Good Premorbid Adjustment Research Articles

Cognitive reserve as a moderator of outcomes in five clusters of first episode psychosis patients: a 10-year follow-up study of the PAFIP cohort.

Cognitive reserve (CR) has been associated with the development and prognosis of psychosis. Different proxies have been used to estimate CR among individuals. A composite score of these proxies could elucidate the role of CR at illness onset on the variability of clinical and neurocognitive outcomes. Premorbid intelligence quotient (IQ), years of education and premorbid adjustment were explored as proxies of CR in a large sample (N = 424) of first-episode psychosis (FEP) non-affective patients. Clusters of patients were identified and compared based on premorbid, clinical and neurocognitive variables at baseline. Additionally, the clusters were compared at 3-year (N = 362) and 10-year (N = 150) follow-ups. The FEP patients were grouped into five CR clusters: C1 (low premorbid IQ, low education and poor premorbid) 14%; C2 (low premorbid IQ, low education and good premorbid adjustment) 29%; C3 (normal premorbid IQ, low education and poor premorbid adjustment) 17%; C4 (normal premorbid IQ, medium education and good premorbid adjustment) 25%; and C5 (normal premorbid IQ, higher education and good premorbid adjustment) 15%. In general, positive and negative symptoms were more severe in the FEP patients with the lowest CR at baseline and follow-up assessments, while those with high CR presented and maintained higher levels of cognitive functioning. CR could be considered a key factor at illness onset and a moderator of outcomes in FEP patients. A high CR could function as a protective factor against cognitive impairment and severe symptomatology. Clinical interventions focused on increasing CR and documenting long-term benefits are interesting and desirable.

Use of Ecological Momentary Assessment Through a Passive Smartphone-Based App (eB2) by Patients With Schizophrenia: Acceptability Study.

BackgroundEcological momentary assessment (EMA) tools appear to be useful interventions for collecting real-time data on patients’ behavior and functioning. However, concerns have been voiced regarding the acceptability of EMA among patients with schizophrenia and the factors influencing EMA acceptability.ObjectiveThe aim of this study was to investigate the acceptability of a passive smartphone-based EMA app, evidence-based behavior (eB2), among patients with schizophrenia spectrum disorders and the putative variables underlying their acceptance.MethodsThe participants in this study were from an ongoing randomized controlled trial (RCT) of metacognitive training, consisting of outpatients with schizophrenia spectrum disorders (F20-29 of 10th revision of the International Statistical Classification of Diseases and Related Health Problems), aged 18-64 years, none of whom received any financial compensation. Those who consented to installation of the eB2 app (users) were compared with those who did not (nonusers) in sociodemographic, clinical, premorbid adjustment, neurocognitive, psychopathological, insight, and metacognitive variables. A multivariable binary logistic regression tested the influence of the above (independent) variables on “being user versus nonuser” (acceptability), which was the main outcome measure.ResultsOut of the 77 RCT participants, 24 (31%) consented to installing eB2, which remained installed till the end of the study (median follow-up 14.50 weeks) in 14 participants (70%). Users were younger and had a higher education level, better premorbid adjustment, better executive function (according to the Trail Making Test), and higher cognitive insight levels (measured with the Beck Cognitive Insight Scale) than nonusers (univariate analyses) although only age (OR 0.93, 95% CI 0.86-0.99; P=.048) and early adolescence premorbid adjustment (OR 0.75, 95% CI 0.61-0.93; P=.01) survived the multivariable regression model, thus predicting eB2 acceptability.ConclusionsAcceptability of a passive smartphone-based EMA app among participants with schizophrenia spectrum disorders in this RCT where no participant received financial compensation was, as expected, relatively low, and linked with being young and good premorbid adjustment. Further research should examine how to increase EMA acceptability in patients with schizophrenia spectrum disorders, in particular, older participants and those with poor premorbid adjustment.Trial RegistrationClinicalTrials.gov NCT04104347; https://clinicaltrials.gov/ct2/show/NCT04104347

Premorbid adjustment amongst outpatients with schizophrenia in a Nigerian psychiatric facility.

