Differential patterns of premorbid social and academic deterioration in deficit and nondeficit schizophrenia

Numerous studies indicate that social dysfunction is associated with negative symptoms of schizophrenia during the chronic phase of illness. However, it is unclear whether social abnormalities exist during the premorbid phase in people who later develop schizophrenia with prominent negative symptoms, or whether social functioning becomes progressively worse in these individuals from childhood to late adolescence. The current study examined differences in academic and social premorbid functioning in people with schizophrenia meeting criteria for deficit (i.e., primary and enduring negative symptoms) (DS: n = 74) and non-deficit forms of schizophrenia (ND: n = 271). Premorbid social and academic functioning was assessed for childhood, early adolescence, and late adolescence developmental periods on the Premorbid Adjustment Scale (PAS). Results indicated that both DS and ND participants showed deterioration in social and academic functioning from childhood to late adolescence. However, while ND schizophrenia demonstrated greater deterioration of academic compared to social premorbid functioning from childhood to late adolescence, the DS group exhibited comparable deterioration across both premorbid domains, with more severe social deterioration than the ND group. Findings suggest that people with DS show poorer social premorbid adjustment than those with ND as early as childhood, and are particularly susceptible to accelerated deterioration as the onset of schizophrenia becomes imminent. Thus, poor premorbid social adjustment and significant social deterioration from childhood to adolescence may be a hallmark feature of people who later go on to develop prominent negative symptoms and a unique marker for the DS subtype of schizophrenia.     

Differential patterns of premorbid academic and social deterioration in patients with schizophrenia

Schizophrenia is a neurodevelopmental disorder that is characterized by a number of behavioral abnormalities that are present prior to onset. These premorbid abnormalities may serve as unique markers for the disorder. The current study examines academic and social functioning prior to schizophrenia onset in a group of 58 males diagnosed with schizophrenia. The pattern of deterioration for social and academic functioning was examined across three age periods including childhood, early adolescence, and late adolescence, using the retrospective Premorbid Adjustment Scale (PAS). Results indicated that while increasing deterioration was present for both social and academic adjustment across age periods, there was a significant difference in deterioration between academic and social functioning (p<.05) during late adolescence, with greater deterioration in academic functioning. Results of the current study suggest that premorbid academic functioning is particularly susceptible to deterioration during late adolescence, with accelerating deterioration as schizophrenia onset becomes imminent. When considered together with results from other studies, the present findings suggest that deterioration in premorbid academic functioning from early to late adolescence may be a unique premorbid marker for schizophrenia.     

The Maudsley early onset schizophrenia study

OBJECTIVE: To examine the contribution of premorbid function, duration of untreated psychosis (DUP), age of onset, severity of symptoms at presentation, and number of subsequent hospitalisations to the outcome of early onset schizophrenia (EOS; onset before 17th birthday). METHOD: Twenty-three EOS patients (mean age at onset 15.16 +/- 1.39 years) were re-assessed after a mean interval of 4 +/- 1.08 years. At baseline and follow-up clinical diagnoses were confirmed using the Structured Clinical Interview for DSM-IV Axis I Disorders and symptoms were assessed with the Positive and Negative Syndrome Scale. Premorbid function, as measured with the Premorbid Adjustment Scale, age of onset and DUP were assessed at baseline only. Outcome was evaluated using the Social Adaptation Self-Evaluation Scale (SASS) and the Global Assessment of Functioning (GAF) Scale. RESULTS: Mean DUP was 2.95 +/- 3.59 months and mean total PAS score was 6.65 +/- 3.02. They had an average of 2.09 +/- 1.44 hospitalisations and their mean SASS and GAF scores were 37.27 +/- 6.5 and 54.19 +/- 18.99, respectively. Poor childhood premorbid function and the severity of negative symptoms at baseline were correlated with worse SASS and GAF scores. No other significant associations were found. CONCLUSIONS: Poor childhood function is the most significant predictor of outcome in EOS.     

