The Relationship Between Anamnestic Factors and the Course of Schizophrenia Christian Mijller and Luc Ciompi
0
VER THE COURSE of many years, a vast amount of material has been brought together documenting the development of schizophrenia. Milestones in these efforts are the contributions of Mayer-Gross, M. Bleuler, Langfeldt, and Vaillant, which, though worthy of acknowledgment, need not be summarized here. For a long time, the mainstream of attention focused on the question of whether Kraepelin’s original opinion had retained its validity. Kraepelin, of course, maintained that “dementia praecox” had an absolutely unfavorable prognosis and, over the years, would lead to a special dementia or to a defective condition. With the gradual discovery that schizophrenic developments indeed exist which do not invariably lead to a severe terminal state, psychiatry began to examine the question of whether a distinction would have to be made between schizophrenias per se, in the narrower sense, and other forms of psychoses. Linked to the assumption that there exists a “core group” of schizophrenias characterized by an unfavorable course was the hypothesis that schizophrenia pursues a course whose process is-ultimately-organicahy determined. And, though its nature is as yet unknown, it will sooner or later be clarified. It is interesting to note that E. Bleuler, the father of the concept of schizophrenia. never spoke of a process, although he, too, had no doubt that in the final analysis the genesis of schizophrenia was organic. When we survey the innumerable studies available today on the catamnesis of schizophrenia, we cannot but observe that, depending on the author’s basic conception, the material has been differentially selected and its interpretation approached in the same manner. Repeatedly, one senses the attempt to exclude from the diagnosis of schizophrenia those cases which did not conform with the model pattern of the “unfavorable course.” All along we have taken a firm stance against this blending of diagnostics and course typology. In our opinion it is inappropriate to formulate a disease entity that is based only on the principle of incurability. In the entirety of medical sciences, such a procedure has never been applied. On this point we are in accord with M. Bleuler, with whose magnificent work on schizophrenia the audience is assumed to be familiar. Moreover, Mosher et al., of the National Institute of Mental Health, have arrived at similar conclusions. In a review article from 1972, this group explicitly pointed out the difficulty of comparability of diagnostic criteria, noting that the symptoms described in the literature as typical often depend on the theoretical stance of the researcher. “While past history is useful in differentiating extreme types (e.g., good from poor From rhe Hospiral De Cer_v. Psychiatric Clinic of Lausanne Vniversit.v. Lausanne. Switzerland. Miiller, M.D.: Director and Chairman, Hospiral De Cecv. Clinique Psychiatrique Vniversitaire. Lausanne. Switzerland; Luc Ciompi, M.D.: Associate Prqfessor and Head Physician. PsJ,chiafric Clinic of Lausanne Vniversit_v. Lausanne. Sti,ir:erland. Reprint requests should be addressed IO Professor C. Miiller. Direcror and Chairman. Hospital De
Christian
Cery. Clinique Psychiatrique Vniversitaire. 1008 Prilly. Swit-_erland. c 1916 hy Grune & Strarton. Inc. Comprehensive Psychiatry, Vol. 17, No. 3 IMay/Junel. 1976
387
388
MijLLER
AND CIOMPI
premorbid patients) it fails to characterize adequately the majority of schizophrenic patients who fall midway along the process-reactive-continuum. As a diagnostic tool, prognosis too seems inadequate-affected as it is by the uncertain influences of intervention efforts.” This problem complex is cited in these introductory remarks because of its importance for an understanding of our subsequent presentation, a study of the lifelong course of schizophrenia. As basic material, we selected a larger number of hospitalized patients who had been unequivocally diagnosed as schizophrenic. Having access to the archives of the Clinic of Lausanne, these date were processed within the framework of the larger study, “Enqutte de Lausanne.” The composition of this material deserves a brief explanation. Ever since E. Bleuler, Swiss psychiatry has known a certain “unite de doctrine” with regard to the definition of schizophrenia. In Lausanne, also, from 19 11 onward, diagnoses were based on his criteria. Our old case histories are amazingly detailed and contain well-documented information on the admitting condition at the time of hospitalization, on the subsequent course, patient’s premorbid personality, and his familial and socioprofessional situation. Added to this advantage of a thorough documentation is the favorable circumstance that, during the past 60 years, the Swiss population has remained markedly stable. Being spared wars, as was its good fortune, there were few migratory movements. When one adds that the municipal archives and population control have always been wellmaintained, this amounts to virtually ideal conditions for tracing a maximum number of former patients, even after so long a period of time. Thus, we proceeded along the following lines. From 1963 onward, we attempted systematically to contact all former clinic-patients who, at that time, were age 65 or over, i.e., the age groups 1873-1897. By far, the majority of these patients were admitted to our clinic between the years 1920 and 1940, since it was then the only psychiatric hospital for the population under study. Of a total of 5661 patients, 1642 had been diagnosed as schizophrenic. We obtained catamnestic information from 1586 of these formerly schizophrenic patients, 1239 of whom had deceased by the time of the follow-up investigation. Of these surviving 347 patients at the time of the catamnestic study, 8 could not be reached, 35 refused the examination, and in 16 cases, the original diagnosis could not be confirmed. Thus, 