BackgroundStudies from developed countries have shown that poor premorbid adjustment in patients with schizophrenia is associated with poor outcome. However, similar studies in developing countries like Nigeria are few despite the stability of schizophrenia prevalence across cultures.AimThe aim of this study was to assess the prevalence and correlates of poor premorbid adjustment amongst outpatients with schizophrenia.SettingThe Neuropsychiatric Hospital, Abeokuta in Ogun State, Nigeria.MethodsThe premorbid adjustment of 300 outpatients with schizophrenia was assessed using the premorbid adjustment scale. Pattern and severity of psychosis, overall illness severity, global assessment of functioning and socio-demographic factors were investigated as correlates of premorbid functioning.ResultsAbout half (53.3%) of the respondents had poor premorbid adjustment and most of them were males (56.9%). Poor premorbid adjustment was associated with male gender (χ2 = 7.81, p = 0.005) whilst good premorbid adjustment was associated with no or borderline illness severity (χ2 = 8.26, p = 0.016) as well as no or mild impairment in functioning (χ2 = 7.01, p = 0.029) amongst the respondents. Positive, negative and general symptomatology were predicted by premorbid adjustment at different developmental stages.ConclusionConsistent with existing literature, poor premorbid adjustment was prevalent amongst patients with schizophrenia in this study and was associated with male gender, poorer clinical outcomes and greater illness severity. Mental health promotion and other preventative approaches are recommended as possible early intervention strategies in dealing with schizophrenia.

Clinical characterization of brief psychotic disorders triggered by the COVID-19 pandemic: a multicenter observational study.

This study aimed to characterize the clinical profile of patients with brief psychotic disorders (BPD) triggered by the psychosocial distress derived from the COVID-19 crisis. A multicenter study was conducted from March 14 to May 14, 2020 (the peak weeks of the pandemic in Europe). All consecutive patients presenting non-affective psychotic episodes with a duration of untreated psychosis of less than 1 month and whose onset was related to the COVID-19 crisis were recruited, but only those patients meeting Diagnostic Statistical Manual 5th edition (DSM-5) criteria for “BPD with marked stressors” (DSM-5 code: 298.8) during follow-up were finally included. Patients' sociodemographic and clinical characteristics were collected at baseline and summarized with descriptive statistics. During the study period, 57 individuals with short-lived psychotic episodes related to the emotional stress of the COVID-19 pandemic were identified, of whom 33 met DSM-5 criteria for “BPD with marked stressors”. The mean age was 42.33 ± 14.04 years, the gender distribution was almost the same, and the majority were rated as having good premorbid adjustment. About a quarter of the patients exhibited suicidal symptoms and almost half presented first-rank schizophrenia symptoms. None of them were COVID-19 positive, but in more than half of the cases, the topic of their psychotic features was COVID-19-related. The coronavirus pandemic is triggering a significant number of BPD cases. Their risk of suicidal behavior, their high relapse rate, and their low temporal stability make it necessary to closely monitor these patients over time.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00406-021-01256-w.

Pending challenges to e-mental health in the COVID-19 era: Acceptability of a smartphone-based ecological momentary assessment application among patients with schizophrenia spectrum disorders

IntroductionConcerns have been raised about ecological momentary assessment (EMA) acceptability among patients with schizophrenia spectrum disorders (SSD), which is of major relevance during the e-Mental health-focused COVID-19 pandemic.ObjectivesTo investigate i) the levels of adherence to a passive smartphone-based EMA tool, the Evidence-Based Behavior (eB2), among SSD patients; and ii) putative predictors of this.MethodsSample: SSD (F20-29-ICD10) outpatients, age 18-64, without financial incentives, recruited over 17/06/2019-11/03/2020 at the Hospital Universitario Fundación Jiménez Díaz (Madrid, Spain). Those who accepted the eB2 installation -users- and those who did not -non-users- were compared in sociodemographic, clinical, premorbid adjustment, neurocognitive, psychopathological, insight and metacognitive variables by a multivariable binary logistic regression model.ResultsSample (N=77): n=41 males; age: 47.69±9.76 years, n=24 users (31.2%). n=14 users (70%) had the eB2 installed at follow-up (median=14.50 weeks).Multivariable binary logistic regression model on ‘user’ as outcomeβSEWaldpOR95% CIAge-0.0750.0383.9100.0480.9280.861-0.999Education level-0.9671.2890.5630.4530.3800.030-4.755Early adolescence premorbid adjustment-0.2850.1106.6950.0100.7520.606-0.933Trail Making Test A-0.0300.0251.4880.2220.9700.924-1.018Trail Making Test B-0.0050.0100.2780.5980.9950.976-1.014Cognitive Insight0.0620.0611.0430.3071.0640.944-1.200X2=25.296,df=6,p<0.001. Nagelkerke-R2=44.7%. Correctly classified: 76.9%, users:54.5%, non-users:88.4%.ConclusionsAcceptability of a smartphone-based EMA application among SSD patients was low. Age (young) and good premorbid adjustment predicted acceptability. e-Mental Health methods need to be tailored for patients with SSD. Otherwise, these highly vulnerable individuals may be neglected by e-health-based services in the post-COVID-19 years ahead.