Premorbid functioning of patients with first-episode nonaffective psychosis: a comparison of deterioration in academic and social performance, and clinical correlates of Premorbid Adjustment Scale scores

BACKGROUND: Motivated by a previous study among male veterans [Allen, D.N., Frantom, L.V., Strauss, G.P., van Kammen, D.P., 2005. Differential patterns of premorbid academic and social deterioration in patients with schizophrenia. Schizophr. Res. 75, 389-397], the present analysis examined: (1) patterns of premorbid academic and social functioning during childhood, early adolescence, and late adolescence, and (2) associations between these premorbid functioning dimensions and a number of clinical variables. METHODS: Data on premorbid functioning were collected using the Premorbid Adjustment Scale (PAS) in 95 hospitalized first-episode patients. Analyses were similar to those conducted by Allen and colleagues (2005). RESULTS: Deterioration was evident in both academic and social functioning from childhood to early adolescence, along with a pronounced/accelerated deterioration in academic functioning from early adolescence to late adolescence, occurring in both male and female patients. Age at onset of prodromal symptoms was predicted by childhood/early adolescent/late adolescent academic functioning scores, and age at onset of psychotic symptoms was significantly associated only with childhood academic functioning. Severity of negative symptoms was predicted by childhood and late adolescent social functioning scores, and severity of general psychopathology symptoms was predicted by late adolescent academic functioning, as well as childhood and late adolescent social functioning scores. CONCLUSIONS: Consistent with prior findings, deterioration in premorbid functioning appears to be more pronounced in the academic than social dimension of the PAS. Some PAS scores are predictive of ages at onset of prodrome/psychosis and severity of psychotic symptoms. Ongoing research on premorbid adjustment in schizophrenia may have implications for future prevention goals.     

Premorbid adjustment and remission of positive symptoms in first-episode psychosis

The impact of premorbid social and intellectual functioning in childhood and early adolescence on the developmental course of schizophrenia is not sufficiently understood. In a retrospective case study (93 consecutive in-patients, 43 males and 50 females) of first-episode psychosis occurring in adolescence, the relationship between premorbid adjustment and short-term therapeutic outcome under treatment conditions was examined. All of the patients had a DSM-111-R diagnosis of schizophrenia (n=56) or schizoaffective disorder (n=37). The mean age of the patients at the time of the study was 15.8 (SD=1.0). Premorbid functioning during childhood and early adolescence was assessed by using the Cannon-Spoor et al. Premorbid Adjustment Scale (PAS) and studied with respect to its prognostic relevance for short-term therapeutic outcome (eight weeks) under neuroleptic treatment (350–700 mg Chlorpromazin dose equivalent). Criteria for clinical outcome were obtained from the study by Pearlson et al. (1989) which defines three grades (complete remission, partial remission and no response), according to the degree of positive symptomatology. Statistical analysis was based on nonparametric variance analysis. Patients with complete remission of positive symptoms after eight weeks of therapy had experienced far better premorbid adjustment in early adolescence and in childhood. Diagnosis and gender did not bias this result. Our data suggest that premorbid social functioning is a crucial variable with regard to therapeutic outcome in first-episode psychosis. Previous studies have reported a relation between poor premorbid functioning and negative symptoms. We found premorbid adjustment related to the course of positive symptoms.     

Diagnostic specificity of poor premorbid adjustment: Comparison of schizophrenia, schizoaffective disorder, and mood disorder with psychotic features

Individuals with schizophrenia have significant deficits in premorbid social and academic adjustment compared to individuals with non-psychotic diagnoses. However, it is unclear how severity and developmental trajectory of premorbid maladjustment compare across psychotic disorders. This study examined the association between premorbid functioning (in childhood, early adolescence, and late adolescence) and psychotic disorder diagnosis in a first-episode sample of 105 individuals: schizophrenia (n=68), schizoaffective disorder (n=22), and mood disorder with psychotic features (n=15). Social and academic maladjustment was assessed using the Cannon-Spoor Premorbid Adjustment Scale. Worse social functioning in late adolescence was associated with higher odds of schizophrenia compared to odds of either schizoaffective disorder or mood disorder with psychotic features, independently of child and early adolescent maladjustment. Greater social dysfunction in childhood was associated with higher odds of schizoaffective disorder compared to odds of schizophrenia. Premorbid decline in academic adjustment was observed for all groups, but did not predict diagnosis at any stage of development. Results suggest that social functioning is disrupted in the premorbid phase of both schizophrenia and schizoaffective disorder, but remains fairly stable in mood disorders with psychotic features. Disparities in the onset and time course of social dysfunction suggest important developmental differences between schizophrenia and schizoaffective disorder.     

