What You Need to Know About Prodromal Schizophrenia

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Schizophrenia is a mental illness that affects a person’s ways of thinking, behaving, and feeling. While the hallmark symptoms include hallucinations and disconnecting from reality, it can take years for these more advanced symptoms to appear.

Before them comes the prodromal schizophrenia stage, or the earliest stage of brain degeneration where people (often still in adolescence) begin experiencing prepsychotic mild or moderate disturbances in everyday functioning, including speech and movement difficulties. These changes can be attributed to heredity, genetic, environmental, and other causes. 

Schizophrenia was once seen as an illness that occurred in the beginning courses of eventual memory loss (aka dementia precox). Later, it was described as a group of psychosis with a variable and chronic course that unfolds throughout life.

Portrait Of Young Man Against White Background
Kevin Wong / EyeEm / Getty Images 

Schizophrenia Phases 

Schizophrenia develops and progresses rather slowly from one phase to another. While everyone diagnosed with schizophrenia will experience the active phase, they may not experience the prodromal (before) or residual (after) phases.

Prodromal (before)

The prodromal phase is the earliest phase and is absent of schizophrenia symptoms. As such, it’s commonly diagnosed only after a person has entered the active schizophrenia phase.

Active (during)

This is the (acute) phase where symptoms are most noticeable and potentially damaging to a person’s life. Friends and family will notice marked differences in their loved one, but the person may not be able to recognize or acknowledge the changes. 

Residual (after)

This is the unofficial phase that occurs after active schizophrenia. In this phase, symptoms are much less obvious and may even be in remission but could still be present to some degree. Entering this phase doesn’t mean you’ll never enter an active phase again, though.

Prodromal Symptoms

Prodromal symptoms are generally seen as unspecific symptoms of schizophrenia (those involving an absence of normal interactions and functioning) that evolve over time.

They can fluctuate in intensity, severity, and length of time. Such symptoms can begin in adolescence and the teenage years, although they aren’t likely to be seen as such unless a future diagnosis of schizophrenia is made later in life (a retrospective diagnosis).

Small changes to personality and behavior or normal routine may be some of the first signs of prodromal phase schizophrenia.

Common early signs and symptoms of schizophrenia include:

  • Nervousness and/or restlessness
  • Depression
  • Anxiety
  • Thinking or concentration difficulties
  • Worrying
  • Lack of self-confidence
  • Lack of energy and/or slowness
  • Significant drop in grades or job performance
  • Social isolation or uneasiness around other people
  • Lack of attention to or care for personal hygiene 

One estimate suggests that 75% of the patients with schizophrenia may pass through the stages of prodromal symptoms.

Some of the prodromal signs, such as a significant change in personal hygiene and a worrisome drop in grades or job performance, can also be early warning signs of other issues, including psychosis or detachment from reality.

If your child or teen starts showing the above signs and symptoms, talk to a pediatrician or mental health professional as soon as possible.

Prodrome Types

There are two main patterns the prodrome takes. Again, you likely won’t know for sure which type is applicable until later schizophrenia phases.

Pattern 1 prodrome is characterized by certain nonspecific changes (e.g., sleep disturbances that could be signs of other mental illness), followed by specific pre-psychotic symptoms (early warning signs of schizophrenia) and then eventually leading to psychosis.

Pattern 2 prodrome is characterized by early, specific changes associated with schizophrenia, followed by neurotic symptoms like anxiety and irritability in response to changes, and then psychosis.

These symptom patterns were later divided into five more patterns of disturbances (areas of most difficulty), including disturbances in:

  • Attention
  • Perception
  • Speech production
  • Motor function
  • Thinking (e.g., thought blocks)

Prodrome phase can also be categorized in three different ways:

  • Category 1 means the patient should have at least one of the following symptoms: False beliefs that random events in the world directly relate to them, odd beliefs, or magical thinking; visual disturbance; odd thinking and speech; paranoid ideation; and odd behavior or appearance.
  • Category 2 includes patients who have experienced psychotic symptoms that come and go, which have spontaneously resolved within a week.
  • Category 3 includes a combination of genetic risk (i.e., being the first-degree relative of an individual with a diagnosis of schizophrenia) with substantial changes in personal daily functioning in the previous year. 

Why Prodromal Schizophrenia Is Hard to Identify

Prodromal schizophrenia is hard to identify because it lacks the characteristic symptoms of schizophrenia and instead presents other symptoms commonly associated with a spectrum of other mental illnesses like depression and anxiety.

This means that you or someone you love may be underdiagnosed and incorrectly treated for mood disorders until other symptoms present later in life.

It’s also possible, though, that a person has a mood disorder and later develops active schizophrenia without going through prodromal schizophrenia, which further complicates getting an accurate diagnosis. 