Suicide in Schizophrenia: An Educational Overview.

Suicide is an important public health problem. The most frequent psychiatric illnesses associated with suicide or severe suicide attempt are mood and psychotic disorders. The purpose of this paper is to provide an educational overview of suicidal behavior in individuals with schizophrenia. A lifetime suicide rate in individuals with schizophrenia is approximately 10%. Suicide is the largest contributor to the decreased life expectancy in individuals with schizophrenia. Demographic and psychosocial factors that increase a risk of suicide in individuals with schizophrenia include younger age, being male, being unmarried, living alone, being unemployed, being intelligent, being well-educated, good premorbid adjustment or functioning, having high personal expectations and hopes, having an understanding that life’s expectations and hopes are not likely to be met, having had recent (i.e., within past 3 months) life events, having poor work functioning, and having access to lethal means, such as firearms. Throughout the first decade of their disorder, patients with schizophrenia are at substantially elevated suicide risk, although they continue to be at elevated suicide risk during their lives with times of worsening or improvement. Having awareness of symptoms, especially, awareness of delusions, anhedonia, asociality, and blunted affect, having a negative feeling about, or non-adherence with, treatment are associated with greater suicide risk in patients with schizophrenia. Comorbid depression and a history of suicidal behavior are important contributors to suicide risk in patients with schizophrenia. The only reliable protective factor for suicide in patients with schizophrenia is provision of and compliance with comprehensive treatment. Prevention of suicidal behavior in schizophrenia should include recognizing patients at risk, delivering the best possible therapy for psychotic symptoms, and managing comorbid depression and substance misuse.

Predictors of diagnostic stability in acute and transient psychotic disorders: validation of previous findings and implications for ICD-11.

Acute and transient psychotic disorders (ATPD) have moderate prospective diagnostic stability. Female gender, older age at onset, good premorbid adjustment, abrupt onset, shifting polymorphic symptomatology and absence of schizophrenic features have been found to be predictive factors of diagnostic stability in ATPDs. Nevertheless, most of these findings need to be replicated. The purpose of this study was to evaluate the diagnostic stability of patients with ATPD, and to determine whether previously accepted predictors of diagnostic stability for ATPD could be externally validated in our cohort. To that end, a prospective 2-year observational study was conducted on patients with first-episode ATPD. Multivariate analysis was performed to determine factors associated with ATPD diagnostic stability at the end of the follow-up period. The following prior knowledge variables were analyzed: female gender, older age at onset, good premorbid adjustment, abrupt onset, shifting polymorphic symptomatology and absence of schizophrenic features. Sixty-eight patients with first-episode ATPD completed the follow-up, of whom 55.9% (n = 38) retained their diagnosis of ATPD at the end of the study. Multivariate analysis revealed that diagnostic stability was independently significantly associated with the presence of shifting polymorphic symptomatology (OR = 7.42, 95% CI 1.65-33.30; p = 0.009) and the absence of schizophrenic features (OR = 6.37, 95% CI 1.47-27.54; p = 0.013) at the onset of the psychotic disorder. Our findings provide empirical support for the ICD-11 proposal restricting the new ATPD category to the acute polymorphic disorder without schizophrenia symptoms.

Functional deterioration from the premorbid period to 2 years after the first episode of psychosis in early-onset psychosis.

The aim of the study was to analyze changes in functional adjustment from childhood to 2 years after the first episode of psychosis (FEP) in patients with early-onset schizophrenia spectrum disorders (SSD) and affective psychoses (AFP) and a good or intermediate level of premorbid adjustment. We followed 106 adolescents (aged 12-17 years) with FEP for 2 years after recruitment. Premorbid adjustment in childhood was assessed in 98 patients with the childhood subscale of the Cannon-Spoor Premorbid Adjustment Scale (c-PAS). Global functioning was assessed 2 years after the FEP with the Children's Global Assessment Scale (c-GAS) or the Global Assessment of Functioning scale (GAF), as appropriate. Functional deterioration was defined as a downward shift in the level of functional adjustment from childhood to 2 years after the FEP. In patients with good or intermediate premorbid adjustment, functional deterioration was observed in 28.2 % (26.5 % of the AFP group, 29.4 % of the SSD group). Longer duration of untreated psychosis (Beta = 0.01; P = 0.01) and higher symptom severity at the FEP, as measured with the Clinical Global Impression Scale (Beta = 1.12; P = 0.02), significantly predicted the presence of functional deterioration, accounting for 21.4 % of the variance. Irrespective of diagnosis (SSD or AFP), almost one-third of adolescents with FEP and good or intermediate premorbid adjustment showed functional deterioration from the premorbid period to 2 years after the FEP.

