Substance abuse and the onset of schizophrenia

Up to 60% of chronic schizophrenic patients are reported to abuse alcohol or drugs. This comorbidity raises the question whether one disorder is a consequence of the other. With the structured interview "IRAOS," the onset and course of schizophrenia and substance abuse were retrospectively assessed in a representative first-episode sample of 232 schizophrenic patients. Information by relatives validated the patients' reports. Alcohol abuse prior to first admission was found in 24%, drug abuse in 14%-twice the rates in the general population. Alcohol abuse more often followed than preceded the first symptom of schizophrenia. Drug abuse preceded the first symptom in 27.5%, followed it in 37.9%, and emerged within the same month in 34.6% of the cases. The study demonstrates a remarkable association between first-episode schizophrenia and substance abuse, but a unidirectional causality is not supported, nor is a specific psychotic disorder in comorbid cases.

[Psychiatric handicap--precursor or social sequelae of schizophrenia?]

Having finalized the ICD 10, the WHO is now preparing a new version of the "International Classification of Impairments, Disabilities and Handicaps" (ICIDH). At present this threefold scheme is designed to classify the consequences of mental illness. Impairment is defined as either a loss of function or a damage to structure. Disability is the resulting limitation in performance. The restriction in the ability to fulfill social roles is known as role handicap. These three aspects conceptualised in strict sequence have thus far been understood only in terms of the result of the illness. The planned review of the ICIDH will most likely consist of substituting this rather rigid scheme by a more flexible one. This will allow for feedback mechanism between the different levels. Premorbid disabilities/handicaps as possible risk factors for the development of mental illness may even be taken into consideration. The analyses within the Mannheim ABC schizophrenia study have convincingly shown that social disability and role handicaps are present in a high percentage of patients (57%) prior to the onset of the first psychotic symptom. On an average they begin about two to four years before the first hospitalisation and one to three years prior to the first psychotic symptom. While the correlation between social disability and positive symptoms is not significant, disability and negative symptoms are closely related. In addition to this only part of this correlation can be explained as a conceptual overlap (i.e. the SANS subscales Avolition and Anhedonia have items comparable to the Disability Assessment Schedule). In fact, we found comparably high correlations between affective blunting and alogia and social disability as well. Patients with early disability not only have an overall unfavourable course of negative symptoms but negative symptoms are shown to be useful predictors for social disability three years after the first hospitalisation.

[2 class psychiatry]

Community care and sectorisation, specialisation and differentiation, integration of psychiatric and other medical services, crises intervention and emergency psychiatry--and patient's choice--are basic issues of the organisation of psychiatric services. They are discussed and evaluated in respect of the Region of Mannheim and the Mannheim Zentralinstitut für Seelische Gesundheit.

[Do alcohol or drug abuse induce schizophrenia?]

The high comorbidity of schizophrenia and substance abuse raises the question of a causal relationship between the two disorders. Clarifying the temporal sequence of their onsets can shed light on this issue. For this purpose, onset and course of schizophrenic symptoms and of alcohol and drug abuse were retrospectively investigated within the ABC Schizophrenia Study in a representative first-episode sample of 232 schizophrenic patients. The rates of alcohol abuse (24%) and of drug abuse (14%) were twice the rates compared to the general population but schizophrenic patients seemed to have started substance abuse later than the control group. Male sex and early symptom onset were major risk factors. At all important landmarks during the early course of schizophrenia, drug-abusers were younger than alcohol-abusers who were younger than non-abusers. Alcohol abuse usually started during the prodromal phase, i.e., after the first sign of schizophrenia but before the first positive symptom. Drug abuse emerged before the first symptom in one third, simultaneously with it in another third, and during the prodromal phase in the last third of patients. Drug abuse significantly preceded the psychotic phase. The hypothesis that substance abuse causes schizophrenia thus is not generally supported. Findings on symptomatology illustrate the problems substance-abusing schizophrenics pose from early on with dissocial behaviors and preoccupation with magical ideas but without a specific positive or negative subsyndrome.

