Evolution of Symptoms in the Early Course of Schizophrenia in Pakistan: Effect of Age and Gender

Abstract Objective: This study was conducted to examine the evolution of symptoms in Pakistani subjects with first-episode schizophrenia from onset until hospital admission by gender and age. Patients and Methods: Retrospective and current symptoms were assessed in 140 Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition schizophrenic patients in Pakistan by using a symptom checklist based on the Structured Clinical Interview for the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition and Structured Clinical Interview for the Positive and Negative Symptom Scale. Results: The current work failed to show gender differences in age at either the true age of onset or at the time of admission. Negative symptoms showed greater stability with an excess at both times of assessment, whereas positive symptoms showed a higher progression from onset until admission. Significantly greater number of men reported symptoms of avolition, affective flattening, disorganised behaviour, and inappropriate affect, whereas women showed a higher incidence of persecutory delusions. Similarly, early-onset patients were more likely than late-onset patients to exhibit symptoms of affective flattening, inappropriate affect, disorganised behaviour, and delusion of grandiosity. Late-onset patients, on the other hand, exhibited greater ideas of persecution. Conclusion: The early course of schizophrenia in these Pakistani patients showed reasonable consistency with the findings obtained from other countries. The core symptoms of schizophrenia did not show significant differences with gender or age, although in male gender and early-onset disease were associated with greater symptomatology. Key words: Age of onset, Pakistan, Schizophrenia, Sex factors, Severity of illness index Introduction Studies conducted with first-episode schizophrenia have shown a fairly uniform and robust clinical picture. Schizophrenia has been reported to begin in early adulthood mainly with negative symptoms, followed by decompensation with positive after a considerable time lag. (1) However, there are some inconsistencies concerning the impact of gender and age of onset (AOO) on disease manifestation and symptoms. The inconsistencies across studies may be related to factors such as differences in diagnostic criteria, methodologies, chronicity of disease, and age limits of the research sample. Most previous work about the course of schizophrenia has focused on chronically ill patients with stable symptoms. (2-4) However, there is ample supportive evidence that first episode samples are the most representative and allow examination of symptoms close to their genesis. (5) Studies involving first-episode cases have typically evaluated subjects at first clinical presentation or first hospital admission, (6,7) which in itself is determined by various factors in addition to symptomatology. 8 Early signs and symptoms could start and be detected years before first presentation. (1) Gender differences in AOO and symptomatology in schizophrenia have been extensively studied. It is established that the morbid risk for schizophrenia changes with age and that gender has a strong impact on age at onset. Many studies have reported an earlier AOO for men as compared to women. (9,10) Incidence rates in men are at their highest in young adulthood, whereas in women a broader peak extending beyond the age of 30 and a second peak between ages 45 and 49 were reported. (11) A delay in onset as well as the second peak for the emergence of schizophrenic symptoms in women has been attributed to mildly protective effects of oestrogen. (12-14) Indeed, gender differences in AOO have also given rise to hypotheses about genetic differences among men and women in the development of the disorder. (15) A number of clinical studies have shown that men display more negative symptoms than women. (16,17) In terms of positive symptoms, a greater incidence of auditory hallucinations (18,19) and persecutory delusions (20) has been reported in women. …