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The metamorphosis of schizophrenia: from chronicity to vulnerability

  • Joseph Zubin (a1), Jay Magaziner (a1) and Stuart R. Steinhauer (a1)

On the evidence of long-term follow-up studies of cohorts of patients in Europe the outcome of schizophrenia appears to be changing from chronicity to an episodic course with a more favourable outlook. While the reasons for this change are unclear it is suggested that schizophrenia is characterized essentially by a state of vulnerability to the disorder. This vulnerability may or may not give rise to an episode of illness, depending on the incidence of triggering life event stressors and on the moderating influences of social networks, ecological factors, and premorbid personality. The traditional view of schizophrenia as an essentially chronic condition reflects not so much the natural history of the disorder as iatrogenic influences, lack of satisfactory extra-mural care, the accumulation of a relatively small proportion of truly chronic illnesses and the failure to recognize the termination of an episode of illness in patients with poor premorbid personalities. Evidence for the episodic nature of schizophrenia is presented.

Corresponding author
1Address for correspondence: Dr J. Zubin, Biometrics Research, 151R, Veterans Administration Medical Center, Highland Drive, Pittsburgh, PA 15206, USA.
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Achté K. A. (1967). On prognosis and rehabilitation in schizophrenia and paranoid psychoses. Acta Psychiatrica et Neurologica Scandinavica Supplement 125, 33.
Altman I. (1975). The Environment and Social Behavior. Brooks/Cole Publishing Co.: Monterey, CA.
American Psychiatric Association (1980). Diagnostic and Statistical Manual – III (DSM–III). APA: Washington, D.C.
Andreasen N. C. (1982). Negative symptoms in schizophrenia: definition and reliability. Archives of General Psychiatry 39, 784788.
Andreasen N. C. & Olsen S. A. (1982). Negative vs. positive schizophrenia: definition and validation. Archives of General Psychiatry 39, 789794.
Andreasen N. C., Olsen S. A., Dennert J. W. & Smith M. R. (1982). Ventricular enlargement in schizophrenia: relationship to positive and negative symptoms. American Journal of Psychiatry 139, 297302.
Berkman L. & Syme S. (1979). Social networks, host resistance and mortality: a nine-year follow-up study of Alameda County residents. American Journal of Epidemiology 109(2), 186204.
Bleuler M. (1941). Krankheitsverlauf, Persönlichkeit und Verwandtschaft Schizophrener und ihre gegenseitigen Beziehungen. Thieme: Leipzig. (Disease Course, Personality and Kinship of Schizophrenics and their Mutual Relationships. Cited by Bleuler (1978).)
Bleuler M. (1978). The Schizophrenic Disorders: Long-term Patient and Family Studies (transl. Clemens S. M.). Yale University Press: New Haven. (Translation of Die Schizophrenen Geistesstörungen im Lichte: Langjahriger Kranken- und Familiengeschichten. Georg Thieme Verlag: Stuttgart. 1972.)
Brenner M. H. (1973). Mental Illness and the Economy. Harvard University Press: Cambridge, Mass.
Brown G. W., Birley J. L. T. & Wing J. K. (1972). The influences of family life on the course of schizophrenic disorders: a replication. British Journal of Psychiatry 121, 241258.
Brown G. W., Ní Bhrolchaín M. & Harris T. (1975). Social class and psychiatric disturbances among women in an urban population. Sociology 9, 225254.
Brown G. W., Preisman R. C., Anderson M. D., Nixon R. K., Isbister J. L. & Price H. A. (1981). Memory performance of chemical workers exposed to polybrominated biphenyls. Science 212, 14131415.
Cassel J. (1976). The contribution of the social environment to host resistance. American Journal of Epidemiology 104, 107123.
Ciompi L. (1980). The natural history of schizophrenia in the long term. British Journal of Psychiatry 136, 413420.
