CLINICAL HANDBOOK OF SCHIZOPHRENIA

112 I. CORE SCIENCE AND BACKGROUND INFORMATION• The disease construct of schizophrenia comprises several relatively independent symptomdimensions, with negative symptoms and cognitive impairment remaining relatively stableover the illness course, and psychotic symptoms occurring in most patients on an episodicbasis.• The onset of schizophrenia usually occurs with depressive and negative symptoms, andfunctional impairment during a prepsychotic prodromal phase that on average lasts for severalyears, followed by a psychotic prephase, defined as the period between the first positivesymptom and the maximum of positive symptoms, lasting on average for 1 year.• The power of prognostic indicators of illness course is limited to the domains to which theybelong: symptom dimensions, psychotic relapses, social functioning, and so forth.• A very early age of onset (under age 15), male gender and onset before middle age, femalegender and onset after menopause, poor premorbid adjustment, an insidious onset, and aprolonged psychotic prephase with pronounced negative symptoms and cognitive impairmentat first treatment contact are reliable predictors of a poor long-term social course ofschizophrenia.• Comorbidity of alcohol and cannabis abuse predicts more severe positive symptoms, morerelapses, and a poor social course, whereas a short prodromal stage characterized by fewor no negative symptoms, minor functional impairment, and an acute onset of psychosispredicts a favorable social course.• Depressed mood is the most frequent symptom in schizophrenia throughout the entire illnesscourse, including psychotic relapses.• Risk of suicide is slightly elevated in schizophrenia (5–10% over the illness course), whichis increased by depressive symptoms and decreased by severe negative symptoms, particularlyaffective flattening.REFERENCES AND RECOMMENDED READINGSAmerican Psychiatric Association (1996). Diagnostic and statistical manual of mental disorders (4thed.). Washington, DC: Author.an der Heiden, W., Könnecke, R., Maurer, K., Ropeter, D., & Häfner, H. (2005). Depression in thelong-term course of schizophrenia. European Archives of Psychiatry and Clinical Neuroscience,255, 174–184.an der Heiden, W., Krumm, B., Müller, S., Weber, I., Biehl, H., & Schäfer, M. (1995). MannheimerLangzeitstudie der Schizophrenie (Mannheimer Long-Term Schizophrenia Project). Nervenarzt,66, 820–827.Arndt, S., Tyrrell, G., Flaum, M., & Andreasen, N. C. (1992). Comorbidity of substance abuse andschizophrenia: The role of pre-morbid adjustment. Psychological Medicine, 22, 379–388.Bleuler, M. (1972). Die schizophrenen Geistesstörungen im Lichte langjähriger Kranken- undFamiliengeschichten [The schizophrenic disorders in the light of long-term case and family histories].Stuttgart, Germany: Thieme.Bromet, E. J., Naz, B., Fochtmann, L. J., Carlson, G. A., & Tanenberg-Karant, M. (2005). Long-termdiagnostic stability and outcome in recent first-episode cohort studies of schizophrenia. SchizophreniaBulletin, 31, 639–649.Ciompi, L., & Müller, C. (1976). Lebensweg und Alter der Schizophrenen [Life course and age ofschizophrenic patients]. Berlin: Springer.Häfner, H., & an der Heiden, W. (2003). Course and outcome of schizophrenia. In S. R. Hirsch & D.R. Weinberger (Eds.), Schizophrenia (2nd ed., pp. 101–141). Oxford, UK: Blackwell.Häfner, H., Löffler, W., Maurer, K., Hambrecht, M., & an der Heiden, W. (1999). Depression, negativesymptoms, social stagnation and social decline in the early course of schizophrenia. ActaPsychiatrica Scandinavica, 100, 105–118.Häfner, H., Maurer, K., Trendler, G., an der Heiden, W., Schmidt, M., & Könnecke, R. (2005). Schizophreniaand depression. Schizophrenia Reseach, 77, 11–24.Harding, C. M., Brooks, G. W., Ashikaga, T., Strauss, J. S., & Breier, A. (1987). The Vermont longitudinalstudy of persons with severe mental illness. II. Long-term outcome of subjects who retro-