What Is Prodromal Schizophrenia? Symptoms & Treatment
Schizophrenia is a complex psychotic disorder listed in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a manual that psychologists and doctors frequently use to diagnose mental illnesses. Understanding schizophrenia can mean understanding the different forms schizophrenic episodes can take, such as the prodromal phase of schizophrenia, which can involve minor symptoms that indicate a psychotic episode may happen soon. If you believe you may be living with schizophrenia or experiencing prodromal symptoms, working closely with a licensed mental health professional may help you receive an accurate diagnosis and information on how to manage symptoms.
What is schizophrenia?
In the fifth edition of the DSM, schizophrenia is classified as a mental illness under the “Schizophrenia Spectrum and Other Psychotic Disorders” category. According to the DSM-5, several symptoms must be present for this condition to be officially diagnosed, including two or more of the following:
- Delusions (False beliefs that are maintained despite evidence against them)
- Hallucinations (Sensory perceptions that are not truly occurring)
- Disorganized speech and behavior
- Catatonia
- Paranoia
- Negative symptoms, such as diminished emotional expression
- Decreased function in significant areas of life
In general, for diagnosis to take place, symptoms must last at least six months, including at least one month of symptoms in the “active phase.” In addition, other psychotic and psychological disorders must be ruled out.
Different categories of schizophrenia and symptoms of schizophrenia
In the prior edition of the DSM, schizophrenia was organized into different categories, including paranoid schizophrenia, disorganized schizophrenia, catatonic schizophrenia, undifferentiated schizophrenia, and residual schizophrenia. In the DSM-5, all schizophrenia presentations are labeled under the schizophrenia spectrum, which may showcase the wide range of symptoms and experiences people with this condition can have.
Not everyone with schizophrenia shows the same symptoms. Because schizophrenia is considered a spectrum, people may experience a few of the above symptoms while not experiencing others. Some people with schizophrenia struggle more with paranoia, whereas others may experience frequent episodes of catatonia, which can involve becoming non-verbal and non-moving or having uncontrollable and unusual movements.
What is the schizophrenia prodrome?
Schizophrenia as a mental illness: Types of schizophrenia episodes
To understand the prodromal period, understanding the different types of schizophrenia episodes an individual might be diagnosed with can be helpful, including the following:
- First episode, currently in an acute episode
- First episode, currently in partial remission
- First episode, currently in full remission
- Multiple episodes, currently in acute episode
- Multiple episodes, currently in partial remission
- Multiple episodes, currently in full remission
- Continuous
Acute episodes of schizophrenia tend to occur suddenly, causing symptoms of the disorder to appear. Depending on the symptoms, this episode may be considered a psychotic episode. Partial remission generally refers to residual symptoms and only partial fulfillment of disorder criteria. Meanwhile, full remission typically refers to a period during which no disorder symptoms are present.
After one’s first episode, their episodes are normally categorized in the “multiple episodes” category. Continuous episodes can refer to “symptoms fulfilling the diagnostic symptom criteria of the disorder, remaining for the majority of the illness course.” In this case, residual or remission periods tend to be very short or non-existent.
Prodromal phase of schizophrenia
The prodromal phase of schizophrenia usually occurs after a person has experienced their first episode and before all following episodes. Prodromal symptoms can be defined as those that are often present for the individual as a warning sign that a full episode may soon occur. Understanding these warning signs can help someone with schizophrenia prepare by taking their medication, reaching out for help, or implementing a safety plan.
