Lecture 3: Course and outcome

Question 1

Why do we care about the time-course of a disorder?

Answer 1

• May allow us to predict who will develop the disorder and treat them early
• Helps us to plan treatment; inform patients and families
• Assess the effects of medication, other interventions
• Perhaps identify sub-types that have different causes, treatments

Question 2

What are the stages of illness?

Answer 2

• Premorbid phase (before onset of psychotic symptoms)
• Prodromal phase (sub-clinical psychotic symptoms)
• Onset (first episode)
• Long-term course or outcome

Question 3

Define the Premorbid stage.

Answer 3

Some people show signs of poor function or disturbed development in childhood and adolescence

Question 4

What do we know from Retrospective studies?

Answer 4

1) Delayed motor development (walking, balance, coordination)
2) Lower IQ
3) Poor performance on tests of processing speed, attention, memory
4) Poor social understanding (theory of mind) and impaired social skills (family and peer interactions)
- But, these deficits overlap with other developmental disorders and adjustment problems

Question 5

Define the prodromal stage

Answer 5

Most people with SZ show signs of disturbance from 1-3 years before diagnosis

Question 6

What are the psychotic-like symptoms in the prodromal stage?

Answer 6

Hallucinations, delusions and thought disorder
Less persistent – come and go for brief periods
The person retains insight – they can tell they are not “real”

Question 7

What are the negative symptoms in the prodromal stage?

Answer 7

• Cognitive changes (confusion, lack of concentration)

- Poor social functioning and social withdrawal

Question 8

These symptoms in the prodromal stage indicate ___________________

Answer 8

a risk that the person will develop SZ

Question 9

In the prodromal stage, medication is __________

Answer 9

not typically used

Question 10

Psychological interventions at the prodromal stage can ____________

Answer 10

reduce this risk

Question 11

What is the percentage of risk that when these symptoms first appear the person will develop SZ?
(prodromal stage, positive and negative symptoms)

Answer 11

25% within 2 yrs; 35% within 5 yrs

Question 12

What makes it difficult to diagnose SZ in the prodromal stage?

Answer 12

The most common prodromal symptoms are signs of depression and negative symptoms such as confusion and social withdrawal

Question 13

In the prodromal stage, only ____ show positive symptoms?

Answer 13

6.5%

Question 14

In the prodromal stage, ___ show both negative and positive symptoms

Answer 14

20%

Question 15

The most predictive factor for later diagnosis is _______

Answer 15

poor social skills and few friends

Question 16

What are the characteristics of onset in SZ

Answer 16

• Variable rate of onset of symptoms

- Half experience a rapid onset of acute symptoms, in others the onset may take months or years

Question 17

What is the Outcome of SZ?

Answer 17

Outcome is variable and has changed with the development of more effective medications

Question 18

When Kraepelin first defined SZ, he called it ________________

Answer 18

“dementia praecox” or “early dementia”

Question 19

Kraepelin wanted to differentiate it from ________

Answer 19

the type of dementia defined by Alois Alzheimer

Question 20

Kraeplin thought that there were two different sub-types of SZ, what were they?

Answer 20

Group I: mostly psychotic symptoms and a variable course

Group 2: mostly negative symptoms with a declining course

Question 21

Why did Kraepelin divide SZ into two sub-types?

Answer 21

He hoped that by defining sub-groups, more specific treatment could be given

Question 22

Name one of the goals of studying the time course of SZ

Answer 22

Specify treatment

Question 23

Current research focuses on __________

Answer 23

positive vs negative symptoms

Question 24

Follow-up studies of time-course of SZ, before antipsychotic medications (1-10 yrs) showed on average that _______________

Answer 24

• The symptoms got more severe as time progressed without medication

[67% still severely ill; 21% were moderately ill; 12% recovered
Studies with longer follow-up showed more severe outcome]

Question 25

Follow-up studies after antipsychotic medications (5-15 yrs) showed on average:

Answer 25

• 21% recovered.
• Symptoms did not get worse over time with medication.

[25% severe; 54% moderate; 21% recovered
No pattern of worse outcome with longer follow-up
Despite the fact that modern criteria are stricter]

Question 26

What is recovery?

Answer 26

Full recovery from SZ – with no psychotic symptoms and no impairment – is rare

Question 27

Many people considered recovered will experience __________

Answer 27

relapse or have residual negative (especially cognitive) symptoms

Question 28

What is the effect of antipsychotics on SZ?

Answer 28

Antipsychotics control symptoms, but do not cure

Question 29

_________ of people considered recovered in a WHO study were taking medication

Answer 29

Less than half

Question 30

Why were less than half of people considered recovered in a WHO study were taking medication?

Answer 30

• Taking medications has a negative effect
• Those who have recovered more likely to stop taking medications
• Other social factors may be important

Question 31

How do Antipsychotics improve outcome? (hint: 3)

Answer 31

1) Decrease positive symptoms
2) Increase time between relapse – more frequent relapse is related to poorer long-term outcome
3) Reduce mortality

Question 32

Does Cognitive function change?

Answer 32

• Cognitive deficits appear to be stable
• No differences between new and chronic cases
• No differences over time
• These may be linked to pre-existing differences in brain structure or function

Question 33

In regard to the prediction from the period before diagnosis, Hafner predicted that the ____________________________

Answer 33

the longer a person had symptoms before being diagnosed and treated for SZ, the worse would be their outcome

Question 34

What were the two measures of Hafner’s study and what did they predict?

Answer 34

Two measures:
Duration of untreated psychosis (DUP)
Duration of untreated illness (DUI; not psychotic)

DUP predicts level of positive symptoms
DUI predicts level of negative symptoms

Question 35

Does Social functioning change?

Answer 35

People at high risk of developing SZ already show social impairments compared to controls and do not differ from those already diagnosed.