Methodological aspects of onset assessment in schizophrenia

Psychiatric disorders in general and schizophrenia in particular often begin with a prodromal phase progressing into more specific syndromes long before the first treatment contact. More longitudinal studies on course and outcome of schizophrenia begin with first hospital admission not taking into account the preceding early course. The reason for this is the unsurmountable difficulties in observing and assessing real onsets with unspecific symptomatology directly and collecting a sufficient number of 'precontact' cases of rare diseases in the general population. There are in principle two practical ways of assessing time and type of onset and the early course of schizophrenia: the application of a screening procedure for establishing a prospective approach, e.g. the study of individuals at high risk for schizophrenia, and the retrospective assessment of the preceding course carried out at first treatment contact. Methodologically both strategies share the same problems, especially recall bias. In a comprehensive discussion of methodological issues ways are described to reduce and even control recall deficits by using appropriate techniques (standardised assessment with the IRAOS, the 'Interview for the Retrospective Assessment of the Onset of Schizophrenia'; time grids; interval assessment, comparison of independent sources of information etc.). A representative sample of 232 patients with a first episode of schizophrenia were selected from the 276 first admissions of the ABC schizophrenia study taken from a German population of 1.5 million. Results are represented for the crucial questions: when, how and with what symptoms does schizophrenia begin and how does the disorder develop up to the first admission? For example, the gender-specific mean age at different points in time during the development of the disease is presented, and the sequence and cumulation of symptoms in the early course examined. Additionally, the consecutive fulfillment of DSM-III criteria sets for schizophrenic and schizophreniform disorders are presented along with the frequency of different types of onset in schizophrenia.

Symptom assessment in casenotes and the clinical diagnosis of schizophrenia

It is well known from several international studies that the incidence rates for schizophrenia, based on first-admission samples, are low in Denmark, especially in females, compared with other countries. This might be due to special diagnostic traditions in Denmark. To analyze how Danish psychiatrists reach a diagnosis of schizophrenia, a stratified subsample of 122 cases out of all 1,259 patients, aged between 12 and 64 years, with a first hospital admission in 1976 under the diagnosis of schizophrenia, paranoid psychosis, acute reactive paranoid psychosis, or casus limitaris was selected. For this subsample, psychopathological symptoms, as documented in the clinical casenotes, were rated by PSE-9 symptom lists for subsequent CATEGO analysis. The core syndrome of schizophrenia, as defined by the CATEGO class S+, showed no association with the clinical schizophrenia diagnosis compared with the other diagnoses mentioned. Also, positive symptoms of schizophrenia did not determine the diagnosis, but for typical negative symptoms such associations were indicated. Some negative symptoms also seemed to be linked to a depressive state. Furthermore, the present work indicates that using first-admission data leads to a higher age at schizophrenia onset and a lower first-admission rate in Denmark compared with Germany.

Epidemiology of early-onset schizophrenia

A total of 232 (84%) first episodes of schizophrenia from our epidemiologically defined ABC sample (Age, Beginning and Course) were retrospectively assessed with regard to the onset and early course of the disorder. In a follow-up study a representative subgroup (n = 133) was prospectively examined in five cross sections over 3 years from first admission on. Population-based incidence rates for 5-year age groups comprising a range of < 10 - < 60 years were calculated on the basis of two definitions of onset: first sign of disorder and first psychotic symptom. In 40% of adult patients who had been admitted with a first schizophrenic episode after age 20 years the prodromal phase, in 11% the psychotic prephase, began before that age. This demonstrates that schizophrenia often begins in an age period in which the social and cognitive development and brain maturation are still unfinished. Early-onset schizophrenias (< or = 20 years) were compared with a medium-onset group (21 - < 35 years) and a late-onset group (35 - < 60 years) with regard to age and type of onset, early symptom-related course, social development and social course. The number of schizophrenia-specific positive and negative syndromes in early-onset schizophrenia is comparable to that of higher age groups. However, neurotic syndromes, emotional disorders and conduct disorders are most frequent in younger patients, especially in young men. Paranoid syndromes seem to prevail in late-onset schizophrenia, whereas less differentiated positive syndromes, such as delusional mood, are more frequent in the youngest age group. An earlier onset of schizophrenia has more severe social consequences than onset in adults, because it interrupts the cognitive and social development at an earlier stage. The worse social course of schizophrenia in men compared with women cannot be related to a more severe symptomatology, but to the earlier age at onset and the impairment or stagnation of social ascent at an earlier stage of social and cognitive development. Social disability in the sense of an adaptation to the expectations of the social environment, as well as symptomatology during the further course of schizophrenia, show no major differences between the genders nor between the age groups.

When and how does schizophrenia produce social deficits?

The present study is an empirical contribution to the controversy over whether the poor social performance and lower social class of schizophrenic patients are consequences of the illness, consequences of changes in the individuals predisposed to develop schizophrenia or are due to the adverse social conditions that lead to schizophrenia. The study focuses on the socioeconomic status at onset, on the performance of social roles in the early course of schizophrenia by taking age, gender and the individual level of social development into account. In a representative sample of 232 first episodes of schizophrenia age and type of onset.type and accumulation of symptoms and social functioning in the prodromal and the psychotic prephase and at first admission were assessed and analysed for their predictive power concerning social disability 2 years after first admission. In a case-control study expected and observed social functioning from onset until first admission were compared. The subsequent course was followed up prospectively in five cross sections until 2 years after first admission. In women the age at onset was significantly higher than in men, whereas symptomatology and type of onset showed no gender differences. In 73% of the sample the prodromal phase covered 5 years on average, and the psychotic prephase (until the maximum of positive symptoms) 1.1 years. Deficits in social functioning occurred predominantly during the prodromal and the psychotic prephase. The course over 14 years showed stable group trends in social and symptom measures. By the end of the prodromal phase it was possible to predict social disability 2 years after first admission with a correct classification of 81%. The main factor determining social outcome appeared to be the acquired social status during the prodromal phase of the disorder. The unfavourable early course in men was due mainly to their significantly lower age at onset. These results raise questions concerning an earlier therapeutic and rehabilitative intervention.