青少年期与成年期首发精神分裂症病前适应状态及临床症状的对照分析

目的探讨早发型精神分裂症的病前适应状态及临床特征。方法按照中国精神障碍分类与诊断标准（第3版）,调查住我院的19例首发早发型精神分裂症患者与20例成年期首发精神分裂症患者的病前适应状态及临床特征,并进行对照分析。结果在病前适应状态方面,早发组在孤僻、同伴关系、学校适应性方面明显差于成年组。临床特征方面,早发组的焦虑抑郁和激活性评分明显高于成年组;敌对猜疑评分,成年组则明显高于早发组;早发组的病前适应状态与临床症状具有显著相关性。结论病前适应不良与精神分裂症的起病年龄、临床特征呈相关性。     

Premorbid adjustment and neuropsychological performance in schizophrenia

To examine the relationship between premorbid adjustment and neuropsychological deficit in schizophrenia, this report examined retrospective ratings of social and school adjustment during three age epochs (childhood, early adolescence, and late adolescence) as predictors of neurocognitive performance in 61 clinically and pharmacologically stabilized schizophrenia outpatients. Results indicated greater cognitive deficits when premorbid adjustment was unfavorable, particularly for measures of attention and executive functions. Premorbid number and quality of peer relationships and psychosocial adaptation to the school environment were more closely related to neuropsychological performance during adulthood than were premorbid withdrawal and premorbid academic performance. Early onset of poor premorbid adjustment rather than deterioration from childhood to adolescence was associated with greater neuropsychological disturbance in adulthood. It is suggested that childhood onset of premorbid deficits in selective areas of social and academic adjustment appears to influence the cognitive performance seen in adult schizophrenia. This study is consistent with findings from other related reports; it extends these findings to a larger and clinically stabilized sample.     

The relationship of early premorbid adjustment with negative symptoms and cognitive functions in first-episode schizophrenia: A prospective three-year follow-up study

Premorbid adjustment is an important prognostic factor of schizophrenia. The relationships between sub-components of premorbid adjustment and outcomes on symptoms and cognition in first-episode schizophrenia were under-studied. In the current study, we prospectively followed up 93 patients aged 18–55 years presenting with first-episode schizophrenia-spectrum disorder. Psychopathological and cognitive assessments were conducted at baseline, clinical stabilization, 12, 24 and 36 months. Premorbid adjustment was sub-divided into discrete functional domains, developmental stages and premorbid-course types based on ratings of the Premorbid Adjustment Scale (PAS). The study focused on early developmental stages to minimize contamination by prodromal symptoms. Results indicated that gender differences in premorbid functioning were primarily related to early-adolescence adjustment and academic domain. Social domain was more strongly related to negative symptoms, while academic domain was more consistently linked to cognitive outcome (Wisconsin Card Sorting test and verbal fluency). Patients with stable-poor premorbid course had more severe negative symptoms and cognitive impairment. In conclusion, in a Chinese cohort of first-episode schizophrenia-spectrum disorder, sub-components of early premorbid adjustment were shown to be differentially related to clinical and cognitive measures. The results highlighted the importance of applying a more refined delineation of premorbid functioning in studying illness outcome.     

