The initial stages of schizophrenia

Schizophrenia is classified as a mental disorder that has preliminary signs that may signal the development of this disease. The set of early symptoms and the entire period of their manifestation are considered the prodromal or prepsychotic phase, which is defined by such terms as initial schizophrenia, psychosis risk syndrome, and schizophrenia prodrome. The duration of this period is individual for each case and varies from several months to several years. [ 1 ]

Epidemiology

The prevalence of schizophrenia among the population is generally 0.7-1.1%; according to other information, for every thousand of the population there are 3-4 cases of schizophrenia and 3.3 cases of prodrome, that is, initial schizophrenia.

The proportion of people diagnosed with schizophrenia is 0.29% of the total population, varying in different countries from 0.2 to 0.45%. [ 2 ]

According to WHO data from 2016, more than 21 million people worldwide suffered from this severe chronic mental disorder. 70-90% of patients experienced a prodromal stage.

If the initial stage of schizophrenia in men usually appears between 15-25 years, then the initial stage of schizophrenia in women is detected later - at 25-30 years, and almost one and a half times less often than in men (according to other data, the number of men and women with schizophrenia is approximately the same). [ 3 ]

Schizophrenia is rarely diagnosed in children and people over 45 years of age.

Causes initial schizophrenia

Currently, the exact causes of schizophrenia continue to be studied, and often in psychiatry there is a very vague definition of the etiology of this disease, as the result of a complex interaction of genetically determined factors with the environment.

Thus, risk factors for the initial stage of schizophrenia exist and, as it seems, partially contribute to both its emergence and the subsequent transition to the manifestation stage (in 35% of cases – after two years). [ 4 ]

Versions and theories regarding the causes of this disease include:

• transmission of genetic mutations by inheritance (schizophrenia is often observed in close relatives, although it is not considered a hereditary disease, but, as researchers suggest, it can develop in cases of unbalanced genomic imprinting);
• dysfunction of the brain due to an imbalance of biogenic amines acting on nerve cells – neurotransmitters dopamine, serotonin, norepinephrine, glutamic acid (N-methyl-D-aspartate glutamate) and GABA (gamma-aminobutyric acid);
• the presence of problems of communication and interaction between individual cerebral regions and structures due to abnormalities of the brain cells themselves, especially glial cells that surround the neurons of the central nervous system;
• immunological shifts – increased activation of the immune system of inflammatory or autoimmune origin;
• exposure of the embryo or newborn to viral infection (Morbillivirus, Varicella Zoster, Rubella virus, genital Herpes simplex virus type II, Bornavirus) or toxins;
• perinatal damage to the central nervous system due to hypoxia and/or cerebral ischemia;
• chronic stress (including maternal stress during pregnancy) and psychosocial factors;
• use of psychotropic (psychoactive) substances.

Whether there is a seasonal factor is still unclear, but studies have shown that those born in winter or early spring (when the body lacks vitamin D) are more likely to develop schizophrenia. [ 5 ]

Pathogenesis

Many experts see the pathogenesis of schizophrenia in disturbances in the transmission of nerve impulses mediated by the neurotransmitter dopamine. Read more about the so-called dopamine theory in the publication – Schizophrenia.

Current research into the mechanisms involved in the development of this mental disorder suggests a leading role in disruptions in the connections between the functional structures of the brain that perceive sensory signals and generate corresponding responses: the associative area in the frontal part of the prefrontal cortex, the auditory cortex of the temporal lobes, the associative areas of the cerebral cortex of the inferior parietal lobes, etc.

It is possible that the pathological change in the interconnections and interactions of the associative zones of the brain is the result of a progressive decrease in the number of membrane calyrin outgrowths on the processes of cortical pyramidal neurons – dendritic spines. [ 6 ]

On the other hand, genetic studies have shown that chromosomal microrearrangements – non-allelic homologous recombinations of genes of neurotransmitters and their receptors with molecular damage in the form of loss of microscopic chromosomal fragments (deletions) or their segmental doubling (duplication) – are directly related to the mechanism of development of sporadic schizophrenia (in the absence of cases of this disease in the family). [ 7 ]

Symptoms initial schizophrenia

In essence, when this disorder develops, changes occur in a person’s psyche that lead him into an inner world that is unknown and incomprehensible to others.

