L. Stephen Miller
The University of Georgia
In spite of the expansion of knowledge in recent years concerning Schizophrenia, as well as an increase in our ability to treat it, schizophrenia remains a baffling disorder in which numerous environmental, biological, and social causes or triggers may be implicated. Schizophrenia afflicts approximately 1% of all adults residing in the United States (Keith, Regire, & Rae, 1991). While this sounds somewhat uncommon, in fact schizophrenia is more prevalent than Alzheimer's disease. Additionally, while it may directly impact "only" 1% of the adult population, in the U.S., it accounts for approximately 2.5% of the annual health care expenditures (Rupp & Keith, 1993) and may cost as much as $33 billion a year (Rice, Keller, & Miller, 1991; Rice & Miller, 1992). Schizophrenia is a malady that epitomizes the worst fears of having a mental disorder. While symptoms are multiple and often unique to the individual, it is a disorder that, at its essence, interferes with the meaningful connections between thoughts, feelings, and behavior. Its impact on the individual as well as those around the individual are often dramatic and devastating. Primary "positive" symptoms usually associated with schizophrenia include hallucinations -- sensations that the person experiences as real even though no evidence supports them; delusions -- the usually fixed beliefs that a person maintains in spite of evidence to the contrary; and thought disorder -- interference of the capacity to reason or think logically. Additional "deficit" or "negative" symptoms are often prominent and include affective loss or flatness; avolition -- a lack of will; anhedonia -- a lack of ability to experience pleasure; impaired attention; and difficulty relating to others.
The traditional view of the developmental course of schizophrenia has been thought of as consisting of a series of stages. The first is the prodromal phase, consisting of noticeable behavior changes such as social withdrawal, degradation of personal appearance, and peculiar and idiosyncratic actions, coupled with the emergence of the beginnings of classic symptoms. This has been most often identified as occurring in late adolescence or early adulthood, with a somewhat earlier onset for men compared to women. The prodromal phase may precede the actual onset of the disorder by as little as a few weeks to several years. It has long been suggested that the longer the prodromal phase, the worse the prognosis of the disorder. The active phase follows, notable for the emergence of the classic symptoms of hallucinations, delusions, and/or thought disorder. This phase typically requires hospitalization due to the debilitating effect of the mental disarray on the person's behavior and subsequent interactions with the environment. The length of the active phase is quite variable, sometimes a single short-lived episode, sometimes a chronic, long-lasting presentation. Most often, the active phase is interspersed with periods of remission, a time of relatively fewer or less pronounced symptoms when the individual may show a relative return to premorbid or near-premorbid functioning. These periods of remission themselves may vary from short to long intervals. Lastly, the residual phase is often identified by the reduction of the classic active symptoms and the increasing prominence of the "deficit" symptoms of apathy, avolition, alogia, anhedonia, and relational problems. The residual phase typically has been viewed as the "end-product" of the schizophrenia disorder. This final phase is what has been most traditionally associated with "late-life" schizophrenia.
As this readership is most sensitively aware, the traditional historical view of the natural course of aging was that it was equal to a relentless and progressive deterioration of physical and cognitive abilities, ultimately resulting in loss of function and inexorably leading to death. However, landmark studies such as the Baltimore Longitudinal study of the NIA (Department of Health, Education, and Welfare, 1978) have reshaped our views and shown that the effects of aging are much more complex and that an ever-declining functional trajectory throughout late-life is not immutable. We now know that the aging process is differentially impacted by a complex set of multiple variables, both biological and environmental. Depending on these variables, persons have the capability to maintain many functions indefinitely, regain lost functions, and develop new compensatory strategies. This increasingly positive perspective on aging, while it has taken time to change traditional assumptions, has resulted in renewed interest in the study of aging, the treatment of issues relevant to aging, and the reformulation of the view of the aging process to one of a dynamic, heterogenous process with a myriad of possible courses. In many respects, the beliefs regarding the course of schizophrenia have followed a similar path.