Functional development in clinical high risk youth: Prediction of schizophrenia versus other psychotic disorders

This study evaluates premorbid social and academic functioning in clinical high-risk individuals as predictors of transition to schizophrenia versus another psychotic disorder. Participants were 54 individuals enrolled in phase one of the North American Prodrome Longitudinal Study who over two and a half years of follow-up met criteria for schizophrenia/schizophreniform disorder (n=28) or another psychotic disorder (n=26). Social and academic functioning in childhood, early adolescence, and late adolescence was assessed at baseline using the Cannon-Spoor Premorbid Adjustment Scale. Social maladjustment in late adolescence predicted significantly higher odds of transition to schizophrenia versus another psychotic disorder independent of childhood and early adolescent adjustment (OR=4.02) and conveyed unique risk over academic maladjustment (OR=5.64). Premorbid academic maladjustment was not associated with psychotic disorder diagnosis. Results support diagnostic specificity of premorbid social dysfunction to schizophrenia in clinical high-risk youth and underscore an important role for social maladjustment in the developmental pathology of schizophrenia and its prediction.     

Premorbid speech and language impairments in childhood-onset schizophrenia: association with risk factors

OBJECTIVE: As both premorbid neurodevelopmental impairments and familial risk factors for schizophrenia are prominent in childhood-onset cases (with onset of psychosis by age 12), their relationship was examined. METHOD: Premorbid language, motor, and social impairments were assessed in a cohort of 49 patients with childhood-onset schizophrenia. Familial loading for schizophrenia spectrum disorders, familial eye-tracking dysfunction, and obstetrical complications were assessed without knowledge of premorbid abnormalities and were compared in the patients with and without developmental impairments. RESULTS: Over one-half of the patients in this group had developmental dysfunction in each domain assessed. The patients with premorbid speech and language impairments had higher familial loading scores for schizophrenia spectrum disorders and more obstetrical complications, and their relatives had worse smooth-pursuit eye movements. The boys had more premorbid motor abnormalities, but early language and social impairments did not differ significantly between genders. There were no other significant relationships between premorbid social or motor abnormalities and the risk factors assessed here. CONCLUSIONS: Premorbid developmental impairments are common in childhood-onset schizophrenia. The rates of three risk factors for schizophrenia (familial loading for schizophrenia spectrum disorders, familial eye-tracking dysfunction, and obstetrical complications) were increased for the probands with premorbid speech and language impairments, suggesting that the pathophysiology of schizophrenia involves the abnormal development of language-related brain regions.     

Premorbid functioning in schizophrenia: relation to baseline symptoms, treatment response, and medication side effects

Impaired premorbid functioning prior to the onset of acute psychosis has frequently been noted in schizophrenia. This study examined retrospectively the premorbid status of patients in their first episode of psychosis in order to determine relationships with baseline symptoms, treatment response, and medication side effects. One hundred eleven schizophrenic and schizoaffective patients participating in a large prospective study of first episode schizophrenia were evaluated with the Premorbid Adjustment Scale (PAS). Premorbid functioning in males became progressively worse over time. Deficit state patients exhibited worse premorbid functioning. A third of patients exhibited sustained poor premorbid functioning. At various developmental stages, lower "sociability and withdrawal" scores correlated with increased time to treatment response, more severe negative symptoms, increased drug-induced parkinsonism, and deterioration of premorbid functioning. Various mean PAS scores predicted susceptibility to tardive dyskinesia. Our findings suggest that prior to acute psychosis onset there are certain behavioral precursors reflected in premorbid functioning that may predict subsequent illness manifestations. Measures of premorbid functioning indicate that disease pathogenesis is manifest, albeit more subtly, prior to presentation of first psychotic symptoms.     

Deterioration in premorbid functioning in schizophrenia: a developmental model of negative symptoms in drug-free patients.

OBJECTIVE: The authors examined the relationship between negative symptoms and premorbid variables in drug-free schizophrenic patients. METHOD: The authors studied 63 clinically stable male schizophrenic inpatients who were not receiving any psychoactive medication. The patients were classified as having negative, positive, or mixed symptoms, and their premorbid functioning during childhood, early adolescence, and late adolescence was assessed by using the Premorbid Adjustment Scale. Correlational analyses were applied to the classification and developmental models. RESULTS: Patients with negative symptoms had significantly lower levels of premorbid functioning during late adolescence and significantly greater premorbid deterioration between childhood and early adolescence. Correlational analysis revealed significant positive relationships between premorbid variables and negative symptoms. CONCLUSIONS: The data suggest that a deterioration in social and intellectual functioning between childhood and adolescence is associated with the development of a negative symptom syndrome in schizophrenia. The premorbid deterioration appears to be an early prodrome of the disorder. Whether this residual negative symptom syndrome is in some way related to the deficit syndrome of schizophrenia awaits a prospective study.     

