2) Stages of Paranoid Schizophrenia

The progression of schizophrenia stages
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Acute stage of schizophrenia has the worst cognitive function compare to early and late stage of schizophrenia
image source: http://www.schizophrenia.com/images/earlygraph.gif

Paranoid Schizophrenia, although it no longer exists in the new Diagnosis and Statistical Manual 5 (DSM-5), was once the most known subtype of schizophrenia. Patients were characterized with strong positive symptoms of schizophrenia, such as the present of auditory hallucination and delusion[2]. These patients were relatively more functional in daily life comparing to other subtypes of schizophrenia. There are 3 different stages in the development of schizophrenia, prodromal, acute and residual stage[1][2][3]. People in prodromal stage experience ambiguous mental symptoms that are often misdiagnosis as depression or anxiety disorders. Acute stage patients experience the full-blown symptoms (the positive and negative symptoms) of schizophrenia. Residual stage patients experience negative symptoms (social withdraw) and some level of positive symptoms but less severe. Early detection and treatments on early stage of schizophrenia (especially prodromal stage) seems to significantly prevent or delay the full-development of schizophrenia[1][2][3].

The Three Stages

Prodromal Stage

Prodromal stage is an early stage of a disease, which the early symptoms and signs are different from the actual full-blown disease [4]. This Stage is often described as a progression development of psychosis disorder. Prodromal stages patients are usually adolescence or young adults. Patients in prodromal stage are often difficult to be discovered due to its ambiguous symptoms6. Prodromal symptoms of schizophrenia could include anxiety, sadness, lability, irritability, sleep disturbance, cognitive impairment in attention, mild positive symptoms (hallucination, delusion, strange believes and magical thinking), mild negative symptoms (social withdrawal) and substances use6. These symptoms are non-specific and often misdiagnosis into different mood disorders, such as depression and anxiety[4][6]. These symptoms could last from weeks to years[1][2][3][4][6][9]. Early interventions seem to have a better impact on the patients’ lives in terms of retaining or improving their cognitive function and delay of the full-blown development of schizophrenia comparing with interventions on schizophrenia developed patients[1][2][7]. Therefore, high sensitivity test is needed to select people that have a high risk of developing schizophrenia, so that interventions can be given as soon as possible to prevent or delay the full-blown development of the irreversible disorder – schizophrenia [1][2][6][7]. Prodromal stage patients could be diagnosis with retrospective and prospective assessments in a scaling system, high-risk individuals would undergo a series of systemic interviews, and diagnosis is based on their scoring9. In addition to cognitive assessment, visual function assessment (p300) could also provide significant evidences for assessing patient in prodromal schizophrenia10. The brain activity (p300) of people in prodromal stage, although not as significant as schizophrenia patients, was affected and can be potentially used as a marker for prodromal stage. Pantelis et al. (2005) had reviewed different MRI brain structure studies on the prodromal stage and suggested that brain structure alterations could occur as early as prenatal period. In the MRI brain images of prodromal stage individuals[5][8][11][13], they showed reduction in the amygdala, thalamus, inferior temporal lobe and possibility the frontal lobe as well comparing to control groups. However, although we know that early detection and treatments could help prevent or delay the development of paranoid schizophrenia, the ambiguous symptoms of prodromal stage limits the validity of the diagnosis and often delays interventions[3][9].

Acute Stage

This is the active stage of schizophrenia. Patients in this stage experience the positive symptoms and negative symptoms of schizophrenia6. Delusion and hallucination are typical positive symptoms that paranoid schizophrenia patient will experience6. Negative symptoms, such as social withdrawal, impair cognitive function and lack of emotion, might be present in Paranoid schizophrenia patients as well3,6. However, they usually experience more of the positive symptoms, such as hearing voices or believing they are being spied on, than the negative symptoms, such as flat affect[12]. On the other hand, their cognitive functions and emotional expression are relatively intact comparing to other schizophrenia subtypes [12].The anatomical structure of the brain changes along with the progression of the disorder[11][13][15]. White matter in the cortical-subcortical brain regions changes, and these changes seemed to correlate with the cognitive function of the patients. In addition to the whiter matter changes, the grey matters, such as hippocampus, reduce in size in schizophrenia patients[11][13][15]. There is also a reduction in the size of the brain, which might due to the enlargement of the ventricle spaces. Some studies also showed that some patients have a reduction in the size of their left frontal lobe and temporal lobe of the patients, which might contribute to the asymmetry brain images that are capture by MRI[11][13][15].

