Early diagnosis of schizophrenia--the first step towards secondary prevention

Schizophrenia: Communication Disorders and Role of the Speech-Language Pathologist

PURPOSE

This clinical focus article aims to provide a comprehensive overview of schizophrenia and understanding of communication disorders resulting from its psychopathology. Schizophrenia is a spectrum disorder with varying levels of symptom expression. It is characterized by positive and negative symptoms that can cause communication disorders of different severity levels. Communication difficulties manifest as a range of symptoms such as alogia, disorganized speech, and impaired social communication. These challenges may result in receptive and expressive language deficits that lead to misunderstandings, reduced social interactions, and difficulties expressing thoughts and emotions effectively. The purpose of this clinical focus article is to explore the role of the speech-language pathologist (SLP) in assessing and treating communication disorders presented in schizophrenia.

CONCLUSIONS

In order to understand the role of the SLP in assessing and treating communication disorders in schizophrenia, it is imperative to understand the overall course, etiology, assessment, and treatment consideration of this condition. SLPs can provide services in the areas of social skills training and community-based intervention contexts.

Co-morbid social phobia in schizophrenia

BACKGROUND

The co-morbid occurrence of anxiety disorders and schizophrenia has recently begun to be investigated. Social anxiety may be especially important to diagnose and manage among patients with schizophrenia.

AIM

To investigate the prevalence and correlates of social phobia in patients with schizophrenia.

METHOD

Diagnosis of schizophrenia and schizoaffective disorders as well as co-morbid anxiety disorders was established according to DSM-IV and the Structured Clinical Interview for Diagnosis (SCID-P Hebrew version). Severity of psychotic symptoms and social anxiety symptoms was assessed with the Positive and Negative Symptom Scale (PANSS) and the Liebowitz Social Anxiety Scale (LSAS).

RESULTS

The cohort studied included 117 patients with schizophrenia. Thirteen patients were diagnosed as suffering from co-morbid social phobia (11%). There was a tendency for patients with co-morbid social phobia to have higher severity PANSS total score. There was a significant correlation between the score of the LSAS ;fear' and PANSS positive subscales. Avoidance scores were higher among patients with negative signs.

CONCLUSION

Co-morbidity of schizophrenia and social anxiety disorder is not rare among patients with schizophrenia. Treatment implications need be further investigated.

Emotional and behavioural antecedents of young adults who screen positive for non-affective psychosis: a 21-year birth cohort study

BACKGROUND

Birth cohort studies have shown that individuals who develop non-affective psychoses display subtle deviations in behaviour during childhood and adolescence. We had the opportunity to examine the widely used Child Behavior Checklist (CBCL) and the Youth Self-Report (YSR) to explore the antecedents of non-affective psychosis.

METHOD

Based on a birth cohort of 3801 young adults, psychopathology was assessed at years 5 and 14 using the CBCL and/or the YSR. Screen-positive non-affective psychosis (SP-NAP) was assessed at year 21 by using the Composite International Diagnostic Interview (CIDI) or a self-report checklist. The association between childhood symptoms and SP-NAP was examined using logistic regression.

RESULTS

Of the cohort, 60 subjects were classified as SP-NAP. In males, SP-NAP was associated with higher scores: (a) on year 5 CBCL 'Total', 'Aggression' and 'Social, Attention and Thought' scores; (b) on year 14 CBCL 'Social', 'Attention' and 'Delinquency' scores, and (c) YSR 'Total' and many YSR subscores. These associations were less clear for females. Hallucinations at year 14 were associated with SP-NAP for both sexes. Boys with high 'Total' scores at both years 5 and 14 were at greatest risk of SP-NAP (a 5-fold risk), followed by boys and girls whose 'Social, Attention and Thought' scores either increased or remained high from years 5 to 14 (3- to 13-fold risk).

CONCLUSIONS

Individuals who screen positive for non-affective psychosis show increased psychopathology during childhood and adolescence. The psychopathological trajectory of children who go on to develop schizophrenia anticipates the heterogeneity associated with the full clinical syndrome.

The early manifestations of bipolar disorder: a longitudinal prospective study of the offspring of bipolar parents

OBJECTIVE

A major aim of this longitudinal high-risk study is to identify reliable early indicators of emerging bipolar disorder (BD) among offspring from well-characterized parents.

METHODS

High-risk offspring were recruited from families in which one parent had BD diagnosed on the basis of the Schedule for Affective Disorders and Schizophrenia - Lifetime version (SADS-L) interviews and DSM-IV diagnostic criteria and the other parent was well. Bipolar parents were further subdivided on the basis of response or non-response to long-term lithium. A comparison group of offspring was recruited from well parents diagnosed on the basis of either SADS-L interviews or the family history method. All consenting offspring from high-risk and control families were assessed longitudinally with the Schedule for Affective Disorders and Schizophrenia for School-aged Children - Present and Lifetime version (KSADS-PL) interviews and DSM-IV diagnoses were made on a blind consensus review. The offspring were reassessed on average annually, as well as at any time symptoms developed.

