Course of schizophrenia

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The course of schizophrenia has been the subject of intensive research for several decades. Despite major methodological limitations in the comparability of the studies carried out, there was a certain regularity in the description of the course of the disease.

Historical aspects

In his fundamental study from 1893, Kraepelin first differentiated “dementia praecox” ( schizophrenia ) from “manic-depressive insanity” (affective disorder). Kraepelin assumed an unfavorable prognosis for schizophrenia. This assumption was soon criticized. In his 1911 study, Bleuler rightly pointed out the heterogeneity of the disease. Kraepelin referred to this criticism in his later work. Other authors confirmed the assumption that a simplistic dichotomization does not do justice to clinical reality.

Criticism of Kraepelin came not only from the ranks of his own students (Robert Gaupp (1870-1953) was senior physician at Kraepelin), but also from competing schools. Carl Wernicke (1848–1905) attempted to systematize endogenous psychoses in a similar way to neurological diseases. His pupil Karl Kleist (1879–1960), who dealt primarily with the study of catatonia , and Karl Leonhard (1904–1988), who was associated with the Wernicke School , developed a classification scheme in which the group of diseases took shape " Cycloid psychoses " called.

The spectrum of "endogenous psychoses" familiar to today's psychiatry includes a group of illnesses that Robert Gaupp first described as "mixed psychosis" in the work cited above and which are now known as "schizoaffective psychoses" (ICD-10 F 25) . These diseases differ not only in their cross-sectional picture, but also in their course and prognosis. Although these facts were already well known in psychiatry in the 1920s, nothing changed in the practice of hospitalization for schizophrenic patients. Retrospective research showed that in the 1930s, 40–50% of schizophrenic patients had been hospitalized for more than five years.

Long-term studies on schizophrenia

The length of hospitalization for schizophrenic patients changed from around 1960. Two things are largely responsible for this. On the one hand, the development of neuroleptics , with which the positive symptoms of schizophrenia could be treated with relatively few side effects for the first time. On the other hand, the first large empirical progress studies on schizophrenic psychoses were published from 1960 onwards, which proved that Kraepelin's pessimistic prognosis regarding “dementia praecox” was wrong.

The following table provides an overview of these studies:

Long-term studies on schizophrenia
author Observation
period in years 		Proportion of patients with a
rather favorable outcome in%

Faergemann 1963
Eighth 1967
Noreik 1967
Beck 1968
Bleuler 1972
Hinterhuber 1973
Tsuang 1975
Ciompi 1976
Stephens 1978
Bland 1978
Huber 1979
Ichimiya 1986
Marinow 1986
Helgason 1990
Marneros 1991

16-19
15
22
25-35
23
30-40
30-40
37
12
14
22
20
20
21
23

0
6
16
7
30
29
19
27
6
16
22
17
50
30
7

Comparability of the studies

The results of these investigations are sometimes very different. The proportion of patients with a rather favorable course was given as 50% in one study (Marinow 1986) and as 0% in another study (Faergemann 1963). Faergemann's study included only 23 patients. In it, the diagnosis was made dependent on the course: patients with a favorable course were not classified as schizophrenia.

There are three meta-analyzes of progression studies. An employee of Hans Häfner (W. an der Heiden) examined 49 studies from the period from 1932 to 1996. An Austrian group examined 40 studies and a North American study seven studies. The proportion of favorable courses varied between 0 and 68%.

If you compare all of the larger progress studies, you will find significant deficiencies that limit the comparability of the results. These are among others:

  • The patient populations are not uniform: some studies include schizoaffective psychoses, others do not.
  • Social aspects were considered differently.
  • The observation periods range from 12 to 40 years.
  • The treatment situations differ significantly: Some studies extend into the time before the use of neuroleptics. Integrative treatment concepts have only been taken into account in the most recent studies.
  • Today there are no more studies that describe the natural (untreated) course of the disease.

Due to the shortcomings described, Häfner has suggested that only the results of studies that are comparable in design should be summarized. If you do this with the studies from German-speaking countries (including a study from Iceland), only a few are well comparable.