288 persons in our study remained available for thoroughgoing individual foIIow-up. As a rde, this consisted of a visit to the patient’s home, lasting from 1 to 3 hr. In each instance, the examination was conducted by a trained psychiatrist. Besides studying the old case history, there was a semistructured interview, and after the follow-up examination, a new record was compiled which included a report of several pages plus a completed questionnaire of approximately 90 items. One may infer, therefore, that our basic data represented all of the more severe cases of schizophrenia in our population-at least so far as the age group 1873-1897 is concerned-which had led to hospitalization. Let us now examine the distribution of age and sex in the subjects of our study and the period of time we were enabled to work with them. At the time of admission to hospital, i.e., at the very beginning of observation, the mean age was 33.2 years for the male and 41.3 for the female patients. At the time of our followup study the average age was 75.2 years for the males, and 75.8 for the females. Thus, the average span of catamnesis for both sexes totaled 36.8 years.
ANAMNESTIC
FACTORS
AND
SCHIZOPHRENIA
389
Except for a study by Lawton, this is the longest catamnestic period known in the literature today. It should be noted, moreover, that our study deals with schizophrenics who had long ago been discharged from hospital care. We believe that, from both the theoretical and practical standpoints, it would be impossible to visualize a population of schizophrenics that would afford a longer observation period for statistical evaluation. Considering the limits imposed by genera1 life expectancy, we have pretty well reached the maximum feasible observation period. We would surmise, therefore, that with respect to length of the observation period, our findings are valid. Whereas in the case of investigations by other authors, the objection can always be raised that a longer observation period might yet have led to changes in the type of course, this element of doubt is ruled out in our study. In contrast with other authors, the determining factor for us in accepting the diagnosis of schizophrenia was not the course which, at the time of the initial hospitalization, was unknown, but the severe psychopathologic picture presented during the onset of the illness. Herewith, our concept of schizophrenia differs from that of the Americans, whose concept is often very broad with a tendency “to diagnose practically all non-organic psychoses as schizophrenia” (Stephens, 1969), as well as from that of the Scandinavians who, depending on the course, speak of a schizophrenic “core group” as distinguished from a schizophreniform reactive psychosis. It is beyond the scope of the present study to discuss the relationships between those patients who have been followed-up and those who are deceased. This question has been examined elsewhere, particularly with reference to the extent to which those surviving can be regarded as “representative.” Nor is it possible here to consider the interesting problems of increased mortality among schizophrenics. However, let us direct our attention more specifically toward our theme, i.e., the influence of premorbid factors as they affect the course of schizophrenia. In analyzing the course of schizophrenia we have distinguished five different aspects: (1) overall development of schizophrenia (favorable, unfavorable, uncertain), (2) “terminal state” (favorable, unfavorable, uncertain), (3) presence of an organic psychosyndrome (favorable, unfavorable, uncertain), (4) social adaptation (favorable, unfavorable, uncertain), and (5) overall state of mental health (favorable, unfavorable, uncertain). The first question we asked ourselves was whether significant differences could be observed between the sexes. On the basis of our computations, the answer was negative for all five of our developmental aspects. Nor did the added assessment of the relationship between (A) sex and (B) the “extremely favorable” and “extremely unfavorable” development show any different result. Thus, the sex factor appears in no way to have influenced the long-term development of our subjects-extending even as far as old age. Furthermore, we analyzed the relationship between long-term course and familial conditions in our subjects’ childhood. Here, understandably, we could apply only rough criteria, and in a number of cases, the question had to remain open. Nevertheless, we found that in 70 patients (24.2%) the childhood situation had been severely disturbed in the sense of “broken home” through death of one or both parents, divorce, institutionalization, etc. This figure seems relatively high. By means of far more differentiated and reliable investigations, however, M. Bleuler was able to observe that, on the average, the loss of parents and childhood
MULLER
390
AND
CIOMPI
situations of the “broken home” type are only slightly more frequent among schizophrenics than in the total population, and even less frequent than in certain other psychic illnesses (e.g., alcoholism). Moreover, it must be taken into account that the influence of events, such as the loss of parents, depends on the overall internal and external situation. In other words, it may have a relieving effect as well as traumatizing. As was to be expected, therefore, our statistical computations confirmed that for the five course aspects under consideration, no significant correlations exist with the disturbed childhood conditions mentioned. With respect to long-term development extending into the old age of our subjects, childhood conditions appear to be of no consequence. What, then, is the relationship of the premorbid personality with respect to long-term development? On the basis of the personality characteristics reported in the old case histories, we constructed two different scales: (A) (B) (C) (D)