Cooper J. E., Kendell R. E., Gurland B. J., Sharpe L., Copeland J. R. M. & Simon R. (1972). Psychiatric Diagnosis in New York and London: A Comparative Study of Mental Hospital Admissions. Maudsley Monograph No. 20 Oxford University Press: London.
Crow T. J. (1980). Discussion: positive and negative schizophrenic symptoms and the role of dopamine. British Journal of Psychiatry 137, 383386.
Crow T. J. (1981). Riposte: positive and negative schizophrenic symptoms and the role of dopamine. British Journal of Psychiatry 139, 251254.
Dohrenwend B. P. & Dohrenwend B. S. (1969). Social Status and Psychological Disorder. John Wiley & Sons: New York.
Eaton W. W. (1978). Life events, social supports and psychiatric symptoms: a reanalysis of the New Haven data. Journal of Health and Social Behavior 19, 230234.
Essen-Möller E. & Hagnell O. (1975). ‘Normal’ and ‘regional’ traits of personality according to Sjöbring: re-ratings and prognostic implications. Neuropsychobiology 1, 146154.
Essen-Möller E., Larsson H., Uddenberg C. E. & White G. (1956). Individual traits and morbidity in a Swedish rural population. Acta Psychiatrica et Neurologica Scandinavica Supplement 100, 1160.
Feldman P. G., Ricks N. L. & Baker E. L. (1980). Neuropsychological effects of industrial toxins: a review. American Journal of Industrial Medicine 1, 211227.
Galle O. R., Gove W. R. & McPherson J. M. (1972). Population density and pathology: what are the relations for man? Science 176, 2330.
Gerard D. & Houston L. (1953). Family setting and the social ecology of schizophrenia. Psychiatric Quarterly 27, 90101.
Glass D., Singer J. & Pennebaker J. (1977). Behavioral and physiological effects of uncontrollable environmental events. In Perspectives on Environment and Behavior (ed. Stokols D.), pp. 131151. Plenum Press: New York.
Gottesman I. I. & Shields J. (1976). A critical review of recent adoption, twin, and family studies of schizophrenia: behavioral genetics perspectives. Schizophrenia Bulletin 2, 360401.
Gove W. R. & Hughes M. (1980). Re-examining the ecological fallacy: a study in which aggregate data are critical in investigating the pathological effects of living alone. Social Forces 58, 11571177.
Hagnell O. (1966). A Prospective Study of the Incidence of Mental Disorder. Svenska Bokforlaget Norstedts.
Hammer M., Makiesky-Barrow S. & Gutwirth L. (1978). Social networks and schizophrenia. Schizophrenia Bulletin 4, 525545.
Hare E. H. (1956 a). Mental illness and social conditions in Bristol. Journal of Mental Science 102, 349357.
Hare E. H. (1956 b). Family setting and the urban distribution of schizophrenia. Journal of Mental Science 102, 753760.
Hare E. H. (1974). The changing content of psychiatric illness. Journal of Psychosomatic Research 18, 283289.
Henderson S., Byrne D. G., Duncan-Jones P., Scott R. & Adcock S. (1980). Social relationships, adversity and neurosis: A study of associations in a general population sample. British Journal of Psychiatry 136, 574583.
Holmes T. H. & Rahe R. H. (1967). The Social Readjustment Rating Scale. Journal of Psychosomatic Research 11, 213218.
Huber G., Gross G., Schuttler R. & Linz M. (1980). Longitudinal studies of schizophrenic patients. Schizophrenia Bulletin 6,592605.
Jackson J. H. (1931). Selected Writings (ed. Taylor J.). Hodder & Stoughton: London. (Quoted by Andreasen, N. C. et al. 1982.)
Johnstone E. C., Crow T. J., Frith C. D., Husband J. & Creel L. (1976). Cerebral ventricular size and cognitive impairment in chronic schizophrenia. Lancet ii, 924926.
Kohn M. (1973). Social class and schizophrenia: a critical review and a reformulation. Schizophrenia Bulletin 17, 6079.
