Although we are accustomed to thinking of schizophrenia as an illness with onset in late adolescence or early adulthood and which is presumed to have a neurodevelopmental basis, psychoses that satisfy diagnostic criteria for schizophrenia can arise de novo at any point in life. Indeed, if one examines the incidence of broadly defined schizophrenia and other non-affective, non-organic psychoses across the lifecycle, then both early adult life (particularly for males) and extreme old age (particularly for females) are points when incidence peaks. The diagnostic position of the late-onset cases is controversial for a number of reasons, and neither ICD-10 or DSM-IV have included codings for late age at onset. This is probably because we are so used to thinking of schizophrenia as a young-onset illness and more than a little prejudiced against making the diagnosis in late life. There are also important differences between early- and late-onset cases, which have led old age psychiatrists to view the late-onset cases as different from schizophrenia. ICD-9 included the diagnosis 'late paraphrenia', a term first suggested in 1952 by Roth and Morrisey(1) to describe patients who these authors believed had schizophrenia with an onset delayed until after the age of 55 or 60 years. DSM-IIIR contained a category of late-onset schizophrenia for those cases with an onset after the age of 44 years. Late-onset schizophrenia in the United States and late paraphrenia in Europe were never really meant to be the same thing, and such lack of agreement and international consistency contributed to their disappearance from later classification systems. The loss of age-at-onset coding or an upper age limit for the onset of schizophrenia has meant that these patients are classified within paranoid schizophrenia or delusional disorder, depending upon individual symptomatology. The available evidence supports the recognition of three age-at-onset-related categories for patients with schizophrenia and schizophrenia-like psychoses.

1. Early-onset (before 40 years) schizophrenia is the most typical form.

2. Late-onset (40-60 years) schizophrenia represent cases of 'true' schizophrenia with onset delayed into late middle age.

3. Very-late-onset (over 60 years) schizophrenia-like psychoses, although sharing many of the symptoms of schizophrenia, have a different set of associated risk factors and response to treatment than the other groups.

Features of these three groups are summarized in Table 1.

Table 1 The three ages of schizophrenia and schizophrenia-like psychoses

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