Thomas H. McGlashan

The Varied Outcomes of Schizophrenia

Objective: To review variations in outcomes in schizophrenia across individual, historical, and cross-cultural boundaries, as well as within specific domains of functioning. Method: Research literature on the outcomes of schizophrenia appearing within the last 8 years was reviewed. Results: First, a review of follow-up studies published in the developed world suggests that heterogeneity in outcome across individuals with schizophrenia remains the rule, with affective symptoms, later and acute onset, and responsiveness to biological treatments predictive of good outcome. Negative symptoms are associated with poor outcome, cognitive impairments, and incapacity in social and work domains. Deterioration appears to occur within the first few months of onset if not already in the prodrome, with recent early-course studies finding longer duration of untreated psychosis associated with insidious onset, negative symptoms, social and work incapacity, and poor outcome. Second, a review of recent cross-cultural and historical studies provides evidence that outcome varies across time and place, schizophrenia having a more favourable outcome in the developing world and becoming a more benign disorder over the course of this century. Third, a review of studies of the domains of functioning within individuals identifies 4 relatively independent dimensions of depression and negative, psychotic, and disorganized symptoms. Cognitive deficits, which are associated with negative symptoms, also constitute a relatively stable dimension over time, showing neither marked deterioration nor improvement once established early in the course of disorder. Conclusions: The early appearance and stability over time of negative symptoms and cognitive impairments call for assertive intervention efforts early in the course of disorder to prevent chronicity and prolonged disability.

Discriminating characteristics of suicides. Chestnut Lodge follow-up sample including patients with affective disorder, schizophrenia and schizoaffective disorder.

ABSTRACT Diagnostic, demographic, and outcome profiles were compared between psychiatric inpatients and former inpatients who ultimately committed suicide and those who did not. Results showed that the suicide group contained a greater preponderance of males and patients suffering from schizoaffective disorder or unipolar depression, and comparatively fewer patients with borderline personality disorder. The suicide group also had histories or symptoms indicative of affective difficulties, and premorbidly had achieved a higher IQ and higher levels of socioeconomic functioning. They also demonstrated higher levels of psychopathology on admission and their post‐hospitalization courses were characterized by lower levels of functioning. The risk of suicide thus appeared to be correlated to illness virulence and to the magnitude of the loss of healthy functioning.

Sealing-Over in a Therapeutic Community

Integrating and sealing-over are terms that are frequently used to describe a patients general style of coping with stress, especially the stress of an acute psychotic break. Work to date (McGlashan et al., 1975, 1976, in press; Levy et al., 1975) has defined these terms both clinically and dynamically within the context of a patients relationship to his own psychosis. Integration and sealing-over as concepts have also proved useful in understanding and describing interpersonal and group behavior on an inpatient psychiatric unit. A patients ultimate style of recovery from an acute psychotic episode results from many forces-internal and environmental. The tendency to either review and assimilate (integrate) or deny and repudiate (seal-over) the often painful affects and ideas prominent during psychosis mobilizes various forces within the patients social environment. The way in which the therapeutic milieu and patient interact with one another reflects and, in part, determines the manner and degree to which each party comes to master the patients psychotic experience. This report explores this interaction as observed in an inpatient therapeutic community established to treat acutely schizophrenic patients.

The Tips Project

Schizophrenia is the single most costly disorder between as well the serious psychiatric disorders as for the larger somatic diseases as cancer, vascular diseases (1, 2, 3). In all NATO countries combined, the costs connected with this disorder are estimated at over 1% of the gross national budget (4). While the worldwide rate of new cases (incidence) is low (1 per 10000 per year) (5), the disorder’s lifetime prevalence is high because the disorder often results in chronic deficits in mental functioning. The suffering connected to the schizophrenia spectrum disorders for the affected individuals and their families is enormous and beyond measurement. Although contemporary treatments as neuroleptic medication, family psychoeducation and assertive continuity of care has demonstrated efficacy in clinical trials (6), these treatments are essentially palliative and must apparently be provided indefinitely because discontinuation leads to clinical deterioration in almost every case. Schizophrenia and related psychotic disorders can be seen as disorders developing through different stages or phases. Sullivan (7) wrote that the psychiatrist sees too many end states and deals professionally with too few of the prepsychotic. Kraepelin stated that if no essential improvement intervenes, in at most two or three years after the appearance of the more striking morbid phenomena, a state of weakmindedness will be developed which usually changes only slowly and insignificantly (8). One model for illustrating these different phases is outlined in figure 1.