Early ONSET SCHIZOPHRENIA

Prevalence & Age OF ONSET Early onset, as defined by the DSM is before the age of 13 Typical age of onset is late teens/early 20s. Early onset is considered very rare. Prevalence by age: Adolescents & Adults: 0.5-1% Children 11 to 15 years: 1.4 in 10,000 (.014%) Under age of 11: 1 to 5 children in 100,000 (.001%- .005%) Of all diagnosed cases 1% occur before 10 4% occur before 15 Early diagnosis can occur. But as mentioned above, it is very, very rare. Think about this way 1% of all cases which

Notice age of onset often late teens or early 20s Notice age of onset often late teens or early 20s. More recent research suggests that males develop symptoms earlier than females. It is also noteworthy that symptoms can occur later in life or earlier in life (but it is much less likely).

Symptom Presentation Overall, symptom presentation in children seems to be similar to that of adults. Nonetheless, differential diagnosis can be challenging, especially in younger children. Why? First, think from a developmental perspective about a child’s sense of reality and how the world works (e.g., they may believe that cartoons are real, that their stuffed animals are watching them, they may have imaginary friends). Self-expression and limited ranges of behaviors Regarding the first point above. The diagnostic criteria, which was designed primarily with adults in mind, seems to hold in children (remember this may not be the case for mood disorders. Regarding the second point. As mentioned above, understanding reality is a developmental process. Children often have imaginary friends, unrealistic beliefs about what they are able to do, beliefs in toys coming to life, special powers, and imaginary friends. So how do you tell the difference between typical and atypical? The first part of this is to understand that children often do not have a great sense of reality. Second, the beliefs in normal children often are not particularly upsetting or persistent. My daughter had imaginary friends when she was younger. In fact, she seemed to have an entourage. One day I said, “Harper lets go to the Y.” She said, “can I bring my friends with me.” I said “sure.” So Harper, myself, and her imaginary friends all packed into the Volkswagen and went to the Y. In contrast, they tend to be unwanted and terrifying in children with psychosis. Remember Jani, she had imaginary friends. The thoughts were upsetting and pervasive. One differential early in life is autism versus schizophrenia. Autism onset is usually noticeable earlier, and they typically show specific patterns of social impairment. Children with schizophrenia typically develop symptoms (at least diagnosable symptoms) at a later age. Further, outside of an acute episode, they are often very social and probably have well developed theory of mind.

Symptom Presentation Onset is typically gradual Initial symptoms (prodromal symptoms) are often present over time. Delays or abnormalities in functioning (motor, sensory, cognitive) Social problems “odd personality” See following slide. Very subtle symptoms are often present before the onset of the first acute episode. Many individuals who eventually receive a diagnosis of schizophrenia present as detached, emotionally somewhat flat (flat affect), and somewhat odd or eccentric before the onset of the first episode. In hindsight, the symptoms are often identifiable as prodromal symptoms. However, at the time, the symptoms are not obviously indicative of schizophrenia.

A great chart from the text. Notice that onset is often gradual A great chart from the text. Notice that onset is often gradual. Premorbid stage is present (maybe some but minimal symptoms) than there is often a prodromal phase preceding the acute (more severe stage). During the prodromal phase, they gradually decompensate. It often starts with emotional withdrawal and increases in odd and eccentric beliefs. Also notice that between acute episodes, certain residual symptoms are often noticeable. These often include negative symptoms and some level of odd eccentric behavior.

Notes: Great chart addressing prodromal (early signs) of schizophrenia.

Notes: Prognosis for schizophrenia is often poor and even worse for early age of onset. However, certain factors are associated with more positive versus poorer outcomes. For example good premorbid functioning before onset of the first acute episode is predictive of a more favorable prognosis.

Characteristics and Experiences of Children with Schizophrenia Positive Symptoms: excessive or added behavior or sensory experience (things that most other individuals don’t experience). Examples: Hallucinations Perceptual experiences in absence of external stimuli Delusions Strongly held false beliefs

Characteristics and Experiences of Children with Schizophrenia Negative Symptoms: Deficits or experiences missing when compared to healthy individuals, examples: Flat affect Loss of emotion Alogia Loss of communication Avolition Loss of purposeful behavior

Etiology Genetics: Neurobiological abnormalities Heritability plays a robust role (but does not account for all variability). See next slide Neurobiological abnormalities Structural abnormalities (e.g., enlarged ventricles and loss or brain mass) Functional abnormalities (e.g., excessive dopamine)

Notes. One way to interpret relative risk is to compare to the base rate prevalence rate for the population which is .5 to 1%. For example, in the case of identical twins, if twin A has schizophrenia there is over a 65% chance that twin B will have it. This means that the risk for twin B is 65 to 130 times greater than that of the general population. Genetic influences are very very robust. HOWEVER, notice that about 35% of the time, twin B will not have the disorder. Genetics does not tell the whole story.

Etiology Environment: Prenatal factors & pregnancy factors are relevant (e.g., exposure to certain viruses). Psychosocial stress. Not causal, but seems to have some influence on onset, severity, and course of the disorder (think diathesis stress model).

Interventions Antipsychotic medications are the front line of treatment Usually novel or atypical antipsychotics are used, example: Risperdone (Risperdal) which is a serotonin-dopamine antagonist Medications have side effects, some severe After acute phase ends, maintenance on low doses to reduce chance of relapse Notes: the first generation antipsychotics including Haldol and Thorazine had much more severe side effects.

Interventions Psychological interventions are also important, but usually adjunctive (in addition to medication). Social skills training Medication compliance Educational placement Family support See next slide.

Researchers examined the efficacy of early intervention to prevent the emergence of schizophrenia among youths at high risk for the disorder. Immediately after treatment, youths who received early intervention were less likely to develop psychotic symptoms than youths who received treatment only after symptoms began to emerge (i.e., needs-based treatment). One year later, most youths who received early intervention continued to remain symptom free, but only if they remained on antipsychotic medication. These findings highlight the importance of early intervention and compliance with medication. Based on McGorry and colleagues (2002).