To simplify identification, the entire set of symptoms of this mental disorder, including the initial symptoms of schizophrenia, are divided into subgroups: positive (emerging psychotic signs), negative (lost abilities), emotional (affective) and cognitive (cognitive). [ 8 ]

According to psychiatrists, all symptoms never appear simultaneously in one patient, and many may be observed temporarily and for a very short time; however, some signs of the disease are present permanently and do not respond to treatment. [ 9 ]

Negative symptoms that reduce the ability to adapt appear earlier than others – often remaining unnoticed in the prodrome stage – and are associated with loss of motivation, decreased perception and expression of emotions, loss of feelings of pleasure and enjoyment, reduced self-care, and limited verbal communication (with speech becoming monotonous and no eye contact during conversation). Positive symptoms include:

• fixed false (delusional) beliefs that have no real basis, often of a paranoid nature; a person with distorted thinking and perception of reality becomes distrustful and more suspicious, avoiding contact with people (even to the point of complete isolation);
• auditory or imperative hallucinations (during which patients often talk to themselves or listen to loud music to drown out the “voices in their heads”);
• disorganization of thought processes and speech communication (inconsistency, slurred speech and incoherence);
• behavioral disorganization - from causeless anxiety, agitation and increased motor activity (aimless and useless) to a state of absolute immobility (catatonia).

For family and close people, first of all, these symptoms of the initial stage of schizophrenia become obvious.

Affective symptoms of early schizophrenia include depression and a sense of strangeness in the surrounding world. Cognitive symptoms include decreased attention, the ability to remember new information and establish logical connections, as well as to plan and organize one's actions.

The symptoms of the prodromal and psychotic stages of schizophrenia are differentiated by the intensity and duration of their manifestation, as well as by increasing progression.

Initial signs of schizophrenia in adolescents

The prodrome of schizophrenia often manifests itself precisely in adolescence, which, according to psychiatrists, makes it difficult to identify due to some similarities with the behavioral characteristics of many teenagers. [ 10 ]

In principle, the initial signs of schizophrenia in adolescents are non-specific and can be either depression in adolescents or prodromal signs of a mood disorder, bipolar disorder or anxiety disorder.

Symptoms of early schizophrenia in adolescents are similar to those of adults and include withdrawal from family and friends, detachment from reality, sleep problems, irritability and apathy, decreased stress tolerance, general motivation and academic performance, loss of interest in previous hobbies, and neglect of personal hygiene. Also observed are dull or inappropriate emotions, memory loss, and unreasonable hostility towards others, but delusional ideas are rare, and hallucinations are predominantly visual.

Complications and consequences

If left untreated, schizophrenia at the prodromal stage can progress to overt psychosis and problems that affect all areas of life. Complications include: self-harm, suicidal thoughts and suicide attempts (relative risk is estimated at 12.6%), obsessive-compulsive disorder, alcohol or drug abuse, social isolation. [ 11 ]

Schizophrenia is associated with significant disability worldwide and can negatively impact educational and occupational outcomes.

Diagnostics initial schizophrenia

Despite the non-specificity of the symptoms of early schizophrenia, in psychiatry there are criteria according to which the diagnosis of this disorder is carried out through questioning, anamnesis, analysis of symptoms and a complete psychiatric assessment of the patient. [ 12 ]

Currently, experts use: the Scale of Prodromal Symptoms (SOPS), the Scale of Prodromal Symptoms (Brief Psychiatric Rating Scale) based on the criteria of the Comprehensive Assessment of Symptoms and History, the Comprehensive Assessment of Mental Status at Risk (CAARMS) manual. [ 13 ], [ 14 ]

Read also – Diagnosis of cognitive impairment

Differential diagnosis

Differential diagnostics is carried out using similar methods and allows one to distinguish prodromal schizophrenia from psychotic forms of depression, schizoaffective or bipolar disorder.

In cases with teenagers, the psychiatrist communicates with their parents|/guardians|, clarifying complaints, explaining the principles of diagnosis, methods of therapy, the effect of prescribed drugs, and also answers their questions. For example, is sleepwalking an early stage of schizophrenia? No, sleepwalking or sleep walking is a manifestation of neurosis (neurotic reaction) and refers to sleep disorders that are associated with the functioning of the brain.

