Advice for Parents on Early Signs of Schizophrenia

Dr. Dolores Malaspina applied to medical school with one aim–to understand the illness, schizophrenia, that afflicts her younger sister. Her research has found that about a quarter of all people living with schizophrenia may owe their symptoms to spontaneous mutations in paternal sperm–and the older the father, the more likely his sperm is to carry such mutations.

A practicing clinician with vast experience, Dr. Malaspina was part of the team that helped revise the 5th edition of the Diagnostic & Statistical Manual (DSM-V) used for the diagnosis of psychiatric and behavioral disorders. She and colleagues are now testing the relationship of bacteria in the gut–the microbiome–to inflammation in the brain that may cause or contribute to psychiatric disorders.

Your sister, while she was a freshman in high school, experienced the symptoms of psychosis, the prelude to what was eventually diagnosed as schizophrenia. Can you share with us what this experience was like, as you and your family witnessed it?

My sister, who is two years younger than I, had planned to become a physician from our earliest life, while I wanted to be an astronaut. She was the intellectual, but she was also a teenage dance champion. She was always amazing. At some point during her freshman year, her behavior started changing. She became oddly withdrawn, and preoccupied with sounds. She believed that the neighbors might be speaking about her, and then, shortly before she graduated high school, that helicopters overhead were there to monitor her thoughts. She graduated near the top of her class with a full college scholarship. But she went right to a psychiatric hospital.

What were some of the subtler signs in the period leading up to your sister’s fall into illness? It might help some parents to hear specifically what your family witnessed.

Perhaps, over a period of nine months, there were subtle signs–the withdrawing, the social anxiety, the decline in her grades, the reduced interest in her friends–these are indeed the kind of things that often occur during what we doctors call the “prodrome.”

Does the prodrome always end with the onset of psychosis? Are prodromal symptoms a certain sign that psychosis will follow?

No, and I should make clear that the prodrome is not a period specific to psychosis. In fact, only a third of prodromal young people, who have a change in behavior that affects their friendships, interests, and scholastic performance, will ultimately develop psychosis. But in all instances, it’s a time when people Early Signs of Schizophrenia experiencing these symptoms need some treatment. Sometimes the prodrome leads to psychosis, other times it can mark the onset of another disorder, and sometimes the symptoms resolve themselves and the person does not become ill.

So the prodrome can foreshadow many things. This makes us curious to know, how do parents distinguish between normal adolescence, which can be rebellious and chaotic, and a real and serious problem?

Adolescent behavior can include a lot of acting out, a lot of bargaining, and difficulty with parents. It is a time of preparation for young adulthood. But I think a young person who continues to have good grades and an active social grouping should be reassuring to parents.

I think the concern is when there is a decline in interest in friends and academics, or when the young person has delusions, such as hearing voices. Young people may not have delusions, such as aliens are monitoring their thoughts, or that they are the Savior. But they might have some very unusual ideas. Another change to notice is excessive interest in philosophy or religion, at the same time as a loss of interest in school work and friends.

By and large, most children will not have these problems.We want people to understand the pathology, but not to overreact, or impose too many worries on a developing young person. Perceiving a decline in functioning from a previous period is what should really get the parent’s attention.

If parents do notice these types of behaviors, what should they do?

It’s important, first of all, for the child to have a full medical work-up. The pediatrician should see the child and make sure his or her development is normal and that he or she doesn’t have an endocrine disorder or an infectious disease that might explain a change in behavior. I would also like to call attention to the importance of adequate nutrition and vitamins, especially zinc levels, for young children and teens who are at risk for a mental health disorder. So, first steps are making sure that the child is physically healthy, and then having a good psychological assessment by a psychiatrist or a psychologist. Often symptoms may not be judged as the early onset of psychosis, but they may still require an intervention.

There may be other reasons or risk factors for adolescents having a difficult time, such as family factors, bullying, head injuries, etc. Such risk factors should be addressed as well. Doing so might be sufficient to put the child or young adult back on course.

Where should parents go as they attempt the first step?

Parents should start with their pediatrician. The doctor will usually know the good child study centers around, or the good child and adolescent psychiatrists or psychologists. Of course, major medical centers that have departments of psychiatry are useful as well. But a pediatrician can often give a parent a sense of whether they are worrying too much.

What about medication?

Antipsychotic medications in my view are very over-prescribed to young people. These are very serious medicines that can help treat the delusions and hallucinations in people with psychosis, but they don’t usually cure a disease. Their use in the proper circumstances can be essential, but far too often, doctors are giving young people antipsychotic medicines without symptoms of psychosis.

Can general practitioners or pediatricians recommend antipsychotics?