At the turn of the century, Eugene Bleuler (1911) described schizophrenia as a slowly progressive deterioration of the entire personality, with a generally poor prognosis and seldom any complete remission. In 1918 Emil Kraepelin (1919) reported schizophrenia as maintaining a chronic course with unrelenting residual symptoms and typically life-long resulting deficits. The obvious assumption from such a viewpoint is that older persons who have had schizophrenia throughout their lives become increasingly more symptomatic and develop greater functional impairment than they did earlier in the course of the disorder. This perspective of schizophrenia as an incurable and progressive disorder leading ultimately to an irreversible deterioration of function has had a profound influence on the clinical perspective, and thus the treatment, of schizophrenia, particularly in later life. With such a poor and "inevitable" prognosis, efforts aimed at late-life schizophrenia are only palliative at best and a waste of limited time and resources at worst. Perhaps because of these early pessimistic views, there has been a relative paucity of studies concerned with late-life schizophrenia. In fact, most of what we know about schizophrenia regarding the risk-factors, etiology, presentation, developmental course, neurobiology, environmental influences, and treatment outcome is derived from the study of relatively young persons suffering from schizophrenia. There have been only a few studies of schizophrenia in late-life and even fewer longitudinally-based studies. However, as with the aging process, more recent longitudinally-based studies from Zurich and Lausanne, Switzerland (e.g., M. Bleuler, 1972; Ciompi, 1980; 1985; Ciompi and Muller, 1976), Bonn, West Germany (e.g. Huber et al, 1980), Vermont (e.g., Harding et al, 1987a; 1987b), and Japan (e.g. Ogawa et al, 1987) have suggested a much more optimistic prognosis than traditional perspectives would predict.
In contrast to earlier views, these studies together suggest a great deal of variability in outcome for the course of schizophrenia. The above studies followed a combined group of schizophrenia patients nearly 1,500 strong from an average of 22 to 37 years after initial hospitalization, with some patients seen more than 50 years after initial contact (Ciompi, 1985). Needless to say, a wealth of information has been generated spanning numerous publications from these rich patient data sets. While space does not permit the detail these studies deserve, a very simple summary of their findings reveals a quite different long-term course for schizophrenia than inevitable decline. Rather than the vast majority of patients presenting with increased symptomatology and progressive functional decline, these studies have indicated that many patients either partially or completely recover. The Lausanne Investigations, probably the longest series of follow-up studies (see Ciompi, 1980 for a review), utilizing 289 persons with a mean follow-up period of 37 years (average age of patient at that time, 74 years), indicated that 27% of cases at "end state" could be identified as "recovered" and another 22% of cases could be identified as only "mild" in terms of impairment. Thus, 49% of schizophrenia patients had what could be considered favorable outcomes. Similarly, the 502 patients followed by Huber (see Huber, et al., 1980) in the Bonn, West Germany studies indicated 22% of patients eventually had complete remission of symptoms, while an additional 43% of the patients had improved presentations as identified by only a residual syndrome cluster without psychotic involvement. In fact, in reviewing the patient outcomes in their series of studies, Huber et al (1980) concluded that the aging process itself appeared to be related to a positive outcome. More recently, Harding and colleagues in the Vermont Longitudinal Research Project (see Harding, 1991; Harding et al., 1987a; 1987b) indicated that out of 118 well-defined patients with a mean follow-up period of 32 years (average age of patient after identification, 61 years), 27% reached a recovery stage, and an additional 35% were identified as significantly improved. Additionally, these studies overall suggest that the length of the course of schizophrenia is not suggestive of inevitable decline in that the long-term prognosis of the disorder appears to be independent of the duration of illness (e.g., Huber, et al., 1980, M. Bleuler, 1972).
The specific variables related to good outcome for schizophrenia are many and are complex in nature. However, the longitudinal studies described briefly above have helped to identify some of these. A good premorbid adaptation in familial and social realms, a lack of identifiable personality disorders, high premorbid occupational level, and marriage were seen across studies as important in a positive outcome over time (e.g., Ciompi, 1980; Huber et al., 1980; Harding et al., 1987b). Aspects of the course itself that have been tied to a good outcome include an acute onset, a short initial hospitalization, an episodic course that is interspersed with remissions, the presence of more active rather than negative features, and initial hospitalization before age 45. In this respect, these course related findings are similar to the long-held view that more acute, more "active" presentations of schizophrenia suggest a better course. Additional correlates of good outcome when assessed at the follow-up period may also include noninstitutional residential living, good physical health, and maintenance of a relatively high occupational level.