Understanding prodromal schizophrenia: Prodromal symptoms and warning signs
Prodromal stage warning signs can differ for everyone, depending on their unique symptom presentation and experiences. However, commonly reported signs can include those listed below:
Symptoms of schizophrenia: Prodromal symptoms
- Anxiety
- Depression
- Mood swings
- Sleep disturbances
- Irritability
- Anger
- Suicidal ideation
- Social withdrawal
- Changes in work performance
- Changes in appetite and eating habits
- Minor paranoia
- Refusal to partake in responsibilities
- Difficulty partaking in self-care
- Cognitive changes, such as memory and attention loss
- Lack of speed in social reasoning and emotional processing
- Weight changes
- A lack of energy or changes in sleep patterns
- A loss of interest in previously enjoyed activities
It can be helpful to pick up on prodrome warning signs in the early stage before an episode occurs, as this can give you time to set up a safety system. When you first notice mood and behavioral changes, reaching out to your primary care physician to discuss treatment options or contacting a therapist to explore coping strategies to work through your next episode may be helpful.
A provider can use clinical practice guidelines to assess basic symptoms and build a treatment plan for reducing transient psychotic symptoms. You might also write a plan for yourself to refer to when struggling to connect with reality.
If you are experiencing suicidal thoughts or urges, call the 988 Suicide & Crisis Lifeline at 988 or text 988 to talk to a crisis provider over SMS. They are available 24/7 to offer support. 988 also offers an online chat for those with an internet connection.
Different types of prodrome
There are several types of prodrome an individual might experience, which may not necessarily precede an episode in every case.
Prodromal schizophrenia: Types of prodrome to discuss with your provider
- Attenuated positive symptom prodromal syndrome (APS): APS often involves minor delusions, hallucinations, or disorganization at least once per week within a month, getting gradually worse over the course of a year.
- Genetic risk and deterioration prodromal syndrome (GRDS): Someone may experience GRDS if they are diagnosed with schizotypal personality disorder or have a first-degree relative with a psychotic disorder. This type is usually not seen in schizophrenia.
- Brief intermittent psychosis prodromal syndrome (BIPS): BIPS can cause episodes of brief, intermittent psychosis. These episodes may not meet the criteria to be considered a full episode. Symptoms may be present for at least a few minutes a day at least once a month.
Approximately 85% of prodromal cases fall under the attenuated positive symptom prodromal syndrome category.
Support for schizophrenics: Treatment options for prodromal schizophrenia
If you’re living with schizophrenia and have noticed prodromal phases before your episodes, there are a few treatment options you can consider to better cope and move forward.
Medication
Taking medication for schizophrenia in the prodromal phase before an episode may reduce symptom severity during the episode. Studies show that typical and atypical antipsychotics may be used to reduce prodromal symptom severity or the risk of progression to a full episode. However, each individual is unique, so talk to your doctor to develop a treatment plan for your situation.
Consult a medical doctor before starting, changing, or stopping a medication for any condition. The information in this article is not a replacement for medical advice or diagnosis.
Monitoring
It may be beneficial to have someone you trust monitor you for symptoms to help you catch when a prodromal phase may be occurring. Alternatively, consider marking frequent sessions with a case manager, social worker, therapist, or care provider to check in on your symptoms, mood, and worries. Having someone to talk to before an episode can help you know when it might be beneficial to implement a new safety plan or start building resources for yourself.
Caring for your mental health: Consider therapy
Talking to a therapist can be another way to receive support during the prodromal phase of schizophrenia. A therapist can guide you as you work through symptoms and build a safety plan for yourself. However, it can be challenging to reach an in-person therapist if you’re struggling to practice self-care or remember appointments.
Online therapy
In these cases, online therapy platforms like BetterHelp may be more convenient. Online platforms generally enable you to meet with a therapist via phone, video, or live chat sessions from home or any location with an internet connection. In addition, you can find potentially valuable resources like journaling prompts and worksheets assigned by your therapist.
Is online therapy effective for mental health illness?
Studies show that online therapy may be effective for individuals experiencing first-episode psychosis. A recent study found that online therapy typically reduced symptoms in those experiencing first-episode psychosis, with results similar to studies on face-to-face treatment.
Takeaway
What is the prodromal stage of schizophrenia?
