CLINICAL HANDBOOK OF SCHIZOPHRENIA

54. Remission 563verity. Instruments are already in place that can be applied to a systematic definition ofremission. These instruments can be used reliably by trained raters and are sensitive tochanges in clinical status. The most commonly used instruments are (1) the Scale forAssessment of Positive Symptoms and Scale for Assessment of Negative Symptoms(Andreasen & Olson, 1982), (2) the Brief Psychiatric Rating Scale (Lukoff, Neuchterlein,& Ventura, 1986; Overall & Gorham, 1962), and (3) the Positive and Negative SyndromeScale (Kay, Fizbein, & Opler, 1987).To warrant the qualifier “in remission,” an individual must rate no higher than“mild” on any of the items on these scales for a period of at least 6 months. Additionally,any symptom, when present, must not interfere with a person’s behavior.TREATMENT IMPLICATIONSClinical Criteria for Remission in SchizophreniaTranslating the instrument-based operationalized criteria for remission into clinical practicedoes not require the administration of these scales. Clinicians schooled in the psychopathologyof schizophrenia can implement the concept based on clinical evaluation.Psychotic symptoms include reality distortion and disorganization. Examples of realitydistortion are hallucinations—whether auditory or involving any of the other senses—and delusions. Disorganization can take the form of difficulties with tasks requiring anintegration of planning and behavior, such as driving or getting dressed properly.Thoughts (as expressed in speech), too, may be disorganized—jumping to unrelated topicsor jumbling incoherently.Negative symptoms are generally conceptualized as a lack of something in the patientthat people without schizophrenia seem to have. Some examples of negative symptomsare alogia (not speaking much), anhedonia (not getting pleasure out of things),blunted or flat affect (not expressing feelings through speech tone or body movements),poor hygiene, and decreased social engagement. Negative symptoms have been furthercategorized as primary versus secondary.Secondary negative symptoms are due to causes other than the disorder of schizophrenia.Examples include depression, effects of medication (especially the older antipsychotics;see Chapters 16 and 17 of this volume), and prolonged institutionalization.Primary negative symptoms are those seen as being attributable to the individual’s schizophrenia.People who have a significant amount of and problems with primary negativesymptoms are said to have the deficit form of schizophrenia.The scales used to measure remission in schizophrenia assess more than just the positiveand negative symptoms we reviewed earlier.They also measure preoccupation withphysical health, anxiety, motor agitation, depressed mood, guilt, disorientation, attention,and cooperation with the interviewer. Therefore, in a clinical setting, the individualwith schizophrenia in remission does not have—or has only mildly—problems with thesesymptoms.In summary, the patient who is in remission from schizophrenia will have at least 6months of no symptoms or mild symptoms, as assessed by a health care professional. Thenext piece of the definition of remission is that the symptoms, when present in mild form,cannot interfere with a person’s behavior.Clinical Implications of Defining Remission in SchizophreniaThe principal benefit of defining remission in schizophrenia is to raise expectations andto maximize therapeutic efforts. There are other benefits as well. Treatment algorithms