Patterns of service utilisation in psychosis: Findings of the 2010 Australian National Survey of Psychosis

This paper reports patterns of health service utilisation in the second Australian national survey of psychosis corresponding with changes in available services of this period. Semi-structured interviews were carried out of an age-stratified random sample of adults who screened positive for psychosis. Multivariate logistic regressions were used to identify predictors of service use for a sample of 1825 individuals. Use of psychiatric inpatient services was associated with higher symptom levels, suicidal ideation, poor social functioning and younger age. High users of emergency mental health services similarly reported higher symptom levels, poor functioning and younger age, and also reported being married or in a de facto relationship. Recipients of general practitioner services had greater anxiety symptoms and suicidal thoughts, fewer negative symptoms, single marital status and English as their first language. Rehabilitation service use was associated with greater anxiety symptoms, unemployment, younger age of illness onset, living alone and having no dependent children living at home. Last, outpatient/community services were more frequently used by younger people with good premorbid adjustment, hallucinations and a less severe course of illness. Service utilisation patterns vary with the clinical and socio-demographic features of those who use them - inpatient and emergency service users being similar in such features and differing from users of other services. Comparison with the first national survey of psychosis revealed a significant decline in acute inpatient service use and a substantial increase in the use of outpatient/community and rehabilitation services over the past 10 years.

Suicidal Behavior in Schizophrenia

This study examined Drake's model that individuals with schizophrenia with good premorbid adjustment and insight into their illness are more vulnerable to becoming demoralized and therefore suicidal. One hundred sixty-four patients with schizophrenia (N = 115) or schizoaffective disorder (N = 49) were assessed for depressive symptoms and DSM-III-R depression, premorbid functioning, insight and suicidal behavior using The Diagnostic Interview for Genetic Studies and the Premorbid Adjustment Scale. Premorbid adjustment, insight and past MDE did not discriminate attempters from nonattempters, contrary to the model. However, consistent with the model, the interaction between good premorbid adjustment and insight predicted severity of depressive symptoms, and the psychological symptoms of depression significantly differentiated attempters from nonattempters, whereas the somatic symptoms did not. This study provides support for some aspects of the demoralization model.

Clinical and serotonergic predictors of non‐affective acute remitting psychosis in patients with a first‐episode psychosis

The study aimed to establish clinical predictors of non-affective acute remitting psychosis (NARP) and assess whether these patients showed a distinct serotonergic profile. First-episode never treated psychotic patients diagnosed of paranoid schizophrenia (n=35; 21 men and 14 women) or NARP (n=28; 15 men and 13 women) were included. NARP patients showed significantly lower negative symptomatology, better premorbid adjustment, shorter duration of untreated psychosis, more depressive symptomatology and a lower number of 5-HT2A receptors than the paranoid schizophrenia patients. In the logistic regression, the four variables associated with the presence of NARP were: low number of 5-HT2A receptors; good premorbid adjustment; low score in the item 'hallucinatory behaviour' and reduced duration of untreated psychosis. Our findings support the view that NARP is a highly distinctive condition different from either affective psychosis or other non-affective psychosis such as schizophrenia, and highlight the need for its validation.

The role of traumatic event in the development of children psychosomatic functional diseases

Objective: To assess the outcome of conversion disorder in children and adolescents and to identify factors affecting the prognosis. Method: Forty adolescents with conversion disorder were reevaluated 4 years after their initial interview. Changes in demographic and clinical data and the presence of any mood and anxiety disorders were recorded using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). In addition, Beck Depression Inventory (BDI) and State–Trait Anxiety Inventory (STAI) were applied. Results: Thirty-four patients (85%) had completely recovered from their conversion symptoms and two patients had improved (5%), whereas only four (10%) were unchanged. Fourteen (35%) patients received the diagnosis of mood and/or anxiety disorder. Favourable outcome was associated with early diagnosis (P=.04) and good premorbid adjustment (P=.01). Conclusion: Conversion disorder has a favourable outcome in children and adolescents. However, mood and/or anxiety disorders are encountered at a considerable rate in these patients even after recovery from conversion symptoms. Long clinical follow-up seems appropriate in children and adolescents with conversion disorder.