Validation of Danish case register diagnosis for schizophrenia

The ABC schizophrenia study aims at investigating sex differences in age of onset, symptoms and course of schizophrenic and paranoid disorders. For this purpose, we used case register data from Denmark and Mannheim and a directly examined sample of first admissions (ABC sample). The Danish case register sample included less clinical diagnoses of schizophrenia and more schizophrenia-related disorders (acute paranoid reaction, paranoid states and borderline schizophrenia) than the Mannheim data (case register and ABC sample). The problem therefore was whether the two datasets are comparable and the results are valid. For this reason a randomized, stratified sample of 116 patients was drawn from the Danish case register sample. The case notes of these 116 patients were requested from the hospitals where the patients had been treated and analyzed by means of a scoring sheet based on the Interview for the Retrospective Assessment of the Onset of Schizophrenia (IRAOS). The use of operationalized diagnoses of the CATEGO program, based on PSE items, which are integrated in IRAOS, demonstrated that the samples of the Danish and the Mannheim case registers and the directly investigated ABC sample have comparable diagnostic distributions. Possible explanations for the differences between the clinical and the CATEGO diagnoses in the Danish case register may be the frequent use of diagnoses of borderline schizophrenia and reactive psychoses (previously called psychogenic psychoses), and above all a more narrow concept of schizophrenia; in Denmark, schizophrenia is diagnosed relatively late, i.e., after the presence of enduring negative symptoms, and thus mostly after the appearance of residual state.(ABSTRACT TRUNCATED AT 250 WORDS)

[Depression in the early course of schizophrenia]

Depressive syndromes in schizophrenia are reported in the prodromal stage of the early course, during the first or later psychotic episodes, but also after the fading out of an acute episode and as a precursor of relapse. According to these multiple conditions several explanations also exist as to how to understand depression in schizophrenia. Some authors interpret it as an elementary part of the schizophrenic symptomatology, which is only masked by positive symptoms (revealed depression). However, it can also be understood as a reactive depression or as caused by neuroleptic treatment, as part of the negative syndrome or as co-morbidity. In the ABC-Schizophrenia-Study, depression in the early course was analysed for patients in their first psychotic episode at index admission and an ICD-9 diagnosis of schizophrenia (ICD 295). In 81% of this sample depression was observed, beginning on average 4.3 years prior to index admission. In 42% of the patients depression began in the prepsychotic phase. In 18% the positive and the depressive syndrome developed within one month, and in 21% depression started after the first positive symptom occurred. We could only observe a clear sequence of depressive, negative and positive symptoms in the subgroup characterised by prepsychotic depression. A clear order of negative and positive symptoms was not observed in the other groups. Patients without depression in the early course have lower symptom levels at index admission. They present less positive symptoms (CATEGO-subscore DAH), fewer behavioural disturbances (subscore BSO) and also lower scores of non-specific symptoms (subscores SNR and NSN). More than 80% of the patients with depression in the early course also had a simple depression (as defined by the CATEGO-syndrome SD). Contrary to this, only 20% of the patient group without depression in the early course have positive SD values. Comparable percentages of males and females have depression in the early course, but in females depression begins more frequently in the prepsychotic phase, whereas in the male subgroup it more often starts postpsychotically, i.e. after the onset of the first psychotic symptom.

The epidemiology of early schizophrenia. Influence of age and gender on onset and early course

For the investigation of the early course of schizophrenia starting from onset, the standardised Interview for the Retrospective Assessment of the Onset of Schizophrenia was developed and validated. In a representative sample of 267 first-admitted German schizophrenics of a broad diagnosis from a population of 1.5 million, the age at which different diagnostic and onset definitions were satisfied, the symptoms at the time of the interview, and the accumulation of positive and negative symptoms until first admission were assessed. Comparison between the two sexes and three age groups yielded hardly any differences in the accumulation of symptoms and their course until first admission, except for a slightly shorter period of negative symptoms in young males and a slightly longer one in older women--which contradicts prevailing opinion. At the time of the interview, no significant sex differences were found with respect to the core symptoms of schizophrenia (negative and first-rank symptoms), but clear and substantial differences emerged in disease behaviour. The significantly higher age at first onset in women is explained, on the basis of animal experiments and a clinical study, by the neuromodulatory effect of oestrogen on D2 receptors and by a higher vulnerability threshold in women.

