Schizophrenia is a chronic mental health condition characterized by hallucinations, delusions, disorganized thinking and behavior. It typically begins in young adulthood, with men often developing symptoms in their early 20s and women in their late 20s. Schizophrenia is a lifelong condition that requires ongoing treatment and management. There has been much debate over whether the symptoms of schizophrenia get worse as a person ages. In this article, we will examine the evidence around how schizophrenia progresses with age and factors that influence the course of the illness.
Do symptoms get more severe over time?
In general, the positive symptoms of schizophrenia like hallucinations, delusions and disorganized thinking tend to improve over time in many patients. However, negative symptoms like social withdrawal, lack of motivation and flat affect typically persist and may worsen with age. Cognitive symptoms like trouble with memory, concentration and planning also tend to remain stable or deteriorate as a person gets older.
There are several long-term studies that have shed light on the progression of schizophrenia:
- A 15-year study published in JAMA Psychiatry in 2013 followed 168 people with schizophrenia. It found that positive symptoms declined over time for most patients, while negative and cognitive symptoms remained relatively stable.
- A World Health Organization study followed over 1,600 people with schizophrenia for 15-25 years across diverse countries. Most patients showed improvement in positive symptoms within five years. However, negative symptoms tended to persist.
- The Vermont Longitudinal Study of Persons With Severe Mental Illness followed 269 people with schizophrenia for 30 years. Again, positive symptoms improved while negative remained stable and cognitive declined.
So based on longitudinal research, it appears that the overt psychotic symptoms of schizophrenia often attenuate with age, while the deficits in motivation, emotion expression and cognition tend to persist or worsen. However, there is significant individual variation in symptom progression.
Factors influencing prognosis
Several factors influence the course of schizophrenia over time:
Age of onset
Younger age of onset, particularly in childhood and adolescence, is linked to worse outcomes. Early-onset schizophrenia progresses differently than adult-onset, with more severe cognitive deficits and neurological abnormalities.
Premorbid functioning
Premorbid functioning refers to a person’s level of cognitive and social abilities before developing schizophrenia. Those with poorer premorbid functioning tend to have worse long-term outcomes.
Severity of initial symptoms
More severe positive symptoms at the first episode predict poorer functioning later on. However, even people with predominantly negative symptoms early on can have good outcomes.
Treatment and adherence
Continuous, uninterrupted treatment with antipsychotic medication and psychosocial interventions lead to better long-term outcomes. Non-adherence to treatment is associated with higher relapse rates and worsening of symptoms.
Substance abuse
Comorbid substance abuse such as alcohol, marijuana or harder drugs is linked to much poorer functioning in schizophrenia. It exacerbates symptoms and treatment non-response.
Family involvement
Having a supportive family and social structures improve prognosis in schizophrenia. Social isolation and lack of family support are associated with worse outcomes.
So while schizophrenia symptoms may improve over time for many, good premorbid adjustment, higher functioning, low substance use and family support lead to more favorable outcomes.
Hallmarks of deterioration
There are certain red flags that may indicate a person with schizophrenia is experiencing deterioration in their condition:
- Increasing social withdrawal and self-neglect
- More severe negative symptoms like flat affect and apathy
- Worsening cognitive deficits affecting concentration, memory and planning
- Re-emergence of psychotic symptoms that had previously subsided
- Increasing relapse frequency and need for hospitalization
- New onset of depression or suicidal thoughts
If a person is exhibiting several of these signs, it likely indicates worsening illness that requires modifying treatment. Catching deterioration early maximizes the chances of stabilizing the condition.
Biological factors in deterioration
The reasons for deterioration in a subset of schizophrenia patients as they age are not fully understood. Some possible biological explanations are:
- Neurodegeneration – Loss of gray matter in the brain over time may play a role in worsening cognitive deficits and negative symptoms.
- Neurodevelopmental insult – Whatever aberrant neurodevelopmental processes resulted in schizophrenia may continue to progressively impair brain functioning.
- Inflammation – Chronic low-grade inflammation in the brain may gradually damage neurons and worsen pathology.
- Oxidative stress – Imbalance between free radicals and antioxidants may accumulate over time, damaging brain cells.
