The myth of lifetime Schizophrenia
Schizophrenia Disorder is a mental illness that occurs worldwide, affecting 21 million of people. The lifetime prevalence of schizophrenia is estimated to be 0.3% – 0.7% approximately, varying across countries (DSM-5; American Psychiatric Association, 2013). Incidents per year are about 1.5 per 10.000 people, while it is more common among men than among women (ratio 1.4:1) (McGrath, Saha, Chant & Welham, 2008). In spite of its relatively low prevalence, schizophrenia is ranked the 8th most disabling illness among all illnesses of the age range of 15-44, contributing significantly into the global illness burden (World Health Organization [WHO], 2001).
People with Schizophrenia Disorder are 2 to 2.5 times more at risk of premature death mainly due to comorbiding chronic conditions associated with lifestyle behaviour characterised by reduced activity and poor quality of diet, such as diabetes, hypertension, cardiovascular and pulmonary illnesses. Stigma pertaining to schizophrenia and to other psychotic disorders is possibly the worst among other illnesses, however schizophrenia is also treatable, from which the majority of patients (approximately 80%) fully recover or can lead meaningful and productive lives (AlAqeel & Margolese, 2012; Harding, C. M., 1988). Effective treatment is usually the integration of pharmacotherapy, psychotherapy and psychosocial support interventions.
Schizophrenia and other psychotic disorders are characterized by the presence of the namely “positive” (delusions or/and hallucinations) and “negative” symptoms. The “positive symptoms” of psychosis are called “positive” because these can be conceptualized as being exerted levels of normal functions. Common positive symptoms include delusions of persecution and auditory hallucinations.
Accordingly, the “negative symptoms” can be considered as diminution of normal functioning, as is anhedonia (inability to feel pleasure in positive everyday tasks or events), avolition (diminished volition), alogia (diminished speech) and flattened affect. Negative symptoms are also present in other psychopathological conditions, such as in Major Depression Disorder and plenty others (Hovington & Lepage, 2012). The assessment of symptoms and diagnosis of psychotic disorders require mental health clinical expertise.
Schizophrenia is a life-time disorder - Myth or truth?
Based on existent research, it is well known that schizophrenia is not necessarily a lifetime disorder.
Research studies about the illness’ course and recovery from schizophrenia and findings on the heterogeneity of schizophrenia’s outcome show that psychosis is not only chronic, though it has been largely considered to be a non-curable and progressive mental disorder (Rösler & Rössler, 1998) - a false perception that might play a negative role on the course of the illness as the retention of hope is absolutely necessary for schizohrenia illness treatment (NICE, 2020 Clinical Guideline Number 178, Upd).
According to the World Health Organization, 45% approximately of patients recover after the first or multiple episodes, and 20% approximately present symptoms continuously or for the most of the time and increasing disability (World Health Organization [WHO], 1998). Also, according to the Curators of University of Missouri and the Handbook of Disabilities (Curators of Disability of Missouri & RCEP7. Handbook of Disability. Updated December 4 2002) in a 10-year span of treatment approximately 1/4 of patients fully recover after their first episode, 1/4 experience important improvement; 1/4 demonstrate moderate improvement, 15% show no improvement and 10% pass away (often by suicide or accident). In addition, 1/3 of patients who have not fully recovered live normal lives, 1/3 suffer from symptoms though adjust well in society and 1/3 face severe impact in their lives.
To be more specific, in the review of Jobe & Harlow for example, (2005, pp.893) a study on 500 inpatients of Iowa state psychiatric hospital - followed up for 10 years, the 200 schizophrenia patients were rated with poorer outcome than all other psychiatric patients. Although on completion, 30% of these patients were married and 20% were symptoms - free. Also, in this review, a third study was on 168 schizophrenia patients of the Vermont State Hospital, of whom 60% scored above 61 (which is a score considered to be above moderate level) on Global Assessment of Functioning Scale (GAF), after 20 years and despite chronic suffering (Jobe & Harlow, (2005). Moreover, this study found no difference between patients of schizophrenia and other psychiatric patients on outcome - comparisons (For reviews on studies on remission please refer to AlAqeel & Margolese, 2012; Chiliza, Asmal & Emsley, 2012).