Kramer M. (1978). Population changes and schizophrenia, 1970–1985. In The Nature of Schizophrenia: New Approaches to Research and Treatment (ed. Wynne L. C., Cromwell R. L. and Matthysse S.), pp. 545571. John Wiley & Sons: New York.
Kreisman D. (1970). Social interaction and intimacy in preschizophrenic adolescents. In The Psychopathology of Adolescence (ed. Zubin J. and Freedman A. M.), pp. 299318. Grune and Stratton: New York.
Leckman J. F., Bowers M. B. Jr & Sturges J. S. (1981). Relationship between estimated premorbid adjustment and CSF homovanillic acid and 5-hydroxyindoleacetic acid levels. American Journal of Psychiatry 138, 472477.
Leff J. (1978). Social and psychological causes of the acute attack. In Schizophrenia: Towards a New Synthesis (ed. Wing J. K.). pp. 139166. Academic Press: New York.
Leff J. & Vaughn C. (1981). The role of maintenance therapy and relatives' expressed emotion in relapse of schizophrenia: a two-year follow-up. British Journal of Psychiatry 139, 102104.
Magaziner J. (1980). Density, living alone, age and psychopathology in the urban environment. Unpublished doctoral dissertation: The University of Chicago.
Mintz N. & Schwartz D. (1964). Urban ecology and psychosis. International Journal of Psychiatry 10, 101118.
Myers J. K., Lindenthal J. & Pepper M. (1974). Social class, life events and psychiatric symptoms: a longitudinal study. In Stressful Life Events (ed. Dohrenwend B. S. and Dohrenwend B. P.), pp. 191205. John Wiley & Sons: New York.
Neale J. M. & Oltmanns T. F. (1980). Schizophrenia. pp. 362388. John Wiley & Sons: New York.
Paul G. L. & Lentz R. J. (1977). Psychosocial Treatment of Chronic Mental Patients: Milieu versus Social Learning Programs. Harvard University Press: Cambridge, Mass.
Pollin W. & Stabenau J. R. (1968). Biological, psychological and historical differences in a series of monozygotic twins discordant for schizophrenia. In The Transmission of Schizophrenia (ed. Rosenthal D. and Kety S. S.), pp. 317332. Pergamon Press: Oxford.
Pollin W., Stabenau J. R., Mosher L. & Turpin J. (1966). Life history differences in identical twins discordant for schizophrenia. American Journal of Orthospychiatry 36, 492509.
Proshansky H., Nelson-Shulman Y. & Kaminoff R. (1978). The role of physical settings in life crisis experiences. In Stress and Anxiety, Vol. 6 (ed. Sarason I. and Spielberger C.), pp. 125. John Wiley & Sons: New York.
Rosenberg G. S. (1970). The Worker Grows Old. Jossey-Bass: San Francisco.
Rosow I. (1967). Social Integration of the Aged. Free Press: New York.
Shapiro R. & Shader R. (1979). Selective review of previous follow-up studies of schizophrenia and other psychoses. In Schizophrenia: An International Follow-up Study, World Health Organization, Geneva, pp. 1143. John Wiley & Sons: New York.
Sjöbring H. (1963). La personnalité: Structure et développement. Paris: Doin. (Reprinted (1973) as: Personality structure and development, a model and its application. Acta Psychiatrica Scandinavica Supplement 244, transl. E. Essen-Möller.)
Sokolovsky J., Cohen C., Berger D. & Geiger J. (1978). Personal networks of ex-mental patients in a Manhattan S.R.O. Hotel. Human Organization 37, 515.
Spitzer R. L., Endicott J. & Robins E. (1975). Research Diagnostic Criteria for a Selected Group of Functional Disorders (2nd edn). Biometrics Research Unit, New York State Psychiatric Institute: New York.
Spring B. & Coons H. (1982). Stress as a precursor of schizophrenia. In Psychological Stress and Psychopathology (ed. Neufeld R. W. J.), pp. 1354. McGraw-Hill: New York.