One of the first studies in German-speaking countries was the follow-up study by Manfred Bleuler from Zurich from 1972 in which 208 initial admissions over 20 years were examined. The study by Luc Ciompi from Lausanne from (1976) deals primarily with schizophrenic patients of advanced age. A total of 289 initial admissions were examined in it. In his Bonn study from 1979, Gerd Huber described 502 patients who were very carefully examined psychopathologically. Great emphasis was placed on changing the patient's social situation. The working group around Marneros from Cologne presented a study in 1991 with 355 patients who were observed over an average of 23 years. Narrow diagnostic criteria were used in this study. Hinterhuber from Innsbruck examined 157 initial admissions over a period of up to 40 years. The work was presented in 1973. A smaller study by Helgason from Iceland examined 82 patients over 6–7 years of age; they come from a register cohort (all patients of a given year).

In these studies, there is relatively good agreement between the proportion of favorable (22.5%) and rather unfavorable outcomes (32.5%).

Course parameters

Numerous parameters can be considered in progress studies. In the case of schizophrenia studies, high demands are made on the study design. The documentation of the processes must be sufficiently good to be able to make valid statements. This is already countered by the fact that medical records do not have to be archived for more than 20 years. For meaningful long-term studies in the case of schizophrenia, however, a course of 20 years is the lower limit.

First of all, the number of episodes of illness must be well documented. A consolidation of patient data from different facilities is now inevitable, as the patients are no longer treated in the state hospitals that treated large regions as they used to be.

The duration of the episodes of illness no longer correlates with the duration of hospitalization: the patients are definitely ill longer than they are treated in hospital. This means that the duration of the disease cycles can only be specified if the patients are regularly examined in a standardized manner.

Due to the highly standardized examination procedures (ICD or DSM diagnoses, AMPD system, PANSS score, standardized training of the examiners, etc.), statements on the cross-sectional findings will be easier to compare in the modern studies. In modern studies, as a result of recent research, more and more emphasis is placed on the documentation of prodromes, residuals and negative symptoms.

The number and duration of hospitalizations can no longer be compared easily between the studies. In general, the duration of hospital treatments has decreased. On the other hand, community-based care can increase the number of short-term hospitalizations. In addition, there are now a number of treatment offers that are institutionally between the classic hospital stay and outpatient care: day clinic, day clinic with overnight accommodation, day clinic offers with full-day or half-day care, outpatient occupational therapy, low-threshold therapy offers in day care centers, high-frequency outpatient Treatments (home treatment) etc. Compare this to the article on social psychiatry .

The social handicap of patients can be assessed better today, because there are diverse social support offers that can be easily compared with each other: dormitories, assisted living, workshops for the disabled.

The measurement or assessment of the therapy response is no longer limited to determining whether a psychotic episode is over and how long it may have lasted. The effect of different drugs or a combination of different treatment methods on psychopathological items, cognitive performance, social skills and the degree of everyday integration can also be assessed. With this, however, the modern studies lose their comparability with older studies in which such diverse procedures were not available.

Finally, the estimation of direct and indirect costs is an important parameter of the long-term course of schizophrenia. A key argument in favor of establishing psychiatric departments in general hospitals was that the treatment times, in contrast to those in the state hospitals, would be shortened and patient care would therefore be cheaper. Of course, this has to be proven empirically if the psychiatry reform is to continue in the future. In Germany today, 60% of all psychiatric beds are still in state hospitals.

Onset of illness

The onset and early course of schizophrenia is the subject of a separate article. At this point only the essential summarizing points should be pointed out: Schizophrenia usually begins chronically, untreated and with unspecific precursor symptoms. It takes an average of five years from the first outpost symptoms to the onset of the first psychotic symptoms and then about another year until the first hospitalization as part of a severe psychotic crisis. Most patients will have developed a social disability by this point.

Episode number and frequency

If representative studies of the course of patients with schizophrenia are broken down according to the number of episodes, the following picture emerges:

“Rule of thirds” on the course of schizophrenia
frequency Proportion of patients in percent

One episode
Two or three episodes
More than four episodes

8.8%
31.8%
23.6%

In the Marneros study, the average frequency of psychotic episodes was 0.2 = one episode every five years. The average length of hospitalization per episode was 60 days, and the average incapacity for work per episode was 76 days. These figures show a wide range of fluctuations. Since in the three studies by Bleuler, Ciompi and Huber approx. 25% of the patients examined showed only one psychotic episode, the concept of the rule of thirds was introduced: one third of the patients can be cured, one third suffers a chronic course with severe disease, one third have a recurrent course with moderate severity of the disease.