In the context of schizophrenia and related psychotic disorders, the prodromal stage is the early period of illness before a person has their first psychotic episode. During the prodromal stage, subtle symptoms of schizophrenia may start to appear even if the person isn’t yet experiencing full hallucinations or delusions. The schizophrenia prodrome can take several forms, depending on current symptoms, genetic factors and family history, substance use, existing mental health conditions, and other factors.
The types of schizophrenia prodrome include:
- Genetic risk and deterioration syndrome (GRDS): GRDS describes situations where someone shows symptoms of schizotypal personality disorder, or has a first-degree relative with a psychotic illness.
- Brief limited intermittent psychotic symptoms (BLIPS): BLIPS are brief episodes of psychosis that resolve on their own and occur at least once a month, but might not meet the criteria for a full schizophrenia diagnosis.
- Attenuated psychosis syndrome (APS): Previously referred to as “psychosis risk syndrome,” APS
What happens in the prodromal phase?
During the prodromal phase of schizophrenia, a person may experience various changes in their thoughts, behaviors, emotions, and beliefs. These changes can be subtle, and they may linger for months or years before the person has their first full psychotic episode. Common prodromal signs include:
- Social withdrawal
- Changes in sleeping or eating patterns
- A decrease in motivation or loss of interest in hobbies and relationships
- Neurotic symptoms like irritability, depression, mood swings, or anxiety
- Challenges with attention, concentration, verbal memory, and processing information
- Growing suspicion or paranoia
- Unusual new beliefs
- Minor or subtle hallucinations
Keep in mind that nonspecific symptoms like these may not always have strong predictive validity. In other words, just because someone experiences these symptoms, that doesn’t necessarily mean they will go on to develop psychosis. Several other mental illnesses and psychiatric disorders can sometimes cause similar symptoms, such as:
- Depression
- Bipolar disorder
- Schizoaffective disorder or schizotypal personality disorder
- Obsessive-compulsive disorder
- Dissociative identity disorder or derealization/depersonalization disorder
- Substance abuse (Note that the term “substance abuse” is outdated and no longer used clinically. Instead, mental health professionals use the term “substance use disorders” to describe symptoms and behaviors previously associated with this term.)
What are the stages of schizophrenia?
Schizophrenia tends to progress in three distinct stages, or “phases,” each with its own symptoms and effects. While not everyone with schizophrenia may experience all three of these stages, the stages of schizophrenia typically include:
- Prodromal schizophrenia: Prodromal schizophrenia occurs before a person has their first full episode of psychosis. During the prodromal period, people may experience subtle changes in their thinking, emotions, and behaviors. Common prodromal symptoms include a decline in personal hygiene, a depressed mood, lower cognitive functioning, social isolation, and unusual or odd behavior.
- Active schizophrenia: Also known as the “acute” stage, the active stage of schizophrenia happens after someone has their first psychotic episode. In addition to other symptoms present in the prodromal stage, active symptoms may also include delusions, hallucinations, disorganized thoughts and speech, and other, more severe symptoms.
- Residual schizophrenia: Residual symptoms are schizophrenia symptoms that linger after a person is no longer in full psychosis. Even if someone has stopped having hallucinations and delusions, they may still experience subtle changes in their speech, mood, motivation, and beliefs. People with untreated psychosis may be at a higher risk of residual schizophrenia.
A person with schizophrenia may experience multiple active and residual phases during their lifetime. People
What is the prodromal stage experience?
The prodromal stage is a period in which someone with an at-risk mental state begins to develop early symptoms of schizophrenia. This experience often includes mood and behavior changes, social isolation, and other subtle symptoms. Some people may also experience subtle changes in their perception that can mimic hallucinations.
Because schizophrenia can look different for different people, there may not be a single universal “prodromal experience.” That said, it can be common for people in the prodrome to display noticeable changes in their work performance, hygiene, relationships, and daily habits. If you’re concerned about symptoms or experiences you’ve been having, consider talking to a mental health professional. They may be able to determine your risk and advise you on next steps.
What is the most common manifestation during the prodromal stage?
