Prodromal Social Dysfunction as an Early Indicator of Schizophrenia
Introduction
We know that the deterioration of social functioning, isolation from the surrounding world, seclusion, and distancing from other people often manifests much earlier than the positive symptoms of schizophrenia.
In the 20th century, great attention was paid to the study of interpersonal and social functioning problems experienced by individuals with schizophrenia. Prodromal symptoms of schizophrenia were already noted by Eugen Bleuler (1911) and Emil Kraepelin (1919) (Table 1).
Views on this issue are distributed across a wide spectrum — from E. Bleuler’s concept of autism to phenomenological considerations of intersubjectivity; from studies of family relationships and communication to research on social cognition.
It has been observed that even before the onset of psychotic symptoms, the patient usually becomes withdrawn — communication is disrupted, and social functioning deteriorates. It is believed that research on interpersonal problems during the prodromal period could help better understand the mechanisms of altered patient behavior and possibly contribute to identifying specific treatment methods.
Recently, there has been an increasing amount of scientific medical literature describing research in this field. These studies consistently indicate that disturbances in social functioning are noticeable before the onset of psychosis and may be considered predictive symptoms of schizophrenia (Table 2).
Symptoms and signs of schizophrenia prodrome |
|
| Neurotic symptoms | Anxiety, anger, irritability |
| Mood changes | Depression, anhedonia, feelings of guilt, suicidal thoughts, mood swings |
| Changes in will | Apathy, decreased motivation, loss of interest, boredom, fatigue, lack of energy |
| Cognitive changes | Impaired attention, inability to concentrate, worry, daydreaming, thought blocking, worsened thinking abstraction |
| Physical symptoms | Somatic complaints, weight loss, poor appetite, sleep disturbances |
| Other symptoms | Obsessive-compulsive symptoms, dissociation, increased interpersonal sensitivity, changes in self, others and world perception, changes in movements, unusual or altered speech, perceptual disturbances, suspicion, changes in affect |
| Behavioral changes | Deterioration in overall functioning, difficulty learning, working, social isolation, impulsivity, aggressiveness, strange, disruptive behavior |
It is important to note that not only the symptoms and behavioral changes listed in Table 1 are important, but also their developmental course, as the prodrome is a process during which these signs dynamically develop and behavior deteriorates. As the condition progresses, the symptoms of the disease worsen, the onset of psychosis approaches, and the patient's behavior may deteriorate both at the very beginning of the prodrome and during its later stages, including the transition to fully developed psychosis.
Table 2. Most common signs of psychosis prodrome*
| Impaired attention, difficulty concentrating |
| Decreased motivation, energy |
| Worsened mood |
| Sleep disturbances |
| Anxiety |
| Social isolation |
| Suspicion |
| Difficulty performing duties (learning, working, etc.) |
| Irritability, restlessness, nervousness |
Prodrome course and its identification
The prodromal period can last from weeks to several years. During this period, comorbidities often develop (e.g., depression, various addictions). As mentioned, when the prodrome of schizophrenia and other psychoses appears, the patient's behavior changes or deteriorates, and various subjectively perceived signs are noticed.
Investigators have attempted to describe the course of the prodrome. Evidence confirms that prodromal development can be clinically observed. Initially, individuals usually experience negative or nonspecific clinical symptoms, such as depression, anxiety, social isolation, and worsening academic or professional performance. Most commonly, this is followed by the emergence of core disease symptoms—mild positive symptoms or brief, moderate-intensity positive symptoms.
As psychosis approaches, positive symptoms intensify and become more frequent, but still do not reach the level of full psychosis (occurring 1–2 times per month and usually lasting from a few minutes to a day). These symptoms cannot yet be considered true hallucinations or delusions—patients may express unusual or altered thoughts, changes in perception, or disturbances in their experiences.
In the 1960s, researchers, after analyzing data from long-term studies, noticed that patients exhibit certain deficit symptoms even before the onset of psychosis. This led to the development of the Bonn Scale for the Assessment of Basic Symptoms (BSABS). Basic symptoms are considered essential signs of the disease and include subjectively assessed disturbances in thinking, speech, perception, and motor functions; altered bodily sensations; reduced stress tolerance; and disturbances in emotions, energy, attention, concentration, memory, and social functioning.
These basic symptoms were later incorporated into other assessment tools designed to identify individuals at risk of developing psychosis, such as the Scale of Prodromal Symptoms (SOPS).
Once the prodrome of psychosis is identified, early diagnosis and timely initiation of treatment become possible, as well as the detection of disease recurrence. It has been shown that delayed treatment of a psychotic episode is associated with poorer outcomes. Therefore, identifying the prodromal phase is crucial for disease prognosis.
Interpersonal issues in the onset of schizophrenia prodrome: a study
Danish researchers Lise Mondrup and Bent Rosenbaum conducted a study to investigate how patients themselves assess interpersonal issues during the prodromal period of schizophrenia and what types of support might be most appropriate.
The researchers hypothesized that interpersonal problems arise even before the onset of psychotic symptoms and worsen as psychosis develops. They also emphasized the importance of therapeutic approaches that could address prodromal symptoms and improve long-term outcomes.
L. Mondrup and B. Rosenbaum compared four groups: healthy individuals (n=363), individuals with at-risk mental states (n=11), individuals in the prodromal phase (n=12), and patients in a psychotic state (n=12).
The prodromal phase was assessed using the Structured Interview for Prodromal Syndromes (SIPS), while interpersonal problems were evaluated using the Inventory of Interpersonal Problems (IIP), a self-report questionnaire. SIPS includes four subscales: positive, negative, disorganized, and general symptoms. Inclusion in the prodromal group was based on scores in the positive symptom subscale.
Significance and benefits of the study
This study is one of the first to compare individuals across different stages of the disorder. It shows that patients already experience difficulties in communication, emotional expression, initiative, and being the center of attention before and during the development of psychosis.
As expected, interpersonal difficulties worsen as psychosis progresses. A particularly significant difference was observed between individuals in the prodromal phase and healthy controls.
The findings suggest that as psychosis develops, dominant or controlling behavior may emerge as a defense mechanism in response to increasing insecurity, which is already present during the prodromal period. Although this may temporarily provide relief, it can make recovery more difficult.
These results indicate that early intervention—even during the prodromal phase—may be beneficial. The authors emphasize that establishing and maintaining a therapeutic alliance is one of the most important aspects of treatment. Therefore, interpersonal psychotherapy may be especially appropriate. This approach is based on the ideas of Harry Stack Sullivan, who highlighted the importance of interpersonal relationships in the development of mental disorders.
Conclusions
- Detecting the prodrome of psychosis may enable early diagnosis, timely treatment, and identification of disease recurrence.
- Impairments in social functioning are present before the onset of schizophrenia and can be considered prodromal symptoms.
- Social functioning deteriorates as schizophrenia progresses.
- Studying interpersonal difficulties during the prodromal phase may help better understand behavioral changes and contribute to the development of more targeted treatment methods.
