Recovery From Schizophrenia: Psychiatry And Political Economy

14 BACKGROUNDpatients the history of the illness extended back for more than thirty-five years, inmany cases for more than fifty years. This is one of the longest follow-up studiesin the literature. Dr Ciompi describes in detail his diagnostic criteria, which arethose of Emil Kraepelin and Eugen Bleuler—neither particularly narrow norbroad.Figure 1.1 is a diagrammatic representation (adapted from Dr Ciompi’s paper)of the onset, course and outcome of the illness in the 228 patients for whom theinformation could be determined with certainty. Dr Ciompi found that the onsetof the illness had been either acute (with less than six months from first symptomsto full-blown psychosis) or, conversely, insidious, in roughly equal numbers ofcases. Similarly, the course of the condition was episodic or continuous inapproximately equal numbers of patients; and the outcome was moderate tosevere disability in half the cases and mild disability or full recovery in the otherhalf. Full recovery was noted in more than a quarter of the patients. 28 Theoutcome from schizophrenia varies from one period to another and from place toplace. These results, like Eugen Bleuler’s, are somewhat better than average and,as we shall see (in Chapter 6), this may be a consequence of the superioreconomic conditions in Switzerland throughout most of the twentieth century.We can see from these results, nevertheless, that the course of schizophreniavaries a good deal between patients and that the outcome is often favorable—regardless of treatment.Many attempts have been made to predict which patients will have a benigncourse and a good outcome—good-prognosis schizophrenia—and to identify thefeatures that will distinguish them from patients with poor-prognosisschizophrenia. (This distinction is similar to Dr Langfeldt’s differentiationof process and reactive schizophrenia mentioned earlier.) The results of this workwill be discussed in some detail in Chapter 10. Here we may briefly state that it isthe patient with higher levels of functioning (social, sexual and vocational) beforedeveloping a psychosis who tends to do better. A sudden onset to the illness andan onset late in life are also good prognostic features.HOW WIDESPREAD IS SCHIZOPHRENIA?Results of prevalence studies range from as few as one person with schizophreniafor every 1,000 adults in one community to one for each 60 adults in others. Thiswide variation is in part due, as we have seen, to differences in diagnosticpractices and, in part, to differences in recovery and death rates for people withschizophrenia in different parts of the world. It is possible that there are alsovariations in the true frequency of occurrence of the illness, but a World HealthOrganization multi-national study makes this seem less likely. The WHO researchdemonstrates that the rate of occurrence of new cases (the incidence) of narrowlydefined schizophrenia is surprisingly similar in ten widely dispersed countries. 29Chapter 9 will examine differences in the prevalence of schizophrenia in detailand the possibility of environmental effects on the frequency of the illness. The