Overall, information gathered from these studies as well as from more recent studies of neuroanatomical and neurochemical variables (see Brown, 1993, for a review), as well as psychosocial variables portray a different and much more optimistic picture of the life long course of schizophrenia and thus the prognosis for late-life schizophrenia. Briefly, this picture is one of great variability from patient to patient with biological, environmental, and psychological variables impacting that course; a general reduction of positive symptoms as the patient ages; a far greater number of remissions and recovery than previously thought; a generally attenuating effect of age on schizophrenic symptoms; and, most importantly, the realization that approximately half of schizophrenia patients have a favorable outcome over time.
Note: In the preceding paragraphs, I presented only a very brief background of schizophrenia as well as past and current perspectives on the disorder's outcome in late life. This has necessarily been a very cursory coverage of a complex and controversial area and for brevity's sake did not include a specific discussion on late-onset schizophrenia, the development of schizophrenia with first onset in late life. For those interested in pursuing information concerning late-onset or late-life schizophrenia, I will be happy to direct you to additional readings. You may contact me by E-mail at LSMILLER@EGON.PSY.UGA.EDU.
REFERENCES
Bleuler, E (1911) Dementia praecox or the group of schizophrenics (J. Zinkin, trans.) New York, Int'l Univ Press [Reprinted in 1950].
Bleuler, M (1972) Die schizophrenen Geistesstorungen im lichte langjahriger kranken- und familiengeschichten, Stuttgart, Georg Thieme.
Brown, FW (1993) The neurobiology of late-life psychosis. Critical Reviews of Neurobiology, 7, 275-289.
Ciompi, L (1980) Catamnestic long-term study on the course of life and aging of schizophrenics. Schizophrenia Bulletin, 6, 606-618.
Ciompi, L (1985) Aging and schizophrenic psychosis. Acta Psychiatrica Scandinavica, S319, 17, 93-105.
Ciompi, L, Muller, C (1976) Lebensweg und alter der schizophrenen. Eine katamnestische langzeitstudie bis ins senium. Berlin, Springer/Verlag.
Department of Health, Education, and Welfare (1978). The Baltimore Longitudinal Study of the National Institute on Aging, 1-20. NIH Publication 78-134, Washington, DC, US Government Printing Office.
Harding, CM (1991) Aging and Schizophrenia: Plasticity, reversibility, and/or compensation. In Walker, EF (Ed), Schizophrenia: A life-course developmental perspective, San Diego, Academic Press, 257-273.
Harding, CM, Brooks, GW, Ashikaga, T, Strauss, JS, Breier, A (1987a) The Vermont longitudinal study of persons with severe mental illness: I. Methodology, study sample and overall status 32 years later. American Journal of Psychiatry, 144, 718-726.
Harding, CM, Brooks, GW, Ashikaga, T, Strauss, JS, Breier, A (1987b) The Vermont longitudinal research project: II. Long-term outcome functioning of subjects who retrospectively met DSM-III criteria for schizophrenia. American Journal of Psychiatry, 144, 727-735.
Huber, G, Gross, G, Schuttler, R, Linz, M (1980) Longitudinal studies of schizophrenic patients. Schizophrenia Bulletin, 6, 592-605.
Keith, SJ, Regire, DA, Rae, DS (1991) Schizophrenic disorders. In Robins, LN, Regier, DA (Eds), Psychiatric disorders in America: The epidemiologic catchment area study, New York, Toronto, Free Press.
Kraepelin, E (1919) Dementia praecox and paraphrenia (RM Barclay, trans.). New York, RE Krieger [Reprinted 1971].
Ogawa, K, Miya, M, Watarai, A, Nakazawa, M, Yuasa, S, Utena, H (1987) A long-term follow-up study of schizophrenia in Japan, with special reference to the course of social adjustment. British Journal of Psychiatry, 151, 758-765.
Rice, DP, Kelman, S, Miller, L (1991) Estimates of economic costs of alcohol and drug abuse and mental illness, 1985 and 1988. Public Health Report, 106, 280-292.
Rice, DP, Miller, LS (1992) The economic burden of schizophrenia Presentation at the Sixth Biennial Research Conference on the Economics of Mental Health, Bethesda, MD. Cited in Rupp, A, Keith, SJ (1993) The costs of schizophrenia: Assessing the burden. Psychiatric Clinics of North America, 16, 413-423.
Rupp, A, Keith, SJ (1993) The costs of schizophrenia: Assessing the burden. Psychiatric Clinics of North America, 16, 413-423.
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