The main reasons why identifying prodromal schizophrenia is difficult include:

  • A lack of clear symptoms associated specifically with schizophrenia
  • The age at which it typically presents (during a time of adolescent hormonal ups and downs)
  • The fact that it commonly co-occurs with other mental illnesses or substance use disorders

When symptoms start in adolescence, they may be dismissed as “just a phase,” “hormones,” and “teen angst.” There are many stereotypes that mark the teen years and many involve emotions, mood management, and behavior. That makes it hard for parents, teachers, and caregivers to distinguish normal teen stuff from a mood disorder from prodromal schizophrenia. 

Mental Health Resources

If you or a loved one are struggling with prodromal schizophrenia, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 800-662-4357 for information on support and treatment facilities in your area. For more mental health resources, see our National Helpline Database.

Diagnosing Prodromal Schizophrenia

Researchers have been working on ways to diagnose prodromal schizophrenia earlier on, rather than retrospectively. Earlier detection means minimizing the time between when the illness starts and first psychosis. It also offers more room for the prevention of psychological and social disruptions (work, school, friendships, etc.) associated with active schizophrenia.

Some diagnostic tools include:

  • "Ultra-high-risk" (UHR) states tool by the Personal Assessment and Crisis Evaluation (PACE) clinic is based on personal risk factors for schizophrenia. Risk factors such as age, family history of psychosis, and symptom scores are combined in a multifactorial index of risk to assess likelihood of disease. 
  • CAARMS by PACE includes assessment of symptom intensity, frequency, and duration as well as decline in functioning. 
  • Structured Interview for Prodromal Syndromes (SIPS) was developed by the Prevention through Risk Identification, Management, and Education (PRIME) prodromal research team at Yale University. It includes minor differences and is used interchangeably with the others. 

Diagnosis will ultimately depend upon the individual experiencing the prodromal schizophrenia symptoms taking action and talking to a medical professional. This can be a major barrier to diagnosis, especially if the person doesn’t have a strong support network to encourage them to get help. 

Outlook

Many factors can interfere with someone’s treatment plan and outlook or prognosis. With prodromal schizophrenia, the outlook is negatively influenced by the following:

  • Lower cognitive functioning (lower IQ or thinking, problem solving, and comprehension impairments)
  • Lower social skills
  • History of substance abuse
  • Comorbid disorders (disorders that happen at the same time as others)
  • Lack of social or community support 

Substance use disorders are among the most common comorbid illnesses affecting the outlook for people with prodromal schizophrenia. Psychoactive substances like cannabis can also influence the onset of psychosis and are a known risk factor for schizophrenia, although the cause-and-effect is unclear and findings are not always consistent.

Seeking help for psychiatric symptoms before they begin to create personal, interpersonal, and professional problems is always the best-case scenario for an outlook when it comes to mental illness. Staying the course of treatment will also be a major factor in overall outlook and outcome. 

Summary

Prodromal schizophrenia is the earliest stage of schizophrenia. Not all people with schizophrenia experience this phase. Hallmark symptoms of the prodromal stage include nervousness, anxiety, depression, difficulty concentrating, excessive worrying, and more. Prodromal schizophrenia can be especially hard to identify because these symptoms are related to many other conditions.

Early detection can make a big difference for patients with schizophrenia. If you or a loved one are experiencing symptoms, seek help from a medical professional.

A Word From Verywell

Before deciding that you or someone else is experiencing the prodromal phase of schizophrenia, you need to talk to a professional who can help to distinguish symptoms from other conditions. Often, there are very small differences between diagnoses that may not seem major, but they can mean a lot when it comes to getting the right diagnosis and treatment.

If you or your loved one has a history of psychosis or schizophrenia in the family, or consumes psychoactive substances like cannabis, be sure to tell the doctor or mental health professional. When it comes to substance use, it can be really difficult to share the full truth about how much and how often you’re using. But know that it’s essential in getting the right assistance and helping the professional develop the best course of action. 

Frequently Asked Questions

When does the prodromal phase of schizophrenia occur?

The prodromal phase of schizophrenia can occur in adolescence and the teen years, although it may be dismissed as just a phase or diagnosed as another mental illness such as anxiety or depression.

How do you help someone with schizophrenia?

You can help someone with schizophrenia by encouraging them to seek treatment and stay the course with doctor’s recommendations. You can also read about schizophrenia to better understand and empathize with what they are going through. 

How is schizophrenia treated?

Schizophrenia is treated with medications that target symptoms ranging from psychotic symptoms (treated with antipsychotics) to depressive and anxiety-related symptoms that are treated with antidepressants and anti-anxiety medications. Therapy with a trained professional can help a person develop healthier coping skills, manage substance use disorders, and work on their relationships with others. 

 

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