Schizoid personalities Other types of abnormal personality traits Inconspicuous (not deviating from norm) Uncertain
126cases 53 cases 50cases 60cases
= = = =
43.6% 18.4% 17.3% 20.8%
These figures differ from those of M. Bleuler by a greater proportion of nonschizoid personality disturbances and by a lesser percentage of prepsychotically nondeviant subjects. The second scale we employed was based on the descriptive adjectives occurring in the original personality descriptions: (A) Scrupulous-anxious-dysphoric-uncommunicative personalities (B) Impulsive-irritable-excitable-choleric-sensitive (C) Dependent, infantile hysteriform, demonstrative (D) Other abnormal traits (E) Nondeviant, syntonous, well-balanced, cheerful, active (F) Uncertain
71 cases 33 cases 13 cases 38cases 40 cases 49 cases
= = = = = =
24.6% 11.4% 4.5% 13.1% 13.8% 32.5%
Both scales were adjusted with relationship to the five evolutionary aspects previously mentioned. From a statistical standpoint, this now yielded clearly significant correlations. For both scales, we found more favorable evolutionary tendencies in the nondeviant premorbid personalities as compared to all others, notably for all five evolutionary factors with the single exception of psycho-organic change. By contrast, differences in course tendencies could be shown within the group of abnormal premorbid personalities. Specifically, the schizoid personalities were not marked by exceptionally poor developmental tendencies. Hence, premorbid personality disturbances indiscriminately worsen the prognosis, while their lack improves it. These findings in themselves are not new. Authors such as Gottlieb, Chase and Silverman, Vaillant, Cancro, and recently also M. Bleuler, had already arrived at similar results. New, however, is the disclosure that the relationship between premorbid personality and course of the disease applies not only to earlier stages, but continues into senescence. Thus, our investigations seem to confirm that factors are laid down in the prepsychotic personality structure which
ANAMNESTIC
FACTORS
AND
SCHIZOPHRENIA
391
decisively codetermine psychic development during the entire course of life. We are aware, naturally, that with regard to the concept, prepsychotic personality. nothing has yet been said about its origins. Intelligence and Education in Relation to the Course ofthe Disease In ten subjects we found an intelligence that had originally been above average, in 183, average intelligence, and in 26, an intelligence below average. Twentyseven of our subjects were clearly mentally retarded, and in 43, the intelligence at the time of onset of the illness could not be determined with certainty. Correlated with the evolution was the well-known fact that the “terminal states” in oligophrenics often bore a more severe stamp than in the remaining subjects. The overall evolution of the schizophrenic disturbance, however, is not significantly influenced by a deficiency in intelligence. In the small group of persons whose intelligence was above average, neither a particularly favorable nor a particularly unfavorable evolutionary tendency was found. To summarize, therefore, it may be said that intelligence is only very loosely related to the course of schizophrenia. Neither is a significant correlation to be found in the relationship between education and the course of the disease. Prqfessional Training, Occupationai Activities. and Adaptation We subdivided our subjects into four groups depending on whether they had received complete, incomplete, or no professional training prior to the onset of their illness, or whether the data on these factors were uncertain. Here, we found a loose correlation with the evolution of the disease: late social adaptation was significantly better in patients who, at one time, had completed a professional training. With regard to professional level and occupational activities, the correlation with the subsequent course is minimal. The general evolutionary tendency lies in the direction of somewhat better developmental chances in the case of persons with higher qualified occupations, and less favorable chances in those who are less qualified. This is particularly true among subjects who were already professionally inactive at the time of the onset of their illness. Finally we have observed that premorbid, inadequate occupational adaptation correlates with urzfavorable evolution; adequate adaptation with favorable longterm developments. Early>Socio-Familial Adaptation and Long-Term Evolution Here, again, we classified the subjects of our follow-up study into four groups: bad, mediocre, unequivocally good, and “uncertain” socio-familial adaptation. We learned that the overall course of the schizophrenic illness and severity of the terminal stages-coupled with the social adaptation and general mental health in old age-are significantly and invariably, in the same sense, related to the sociofamjbal adaptation as it at one time existed. Had that adaptation been inadequate, then ordinarily, we find a tendency toward an unfavorable development. If the adaptation was good, the long-term development was also favorable. For the most part these correlations were even high!,~sign$cant. With regard to marital status we were able to confirm observations made by
MtiLLER
392
AND CIOMPI
other authors: a larger number of single persons was found among schizophrenics at the time of onset of the illness in comparison with the total population. We found no certain relationship, however, between the earlier marital status and the development of schizophrenia. Social adaptation at the time of the follow-up study was shown to be significantly better in the case of those who were married at the time of the onset of illness than among single individuals. Thus, the married state, in the initial phases of the iIIness, seems to provide an indication, from the Iongrange viewpoint, for better social adaptation. This, however, contains no further prognostic value regarding the evolution of the illness.