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 first 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, suicidal 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.

Higher morbidity risk for schizophrenia in males: fact or fiction?

Male to female ratios in published annual incidence rates for schizophrenia range from 0.70 to 3.47. These variations between studies are attributed to differences in sampling, diagnostic criteria, design characteristics, and methods of calculation, which limit the quality of the studies. In an effort to overcome these shortcomings, we collected a comprehensive sample of 392 consecutive first admissions with a diagnosis of schizophrenia or a similar disorder out of a population of 1.5 million in a central region of western Germany. In this large representative sample, no significant gender differences in the incidence of schizophrenia could be detected regardless of different diagnostic definitions.

Can estradiol modulate schizophrenic symptomatology?

Using epidemiologic data, in an earlier study we formulated the hypothesis that estrogens can delay the onset of schizophrenia in females by raising the vulnerability threshold for this disease. In animal experiments, Häfner and colleagues found evidence that chronic estradiol treatment reduces the sensitivity of dopamine (D2) receptors in the brain. In the clinical study presented in this article, as a further step we examined the antipsychotic properties of estradiol in human females by testing whether schizophrenic symptomatology varies with estradiol serum levels throughout the menstrual cycle. We examined 32 acutely admitted female schizophrenia patients (Present State Examination/CATEGO diagnosis, ICD-9) with a history of regular menstrual cycles, ages 18 to 43 (mean = 30.5), during their hospital stays (3-8 weeks), analyzing hormonal parameters and applying various rating scales for psychopathology every 7 days. In all patients, estradiol serum levels were markedly reduced as compared with the normal population, and fluctuations throughout the cycle were dampened. Nevertheless, a significant association emerged between estradiol levels, on the one hand, and psychopathology scores, on the other--that is, the psychiatric symptomatology as assessed by the clinical psychiatrist (Brief Psychiatric Rating Scale, p < or = 0.01), behavior on the ward as assessed by the nursing staff (Nurses' Observation Scale for Inpatient Evaluation p < or = 0.01), paranoid tendencies and general well-being as assessed by the patients themselves (Paranoid-Depressivitäts-Skala paranoid score p < or = 0.05; Befindlichkeits-Skala p < or = 0.05). Psychopathology seems to improve when estradiol levels rise, and vice versa. These findings can be interpreted as further evidence for a protective effect of estrogens in schizophrenia, possibly due to the known anti-dopaminergic activities of these hormones.

[Do estrogens have an antipsychotic action?]

Within the framework of our ABC study, an epidemiological study on schizophrenia (Häfner et al., 1989, 1991 a; Riecher et al., 1991), we were able to show that the mean age at onset of the disease is 3-4 years higher in women than in men and that women have a second peak of onsets after 45 years of age. In a systematic analysis we developed and tested different psychosocial and biological explantory hypotheses. The oestrogen hypothesis could be identified in the course of this analysis as the most plausible one. According to this hypothesis (Häfner, 1987) female sex hormones enhance the vulnerability threshold for schizophrenia. In this case women from puberty to (pre-)menopause would be protected from the outbreak of the disease to a certain extent by their high physiological oestradiol production; they would, however, later "draw level" in respect of morbidity risk. Animal experiments conducted to test this hypothesis and to explain the underlying pathophysiological mechanism implied that oestradiol can modulate the sensitivity of dopamine-D2-receptors in the brain (Häfner et al., 1991 b; Gattaz et al., 1992). In the clinical study presented, we examined the validity of the oestrogen hypothesis in humans. We tested, whether the acute symptomatology of schizophrenic patients fluctuates with oestradiol serum levels during the female menstrual cycle. We examined 32 acutely admitted schizophrenic women during their hospital stay by analysing hormonal parameters and applying various rating scales for psychopathology on certain days of the cycle. A significant association emerged between oestradiol levels on the one hand, and psychiatric symptomatology, behaviour on ward, paranoid tendencies and general well-being, on the other.(ABSTRACT TRUNCATED AT 250 WORDS)

["Trema, apophany, apocalypse"--is Conrad's phase model empirically founded?]

Among several phase models of beginning schizophrenia, the study by Conrad ("Die beginnende Schizophrenie. Versuch einer Gestaltanalyse des Wahns") was particularly impressive in German psychiatry. The ABC-Schizophrenia-study with its representative sample of 267 first-admissions and a careful retrospective assessment of emerging symptomatology made it possible to test the empirical basis of Conrad's model. In this operationalization "trema" was confirmed as the frequent first stage of the disease process, whereas Conrad's hypothesized order of the two following phrases (first "apophany", then "apocalypse") could not be validated. Therefore, Conrad's model cannot completely be generalized. Because the methods employed so far have some limitations, analyses of additional data (especially reports by significant others) may control and probably enhance the presented results.