CLINICAL HANDBOOK OF SCHIZOPHRENIA

562 VIII. SPECIAL TOPICSsion criteria in other illnesses—including depression and anxiety. Their deliberation issummarized in the sections below.Remission in Depression and Anxiety versus SchizophreniaExperts in both depression and anxiety have defined remission as a significant decrease insymptoms. An individual does not have to be completely symptom-free to be in remission.When determining the level of symptom decrease that would merit the qualifier remission,the consensus is to examine the patient’s functioning. Depression and anxiety areconsidered to be “in remission” if symptoms are mild and the impact of those symptomson an individual’s functioning is minimal.However, schizophrenia presents a unique challenge to using identical criteria. Althoughit is certainly possible to measure symptoms, it is worth noting how the symptomsof schizophrenia differ from those of depression and anxiety. In some sense, the symptomsof depression and anxiety may be experienced—albeit to a lesser degree—by individualswithout a diagnosable depression or anxiety disorder. Therefore, someone withgeneralized anxiety disorder could be recognized as being “in remission” despite experiencingsymptoms of anxiety around an important meeting. Could a person with schizophreniasimilarly be considered to be “in remission” when he or she still occasionallyhears voices?Another challenge to adopting the same type of remission criteria for schizophreniais the requirement that symptoms have only a minimal impact on functioning. In a disorderin which the very diagnosis depends on social and/or occupational dysfunction, therequirement that dysfunction be “minimal” may not be useful in defining remission inschizophrenia.In answer to the first of these challenges, we have seen that negative, indeed evenpsychotic, symptoms are on a continuum of severity—with low levels of both recognizedin persons without mental illness. For that reason, complete cessation of symptoms maynot be necessary for remission in schizophrenia. Regarding a person’s disability, it hasbeen determined that full neurocognitive and psychosocial functioning should not be acondition of remission in schizophrenia. Rather, symptoms should not interfere with aperson’s behavior. Improved cognitive, social, and occupational functioning should begoals of treatment, but these goals are long term and best addressed during periods ofsymptomatic remission. As a practical matter, remission in schizophrenia is defined byabsent or mild symptoms, clinical stability, and the absence of a direct and immediate,symptomatic adverse effect on behavior.Measuring Remission in SchizophreniaThere are no validated biomarkers for remission, and assessment is based on clinical observationof symptoms and function. Reality distortion, disorganization, and disturbedaffect are the symptoms with the most temporal fluctuation and are potentially episodic.They are also the symptoms that appear largely treatable. Thus, they are most relevant tothe medical definition of remission. Negative symptoms not only appear to be more stableover time but are also relevant to the definition of remission. Severe negative symptoms,even in the presence of clinical stability, are not compatible with the definition ofremission. Cognitive impairment, as measured with neuropsychological test procedures,is not an aspect of the remission definition.The definition of remission requires absent or mild symptoms. Clinicians may varyin how they calibrate judgment of remission, but the concept is common in medicine. Inresearch studies, there needs to be a uniform and reliable way of assessing symptom se-