Does treatment delay in first-episode psychosis really matter?

Relatively few predictors of outcome in first-episode psychosis are potentially malleable and duration of untreated psychosis (DUP) is one. However, the degree to which DUP is mediated by other predictors of outcome is unclear. This study examines the specific effects of DUP on 12-month outcome after adjusting for effects of potential confounders and moderating variables. The sample comprised 354 first-episode psychosis patients followed up 12-months after remission/stabilization of their psychotic symptoms. Outcome measures included functional outcome, severity of positive symptoms and negative symptoms. Hierarchical multiple regression assessed whether DUP significantly predicted 12-month outcome after adjusting for other predictors. Contrast analysis further clarified the differential effects of DUP on 12-month outcome. DUP remained a significant predictor of outcome after adjusting for the effects of other variables. This finding remained robust for the subset of patients with schizophrenia or schizophreniform disorder. Functional outcome appeared to decline substantially even after very short treatment delays (> 7 days), with more gradual deterioration in functioning until very long DUP (> 1 year). Good outcome was variably associated with good pre-morbid adjustment, female gender, diagnosis of affective disorder, short duration of prodromal symptoms, and treatment within the Early Psychosis Prevention and Intervention model in contrast to other models of care. DUP consistently predicts outcome independently of other variables, and is not simply a proxy for other factors. As one of the few potentially malleable factors influencing outcome, DUP could prove to be a target for secondary preventive efforts in early psychosis.

Conversion and somatization disorders: the dissociative symptoms and other characteristics

Objective: To assess the outcome of conversion disorder in children and adolescents and to identify factors affecting the prognosis. Method: Forty adolescents with conversion disorder were reevaluated 4 years after their initial interview. Changes in demographic and clinical data and the presence of any mood and anxiety disorders were recorded using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). In addition, Beck Depression Inventory (BDI) and State–Trait Anxiety Inventory (STAI) were applied. Results: Thirty-four patients (85%) had completely recovered from their conversion symptoms and two patients had improved (5%), whereas only four (10%) were unchanged. Fourteen (35%) patients received the diagnosis of mood and/or anxiety disorder. Favourable outcome was associated with early diagnosis (P=.04) and good premorbid adjustment (P=.01). Conclusion: Conversion disorder has a favourable outcome in children and adolescents. However, mood and/or anxiety disorders are encountered at a considerable rate in these patients even after recovery from conversion symptoms. Long clinical follow-up seems appropriate in children and adolescents with conversion disorder.

Conversion disorder in children and adolescents: a 4-year follow-up study.

To assess the outcome of conversion disorder in children and adolescents and to identify factors affecting the prognosis. Forty adolescents with conversion disorder were reevaluated 4 years after their initial interview. Changes in demographic and clinical data and the presence of any mood and anxiety disorders were recorded using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). In addition, Beck Depression Inventory (BDI) and State-Trait Anxiety Inventory (STAI) were applied. Thirty-four patients (85%) had completely recovered from their conversion symptoms and two patients had improved (5%), whereas only four (10%) were unchanged. Fourteen (35%) patients received the diagnosis of mood and/or anxiety disorder. Favourable outcome was associated with early diagnosis (P=.04) and good premorbid adjustment (P=.01). Conversion disorder has a favourable outcome in children and adolescents. However, mood and/or anxiety disorders are encountered at a considerable rate in these patients even after recovery from conversion symptoms. Long clinical follow-up seems appropriate in children and adolescents with conversion disorder.

Chronic late-onset schizophrenia-like psychosis that remitted: revisiting Newton's psychosis?

According to historical records, Sir Isaac Newton developed new-onset psychosis at age 51, which was characterized by persecutory delusions. His psychotic symptoms remitted in less than 18 months, but their etiology has since remained a puzzle. The present case conference involves a present-day individual with late-onset paranoid psychosis with later remission, which has some interesting similarities to, as well as important differences front Newton's illness. Our patient had no history of psychiatric illness until age 52, when he developed paranoid delusions, which included thought broadcasting, auditory hallucinations, blunted affect, and poor insight. His early medical history was remarkable for grand mal seizures between ages 15 and 29. His psychosis improved with the use of antipsychotic medication. Approximately 6 years after its onset, his psychotic illness remitted, and all psychotropic medications were discontinued. Four years later, at the writing of this report, our patient continued to function independently with no psychiatric symptoms. We discuss the differential diagnosis for this chronic late-onset schizophrenia-like psychosis with remission.