Absolutely. And general practitioners are more likely, perhaps, to overprescribe them. But even some psychiatrists are of the mind that antipsychotics might help prevent psychosis in a young person at high risk. But there’s no good evidence, yet, that antipsychotics prevent the onset if there are no clear psychotic symptoms. Sometimes in the absence of psychotic symptoms, cognitive behavioral therapy [a kind of talk therapy], or treatments aimed at some depression symptoms would be far better. Also, antipsychotics come with risks, such as movement disorders and obesity for developing young people.

What are some risk factors for schizophrenia, which in some cases develops after a first psychotic episode?

One of the best-known risk factors for schizophrenia is having a family history. In reality, however, 80 percent of people with schizophrenia or bipolar disorder, particularly with psychosis, have no family history at all. Some of the important risk factors have been traced to different individual genes, although there’s no genetic test for schizophrenia yet.

But there are exposures which are much more common in people who develop a serious mental illness. One example is preeclampsia or other severe pregnancy events in the mother. Another is a traumatic brain injury which may have happened during childhood. Another important risk factor is early childhood trauma, which will double or triple the risk for later psychiatric disease.

Early childhood trauma comes in many forms, for example separation from parents, abuse, neglect, and bullying. Additionally, cannabis abuse in the early teen years will triple the risk for later psychosis. That’s very significant. I’ve seen a number of parents who’ve told their children that they can smoke cannabis as long as they don’t drink alcohol. Cannabis has a particular action in the circuitry that connects the “thinking” part of the brain and the “emotional” part. Hence, in my view cannabis consumption should be discouraged. However, I would like people to understand that most people with these exposures are resilient. Even with the tripling of the risk for schizophrenia, 97 percent of people will be well.

What are ways to reduce risk?

A very nurturing family environment is protective. The brain has plasticity–the capacity to change in response to experiences. This applies to positive experiences just as much as to negative ones. Throughout childhood, later childhood, and even into the mid-twenties and later, brain cells are continuously being made. And you want to take advantage of that through nurture, to help young people manage stress better. We don’t do enough of that. Too many parents have this idea that when someone turns 18, they no longer need nurture. Maybe that was true 40 years ago, but our brains are very different now. Young people need a longer period of high nurture, of support, and of encouragement to not abuse substances. You should try to have a home that doesn’t involve a lot of screaming or a lot of fighting.

At one point, it was believed that bad parenting caused schizophrenia.

Sadly that was the case, and of course it is entirely untrue. Maybe that idea came out of the recognition that most people with schizophrenia had no family history of the illness, so it was a way of explaining what happened. But that led to a very sad time in American psychiatry, where mothers were blamed. And I, myself, experienced that perspective when my sister was ill, and my family had to go to family therapy that was particularly confronting towards my mom.

As someone who has been through this, tell us about the experience of your family during the period when your sister began to experience symptoms of psychosis.

My experience, and that of my parents was, fi rst of all, denial. You just can’t believe what you’re seeing, and you don’t pay attention to it, or you tell someone to get on with things. Often family members experience post-traumatic stress disorder (PTSD), and there is the constant desire to see a difficult time, for example a particularly rough phase or the disorder, as “behind” you. And that leads to a lot of families being on a roller coaster. Whereas, a better understanding would be that, like all other conditions, it may ebb and flow. And that would be helpful for families.

How should families react to a loved one with a diagnosis?

We know that one factor in the course and outcome of these diseases is the way emotions are expressed within the family. This field was pioneered 30 years ago, and we saw at that time that families who had a lot of negative observations, hostile comments, and other negative interactions toward those diagnosed had a much worse outcome. You could even predict how quickly someone would be re-hospitalized or how well they would do, based on this negative emotional expression of a family. So, as part of treatment, work is now done with the family to help them understand the nature of the illness, and help them understand other ways of communicating and not criticizing. The reduction of hostile communication really can lead to a great improvement in the diagnosed person.

And the way to achieve this understanding is for the family, as a whole, to go to therapy?

There is a family-wide intervention called psycho-education, often involving social workers who are experts in helping families deal with emotional expression. There might be a family therapy that accompanies the onset of a disorder. Of course, some people will develop psychosis and recover remarkably, but for other families, there can be a grieving: someone with a disorder may have a successful life, but not the one that you had imagined. And helping families cope with that, first of all, gives them hope for their loved ones, but also knowledge that their life needs to go on as well; that this diagnosis shouldn’t end happiness for the whole family.

Any final words of hope and wisdom for parents going through this difficult time?

For parents, the goal is to love the child, where they are, and to understand their uniqueness. This is not easy to do. Your child is a dear and a whole human being. And to accept and reinvest in the person they are becoming, apart from your own expectations, is what gives joy back to a family.

Dolores Malaspina, M.D., M.S., MSPH

Director, Psychosis Program

Icahn School of Medicine at Mount Sinai

2007 Distinguished Investigator Grant

2001 Independent Investigator Grant

1995, 1993 Young Investigator Grant

— Written By Peter Tarr, Ph.D.

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