RESULTS

Antecedent conditions to BD in both high-risk groups included sleep and anxiety disorders, while attention-deficit hyperactivity disorder and pre-psychotic conditions were antecedents among the offspring of lithium non-responders only. Among those offspring developing BD, the index mood episode was almost always depressive.

CONCLUSIONS

Despite a specific genetic risk, BD began with non-specific psychopathology and/or depressive disorders in a majority of offspring. Therefore, diagnosis based only on cross-sectional assessment of symptoms appears to be insufficient for the accurate early detection of emerging BD. Other parameters such as family history and associated antecedents should be taken into account.

Early detection and treatment of schizophrenia: how early?

OBJECTIVE

Whereas early detection and therapy of schizophrenic psychoses until some time ago concentrated on frank schizophrenia, during the last years some centres have also started to treat patients even before a clear diagnosis could be established. This paper attempts to discuss if and when this is justified in the light of recent research.

METHOD

Mini review of literature.

RESULTS

The rationale for early detection and treatment of schizophrenia is based on several observations: diagnosis and treatment of schizophrenia are often seriously delayed. Consequences of the disease are severe already in the early undiagnosed phase of the disorder and early treatment seems to improve the course of the disease. It can therefore be stated quite safely that patients should be treated as early as possible. However, the question of how early has not been sufficiently answered up to now.

CONCLUSION

We are at the moment in an ethical dilemma between either diagnosing and treating this disorder too late or too early. The only way and prerequisite for solving this dilemma is a more reliable identification of individuals at risk and the beginning disease process.

Do maternal folate and homocysteine levels play a role in neurodevelopmental processes that increase risk for schizophrenia?

OBJECTIVE

Evidence from many different lines of research supports the hypothesis that schizophrenia is a disorder of development with etiological factors implicated as early as the second trimester in utero. We suggest that low maternal folate, acting to increase homocysteine levels, may provide a functional link between many of the identified prenatal risk factors and the hypothesized mechanisms whereby neurodevelopmental patterning deviates toward a schizophrenic potential.

METHODS

PubMed was searched from the present back to 1963, when elevated homocysteine was identified as a pathogen in homocystinuria as first described by Carson and colleagues (Arch Dis Child 1963;38:425-36). All articles for homocystinuria, homocysteine, folate, and development with schizophrenia were evaluated.

RESULTS

The findings from this review support the hypothesis that maternal low folate and high homocysteine levels may provide a potential teratogenic mechanism that increases the risk for developing schizophrenia.

CONCLUSION

The potential role of maternal folate deficiency and hyperhomocystinemia in the genesis of schizophrenia would extend the range of their known teratogenic effects. Given the potential for preventive treatment offered by this hypothesis, we believe further investigation into this mechanism is warranted.

Stability and prediction of schizophrenia from adolescence to adulthood

Stability of schizophrenia diagnosis from adolescence to adulthood, antecedents of schizophrenia, and differences in developmental and behavioural histories between subjects with early onset schizophrenia (EOS) and with adult onset schizophrenia (AOS) were investigated in 145 adult subjects diagnosed with mental disorders in adolescence and re-diagnosed on the basis of medical records according to DSM-IV.A very high diagnostic stability schizophrenia was demonstrated at the 28-year follow-up. Several factors, including neurological adversities, delayed language development, low IQ, and congenital functional disability, differentiated significantly between schizophrenic subjects and non-schizophrenic subjects. Histories of concussion, physical abuse, parental divorce, and unstable familial context differentiated significantly between EOS and AOS subjects. Our findings support earlier evidence of schizophrenia being a chronic disorder with high diagnostic stability, and confirm the importance of neurological adversities, delayed language development, and low IQ as factors predictive of schizophrenia. Exploration of four case histories of AOS subjects delineates "pre-schizophrenic warning cluster" where combination of neurological adversities, temperamental problems, antisocial behaviour, preference for solitary play, and unstable family system constitute main factors.

1H MRSI evidence of metabolic abnormalities in childhood-onset schizophrenia

In adult schizophrenia, magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) have revealed volumetric and metabolic defects in multiple brain regions, among them the anterior cingulate, frontal cortex, striatum, thalamus, parietal cortex, and frontal and parietal white matter. This study used proton magnetic resonance spectroscopic imaging ((1)H MRSI) to identify potential metabolic abnormalities in these regions in childhood-onset schizophrenia. (1)H MRSI was acquired at 1.5 T and 272 ms echo time in 11 children and adolescents with schizophrenia (aged 7-18 years; seven boys, four girls; all but two medicated) and 20 age-matched healthy controls (10 boys, 10 girls). Absolute levels of N-acetyl compounds (NAA), creatine plus phosphocreatine (Cr), and choline compounds (Cho) were compared among groups in each region. In schizophrenic patients relative to controls, Cr was 14.3% higher in superior anterior cingulate (mean of left and right hemispheres). Cho was higher in superior anterior cingulate (30.3%), frontal cortex (13.3%), and caudate head (13.5%). In the thalamus, there was also a diagnosis-by-gender interaction, whereby NAA was lower in patients for male but not for female subjects. Elevated Cr suggests abnormal local cell-energy demand and elevated Cho is consistent with a prior proposal that patients with early age-of-onset schizophrenia exhibit phospholipid membrane disturbances. Low NAA may reflect diminished neuronal integrity.

