the underlying neurobiological mechanism in animal experiments. Applicability to humans with schizophrenia was established in a controlled clinical study. A comparison of familial and sporadic cases showed that in cases with a high genetic load, the sex difference in age of onset disappeared due to a clearly reduced age of onset in women, whereas in sporadic cases it increased. To analyse early course retrospectively, a semistructured interview, IRAOS, was developed. The early stages of the disorder were reconstructed in comparison with age- and sex-matched controls from the same population of origin. The initial signs consisted mainly of negative and affective symptoms, which accumulated exponentially until the first episode, as did the later emerging positive symptoms. Social disability appeared 2–4 years before first admission on average. In early-onset cases, social course and outcome, studied prospectively over 5 years, was determined by the level of social development at onset through social stagnation. In late-onset cases, decline from initially high social statuses occurred. Socially negative illness behaviour contributed to the poor social outcome of young men. Symptomatology and other proxy variables of the disorder showed stable courses and no sex differences. Further aspects tested were the sequence of onset and the influence of substance abuse on the course of schizophrenia, primary and secondary negative symptoms, structural models and symptom clusters from onset until 5 years after first admission.

Precipitation and determination of the onset and course of schizophrenia by substance abuse — a retrospective and prospective study of 232 population-based first illness episodes

Onset and lifetime prevalence of substance abuse were assessed retrospectively using the IRAOS interview in a population-based, controlled sample of 232 first episodes of schizophrenia (ABC sample). Subjects with schizophrenia were twice as likely as controls to have a lifetime history of substance abuse at the age of first admission (alcohol abuse: 23.7 versus 12.3%; drug abuse: 14.2 versus 7.0%). 88% of the patients with drug abuse took cannabis. The sequence of substance abuse and schizophrenia was studied on the timing of abuse onset and illness onset, the latter as based on various definitions: first sign of the disorder, first psychotic symptom and first admission. 62% of the patients with drug abuse and 51% of those with alcohol abuse began the habit before illness onset (=first sign of the disorder). Abuse onset and illness onset occurred highly significantly within the same month (drug abuse in 34.6%, alcohol abuse in 18.2%). Unexpectedly, no temporal correlation was found between abuse onset and the onset of the first psychotic episode. We concluded that a small proportion of schizophrenias might have been precipitated by substance--mainly cannabis--abuse. Long-term effects of early substance abuse were studied prospectively at six cross-sections over five years from first admission on in a subsample of 115 first episodes of schizophrenia. Abusers showed significantly more positive symptoms and a decrease in affective flattening compared with controls. Five-year outcome as based on treatment compliance, utilization of rehabilitative measures and rate of employment was also poorer for patients with than without early substance abuse.

Is schizophrenia a disorder of all ages? A comparison of first episodes and early course across the life-cycle

BACKGROUND The heterogeneity of schizophrenic and delusional syndromes by age of onset has frequently been discussed. METHODS The age distribution of symptoms and 5 year course was studied in a population-based first-episode sample admitted to 10 psychiatric hospitals before the age of 60 (N = 232) and in a clinical sample without age limit of consecutive first admissions to a single hospital (N = 1109), both samples with broadly diagnosed schizophrenia. RESULTS Early-onset patients, particularly men, presented more non-specific symptoms and higher PSE-CATEGO total scores than late-onset patients. In men, symptom severity decreased with increasing age of onset. In women, it remained stable except for an increase of negative symptoms with late-onset. Only a few symptoms changed markedly with age: disorganization decreased, while paranoid and systematic delusions increased steeply across the whole age of onset range. Pronounced age- and sex-differences emerged in illness behaviour, socially negative behaviour and substance abuse. Within the group of late-onset psychoses there were continuous transitions in symptom profiles and no discrimination between schizophrenia and paranoid psychosis or late paraphrenia. The main determinant of social course was onset level of social development. Early-onset patients did not improve in social status, while late-onset patients, prior to retirement, suffered considerable decline in social status. CONCLUSIONS Gender differences in age at onset and in age trends in symptom severity support the hypothesis of a mild protective effect of oestrogen. Social course results from an interplay between biological factors (age at onset and functional impairment) and development factors (level of social development at onset and illness behaviour).

A randomized comparison of group cognitive-behavioural therapy and group psychoeducation in patients with schizophrenia

Objective:  Although the efficacy of cognitive‐behavioural therapy (CBT) in schizophrenia has been established in a number of studies, no information is available on the differential efficacy of CBT in comparison with patient psychoeduction (PE).

