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Early Onset Schizophrenia. Phenomenology, Course, and Outcome

University of Essen, Germany, July 31, 1998 and IACAPAP Stockholm August 2, 1998

Prof. Dr. med. Christian Eggers,  Dr. phil. Detlef Bunk

Published in: J. Europ.Child & Adolesc.Psychiatry, 1999, 8: suppl.1

Some remarks on etiological aspects of early onset schizophrenia

Christian Eggers, Prof. Dr. med.

Clinic for Child and Adolescent Psychiatry, University Essen

Neurophysiological, neuropsychological, neuroanatomical and neuroradiological findings in schizophrenic psychoses demonstrate that subcortical (e. g. mesolimbic and diencephalic regions) as well as neocortical structures (e. g. dorsolateral prefronatal cortex, superior temporal and inferior parietal cortices) are involved. Special significance is accorded to the neuroanatomical connection between limbic structures and the dorsolateral prefrontal cortex. Here myelinization begins relatively late in humans, during the second and third decade of life – a particularly vulnerable period for schizophrenic onset. The nature of prepsychotic behavioural abnormalities in patients with early onset schizophrenia as well as the existence of typical cognitive dysfunctions preceding the manifestation of psychotic symptoms points to the importance of a dynamic imbalance of neocortical-subcortical interactions in the aetiology of schizophrenia. Based on the crucial importance of the prefrontal-hippocampal circuitry a stimulus barrier model of schizophrenic psychoses is elaborated, which integrates recent neurobiological findings as well as results of research in modern developmental psychology. One of the implications of this model is the multidimensional treatment of schizophrenic patients.

Childhood-onset Schizophrenia: A follow-up Study

Joan R. Asarnow, Ph.D.

UCLA School of Medicine, Neuropsychiatric Institute, Los Angeles

The main results from the UCLA Follow-up Study of Childhood-onset Schizophrenia Spectrum Disorders are presented. Eighteen children with schizophrenia (SZ) were assessed 1 to 7 years following initial project intake. Results demonstrated significant continuity between SZ spectrum disorder in childhood and adolescence Although not all children who were presented initially with SZ continued to meet criteria for SZ spectrum disorder as they progressed through the follow-up period., rates of SZ spectrum disorder ranged from 78% to 89% across the first three follow-up years. Rates of continuing SZ ranged from 67% to 78% across the three follow-up years and rates of schizoaffective disorder ranged from 11% to 13% across the three follow-up years. Variability in levels of functioning were observed with 45% of the sample showing deteriorating course or minimal improvement and 55% of the sample showing moderate improvement. Or good outcome. The variability in outcome is comparable to that seen in adults with SZ, suggesting that with current treatments childhood-onset does not ensure a more severe disorder.

The Ontogeney of Schizophrenia

Robert F. Asarnow, Ph.D., Della Martin, Professor of Psychiatry Professor of Psychology

Department of Psychiatry. University of California-Los Angeles

This paper is a review of studies examining the neurobehavioral antecedents of schizophrenia which flesh out neuordevelopmental models of schizophrenia by detailing the time course of  the ontogeney of neurobehavioral impairments in schizophrenia. A follow back design was used to identify precursors of psychotic symptoms in children with a schizophrenic disorder. The vast majority of children with a schizophrenic disorder had significant developmental delays beginning early in life. For example,  gross deficits in  early language development were found in almost 80% of the schizophrenic children. Somewhat later in development impairments in fine motor and bi-manual coordination are noted. Some of these early developmental delays are transitory. For example, basic language skills are among the best preserved neurocognitive functions in children and adults with schizophrenia. The results of our cross-sectional neurocognitive studies  suggest that children with schizophrenia suffer from limitations in the ability to engage in effortful cognitive processing or  impairments in working memory. The links between these elementary neurocognitive impairments and the development of formal thought disorder as well as discourse deficits in children with a schizophrenic disorder will be discussed.

Early Onset Psychotic Disorders: Diagnostic Stability and Clinical Characteristics

Jon McClellan, M.D., Assistant Professor, Chris McCurry, Ph.D.

University of Washington's Department of Psychiatry, Seattle, WA

Objectives: To examine the clinical features and diagnostic stability of early-onset psychotic disorders.

Methods: These data are from a two-year longitudinal prospective study of youth with psychotic disorders. Standardized diagnostic assessments are administered at baseline, and at one and two year's follow-up.

Results: Forty-eight subjects have been recruited to date; 17 with schizophrenia, 13 with bipolar disorder, 10 with psychosis not otherwise specified (nos), 7 with schizoaffective disorder, and 1 with an organic psychosis.  Thirty-two subjects have been reassessed at year one; twenty at year two. Two subjects have been lost to follow-up.  The study diagnosis was the same as the first onset diagnosis (prior to entering the study) in 56 percent of subjects. Two subjects received a different study diagnosis at year one, one of whom reverted back at year two. Subjects with schizophrenia had higher ratings of premorbid social withdrawal and dysfunctional peer relationships. At the one-year follow-up, subjects with bipolar disorder were functioning significantly better than subjects with either schizophrenia, or psychosis nos. All groups had high rates of comorbid behavior disorders and substance abuse.  Subjects with psychosis nos had questionable psychotic symptoms, higher rates of dissociative symptoms, and an increased history of sexual abuse.