Premorbid cognitive and behavioral functioning in military recruits experiencing the first episode of psychosis

OBJECTIVE

To characterize the premorbid cognitive and behavioral abilities in apparently healthy adolescents who at a later time will be diagnosed with schizophreniform disorder or schizophrenia.

BACKGROUND

Clarifying the pathological relationship between subtle intellectual and behavioral abnormalities and disease could provide markers for the early prediction of future psychosis.

METHOD

Premorbid data on young male patients admitted to the Department of Psychiatry of the Central Military Hospital in Bucharest, Romania, between 1996 and 2002 and diagnosed with a first episode of psychosis or schizophreniform disorder were collected. The premorbid data consisted in the test scores of intellectual functioning and personality traits were collected by the Romanian Draft Board in order to assesses their aptitude to serve in the military. Premorbid cognitive and behavioral scores of male patients (cases=157) were compared with the scores of healthy male individuals (non-cases=169) matched for age, education, and geographic area of residence. The tests were administered when subjects were 18 years of age (initial screening) and the entire assessment was completed and concluded when subjects reached 20 years of age (actual conscription).

RESULTS

As a group, apparently healthy males later admitted for a first episode of psychosis or schizophreniform disorder, obtained lower (worse) scores on the Raven Progressive Matrices test and on relevant personality traits in comparison to controls.

CONCLUSION

The results add to the accumulating body of evidence suggesting that aspects of schizophrenia manifest years before the illness is formally diagnosed. Despite these results, more studies are needed to improve the diagnosing specificity and predictive value of the premorbid cognitive and behavioral manifestations, before they can be used as markers in models of primary or secondary prevention.

Zusammenhänge zwischen Veränderungen in verschiedenen Funktionsbereichen von schizophren Erkrankten während der Durchführung sozialer Fertigkeitstrainings

Zusammenfassung. Theoretischer Hintergrund: Auf Grund einer Übersicht bisheriger Befunde schlugen Green und Nuechterlein (1999) ein Modell vor, welches das Zusammenwirken zwischen verschiedenen Funktionsbereichen schizophren Erkrankter beschreibt. Fragestellung: Die vorliegende explorative Studie untersucht, ob sich Zusammenhänge zwischen Veränderungen im kognitiven und sozialen Bereich sowie der Symptomatik schizophren Erkrankter während der Durchführung sozialer Fertigkeitstrainings ergeben und inwiefern diese dem von Green und Nuechterlein vorgeschlagenen Modell entsprechen. Methode: 80 Patienten, die an einem sozialen Fertigkeitstraining teilgenommen hatten, wurden in die Auswertung einbezogen. Als hauptsächliche Auswertungsmethode wurde der “typologische“ Ansatz zur Veränderungsmessung von Schöttke et al. (1993) verwendet. Ergebnisse: Signifikante Zusammenhänge ergaben sich zwischen den Veränderungen in der Aufmerksamkeitsleistung, der Negativsymptomatik und dem sozialen Funktionsniveau. Die Veränderungen in der Positivsymptomatik zeigten sich von den Veränderungen in den restlichen Bereichen als unabhängig. Schlussfolgerungen: Die Ergebnisse entsprechen weitgehend den bisherigen Befunden und in diesem Sinne dem von Green & Nuechterlein vorgeschlagenen Modell. Eine mögliche Bedeutung dieser Ergebnisse für die differenzielle Indikation in der psychosozialen Behandlung schizophren Erkrankter wird diskutiert.

Considering schizophrenia from a prevention perspective

Schizophrenia is a serious mental illness that causes major disability and psychosocial impairment. Recent advances in the neurosciences are prompting considerations of schizophrenia from a preventive perspective. An overview of the literature is provided on two important aspects of the development of a prevention orientation in schizophrenia research: elucidation of potential causal risk factors for schizophrenia and research on risk markers. Risk factors for schizophrenia include, but are not limited to, family history, older paternal age, velo-cardio-facial syndrome, maternal infections during pregnancy, pregnancy and delivery complications, and social adjustment difficulties in childhood and adolescence. Potential risk markers include structural brain pathology, minor physical anomalies and dermatoglyphic abnormalities, neurocognitive deficits, eye-tracking dysfunction, certain electrophysiologic findings, and olfactory identification deficits. Several early efforts at indicated preventive interventions targeting individuals at particularly high risk for developing the disorder are discussed. The preventive medicine and public health disciplines may have a role in future research and interventions that apply a preventive perspective to schizophrenia and other mental illnesses. Like any other chronic medical condition, schizophrenia can be considered from a preventive perspective.