Premorbid adjustment and violent behavior in schizophrenic patients

We examined the influence of premorbid adjustment on violent behavior in schizophrenic patients. There is some evidence that poor premorbid adjustment predicts violent behavior, then we decided to examine this hypothesis further. METHOD: We recruited 72 schizophrenic patients without concomitant substance abuse 6 months prior to the assessment. Diagnoses were based on the SCID-I. Premorbid adjustment was evaluated with the Premorbid Adjustment Scale and violent behaviors with the Overt Aggression Scale. RESULTS: Violent schizophrenic patients showed an overall worse premorbid adjustment during childhood. In addition, the area of "peer relationships" was significantly diminished in several life period sections such as childhood, early and late adolescence in violent patients. DISCUSSION: Our data indicate that difficulties in social relationships during early stages of life may increase the risk of future violent behavior among schizophrenic patients.     

Reliability and validity of the Premorbid Adjustment Scale (PAS) in a German sample of schizophrenic and schizoaffective patients

Premorbid functioning seems to be a phenomenological marker that possibly distinguishes a subtype of schizophrenia. The Premorbid Adjustment Scale (PAS) is an instrument for measuring premorbid functioning. It has gained international acceptance, although little is known about the reliability and validity of the test. Here data on the reliability and validity of the test derived from a German sample of schizoaffective and schizophrenic subjects (n = 86) and their healthy parents (n = 38) is presented. The DSM-IV diagnosis, PAS and Positive and Negative Syndrome Scale (PANSS) data were used as well as data on the course of the disorder. The estimation of the reliability per scale by internal consistency showed high positive values of Cronbach’s α between 0.809 and 0.931. High scores in PAS representing a bad premorbid social adjustment correlated significantly with a low age of onset, high PANSS scores, an insidious onset and a long period of hospitalisation. The disorganised DSM-IV subtype of schizophrenia showed a trend towards higher mean PAS scores. In the presented sample, the threshold between schizophrenics and healthy individuals is at 0.23. The PAS values higher than 0.53 appeared in patients with an unfavourable course of the disorder. These findings correspond with previous reports in the literature. Received: 15 September 1997 / Accepted: 14 July 1998     

Child and adolescent (early onset) schizophrenia: A review in light of DSM-III-R

Early onset schizophrenia (EOS) is defined as that beginning in childhood or adolescence (under 16 or 17). Studies of EOS are infrequent, and comparative adult figures not always available, but tentative conclusions may be drawn. EOS is more common in males; symptomatology is often undifferentiated; frequencies of homotypic family disorder, premorbid schizotypal personality, and neurodevelopmental abnormalities high; outcome poor but only slightly worse than in adults; response to psychotropic drug treatment probably similar though not properly tested; and confusion with psychotic bipolar disorder particularly common. Onset before language is developed presents special diagnostic difficulties. There are a few reports of autistic children developing schizophrenia but this requires replication. Differences from adult schizophrenia are more marked when onset is in childhood than in adolescence but all are quantitative rather than qualitative suggesting that the disorders are the same and that there should be no separate category for children or adolescents.This review is based on one prepared for the DSM-IV Task Force but the opinions expressed here are solely those of the author.     