More research is needed to elucidate the biological mechanisms underlying deterioration in schizophrenia. Identifying these processes could help develop interventions to slow or prevent decline.
Risk factors for deterioration
Several risk factors that can predict worse outcomes have been identified:
Risk Factor | Description |
---|---|
Male gender | Males tend to have poorer functioning, more severe negative symptoms and cognitive deficits. |
Early onset | Onset before age 18, especially in childhood, is linked to worse outcomes. |
Long duration of untreated psychosis | The longer psychosis goes untreated before first treatment, the poorer the prognosis. |
Prominent negative symptoms | Predominance of flat affect, apathy, lack of motivation predict worse functioning. |
Low premorbid functioning | Poorer cognitive and social abilities before onset indicate poorer outcomes. |
Substance abuse | Comorbid alcohol or drug abuse is strongly associated with worse prognosis. |
Treatment non-adherence | Stopping medication greatly increases relapse risk and deterioration. |
Lack of family involvement | Supportive family predicts better outcomes and functioning. |
Identifying these risks early allows closer monitoring and more aggressive treatment to improve prognosis.
Preventing deterioration
While some deterioration in schizophrenia is common and expected, several strategies can help slow decline:
- Continuous medication treatment – Uninterrupted antipsychotic treatment prevents relapses leading to deterioration.
- Psychosocial interventions – Therapy, social skills training, family education help maintain functioning.
- Cognitive rehabilitation – Targeted exercises improve cognitive deficits and prevent decline.
- Supported employment/housing – Programs providing support and minimizing stress prevent decline.
- Integrated care – Collaboration between mental health and primary care to address physical health.
- Routine monitoring – Regular assessments allow early intervention at signs of deterioration.
While more research is still needed, these evidence-based strategies can help people with schizophrenia preserve functioning and manage symptoms as they age.
The late stage of schizophrenia
In some people with schizophrenia, symptoms do continue to severely worsen later in life. Factors like persistent psychosis, lack of treatment, substance abuse and poor self-care can result in profound deterioration. This late stage is characterized by:
- Severe disorganization, incoherence and bizarre behavior
- Social isolation to the point of neglecting basic needs
- Severe cognitive impairment approaching dementia
- Institutionalization may become necessary for basic care
- High medical morbidity and mortality
However, this extreme late-stage deterioration applies to only a subset of patients with poor prognostic factors. With today’s treatments and interventions, maintaining stability for many decades is achievable for a majority of people with schizophrenia.
The aging process in schizophrenia
Apart from the progression of schizophrenia itself, aging comes with its own challenges for people with schizophrenia:
- Increased social isolation and reduced social supports as parents/siblings age
- Financial hardship from inability to work or receive benefits
- Difficulty accessing geriatric psychiatric care integrated with medical care
- Higher rates of age-related conditions like diabetes, cardiovascular disease
- Sensory changes like vision/hearing loss which exacerbate symptoms
- Higher rates of homelessness, victimization and suicide
Aging patients with schizophrenia require specialized geriatric mental healthcare that addresses their unique medical, social, financial and housing needs.
Late-life schizophrenia
Rarely, schizophrenia can develop for the first time in late life. Known as late-onset or very-late-onset schizophrenia-like psychosis, it comprises:
- Onset after age 40, most commonly in the 60s-80s
- More prevalent in women than men
- High rates of paranoia/persecutory delusions
- Variable hallucinations and disorganization
- Often associated with sensory deficits
- Cognitive deficits less severe than early onset
While late-life schizophrenia can be challenging to distinguish from dementia-related psychosis, the right diagnosis guides appropriate treatment.
Conclusion
In conclusion, the evidence indicates schizophrenia symptoms tend to improve in a majority of patients, especially positive symptoms, while deficits in cognition and negative symptoms persist or worsen. However, there is significant individual variation in course and outcome. Good premorbid functioning, later onset, low substance use and family/social supports predict more favorable outcomes. Targeted treatments, psychosocial interventions and integrated care can prevent deterioration. While a subset of patients do experience severe late-stage worsening, modern treatment allows most people with schizophrenia to maintain a good quality of life for many decades.