CLINICAL HANDBOOK OF SCHIZOPHRENIA

CHAPTER 54REMISSIONBERNARD A. FISCHER, IVWILLIAM T. CARPENTER, JR.Schizophrenia has traditionally been conceptualized as a disease entity defined by psychosis,deterioration, and poor outcome. Emphasis on remission and recovery has beenlimited by this traditional view. Each aspect of the traditional view is flawed. An alternativeparadigm is described, and remission is considered within this framework. Recoveryin the medical sense is discussed in this chapter, whereas Chapter 55 deals more extensivelywith recovery from the vantage point of the care recipient.A BACKGROUND ON SCHIZOPHRENIASchizophrenia is a clinical syndrome that has not been established as a single disease entity.Clinical heterogeneity is evident, and it is probable that subgroups of the syndromehave different etiology and pathophysiology. This being the case, differences in treatmentresponse, course, and outcome are expected. Indeed, concepts of a typical course ofschizophrenia are not compatible with research observations. European and North Americanlong-term outcome studies have consistently documented about eight course types.Favorable outcomes are reported in 20–50% of cases, and a progressive course with persistentdeterioration is rarely observed (see References and Recommended Readings). Tothe extent that schizophrenia is associated with progression, this appears to occur early inthe psychotic phase, reaching a plateau within the first 5–10 years of illness. There maybe a small subgroup of very chronic patients who decline rapidly in late life; however, advancingage is often associated with improvement—perhaps because the psychotic componentbecomes less intense. In any event, the view that there is a typical course of schizophreniais simply incorrect, but the influence of this view has impeded research andclinical application relating to remission and recovery.The “domains of pathology” paradigm is slowly replacing the disease entity paradigm.The domains paradigm is based on observations that various pathological manifestationsobserved in persons with schizophrenia have little relationship with each other. Symptomssegregate into domains representing reality distortion (i.e., hallucinations and delusions),disorganization of thoughts and behaviors, and negative symptoms (e.g., decreased motiva-559