Long-term course and cross-sectional image

The contrast between the long-term course (how did the disease develop if you can retrospectively look at the entire life of a patient?) And the observation of the cross-sectional image (what does the clinical picture look like at a specific examination time?) Has shaped the discussion about the nature of the disease since Kraepelin and Bleuler. In modern long-term studies, both perspectives can be combined. If you summarize the findings, the following picture emerges:

  • In the long-term course of schizophrenia there is no stability of the symptoms.
  • These two findings clarify the need for a syndromic description of schizophrenia (cf. the "dimensional approach" according to Liddle)
  • The concept of clinical subtypes must therefore be questioned.

The question of therapeutic success in the context of long-term observations is of particular importance.

  • The best therapy results show the paranoid-hallucinatory and the depressive symptoms.
  • The worst therapy responses show the psycho-organic and manic symptoms.
  • Up to 20% of patients show no therapeutic effects.

The prodromal phase at the beginning of a relapse (renewed flare-up of the disease) is currently the subject of intensive research. The great interest in the outpost symptoms, which initiate a new psychotic attack, is due to the fact that all progress studies show that the prognosis of the disease worsens with the number of illness episodes. In parallel with the number of episodes, the duration of the episodes increases and the episode interval decreases. This increases the risk of the transition to a chronic form of the disease in the case of the phased forms of schizophrenia.

Gradient forms

The long-term and progressive studies of schizophrenia today make it possible to subdivide the progressive forms of schizophrenia into certain types. Manfred Bleuler made suggestions for such a typification in his long-term study from 1972.

Accordingly, two forms of progress can be distinguished. A third of the patients show simple forms, each of which leads to chronic schizophrenia. Two thirds of the patients show wavy courses. This third shows a rough division into a group with healing and a group whose disease ends in a mild chronic condition. Today, up to ten or more different types of progression are sometimes distinguished.

Summary

In contrast to the more optimistic results of the follow-up studies by Manfred Bleuler (rule of thirds), more recent follow-up studies have shown that complete remissions (cures) are less common than assumed a few decades ago. The main reason for this is that the older studies included patients with schizoaffective disorders. Studies that did not apply such strict diagnostic criteria showed rates of complete remissions of up to 22%. Recent studies using narrow diagnostic criteria show that complete remissions occurred in less than 10% of cases. In addition, there was an above-average number of patients who showed purely negative symptoms (48%). Despite the considerable improvements in the supply options, the long-term prognosis remains unfavorable for some of the schizophrenia patients.

