Social functioning in young people at risk for schizophrenia
Introduction
To better define the prodrome of schizophrenia, it is necessary to identify illness-specific subsyndromal markers which help to accurately differentiate those individuals who will develop schizophrenia from others who present with similar warning signs but do not develop the illness. As current “at risk” criteria can only predict development of a psychotic illness with a sensitivity of up to 40% (Yung et al., 2004), we continue to struggle with the fact that many individuals who meet the operationally defined criteria for an “at risk” state (Miller et al., 2003) will ultimately either fail to convert to an Axis I disorder, or will be diagnosed with an Axis I disorder other than schizophrenia (Haroun et al., 2006). Combining illness-specific risk markers with current clinical “at risk criteria” is of critical importance in not only increasing the sensitivity of current criteria (Mason et al., 2004, Simon et al., 2006), but in identifying those individuals most at risk for schizophrenia (Seeber and Cadenhead, 2005).
Schizophrenia is an illness that presents itself in late adolescence or early adulthood and is often characterized by both a premorbid and a prodromal phase. The premorbid phase is characterized by a period of stable social and cognitive deficits which long precede the first episode of psychosis (Davidson et al., 1999). In contrast, the “prodromal” period is defined by its lack of stability, and a worsening course of psychosocial impairment culminating in the onset of frank psychosis (Keith and Matthews, 1991, Yung et al., 1996). A decline in quality of life and social functioning often precedes psychosis (Melle et al., 2005) and the duration of untreated psychosis corresponds to further decline in terms of total symptoms, depression/anxiety, negative symptoms, overall functioning, positive symptoms, and social functioning (Marshall et al., 2005). As attempts to define a predictive profile for schizophrenia develop, it is becoming clear that early identification of at risk individuals and early intervention prior to onset of psychosis can potentially diminish the toxic effects of untreated psychosis (Marshall et al., 2005).
Many prospective, premorbid high-risk studies have been conducted with children whose parents have schizophrenia or another mental disorder. These studies generally show a pattern of social dysfunction with general social withdrawal, hostility and aggression common in many children with a psychotic parent (Hans et al., 1992). Hans et al. (2000) also found that high-risk adolescents showed poor engagement with peers, immaturity, and social adjustment deficits on the Social Adjustment Inventory for Children and Adolescents (SAICA) and the Youth Self Report (YSR). These high-risk studies propose that adolescents genetically at risk for schizophrenia have social deficits that may predict vulnerability to the disease. Davidson et al.'s (1999) prospective study of Israeli draftees who later developed psychosis found that measures of intellectual ability, organization and social functioning assessed premorbidly were most predictive of future illness.
Recent studies further corroborate the role of social dysfunction as a predictive marker of future psychosis. Lencz et al.'s (2004) prospective study of 82 patients at high-risk for schizophrenia reported that social isolation and/or withdrawal were the most common presenting symptoms at initial evaluation. Yung et al. (2004) also showed that poor functioning, long duration of symptoms, high levels of depression and reduced attention were all predictive of psychosis within a group of 104 “ultra high-risk” subjects, and that combining these highly predictive variables could further increase the positive predictive value of identifying those individuals who will convert to psychosis. Other studies have suggested that the presence of academic decline with comorbid social deficits may further serve as a unique prodromal marker that may differentiate predictive risk for schizophrenia from other affective psychoses (Cannon et al., 1997, Reichenberg et al., 2002, Allen et al., 2005).
Most high-risk studies have examined social premorbid functioning either retrospectively or historically prospectively. Our study prospectively examines social functioning in a group of adolescents putatively prodromal for schizophrenia. Although we now present baseline cross-sectional data, future studies will expand on these findings to include prospective longitudinal data.
We hypothesized that individuals identified as at risk for the development of schizophrenia, or in their first episode of the illness, would exhibit deficits in social functioning compared to age-matched normal subjects at entry into the study. Additionally, we wanted to determine which specific domains of functioning are impaired.
Section snippets
Methods
A full description of the CARE program is detailed in a recent review (Seeber and Cadenhead, 2005). The Cognitive Assessment and Risk Evaluation (CARE) Program at the University of California, San Diego, is a clinic that provides longitudinal assessment of individuals ages 12 to 30 years who are considered to be at risk for developing schizophrenia, or have experienced their first episode of schizophrenia within the last year. At risk subjects are not told that they are specifically at risk for
Results
This article reports the results of a sample of 33 adolescents (AR = 22, NC = 11) assessed on the SAICA and a sample of 83 young adults (AR = 33, FE = 16, NC=34) assessed on the SAS-SR. As a group, adolescent AR individuals demonstrated significant social deficits as assessed by the overall SAICA score when compared to NC subjects (see Table 3). Deficits in the domain of school functioning accounted for this difference between groups. Analysis of individual items in the school functioning domain
Discussion
Individuals presumed to be at risk for schizophrenia and patients in their first episode of the illness demonstrated significant impairments in social functioning across multiple domains. Beyond global deficits in social functioning, the adolescent sample primarily had difficulties in the school setting while the young adults also reported difficulties in multiple aspects of their life.
Although the social functioning scales do not objectively assess occupational or academic performance, they do
Acknowledgments
The authors thank Nasra Haroun, MD, Karin Kristensen, PsyD, Kathy Shafer, BS, and Katherine Seeber, BA, for their assistance with preparing this manuscript. This work was previously presented at the 2005 Annual Meeting of the Society for Biological Psychiatry.
This work was supported by the National Institute of Mental Health Cognitive Assessment and Risk Evaluation (CARE, MH60720).
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