Early Warning Signs Of Schizophrenia

Introduction

Schizophrenia is a chronic mental health condition which creates disorder in an individual's thought processes, perceptions of reality, emotions and the way they interact with other people.¹

Although schizophrenia typically emerges in late adolescence or early adulthood, doctors can follow the condition through its development at different stages of life.¹ Although the early symptoms of schizophrenia aren’t as well defined as the diagnostic symptoms of the full condition, this article will paint a picture of the warning features which suggest that someone may be developing the disease. 

Importance of early detection

Studies into the early course of the illness have found a pre-psychotic prodromal stage (the stage before diagnostic symptoms appear) and a psychotic prophase (the duration between when symptoms first appear and first admission).²

Prepsychotic prodromal stage: Schizophrenia begins with what’s called a prepsychotic prodromal stage,² which means that initial symptoms can be present for a while before the full development of the condition. On average these early symptoms last just under 5 years.² These symptoms may be similar to early symptoms of other conditions such as depression.²

Psychotic pre-phase: lasting on average around 1 year. 

Early intervention is important as even early symptoms of schizophrenia can have negative effects on social interactions and daily activities.² Studies have shown better functioning in social and work settings in those who received early intervention.³ 

Potential to prevent severe symptoms and improve quality of life.

Early intervention may dictate the future course of illness. At the pre-psychotic prodromal stage, cognitive-behavioural therapy (CBT) may have a positive impact on the short-term illness course2, whereas antipsychotic medication may help manage symptoms in the psychotic pre-phase.2 Overall, noticing the changes in someone and supporting early initiation of antipsychotic medication, if appropriate, may lead to a better long-term prognosis.³ Furthermore, according to some studies, antidepressants or anti-anxiety medication may reduce symptoms in those at risk.³

Specific early warning signs in adolescents

Schizophrenia is usually diagnosed in the late teenage years to early 30s; with symptoms usually presenting earlier in people assigned male at birth.⁴

Schizophrenia isn’t usually diagnosed in children, but it is important to be mindful of the symptoms which may appear in teenagers as they may be harder to categorise.⁴ Mayo Clinic describes these as:

• Withdrawing from loved ones 
• Struggling in school: this is due to a lack of focus as the individual gets more disconnected from reality 
• Difficulty falling or staying asleep
• Irritability or low mood; mood swings may be common, and they may have suspicions of other people which can eventually develop into paranoia⁵ 
• Low motivation 

Teenagers with the condition are more likely to experience hallucinations (e.g. seeing, hearing or feeling things that aren’t real) rather than delusions (fixed, firm, false beliefs).⁴

Childhood schizophrenia is an uncommon condition, similar to schizophrenia in adults, but which occurs in those under the age of 18. For it to occur under the age of 13 is extremely rare.⁶Its symptoms focus on problems with thinking and reasoning, behaviour and emotions.⁶

Overview of early warning signs

Categories of Early SignsThe prodromal stage doesn’t strictly define a set of symptoms but is more a gradual observation of changes over time.³

The evolution of the prodrome has two main patterns:³

• Pattern 1: general changes, followed by more specific prepsychotic changes, and then full psychosis 
• Pattern 2: earlier specific changes, followed by neurotic symptoms (such as anxiety, obsessive thoughts, and depressive symptoms) as a response to these early changes, and then psychosis

Here, ‘specific’ refers to symptoms characteristic to schizophrenia.

There is a difference between the ultrahigh risk (UHR) criteria and an at-risk mental state (ARMS), the latter of which may present with symptoms such as depression or anxiety but won’t necessarily develop into full psychosis.³ 

Cognitive symptoms appear as disturbances in 5 main areas.³ These are thought to be:

• Attention 
• Perception 
• Generation of speech 
• Motor functions, such as any type of physical movement 
• Thought block throughout conversations

Usually, disturbances in attention or perception happen before disturbances in movement or speech.³

The DSM-III, the 3rd edition of a diagnostic tool used mainly by American psychiatrists, provides  useful criteria for the types of symptoms which may be experienced in the schizophrenia prodrome:

• Isolating or withdrawing themselves from other people
• Impaired functioning in activities of their daily role
• Strange behaviour 
• Struggles maintaining self-care and hygiene 
• Difficulty expressing emotions through facial expression or tone of voice 
• Changes in speech: rambling and moves away from the main topic, vague speech, overelaborate or circumstantial speech, poverty of speech or its content 
• Magical thinking 
• Differences in perception 
• Lack of interest or energy 

Later editions of the DSM and the ICD, a diagnostic tool used by British psychiatrists, do not define the prodromal symptoms as clearly.³ However, the ICD does acknowledge the prodrome.³

The ‘active’ stage which comes after the early symptoms resembles the better-known symptoms of schizophrenia. According to Cleveland Clinic, this early stage can include symptoms like:

• Delusions
• Visual or auditory hallucinations 
• Incoherent speech 
• Strange movements, from catatonic behaviour to excessive movements 
• Negative symptoms 

The table below summarises both the early and more specific symptoms of schizophrenia, which are important to look out for. 

Many individuals may be in denial about experiencing symptoms⁵ and many families may attribute the problems such as withdrawal and changes in sleeping to an adolescent or teenager ‘phase’.⁷

Risk factors and contributing factors

Schizophrenia is a condition affecting the brain which involves a change in some chemicals, or neurotransmitters, as well as changes in the structure of the brain.⁴ The exact cause of the condition is still unknown. However, some factors can make people more vulnerable, and these may be important to consider when looking out for early warning signs in loved ones. Individuals may have a genetic predisposition if someone in their family has schizophrenia.⁴ Environmental factors such as very low socioeconomic status or experiencing stress or abuse growing up may contribute to the development of schizophrenia.⁴ 

Other environmental factors such as experiences before or immediately after birth may increase risk. These include:

• Inadequate foetal nutrition during pregnancy or after birth 
• A low birth weight 
• Exposure to toxins or infections in the womb which can affect the brain
• Substance abuse involving psychoactive drugs such as cannabis during teenage years.⁴ These may trigger symptoms or make them worse. 

Early intervention as ongoing research

Early intervention programs attempt to detect schizophrenia early, prevent the transition to psychosis, and implement phase-specific treatment to lower the chances of chronic disabilities.⁸

Although very beneficial in some studies, other studies have found modest success in the use of antipsychotics, family interventions or CBT.⁸ Further research is required to balance the risks and benefits of early treatment. 

Treatment in children

Treatment in children will be lifelong even when the condition seems to have improved.⁶ Mayo Clinic lists the main treatment options, which can involve:

• Antipsychotics: because of their side effects, first-generation antipsychotics aren’t usually used in children until other options such as second-generation antipsychotics have been tried.⁶ The side effects of any medication may be different and more dangerous in children, so it’s important for parents to monitor these
• Psychotherapy: such as individual CBT or family therapy
• Life skills training: to help improve social and academic skills, or vocational rehabilitation to help individuals find and maintain employment

It is important that parents pay attention to triggers and warning signs, emphasise physical activity and healthy eating, and discuss the dangers of alcohol and drug use with their children.⁶

There are many things you can do if you require coping help and support.

Summary

Although schizophrenia is usually diagnosed in late adolescence or early adulthood, there may be some early symptoms which can appear in teenagers. These can be categorised as cognitive, behavioural, emotional and physical symptoms. Knowing what warning signs to look out for may allow a timely diagnosis and early intervention, which can reduce the long-term impact of schizophrenia. Interventions such as psychotherapy and CBT may be useful.