Age at Onset and Mode of Onset of Psychosis: Two Prognostic Indicators in the Early Course of Schizophrenia

Michael T. Compton, MD, MPH


July 15, 2010

In This Article

Mode of Onset of Psychosis

A patient’s mode of onset of psychotic symptoms is also known to be a prognostic indicator for schizophrenia and other psychotic disorders; the more gradual the onset of positive psychotic symptoms, the poorer the outcome tends to be. Thus, mode of onset of psychosis refers to how quickly psychotic symptoms evolve during the first episode. In the World Health Organization’s International Pilot Study of Schizophrenia (IPSS), mode of onset was operationalized as follows:[14,15] acute, a florid psychotic state developing within days (up to a week) either in the absence of prior prodromal symptoms (sudden onset) or after a period of preceding prodromal symptoms (precipitous onset); subacute, symptoms appearing and developing into a clear-cut psychotic state over a period of up to 1 month; gradual, the slow, incremental development of psychotic symptoms over a period exceeding 1 month (prodromal symptoms may not be clearly distinguishable from overt psychotic symptoms in terms of a gradual transition from one to the other); and insidious, no clear demarcation between premorbid personality and mental illness.

Mode of onset of psychosis is associated with various outcomes of psychotic disorders; a more acute mode of onset confers a better prognosis than a more gradual mode of onset.[16,17,18,19] In fact, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision refers to acute mode of onset as a good prognostic feature for schizophreniform disorder.[20] Mode of psychosis onset also appears to be strongly related to how quickly help is sought once psychotic symptoms are clearly evident.

Regarding the latter point, in the United Kingdom, Morgan and colleagues[21] found that a gradual/insidious mode of onset was a significant predictor of the duration of untreated psychosis in the Aetiology and Ethnicity in Schizophrenia and Other Psychosis (ÆSOP) study. Similarly, in the United States, Compton and colleagues[22] reported that first-episode patients with a gradual/insidious mode of onset were about 50% less likely to be hospitalized (the indicator of initiating treatment in their hospitalized sample), once frank psychotic symptoms were present, at any given point in time than those with an acute/subacute mode of onset. Specifically, among their patients in the Atlanta Cohort on the Early course of Schizophrenia (ACES) project with an acute/subacute mode of onset, the time from the onset of psychosis to initial hospitalization was 21 weeks, compared with 101 weeks in those who had experienced a gradual/insidious mode of onset.

Thus, mode of onset is known to be associated with early-course outcomes of schizophrenia and related psychotic disorders, and one mechanism through which this might occur is the effect that mode of onset has on how quickly the patient engages in treatment. A more abrupt onset of symptoms or change in behavior results in a faster response in seeking help by patients and their families.[23] Such findings indicate that community-wide informational campaigns and early intervention programs may benefit from focusing on gradually developing psychosis, which confers a longer delay to initiating care.


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