Spring B. & Zubin J. (1978). Attention and information processing as indicators of vulnerability to schizophrenic episodes. In The Nature of Schizophrenia: New Approaches to Research and Treatment (ed. Wynne L. C., Cromwell R. and Matthysse S.), pp. 366375. John Wiley & Sons: New York.
Staudt V. & Zubin J. (1957). A biometric evaluation of the somatotherapies in schizophrenia. Psychological Bulletin 54, 171196.
Strauss J. S., Carpenter W. T. & Bartko J. J. (1974). The diagnosis and understanding of schizophrenia: III. Speculation on the processes that underlie schizophrenic symptoms and signs. Schizophrenia Bulletin 11, 6169.
Torrey E. F. (1980). Schizophrenia and Civilization. Jason Aronson: New York.
United Nations Environment Program and the World Health Organization (1980). Environmental health criteria 12: Noise. Reviewed by Miller, A. R. In American Journal of Industrial Medicine 1, 229232.
Watt N. F., Grubb T. W. & Erlenmeyer-Kimling L. (1982). Social, emotional, and intellectual behavior at school among children at high risk for schizophrenia. Journal of Abnormal Psychology 50, 171181.
Wechsler H. & Pugh T. F. (1967). Fit of individual and community characteristics and rates of psychiatric hospitalization. American Journal of Sociology 73(2), 331338.
Weinberger D. R., Torrey E. F., Neophytides A. N. & Wyatt R. J. (1979). Lateral cerebral ventricular enlargement in chronic schizophrenia. Archives of General Psychiatry 36, 735739.
Weinberger D. R., Cannon-Spoor E., Potkin S. G. & Wyatt R. J. (1980). Poor premorbid adjustment and CT scan abnormalities in chronic schizophrenia. American Journal of Psychiatry 137, 14101413.
Wing J. K. (1966). Five year outcome in early schizophrenia. Proceedings of the Royal Society of Medicine 59, 1718.
Wing J. K. (1978 a). Clinical concepts of schizophrenia. In Schizophrenia – Towards a New Synthesis (ed. Wing J. K.), pp. 130. Academic Press: London.
Wing J. K. (1978 b). Social influences on the course of schizophrenia. In The Nature of Schizophrenia: New Approaches to Research and Treatment (ed. Wynne L. C., Cromwell R. L. and Matthysse S.), pp. 599616. John Wiley & Sons: New York.
Wing J. K. (1980). Social psychiatry in the United Kingdom: the approach to schizophrenia. Schizophrenia Bulletin 6, 556565.
Wing J. K., Cooper J. E. & Sartorius N. (1974). The Measurement and Classification of Psychiatric Symptoms. Cambridge University Press: Cambridge.
World Health Organization (1979). Schizophrenia – An International Follow-up Study. John Wiley & Sons: New York.
Zubin J. (1965). Psychopathology and the social sciences. In Perspectives in Social Psychology (ed. Klineberg O. and Christie R.), pp. 189207. Holt, Rinehart and Winston: New York.
Zubin J. (1972). Scientific models for psychopathology in the '70s. Seminar Psychiatry 4, 283296.
Zubin J. & Burdock E. I. (1965). The revolution in psychopathology and its implications for public health. Acta Psychiatrica Scandinavica 41, 348359.
Zubin J. & Spring B. (1977). Vulnerability: a new view of schizophrenia. Journal of Abnormal Psychology 86, 103126.
Zubin J. & Steinhauer S. (1981). How to break the logjam in schizophrenia: A look beyond genetics. Journal of Nervous and Mental Disease 169, 477492.
Zubin J., Sutton S., Salzinger K., Salzinger S., Burdock E. I. & Peretz D. (1961). A biometric approach to prognosis in schizophrenia. In Comparative Epidemiology in the Mental Disorders (ed. Hoch P. H. and Zubin J.), pp. 143203. Grune & Stratton: New York.
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