Different people may experience different symptoms during the prodromal stage of schizophrenia. That said, some of the most commonly documented symptoms are declines in cognitive functioning, especially in the areas of memory, attention, and concentration. Other common prodrome symptoms may include anxiety, depression, sleep disturbances, irritability/anger, suicidal thoughts, and social withdrawal.
Can you stop schizophrenia prodrome?
Some research has found that early detection and intervention may help keep prodromal schizophrenia from progressing into full schizophrenia. Mental healthcare providers may use pharmacological interventions to help prevent ultra-high-risk patients from developing actual psychosis. Some examples include:
- Antipsychotic medication
- Antidepressants
- Omega-3 supplements
- Mood stabilizers
Research suggests that in some cases, treatments like cognitive-behavioral therapy (CBT) may also be used as an early intervention. In a 2022 paper, researchers reviewed data from 10 studies of a specialized form of cognitive behavior therapy for psychosis. They found that the treatment effectively reduced patients’ rates of transition from the prodrome phase to full psychosis.
Based on this research, it may be possible for people with prodromal schizophrenia to avoid developing psychosis. However, successful intervention may depend on proper risk identification, using tools like the Scale of Prodromal Symptoms developed by the prodromal research team at Yale University. For this reason, if you or a loved one notice early signs of psychosis, significant changes in your thinking and mood, or other concerning symptoms, you may want to see a mental health specialist for a comprehensive assessment.
What causes schizophrenia flare ups?
Schizophrenia flare-ups, otherwise known as relapses, may occur for a variety of reasons, such as:
- Missing doses of medications or not taking them as prescribed
- Using alcohol, drugs, or other mind-altering substances
- Stressful life events
- Being unemployed or having a low household income
- Lacking social support
- Having comorbid disorders, such as substance use disorders, depression, ADHD, or certain health conditions
According to the American Psychiatric Association, warning signs of a schizophrenia flare-up may include trouble sleeping, anxiety, hallucinations, suspicion, and a general increase in symptom severity. Managing stress levels, getting ongoing mental health support, and continuing to take any prescribed medications may help patients with schizophrenia avoid relapses.
What do prodromal symptoms feel like?
People in the prodromal stage of schizophrenia often experience symptoms such as:
- A depressed mood
- A loss of interest in hobbies, work, or relationships
- Unusual beliefs and behaviors
- Perceptual disturbances, such as hearing strange noises or seeing flashing lights
- Trouble concentrating or remembering information
- Social withdrawal
- Reduced emotions or emotional expression
While personal experiences are subjective, these symptoms might feel like:
- Brain fog
- Racing thoughts
- Confusion or disorientation
- Intrusive or unwanted thoughts
- A feeling of general dread or unease
- A sense of distance or detachment from the world and others
- A general loss of joy, motivation, or energy to do tasks
- Fear, mistrust, or suspicion of others
- A sense of knowing important secrets or having information that others don’t
People in the prodrome of schizophrenia often still have some degree of insight (awareness that they’re having symptoms). They may be responsive to logic or concerns from loved ones, and some may recognize that something is wrong and seek help. This is distinct from active schizophrenia, which usually causes a lack of insight, meaning people with active schizophrenia can’t be reasoned with or talked out of their beliefs and behaviors.
What is the difference between premorbid and prodromal schizophrenia?
The “premorbid stage” of schizophrenia refers to the period before patients develop schizophrenia symptoms of any kind. In contrast, the prodromal stage of schizophrenia refers to the period after subtle symptoms have started to appear, but before a patient has their first psychotic episode.
Do schizophrenics talk to themselves?
Keep in mind that not everyone with schizophrenia may think or behave in the same way. That said, some people with schizophrenia may appear to “talk to themselves” in response to visual or auditory hallucinations. Similarly, people with schizophrenia who are experiencing delusions may also appear to talk to themselves depending on the nature of their delusions. For example, if someone is having a delusion that they are a talk show host, they might appear to talk to themselves when in reality they are speaking to what they believe is a studio audience.
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