Full recovery from schizophrenia: the prognostic role of premorbid adjustment, symptoms at first admission, precipitating events and gender

A number of long-term studies of course and outcome in schizophrenia report that about a fourth of the cases show good clinical and social recovery. However, very few studies have been carried out examining the main characteristics of schizophrenia patients who have fully recovered according to a strict definition of ‘full recovery’. The purpose of the present study was, therefore, to compare a group of 17 fully recovered schizophrenia patients (Group A) with a group of 33 patients (Group B) with current symptoms of schizophrenia on several prognostic factors that have been associated with a good outcome. These clinical groups were matched groupwise with a similar mean on two variables: age range at onset of illness and age at time of interview. Duration of illness (length of time from age of onset of illness to time of assessment) was 22.4 years in group A and 21 years in group B. Mean GAS scores were 72.2 and 46.5, respectively. Positive symptoms (delusions and disorganized behavior) at admission predicted an unfavorable outcome. The results confirmed the prognostic significance of several clinical and demographic factors. However, a good premorbid adjustment did not show significant predictive power, but showed substantial association in the predicted direction. In addition, a clear sex difference was found: women report a significantly better premorbid functioning and demonstrate a more favorable psychosocial functioning than men.

Premorbid adjustment as predictor of outcome in schizophrenia: results of a prospective study.

The present prospective follow-up study of 163 schizophrenic patients admitted to hospital for the first time examined the relationship between premorbid adjustment and different measures of the 3-year course and outcome. The same instruments had been used in all phases of the study. The Premorbid Adjustment Scale was used to assess premorbid social functioning. Outcome measures were positive symptoms, negative symptoms, social disability and number of rehospitalizations. The results of the multiple regression analyses showed that premorbid adjustment was the strongest overall predictor of outcome. Premorbid adjustment was significantly associated with negative symptoms and social disability over the 3-year course of illness. In a further step, we examined the relationship between good, moderate and poor premorbid adjustment and the course of positive symptoms, negative symptoms and social disability within the first 3 years after index admission. The most important finding was that premorbid functioning showed a stronger correlation with the course of negative symptoms and social disability than with the course of positive symptoms. Poor premorbid social functioning implies a poor social course of the illness. Female subjects showed better premorbid functioning than male subjects. Good premorbid adjustment was strongly associated with an acute onset of the illness, and poor premorbid adjustment with an insidious onset.

Premorbid and onset features of first-episode schizophrenia.

Most descriptive studies of the psychopathology of schizophrenia have focused on the period following illness onset. Little attention has been paid to the assessment of psychopathology before onset of psychotic symptoms. In this study, 71 first-hospitalization patients diagnosed with schizophrenia, schizoaffective, or schizophreniform disorder using DSM-III-R criteria were assessed on measures of premorbid adjustment, clinical history, and presenting symptomatology. A pattern of progressive decline was characteristic of 21 percent of the cases--primarily males with a long-term history of psychotic symptoms before first hospitalization and a trend for more severe negative symptoms at hospital admission. Patients who had a stable pattern of good premorbid adjustment experienced symptom onset and first hospitalization at a later age than those with a chronically poor premorbid adjustment. Time from onset of first psychotic symptom to first hospitalization varied from less than 1 month to over 20 years and was not associated with symptom severity or age of first psychotic symptoms. Systematic characterization of the earliest manifestations of schizophrenia may be important in identifying subgroups of patients with a similar course of illness, and may ultimately facilitate diagnosis, treatment, and understanding of the pathophysiology of schizophrenia.

Inconsistencies in paranoid functioning, premorbid adjustment, and chronicity: question of diagnostic criteria.

Despite the widely held belief that paranoid behavior is associated with good premorbid adjustment, low chronicity, and high current functioning in psychiatric inpatients, inconsistencies in the literature suggest that supportive evidence may be an artifact of the measurement model commonly used to index paranoid status. In a sample of 497 nonorganic inpatients selected from 19 treatment units, paranoid behavior, when measured by a dimensional/cumulative model, was not found to indicate higher functioning and associated relationships, but simply to reflect a narrower class of problem behavior. Only when paranoid status was defined using a traditional model based on the predominance of the defining class of behavior did paranoid subjects demonstrate better premorbid adjustment, lower chronicity, and higher levels of functioning than nonparanoid subjects. Serious problems exist in the use of information obtained from traditional predominance/class models for either theoretical or practical purposes.