Conclusions:  Early-onset psychotic disorders can be reliably diagnosed using standardized assessments, and are stable over a two-year period. Compared to bipolar disorder, schizophrenia is associated with a poorer premorbid history, and greater dysfunction at outcome.

Premorbid functioning and liftime course of early onset psychotic disorder

Christian Eggers, Prof. Dr. med,  Detlef Bunk,  Dr. phil.

Clinic for Child and Adolescent psychiatry, University Essen

Summarized case histories of a subsample of eleven cases from a total of 44 patients of a long-term follow-up study are presented. The lifetime psychopathological development of these cases of early onset schizophrenia (EOS) is described in terms of  premorbid behavioral disturbances and the subtypes of the following psychotic episodes until late adult life. The results show that behavioral peculiarities like shyness, social withdrawal, bizarre behavior, .aggression, and anxiety already occurred in early childhood long before definite psychotic symptoms were observed. The heterogeneity of  psychotic episodes in the following lifetime course led to the conclusion that illness courses are better qualified for the description of symptoms over time than for diagnostic classifications.

Symtom Dimensions in The Course of Early Onset Schizophrenia

Detlef Bunk, Dr. phil, Christian Eggers, Prof. Dr. med., Marion Klapal, Dipl.-Psych.

Clinic for child and adolescent psychiatry, University Essen

Objective: This study is a symptom orientated approach to describe the symptom dimensions of Childhood-onset schizophrenia (COS) cross-sectionally and longitudinally by focussing on the clinical features at onset of illness during the first episode and at the follow-up after an average time of 42 years from the begin of illness. Stability and change of these dimensions should be examined and related to the outcome variable representing the level of the psycho-social functioning.

Method: The sample comprises 44 patient with COS. Clinical data of the whole course were available from hospital records applying the IRAOS. The Present State Examination (PSE) together with the Disability Assessment Score (DAS-M) at follow-up investigation. All subjects were re-diagnosed according to DSM IV. The symptomatology was evaluated with the positive and negative symptom scale (PANSS) at onset and follow-up examination. Because of the retrospective assessment this scale was applied categorically (presence/absence of symptom). Two principal component factor analysis with varimax-rotation were applied to the complete items set of the PANSS. The two sets of factor scores were correlated with the outcome variables (DAS-M). The frequency of positive, negative, and global symptoms were compared longitudinally in an ANOVA-repeated measures design.

Results: The factor analysis revealed 5 orthogonal symptom dimensions (factors) at onset of psychoses: Cognition, social withdraw, anti-social behavior, excitement, and reality distortion. At the follow-up a five-factor solution was found too but with different dimensions: positive, negative, excitement, cognitive and anxiety/depression component. Social withdrawal at onset was significantly correlated to a low level of psycho-social adaptation at follow up. Positive symptoms decreased significantly during the course of illness, while the frequencies of negative and global symptoms did not change.

Conclusion: COS is accompanied with more unspecific symptoms because of its deteriorating impact on the entire childhood developmental process. So the factor structure is predominated by the dimensions of social withdrawal and antisocial behavior. In the later course of illness the structure of symptom dimensions changes to that found in adult schizophrenia. The negative symptoms, observed at the begin of COS seem to have a reliable prognostic value for course and outcome.

Childhood-onset schizophrenia and affective psychoses: the predictors and features of outcome in adult life

Chris Hollis, Ph.D.

Department of Child & Adolescent Psychiatry, University Hospital Nottingham, NG7 2UJI, U.K

Objective: The aim of this clinical follow-up study of chi1dhood-onset functional psychoses was to examine whether diagnostic categories and symptom dimensions at presentation predict outcome in adult life after contro1ling for age at onset.

Methods: The study sample consisted of a consecutive series of 115 patients, aged 1.6 years or younger, admitted to the Maudsley and Bethlem Royal Hospitals, London between 1975 anti 1990 with DSM-IIIR schizophrenia or an affective psychosis. Full follow-up was achieved for 71 subjects (41 with schizophrenia, 30 with affective psychoses).

Results : The schizophrenic and affective psychosis groups were similar with respect to background demographic features, age at onset of psychotic symptoms (mean 14.7 years for both groups) and duration of follow-up (mean 11.9 vs. 10~6 years respectively). At follow-up, the schizophrenic subjects had experienced a significantly longer period with active psychotic symptoms (mean 9.0 vs. 2.3 years) anti spent longer in hospital (mean 4.7 vs. 2.3 years). The schizophrenic subjects were less likely than the affective psychotic group to be living independently (7% vs. 64%), to be in employment (10% vs. 47%) and to have established close love relationships or friendships (17% vs. 66%). The strongest predictor of poor outcome was the negative symptoms at presentation. The positive symptom dimension (hallucinations, delusions) was unrelated to outcome.

