The prediction of the outcome of schizophrenia when the psychiatrist has beenable only to observe the manifest symptomatology has been a matter of great interestsince the early contributions of Kraepelin and Bleuler. Many authors have studied theprognosis of schizophrenia from a purely statistical point of view, without anyconsideration for the symptomatology. Typical of this type of research is the workdone by the Finnish authors Niskanen and Achte (1971), who have studied theoutcome of first admissions for schizophrenic psychoses in Helsinki in 1950, 1960,129and 1965. The percentage of patients who recovered or were socially recovered after aperiod of five years was 59 percent of the 1950 patients, 68 percent of the 1960patients, and 64 percent of the 1965 patients.
The findings also suggested that theproportion of those who were in need of hospital treatment after a period of five yearsdecreased steadily: 22 percent of the 1950 patients, 14 percent of the 1960 patients,and 10 percent of the 1965 patients.Most authors, however, have done a different type of research. They have triedto determine the prognosis by virtue of the characteristics of the manifestsymptomatology, with the implicit understanding that the treatment to beadministered later would improve the prognosis. Thus the majority of psychiatriststoday do not agree with Bleuler, who stated that he or his contemporaries had “notdiscovered any correlation between the initial disease symptoms and the severity ofthe outcome of the illness”.
Typical of the group of authors who tried to predict the prognosis from thesymptomatology is Vaillant (1967). He listed six criteria that indicated a goodprognosis: (1) Psychotic depressive heredity. (2) Symptoms suggesting a depressivepsychosis. (3) Onset within six months before the fully developed illness. (4) Presenceof precipitating factors. (5) Absence of a schizoid personality. (6) Confusion ordisorientation. As a rule, the recovered schizophrenic presented symptoms suggestiveof an affective psychosis and often possessed a heredity positive for psychotic depression.
In the first edition of this book I stated that although no one can be absolutely130sure what course a given patient will follow, a certain group of symptoms and factorstend to occur more frequently in patients who recover; on the other hand, othersymptoms and factors tend to occur in patients with a poor outcome. In this secondedition I can reaffirm that certain characteristics to be mentioned shortly have aprognostic significance even when they are studied merely in their manifest aspect.
The onset of the illness is prognostically important. The more acute the onset,the more favorable is the prognosis, especially if characterized by a state of confusion.This criterion is not absolute. Every psychiatrist has observed very acute cases thatwere not followed by recovery or improvement.
The obvious occurrence of specific precipitating factors (like loss of employment,broken engagement, childbirth) indicates a good prognosis. As we shall study in moredetail in Chapter 8, the necessary occurrence or presence of these factors for theengendering of the psychosis indicates that the personality has a relatively betterchance of reintegrating once these factors are removed. They also indicate that theunderlying or more obscure part of the etiology was less prominent in these cases.
Conscious anxiety is an important indication of good prognosis. Its presenceindicates that more severe mechanisms of the psychosis are not present or have noteliminated the presence of this emotion. By being distressing, anxiety invites thepatient to continue his search and possibly to return to reality. However, if the anxietyincreases in spite of the treatment, more severe mechanisms of regression maydevelop. For instance, the hebephrenic may become more grandiose and disconnected,the catatonic more immobile. When the paranoid is forced by his anxiety to search for131an increasing number of logical defenses, he may remain ill for a long period of time orpermanently.
Thus anxiety may work in two ways. But without anxiety, no improvement ispossible. Of course, we should not confuse the decrease in anxiety due to improvementwith the decrease in anxiety due to progression of the illness. The latter isaccompanied by more and more detachment from reality, whereas the opposite occursin the former.
The type of prepsychotic personality is prognostically important. The stormytype indicates a more favorable prognosis, the schizoid type a less favorable one. Recent studies have confirmed this statement by concluding that agood “premorbid personality” generally indicates good prognosis and shorterhospitalization (see, for instance, Harrow, Tucker, and Bromet, 1969).
A general attitude of defiance or compliance is also another important prognosticcharacteristic. If the patient is compliant toward therapists and nurses, the chances ofhis recovery are much greater than if he is defiant (Seitz, 1951). This is particularlytrue about the paranoid. The patient who defies the therapist, wants to demonstrate atany cost the veracity of his allegations, and is uncooperative and unwilling to submitto the suggestions of the therapist has a more guarded prognosis. He wastes hisenergies in the fight to retain his psychosis.
The general affective condition is also important. The presence of depressionimproves the prognosis. As we have already discussed, at times the depression is so132marked that the syndrome has been diagnosed schizo-affective, or a differentialdiagnosis from manic-depressive psychosis has been difficult. The schizophrenicdepression is not necessarily accompanied by a conscious feeling of unworthiness. Themore adequate or richer the affective behavior is, the better is the prognosis.
A state of hopelessness, not accompanied by congruous depression, is an ominousprognostic sign.
The content of the delusional or hallucinatory material has important prognosticvalue. The more the patient projects toward others and exonerates himself, the moresevere is the psychosis. If, on the other hand, he believes that he is persecuted becausehe is somehow guilty or responsible, the prognosis is better. The prognosis is muchbetter if the delusions concern feelings of guilt and responsibility. But here again thediagnosis may be uncertain, wavering between schizophrenia, manic-depressivepsychosis, or schizo-affective psychosis. At times, the differential characteristics andthe prognosis are difficult to evaluate, as, for example, when the delusions follow aschizophrenic pattern and the depression and the feeling of guilt present a manicdepressivepicture. The following example is typical of this combination.
Source: Interpretation of Schizophrenia 2nd Edition