Although the symptoms of schizophrenia are always severe, the long-term course does not always involve progressive deterioration. The clinical course varies among clients.
Onset may be abrupt or insidious, but most clients slowly and gradually develop signs and symptoms such as social with-drawal, unusual behavior, loss of interest in school or work, and neglected hygiene. The diagnosis of schizophrenia usu-ally is made when the person begins to display more actively positive symptoms of delusions, hallucinations, and disor-dered thinking (psychosis). Regardless of when and how the illness begins and the type of schizophrenia, consequences for most clients and their families are substantial and enduring.
When and how the illness develops seems to affect the outcome. Age at onset appears to be an important factor in how well the client fares: Those who develop the illness earlier show worse outcomes than those who develop it later. Younger clients display a poorer premorbid adjustment, more prominent negative signs, and greater cognitive impairment than do older clients. Those who experience a gradual onset of the disease (about 50%) tend to have both poorer immediate and long-term course than those who experience an acute and sudden onset (Buchanan & Car-penter, 2005). Approximately one third of clients with schizophrenia relapse within 1 year of an acute episode (Ucok, Polat, Cakir, & Genc, 2006).
In the years immediately after the onset of psychotic symp-toms, two typical clinical patterns emerge. In one pattern, the client experiences ongoing psychosis and never fully recovers, although symptoms may shift in severity over time. In another pattern, the client experiences episodes of psychotic symptoms that alternate with episodes of rela-tively complete recovery from the psychosis.
The intensity of psychosis tends to diminish with age. Many clients with long-term impairment regain somedegree of social and occupational functioning. Over time, the disease becomes less disruptive to the person’s life and easier to manage, but rarely can the client overcome the effects of many years of dysfunction (Buchanan & Carpenter, 2005). In later life, these clients may live independently or in a structured family-type setting and may succeed at jobs with stable expectations and a supportive work environment. However, most clients with schizophrenia have difficulty functioning in the community, and few lead fully indepen-dent lives (Carter, 2006). This is primarily due to persistent negative symptoms, impaired cognition, or treatment-refractory positive symptoms.
Antipsychotic medications play a crucial role in the course of the disease and individual outcomes. They do not cure the disorder; however, they are crucial to its successful management. The more effective the client’s response and adherence to his or her medication regimen, the better the client’s outcome. Marshall and Rathbone (2006) found that early detection and aggressive treatment of the first psy-chotic episode were associated with improved outcomes.