Confirmation of a two-factor model of premorbid adjustment in males with schizophrenia

Because schizophrenia is considered to be a neurodevelopmental disorder, premorbid adjustment is of particular interest. Premorbid adjustment is probably not a unitary construct but rather is expressed across a number of developmental domains. The current investigation examined the validity of a two-factor model that differentiated premorbid adjustment across social and academic domains and evaluated relationships between these premorbid adjustment domains and other variables of interest. Participants with schizophrenia (n = 141) underwent evaluation of premorbid adjustment (using the Premorbid Adjustment Scale), intellectual functioning, and psychiatric symptoms. Using confirmatory factor analysis, a two-factor model of premorbid adjustment was identified that included an academic domain and a social domain. The social domain was associated with symptom variables, while the academic domain was associated with measures of intelligence. Results provide evidence for at least two domains of premorbid adjustment in schizophrenia. Distinguishing between these two premorbid domains may be theoretically important because of potential differences in incidence rates and deterioration courses; some individuals with schizophrenia may exhibit adequate academic adjustment but poor social adjustment, while others may exhibit the opposite pattern.     

A.E. Bennett Research Award. Prenatal rubella, premorbid abnormalities, and adult schizophrenia.

BACKGROUND: Premorbid neurocognitive, neuromotor, and behavioral function tends to be disturbed in schizophrenia. We previously demonstrated that a birth cohort clinically and serologically documented with prenatal rubella evidenced a marked increase in risk of nonaffective psychosis. In our study, we examined whether rubella-exposed subjects destined to develop schizophrenia and other schizophrenia spectrum disorders (SSD), compared with exposed control subjects, had greater impairment in several premorbid functions. METHODS: Subjects were interviewed using a direct, comprehensive research assessment and diagnosed by consensus. We compared the degree of IQ decline, as well as premorbid neuromotor and behavioral dysfunction, between rubella-exposed subjects who developed schizophrenia spectrum psychosis (SSP) and exposed control subjects from the cohort. We also compared the gestational timing of rubella infection between the cases and control subjects. RESULTS: This rubella-exposed birth cohort evidenced a markedly increased risk of SSD (20.4% or 11/53). Rubella-exposed SSP cases, compared with rubella-exposed control subjects, demonstrated a decline in IQ from childhood to adolescence, and increased premorbid neuromotor and behavioral abnormalities. Moreover, it appears that early gestational rubella exposure may represent a period of increased vulnerability for SSD. CONCLUSIONS: These findings link a known prenatal exposure, a deviant neurodevelopmental trajectory in childhood and adolescence, and SSP in adulthood within the same individuals.     

Validity of the premorbid adjustment scale

Background: The aim of the current study was to test the predictive and concurrent validity of the Premorbid Adjustment Scale (PAS) by comparing it with another similar but more elaborate retrospective measure and with data collected during late adolescence. Methods: We compared PAS late adolescence scores (age 16-18 years) of 91 males with schizophrenia or schizoaffective disorder with data on behavior collected in adolescence, before the first psychotic episode as part of standardized Draft Board screening, and with the same measure readministered during adulthood and modified to collect the same data again retrospectively. Results: The correlation of the PAS social withdrawal and social relations items with the social behavior scale of the Draft Board were .76 and .80, respectively, for the concurrent ratings and .52 and .53, respectively, for the data collected at age 17 years. The correlation of the PAS school achievements and school adjustment items with the functioning in structured environments scale of the Draft Board were .71 and .72, respectively, for the concurrent ratings and .43 and .47, respectively, for the data collected at age 17 years. Conclusions: Our results support the predictive and concurrent validity of the PAS and the validity of self-reported data on premorbid functioning in persons with schizophrenia.     

A study of the reliability of reported premorbid adjustment in schizophrenic patients

A study was conducted to determine the interrater reliability and the inter-informant reliability of two rating scales commonly used with schizophrenic patients. Both scales were completed by two informants for each of 45 schizophrenics. The Levels of Functioning Scale, which measures current social functioning, gave consistent results both between raters and between informants. The Premorbid Asocial Adjustment Scale, which measures social functioning during childhood and adolescence, produced very high reliability between raters but very poor reliability between informants. This suggests that much of the data collected about premorbid adjustment of schizophrenic patients are not accurate and that attempts to correlate reported premorbid adjustment with biological measures may be invalid. Ways of increasing the reliability and validity of premorbid adjustment measures are discussed.