Recently, there is a growing interest on first episode - patients and interest on what differentiates patients diagnosed with Brief Psychotic Disorder (duration from at least 1 day to less than 1 month) from other psychotic disorders and schizophrenia (for reviews of studies please refer to Ram, Brommet, Eaton, Pato & Schwartz, 1992; Os, Jones, Sham, Bebbington & Murray, 1998). First episode - patients are at a “level” that can be conceptualized as being after the prodromal phase but non-chronic (Correll etal, 2005). However similarly to chronic schizophrenia research, in a cohort of 255 first – episode of non-affective schizophrenia, 16.7% of patients were found recovered after 5 years of onset (Albert et al., 2011).
In overall, research findings conclude that schizophrenia and related psychosis are best seen developmentally as episodic disorders with a rather favorable outcome for a significant proportion of patients’ (Harisson et al. 2001, pp.70) and that there is a substantial heterogeneity in outcome of psychosis, but the variety of methodologies makes impossible to estimate more exact percentages of cohorts in outcome (Liebermann et. al., 1992). As Gaebel & Frommann, (2000, pp. 50) has put it: “As many kinds of categorizations are possible as describing dimensions are used” (for methodological reviews of studies please refer to Harding, 1988; Klorman, Strauss & Kokes, 1977; Matcheru, Keshavan & Schooler, 1992).
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References
Abbott, A., (2008). “The Brains of the Family,” Nature, 454, 154 - 157. doi: 10.1038/454154a
Albert, N., Bertelsen M, Thorup A, Petersen L, Jeppesen P, Le Quack P, … Nordentoft M. (2011). Predictors of recovery from psychosis. Analyses of clinical and social factors associated with recovery among patients with first episode psychosis after 5-years. Schizophrenia Research, 125, 257-266. doi: 10.1016/j.schres.2010.10.013
Correll, C. U., Lencz, T., Smith, C. W., Auther, A. M., Nakayama, E. Y.,Hovey, L., Olsen, R., … Comblatt, B. A. (2005). Prospective Study of Adolescents with Subsyndromal Psychosis: Characteristics and Outcome. Journal of child and adolescent psychopharmacology. 15(3), 418-433. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/16092908
Gaebel, W. & Frommann, N., (2000). Long-term course in schizophrenia: concepts, methods and research strategies. Acta psychiatrica Scandinavica. Supplementum,407, 49-53. doi: 10.1034/j.1600-0447.2000.00009.x
Jobe, T.H. & Harrow, M. (2005). Long-term outcome of patient with schizophrenia: A review. Canadian Journal of Psychiatry, 50(14), 892-900. Retrieved from http://www.sciencedirect.com/science/jrnlallbooks/sub/psychology/a
Lieberamn, et al, (1992). Prospective study of psychobiology in first – episode schizophrenia at Hillside Hospital. Schizophrenia bulletin, 18(3). Retrieved from http://www.rpa.library.acg.edu/rpa/webauth.exe?lb=acglib&rs=ebscopsyh
Rösler A. R. & Rössler W. (1998). The course of schizophrenic psychoses: what do we really know? A selective review from an epidemiological perspective. European Archives of Psychiatry & Clinical Neuroscience, 248, 189-202. Retrieved from http://www.rpa.library.acg.edu/rpa/webauth.exe?lb=acglib&rs=ebscopsyh
The curators of the University of Missouri. Schizophrenia. Handbook of disability. Retrieved from http://dps.missouri.edu/resources/Handbook/schizophrn
World Health Organization. (1998). Schizophrenia. Retrieved from https://www.who.int/mental_health/media/en/55.pdf
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