Residual Stage

This is the transition stage of schizophrenia[6]. Symptoms are similar to prodromal stage. The positive symptoms of schizophrenia have reduced comparing to the patients in acute stages. However, the negative symptoms do persist. Their cognitive function have improved and they do aware of their strange believes now[6][12]. Moreover, the reduction in positive symptoms (hallucination, delusion and strange believes) might be due to the continuous reduction in size of the brain regions[3][11]. Frontal lobe and temporal lobe are one of the major brain regions that contribute to the production of positive symptoms and the emotion aspect of schizophrenia patients, so the reduction of size in these area could contribute to the reduction of the positive symptoms in residual stage patients[3][8][11]. There is a chance that people in the residual stage could go back to acute stage and experience the full-blown symptoms again[6].

Examples of Assessment method in early/prodromal stage of schizophrenia

The Personal Assessment and Crisis Evaluation (PACE) was the first method that was developed for the assessment of prodromal stage individual[7]. This method takes into account of the person’s age, family history of psychosis and different prodromal symptoms, and assesses the potential risk of developing schizophrenia. There is also another method called CAARMS, which focuses on the symptoms of the high-risk individuals[7]. It assesses the intensity, frequency and duration of potential positive symptoms of schizophrenia.
Like the above, they are all Face to face interviews to assess the basic symptoms of prodromal stage. A quicker assessment called retrospective assessment at age at onset of psychosis (IROAS)[2] is also used to monitor and assess the progression of high-risk individuals. It is a scoring system which patients are asked to score the ten basic symptoms, which are thought interferences, though perseveration, thought pressure, thought blockage, disturbances of receptive language (hear or read), decreased ability to discriminate between ideas and perception, fantasy and true memories, unstable ideas of reference, derealization, visual perception disturbances (Blurred vision, transitory blindness, partial sight, hypersensitivity to light), acoustic perception disturbances (hypersensitivity to sound or noise. The total score of the participants are then calculate and categorize whether those individuals are high risk of developing schizophrenia or normal people[2].

Early Interventions benefit Schizophrenia patients

Like cancer and other diseases, in order to clearly understand the disease characteristic, it is essential to understand its development stages and how it progress. Again, like most of the diseases, the earlier you can detect it and provide proper interventions, the better of the outcome will be. This might also be applicable to the treatment of schizophrenia. With the concept of neurodevelopment, there are more and more studies focus on the effectiveness of early intervention against the onset of schizophrenia. Bechdolf et al. (2012) had conducted a study of preventing progression to first episode psychosis in early initial prodromal states. In this study, they recruited young participants that had a high risk (prodromal stage of schizophrenia) of developing psychosis by conducting a series of checklists with specific criteria. Participants were randomized into two groups, one had a treatment period of 12 months and the other one had a treatment period of 24 months. Their aim was to assess whether early interventions affects on the onset or progress of the high-risk individuals. Each treatment groups were provided the same modules. Each group under went individual cognitive-behavioral therapy (CBT), Group skills training, cognitive remediation and psycho-education multifamily group counseling. In CBT, they taught individuals stress management, symptoms management and crisis management. In group skills training, individuals were taught to manage their mood and social skills. There was also a computer-program based training section where individuals practice their concentration, attention and memory. This study showed that the earlier and the longer length of the treatment period provide to prodromal stage patients could prevent or delay the onset of schizophrenia. Molly Larson et.al.(2010) also suggested that early atypical antipsychotic medications and psychological treatments could delay the onset of the disorder depending on the symptoms that the individuals are experiencing. Lieberman et. al. (2001) had summarized 26 studies from 1997 to 2001 that involved untreated and treated psychosis and suggested that early interventions seemed to effectively delay the onset and improve the outcome of schizophrenia patients. They seemed to have less suffered from the positive and negative symptoms of schizophrenia. However, the biggest challenge was effectiveness in detecting patients in the early stage of schizophrenia.
In conclusion, many of the studies showed that the most effective way to treat or prevent the development/progression of schizophrenia was early stage interventions. However, Future studies should focus on how to develop a more sensitive method/tool to detect prodromal stage patients, and better screening method that could be done as early as the day of birth.

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