Treatment initial schizophrenia

Effective treatment of schizophrenia in the initial stage – based on an integrated therapeutic approach to this mental disorder – should be carried out according to an individual plan drawn up by a psychiatrist for each patient. This includes psychotherapy (individual or group) and psychosocial treatment, which includes psychological education, family therapy, social skills training, vocational rehabilitation, cognitive-behavioral therapy and rehabilitation.

Comprehensive treatment for schizophrenia aims to reduce the long-term disability that people with the disorder often face and help them live normal lives.

Modern psychosocial methods should be combined with drug therapy, which, to correct the symptoms of early schizophrenia, uses drugs from the following pharmacological groups:

• antidepressants;
• anxiolytics: Adaptol (Mebikar), Zolomax, Olanzapine (other trade names – Zolafren, Olanex, Parnasan, Normiton);
• neuroleptics or antipsychotics: Risperidone (other trade names – Rispolept, Rileptid, Ridonex, Rilept, Leptinorm), Azaleptin (Clozapine), Aripiprazole (Aripizole, Amdoal, Zilaxera).

For example, the use of the antidepressant Paroxetine (Paroxin, Paxil, Adepress), which is allowed to be prescribed from the age of 15, can be accompanied by side effects in the form of nausea and loss of appetite, weakness and drowsiness, insomnia and somnambulism, headache and dizziness, increased intracranial pressure and muscle spasms (including orofacial), tachycardia and instability of blood pressure, problems with urination and increased sweating.

Despite the impressive list of side effects, the antipsychotic Risperidone is often prescribed for schizophrenia (the dose is determined by the attending physician). It is not used to treat patients under 15 years of age, or if there is a history of severe heart disease, problems with cerebral circulation, kidney and liver dysfunction, decreased BCC, diabetes, or epilepsy. The list of its side effects includes: sleep disorders, increased excitability and attention deficit, anxiety and a feeling of anxiety, headaches and abdominal pain, increased blood pressure and increased heart rate, seizures, dyspepsia, menstrual irregularities in women, and erectile dysfunction in men.

The antipsychotic drug Azaleptin, prescribed in an individually established dosage, can cause increased drowsiness, headache and dizziness, blurred vision, tremor, nausea, vomiting, dry mouth, constipation, abnormal heart rhythm, increased blood pressure, decreased white blood cell count, urinary incontinence, obesity. The drug is contraindicated in heart problems, hypertension, epilepsy, bowel, blood and bone marrow diseases.

Aripiprazole is contraindicated in cardiovascular disease and under 18 years of age. It may also cause side effects, including: sleep disturbances and psychomotor agitation; salivation and seizures; shortness of breath; nosebleeds; atrial fibrillation, myocardial infarction, and cerebral hemorrhage; memory loss and confusion. [ 15 ]

Prevention

There is no surefire way to prevent early schizophrenia, but following a treatment plan can help prevent symptoms from progressing.

Secondary prevention of schizophrenia will most likely be possible once the risk factors and causes of its development are better understood.

Until then, only early detection of the prodromal phase and intervention can change the course of the disease and help minimize disability.

According to the Recovery from Initial Episode in Schizophrenia (RAISE) study, published in 2015 in the American Journal of Psychiatry, promptly identifying and treating people with schizophrenia prodrome improves their chances of living a full life.

Forecast

Predicting the course and outcome of mental disorders related to chronic diseases is based on the existing symptoms, the intensity of their manifestation and the patient's response to the therapy. And this, as experts say, is possible only in 10-20% of cases.

Schizophrenia is often episodic, so the longer the periods of remission, the better the prognosis for the patient. In addition, some people with this diagnosis - with the right psychotherapeutic and drug support and the development of self-help strategies - are able to manage their symptoms.

However, it should be kept in mind that people with schizophrenia die at a younger age than healthy people. And the main cause of premature death is suicide: according to some estimates, 10-13% of patients resort to suicide - due to severe depression and psychosis, which develop in the absence of treatment.