Determinants of subjective quality of life in post acute patients with schizophrenia

Abstract.Although Quality of Life (QoL) is of growing interest in schizophrenia research, little is known about putative causal determinants of this multidimensional construct. The present study explored the utility of objective indicators, psychopathological symptoms and psychosocial concepts drawn from empirical findings in community samples and the vulnerability-stress-coping model of schizophrenia for predicting general subjective QoL in post acute patients with schizophrenia. The analyses were based on cross-sectional data from 66 post acute patients with schizophrenia. The relationships between QoL and possible determinants were investigated using correlational analysis, regression analysis and structural equation techniques.As a result no significant relationships between objective indicators and general QoL were found. The strongest significant determinants were depressive symptoms and the psychosocial concepts of negative coping, perceived social support and self-efficacy. The empirical causal modelling results indicated that depression led to a direct negative impact upon QoL, whereas the other determinants had direct negative or positive effects on depression and affected QoL indirectly. One could conclude that to enhance patients’ QoL, improvements in depressive symptoms, negative coping style, social support and self-efficacy seem to be most effective.

Transnational stability of gender differences in schizophrenia? An analysis based on the WHO study on determinants of outcome of severe mental disorders.

SummaryGender-specific analyses of the multinational WHO-Determinants of Outcome-Study (including 1,292 cases from 10 countries) demonstrate the transnational stability of major findings on gender differences in schizophrenia: Male patients have an earlier mean age at onset in all countries. In female patients, the distribution of the age at onset shows a second peak after age 40 years. No gender differences on nuclear symptoms of schizophrenia can be detected, but on uncharacteristic symptoms, particularly some aspects of the illness behaviour, differences appear. This investigation supports the transcultural validity of gender differences found in the German ABC-Schizophrenia-Study and in the Danish-German Psychiatric Case Register studies.

Evidence for a gender bias in epidemiological studies of schizophrenia

A higher lifetime morbidity risk for schizophrenia in males has been observed by several investigators. Studies controlled for errors in patient selection and other sources of artefacts, however, find an equal risk in both sexes. In order to detect the causes for the underrepresentation of women in many studies, sample composition of multicentre WHO studies was analysed. Severity of symptoms was not found to be responsible for imbalances in the male/female ratios, but cultural influences and design characteristics were: due to the scarcity of psychiatric facilities, women are less likely to receive adequate treatment in most of the developing countries investigated, since they are kept longer at home and seen by traditional healers in some cultures. Also, studies with an upper age limit of 44 years (according to DSM-III) exclude a greater proportion of female than male schizophrenic patients, and there is some evidence that schizophrenia is more often underdiagnosed in women than in men at least in some countries. Implications for future research on gender differences in schizophrenia are discussed.

Beginning schizophrenia observed by significant others

As a part of the ABC Schizophrenia Study, a large-scale investigation of the influences of age and gender on the onset and course of schizophrenia, this study compared retrospective reports about emerging symptomatology during the early course of schizophrenia given by patients and their significant others in a representative lirst admission sample. The Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS), a comprehensive interview assessing early signs and symptoms, revealed that, in most cases, patients as well as informants perceived negative, depressive, and unspecific symptoms as early signs of the disorder. Pairwise agreement about the presence of certain symptoms was good for a limited number of signs, e. g., substance abuse, suieidal behavior, parental and marital role deficits, and paranoid delusions. These items mainly concern abnormal behaviors that can be observed easily. In contrast, there was little agreement between reports about perceptual and formal thought disorder, i.e., subjective internal phenomena. The results supported a continuity model for the observability of symptoms in schizophrenia.

The early course of schizophrenia

In 73% of cases, the onset of the first psychotic episode is preceded on average by a 5-year prodromal phase. The main earliest signs of the disorder are depressive and negative symptoms. Early depressive symptoms at a cumulative prevalence of 81% until first admission predict higher overall symptom scores in the first illness episode and lower scores for affective flattening in the medium-term course. The social course of schizophrenia is decided before the first treatment contact - in early-onset illness by social stagnation, in late-onset illness by social decline. The sex difference in social course is determined by men’s lower level of social development at illness onset and their socially adverse illness behavior. In most cases comorbidity with alcohol and drug abuse, with a relative risk of 2 for both men and women, begins after illness onset, but before first admission. In a small proportion of cases, the onset of substance abuse and, more rarely, the onset of alcohol abuse might trigger the onset of schizophrenia prematurely, but astonishingly, they do not seem to precipitate the onset of psychosis. In the medium-term course alcohol and drug abuse increase positive symptoms and decrease affective flattening, but also reduce compliance and utilization of rehabilitative measures. Except in the early illness phase the disorder, positive symptoms in particular, seem to have no decisive influence on the gradient of social course and outcome. This has serious implications for treatment, currently aimed at reducing psychotic symptoms.