CLINICAL HANDBOOK OF SCHIZOPHRENIA

110 I. CORE SCIENCE AND BACKGROUND INFORMATIONlife in the long term are male gender, the amount of anxiety and depression, insufficientsocial support, and social stigma.PROGNOSTIC INDICATORS OF THE LONG-TERM COURSEAs stated earlier, prognostic indicators are not identical with etiological risk or protectivefactors whose existence or amount contributes to the risk of developing the disorder.Examples of such risk factors are a family history of schizophrenia or viral encephalitisinfection in early childhood. Prognostic indicators are phenomena associated with the illnesscourse that predict the further course of illness (e.g., cognitive impairment, negativesymptoms). The most important predictors across both categories are family load ofschizophrenia in first-degree relatives; several susceptibility genes (or loci; e.g., G30/72on chromosome 13q); disturbed development of the brain in utero and peripartum (obstetriccomplications, hypoxia in particular), encephalitis or bacterial meningitis infectionin early childhood; pronounced structural changes in the brain prior to illness onset; malesex, with onset before age 45 years; female sex, with onset after ages 45–50 years; andcannabis misuse before onset of the illness.With regard to their relevance to a patient’s life, the main domains are symptomatology(negative, positive, depressive), amount of cognitive, functional, and social impairmentand disability, frequency of relapses, and quality of life. The best predictor ofthe social course is premorbid work and social performance. Because first contact in75% of cases is preceded by a prodromal period of more than 1 year, during which thebulk of social consequences emerge, social performance prior to first contact is notclearly premorbid. The use of social functioning as a prognostic indicator of the futureillness course requires prediction based on the past course of fairly stable factors, suchas cognitive impairment. For this reason, psychological tests (e.g., cognitive testing,persistence, motivation, and stress tolerance), social functioning, and social and maritalstatus measured at the end of the early illness course, which mostly coincides with firstadmission, are good prognostic indicators of the social course and outcome of schizophrenia.A predictor directly associated with the disorder is an early age of onset, especiallythe rare onset in childhood and youth. It is usually associated with a high genetic loadand particularly severe morphological changes on the one hand, and developmental delaysand cognitive deficits on the other. Onset of illness later in life usually involvesfull-blown psychotic symptoms comprising fully elaborated delusions and hallucinationsthat are rarely accompanied by mental disorganization. In late-onset cases, particularlyin men, clarity of the thought process is usually not affected. In addition, in oldand very old adults, social status is fairly stable (retirement pension; a network of longlasting,stable relationships; etc.) and more or less immune to the adverse effects of thedisorder. For this reason schizophrenia in older adults is associated with a lower riskfor social decline.As mentioned earlier, male gender is an unfavorable predictor of early-onset illness,but a favorable predictor of illness developed later in life. In contrast, female gender is afavorable predictor of premenopausal illness, but an unfavorable predictor of peri- andpostmenopausal illness. Not only a prolonged DUP, but also a prolonged DUI, as stated,does predict a more severe, extended first episode and an unfavorable illness course.Severe negative symptoms and considerable cognitive impairment are predictors ofthe dimension “negative symptoms, cognitive and functional impairment” and, hence, ofan unfavorable functional and social course. A high frequency of psychotic episodes and,