A 32-year-old man with schizophrenia comes to the office for follow-up. The patient has been stable on his antipsychotic medication for many years. He has infrequent auditory hallucinations and says that the medication "has helped a lot to turn down the volume of the voices." The patient works stocking grocery shelves part-time and lives with his parents, who are supportive. His symptoms first developed gradually at age 14 when he exhibited nonspecific anxiety and became increasingly paranoid that others were talking about him behind his back; he also became preoccupied with finding special meanings in certain numbers. A year later he was hospitalized for a psychotic episode characterized by paranoid delusions and auditory hallucinations that responded rapidly to antipsychotic medication. The patient was able to finish high school. He was hospitalized again briefly at age 22 but has remained out of the hospital since then. Which of the following factors is most predictive of a favorable prognosis for this patient?
Prognostic factors in schizophrenia | |
Good | Poor |
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Schizophrenia is a chronic psychotic illness with typical onset in early adulthood (peak age: men, early 20s; women, late 20s). Although the disease is chronic, the level of morbidity that those with schizophrenia experience can be dictated by types of symptoms, psychosocial influences, and health care interventions. Notable favorable prognostic factors include:
Patients with predominantly positive psychotic symptoms (eg, hallucinations, delusions), such as this patient, tend to have a more favorable prognosis than patients with predominantly negative symptoms (eg, flat affect, loss of motivation, anhedonia). This is because antipsychotic medications are more effective for treating positive psychotic symptoms than negative symptoms. Early intervention with antipsychotic medication to decrease the duration of active psychosis also improves the course of illness.
(Choices A and B) Most primary thought disorders (eg, schizophrenia, schizoaffective disorder) are chronic, insidious disorders with a gradual onset (prodrome) of weeks to months. In contrast, the presence of sudden onset of symptoms from a precipitating event suggests an underlying cause that may allow for treatment and symptom improvement when the precipitant is addressed.
(Choice C) Although unclear, possible reasons for poorer outcomes in men include biological (ie, genetic influences, changes in brain structure, hormones) and psychosocial (ie, social support deficits, substance use, vocational pressures/expectations) differences.
(Choice D) Patients with childhood or adolescent onset typically have a more severe form of the illness and a worse prognosis; the early onset may be due to a neurodevelopmental process with a deteriorating course.
Educational objective:
Favorable prognostic factors in schizophrenia include predominantly positive psychotic symptoms, acute onset (shorter prodrome) with an identifiable precipitant, and older age at onset.