Conclusion: Childhood-onset schizophrenia has a significantly worse clinical and social outcome when compared to childhood-onset affective psychoses. Poor outcome, regardless of diagnosis, is best predicted by a pattern of premorbid behavioral, cognitive and social impairments and negative psychotic symptoms.


Pressemitteilung 10.08.1998 - (idw) Universität Essen (bis 31.12.2002)

Schizophrenie-Forschung: Bei Erkrankung im Kindesalter eine schlechte Prognose

Je früher ein Kind an Schizophrenie leidet, um so schlechter ist die Prognose für den Verlauf der Krankheit. Das ergab eine der wenigen Langzeitstudien, die zu diesem Thema vorliegen. Die Ergebnisse stellte der Kinder- und Jugendpsychiater Christian Eggers an der Universität-Gesamthochschule Essen vor.

179/98  10. August 1998

Kinder, die das 15. Lebensjahr noch nicht vollendet haben, erkranken nur selten an einer Schizophrenie. Aber wenn sie Opfer dieser schweren Psychose werden, nimmt diese meist einen schlechten Verlauf. Ende der sechziger Jahre - damals noch an der Universität Marburg - leitete der Kinder- und Jugendpsychiater Professor Christian Eggers eine der wenigen Langzeitstudien mit Patienten ein, bei denen der Verdacht auf eine Schizophrenieerkrankung bereits vor dem 14. Lebensjahr bestanden hatte. Mehrfach fanden Nachuntersuchungen statt, an der letzten stellten sich von den anfangs 71 Teilnehmern an der Studie noch 44 bei Eggers vor. Die Ergebnisse diskutierte der Wissenschaftler, der seit 1979 Direktor der Klinik für Kinder- und Jugendpsychiatrie am Essener Universitätsklinikum ist, jetzt im Rahmen eines internationalen Schizophrenie-Symposiums mit Fachkollegen, die sich ebenfalls auf die Erforschung der im Kindes- bzw. im frühen Jugendalter beginnenden Psychosen spezialisiert haben. Das Essener Symposium fand im Vorlauf eines großen Kongresses von Kinder- und Jugendpsychiatern in Stockholm statt und nahm die dort geplante Vorstellung neuer Ergebnisse der Schizophrenie-Forschung bereits vorweg - in einem kleinen, aber hochkarätig besetzten Kreis von Experten aus den USA, aus England und aus Deutschland.

Lange Zeit sei bezweifelt worden, ob schizophrene Psychosen bei Kindern und Erwachsenen überhaupt zum selben Krankheitsbild gehörten, erklärt in der Essener Klinik Dr. Detlef Bunk, der zusammen mit Eggers das Symposium vorbereitet hatte. Inzwischen müsse man aber davon ausgehen, dass zwischen Frühschizophrenien und Schizophrenien bei Erwachsenen eine Kontinuität bestehe. Allerdings: Wenn Kinder sehr früh schizophreniekrank würden - von 1 000 unter 15jährigen sind das 0,14 - müsse man sich auf ungünstige Krankheitsverläufe einstellen. Je jünger der Patient sei, um so schlechter falle die Prognose aus.

Ein wichtiges Anliegen bei der Langzeitstudie war es für Christian Eggers und seine Mitarbeiter, durch den Rückblick auf die Langzeitverläufe Rückschlüsse auf die Behandlung der Psychose im Anfangsstadium ziehen zu können. Die klassische medikamentöse Behandlung müsse möglichst frühzeitig durch einen psycho- und familientherapeutischen Ansatz ergänzt werden. Ziel sei es, die kognitiven Funktionen wie Konzentrations- und Durchhaltevermögen sowie Antriebsfähigkeit zu erhalten und dem Kranken einen möglichst stabilen sozialen Kontext zu verschaffen, erklärt Eggers.

Oft schon acht Jahre vor der eindeutigen Diagnostizierung psychotischer Symptome zeigt das später schizophreniekranke Kind deutliche Aufälligkeiten in seinem Wesen und Verhalten. Sozialer Rückzug, Ängstlichkeit, Depressivität und Scheu, aber auch unmotivierte Wutausbrüche und Aggressivität seien zu beobachten. Zeige, berichtet Eggers, die Krankheit anfangs einen chronisch-schleichenden Verlauf, sei die Chance einer Gesundung äußerst gering. Nur neun v. H. der Patienten erlebten eine erfolgreiche Therapie, 73 v. H. blieben ohne jede Remission. Die Krankheitssymptome bilden sich also nicht zurück. Bei akutem Ausbruch remittieren immerhin 36 v. H. der Patienten.

Redaktion: Monika Rögge, Telefon (02 01) 1 83-20 85