Premorbid Personality Traits

Indicators more closely related with the disorder that have been reported from the recent prospective epidemiological cohort studies seem to offer prospects of identifying at-risk persons. The Swedish conscript study [138] of 50084 young men aged 18 to 20 years showed that four items (having fewer than two friends, preference for socializing in small groups, feeling more sensitive than others, and not having a steady girlfriend) were associated with a high relative risk (odds ratio: 30.7) of being admitted to inpatient treatment with a diagnosis of schizophrenia in a period of risk of 13 years. But in the total sample a positive response to all four items predicted psychosis only in 3%, because of the high prevalence of these features in the conscript population.

Davidson et al. [139] and Rabinowitz et al. [37] studied 16- to 17-year-old Israeli male conscripts. The authors identified 692 individuals who had been hospitalized with a diagnosis of schizophrenia for the first time in a mean period of nine years following initial testing. When these individuals were compared with the entire conscript population and with matched controls, the results pointed in the same direction as in the Swedish study. The main indicator of risk was poor social functioning, with an effect size difference of 1.25. With effect sizes ranging from 0.44 to 0.58, the young males later hospitalized with a diagnosis of schizophrenia also fared worse than controls in all tests of cognitive functioning.

As poor communicability and lack of social drive have also been found in population cohort studies of persons later falling ill with schizophrenia, this stable behavioural dimension probably represents the most pronounced psychological indicator of vulnerability to schizophrenia.

In prospective assessments of schizophrenia onset the distinction must be drawn between prodromal symptoms and premorbid antecedents or indicators of other causes. Since schizophrenia onset is marked by unspecific symptoms in 73% of cases, it is a very difficult event to recognize in prospective studies of whatever design. The same is true for the diagnostic classification of the first unspecific symptoms. For this reason, as long as sufficiently powerful discriminatory and predictive early indicators of schizophrenia are lacking, schizophrenia onset and prodromal stage can only be assessed retrospectively in cases clearly diagnosable as schizophrenia, ideally in recent-onset, representative firstepisode samples.

Three aspects of transition from a premorbid risk status to a prodromal stage of the disorder can be distinguished: (a) new symptoms appear and those already persisting deteriorate, frequently involving increased subjective distress; (b) symptoms accumulate, probably following a typical pattern (stage model); and (c) progressive deterioration occurs in social and cognitive functioning or in deficits measured by neuropsychological tests. A characteristic of the prodromal stage of key importance is the gradient of change or deterioration.

The early illness stage usually involves increasing communicative and social impairment and behavioural changes detrimental to the person's functioning in the social, school, work and family environment.

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