See also

Individual evidence

  1. ^ E. Kraepelin: Psychiatry. 4th edition. Abel (Meixner), Leipzig 1893.
  2. ^ E. Bleuer: Dementia praecox or group of schizophrenias . Deuticke, Leipzig / Vienna 1911.
  3. ↑ E. Kraepelin: The manifestations of insanity. In: Journal for the Whole Neurology and Psychiatry. 62, 1920, pp. 1-29.
  4. ^ R. Gaupp: Insight into illness and mixed psychoses I. The struggle for unity of illness. In: Journal for the Whole Neurology and Psychiatry. 101, 1926, pp. 1-15.
  5. ↑ G. Ewald: Mischpsychose, Degenerationspsychose, structure. In: Monthly magazine for psychiatry and neurology. 68, 1928, pp. 157-191.
  6. ↑ Heinz Häfner: The riddle of schizophrenia. 3. Edition. CH Beck, Munich 2004, p. 65; lists Robert Gaupp as a proponent of euthanasia without giving an exact source.
  7. ^ Karl Kleist: About cycloid, paranoid and epileptic psychoses and the question of degeneration psychosis. In: Swiss Archive for Neurology and Psychiatry. 23, 1928, pp. 3-37.
  8. ^ Karl Leonhard: The cycloid psychoses, mostly misunderstood as schizophrenia. In: Psychol. Neurol. Med. Psychol. 9, 1954, pp. 359-373.
  9. ^ G. Brown: Length of hospital stay in schizophrenia. A review of statistical studies. In: Acta Psych. Et Neurol. Scand. 35, 1960, pp. 414-430.
  10. ^ GW Brown: Social factors influening length of hospital stay of schizophrenic patients. In: Br Med J. 2 (5162), Dec 12, 1959, pp. 1300-1302. PMID 13804935 .
  11. ^ Bangen, Hans: History of the drug therapy of schizophrenia. Berlin 1992, ISBN 3-927408-82-4 .
  12. ↑ PM Faergemann: Psychogenic psychoses. Butterworth, London 1963. OCLC 926980418
  13. ↑ K. Echte : On prognosis and rehabilitation in schizophrenia and paranoid psychosis. A comparative follow-up study of two series of patients first admitted to hospital in 1950 and 1960 respectively. In: Acta Psychiatrica Scand. 196, 1967, pp. 1-217. PMID 4171248
  14. ↑ K. Noreik: A prolonged follow-up of acute schizophrenic and schizophreniform psychoses. In: Acta Psychiatr Scand. 43 (4), 1967, pp. 432-443. PMID 5582394
  15. ↑ M. Beck: Twenty-five and thirty-five year follow up first admissions to mental hospital. In: Can. Psychiatry. Ass. J. 13, 1968, pp. 219-229. PMID 5661687 .
  16. ↑ a b M. Bleuer: The schizophrenic mental disorders in the light of long-term medical and family histories. Thieme, Stuttgart 1972.
  17. ↑ H. Hinterhuber: Catamnestic studies on schizophrenia. A clinical-statistical study of lifelong course. In: Fortschr Neurol Psychiatr Grenzgeb. 41 (10), Oct 1973, pp. 527-558. PMID 4492209
  18. ↑ MT Tsuang: The Iowa 500. Field work in a 35-year follow-up of depression, mania and schizophrenia. In: Can. Psychiatry. Ass. J. 20, 1975, pp. 359-365. PMID 1182649 .
  19. ↑ L. Ciompi: Life path and age of the schizophrenics. A catamnestic long-term study up to the senium. Springer, Berlin 1976, ISBN 3-540-07567-4 .
  20. ^ JH Stephens: Long term prognosis and follow up in schizophrenia. In: Schizophrenia Bulletin. 4, 1978, pp. 25-47. PMID 34208
  21. ^ RC Bland et al .: 14-year outcome in early schizophrenia. In: Acta. Psychiatr. Scand. 58, 1978, pp. 327-338. PMID 717003 .
  22. ^ A b G. Huber: Schizophrenia. A process and social psychiatric long-term study. Springer, Berlin 1979, ISBN 3-540-09014-2 .
  23. ↑ Y. Ichimya include: Outcome of Schizophrenia - extended observation (more than 20 years) of 129 typical schizophrenic cases (I). In: Seishin Shinkeigaku Zesshi. 88, 1986, pp. 206-234. PMID 7732153 .
  24. ↑ A. Marinow: Prognostication in schizophrenia. In: Psychopathology. 19, 1986, pp. 192-195. PMID 3562748 .
  25. ^ L. Helgason: Twenty years of follow-up of first psychiatric presentation for schizophrenia: what would have been prevented. In: Acta psych. scand. 81, 1990, pp. 231-235. PMID 2343745
  26. ↑ a b c A. Marneros et al.: Affective, schizoaffective and schizophrenic psychoses. A comparative long-term study. Springer, Berlin 1991, ISBN 3-540-54323-6 .
  27. ^ H. Häfner: The riddle of schizophrenia . Munich 2001, p. 150.
  28. ↑ H. Häfner, W. an der Heiden: Methodical problems of veraufsforschung on schizophrenia. In: Advances in Neurology and Psychiatry. 68, 2000, pp. 193-205.
  29. ↑ H. Häfner: The riddle of schizophrenia. Munich 2001, p. 151 f.
  30. ↑ H. Häfner: The riddle of schizophrenia . Munich 2001, p. 151 f.
  31. ↑ H. Häfner: The riddle of schizophrenia . Munich 2001, chapter: The cost of illness. Pp. 230-239.
  32. ^ H. Häfner: The riddle of schizophrenia. Munich 2001, p. 116.