DISCUSSION
For now we shall leave this exploration of the relationships between our several anamnestic variables and the course of the disease. Nor shall we take up the question of the relationship between the earliest schizophrenic symptomatology and later development; this question will be discussed within a different context. Instead, let us try to assess our findings and to view our data in larger perspective. Those variables for which we discovered no significant relationship with longterm development included (1) sex, (2) childhood situation, (3) intelligence, and (4) education. According to investigations by other authors, in particular Bleuler, we may still add heredity and body constitution. We have also tested these two variables in our material, arriving at similarly negative findings. In the preceding presentation, no detailed reference was made to these variables because the figures were relatively inconclusive. However, there can be no doubt about Bleuler’s results in this respect. Among the variables that can be verified anemnestically, and which show a positive correlation in either a favorable or unfavorable sense with the evolution, we have found, in the decreasing order of their importance, (1) premorbid sociofamilial adaptation, (2) premorbid occupational adaptation, (3) premorbid personality, (4) marital status, (5) professional education, and (6) occupational activities. Upon closer examination, we see that the overall course of schizophrenia and its terminal stages are intimately and significantly related first of all to the premorbid personality and secondly to the socio-familial and occupational adaptation that existed at the time of onset. This leads us to surmise that the evolution of schizophrenia depends on factors reaching deeply into the original personality structure. Hence, we are far removed from the assumption that a “schizophrenic process” develops in a premorbidly normal personality and from there on runs its regular course. It is a different question, however, how this premorbid personality structure and the capacity for socio-familial or occupational adaptation needs to be interpreted. Does it ultimately, or predominantly, depend on the effects of the early family milieu, or is this an echo of the ego weakness postulated by the pioneers of psychoanalysis? At this point, we have arrived at the boundaries of that which can be clarified through catamnestic work. Further progress will assuredly be achieved through prospective investigations. These may help us to arrive at a better understanding of the relationships between origins and evolution.
ANAMNESTIC
FACTORS
AND
SCHIZOPHRENIA
393
Bl6LlOGRAPHY Bleuler
E:
fenburg Deuticke,
Praecox.
Handbuch
Leiprig/Wien.
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Dementia
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torungen,
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in: Psychiactri
ihre u
M:
torungen
im
Die
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RA
G: The
langjahriger
Munskgaard. I 10):66. 19563
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Langfeldt
Brunner/Mazel,
Review New
Butterworths.
RA.
outcome
Annual
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longue duree sur le vieillissement Ciompi
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197 I ( pp 255 298
C (ed):
years later.
das
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Psychiatr
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der
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das
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Schizo-
1959 in advanced
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Berlin,
1973 JH.
the
et al:
Long-term
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Phillips
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Becker-Wittman
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Am
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tn
Scale
Psychiatry
504, lY69 GE: An historical
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J Nerv
review of the remttMent
Dis 118~48 SC.
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126:498
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1972. Schizophrenia
schizophrenia and
des alcooliques.
Depression
de 555 Anciens
Bern, Huber,
de
151. 1971
Etudes Catamncstiques
A
Re-
Munks-
forty-five
Z Gesamte
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Stephens
L. Ersert M: Etudes catamnestiques
Sot Psychiatry
LR.
Psychiatry
1972,
Bd
Springer,
pp. 1001-1036 Ciompi
Stages.
individual
1922
Miiller Mtiller
Genenwart
York,
W:
Verlaufe.
Mosher
phrenen.
literature,
Psychopathologic
Berlin-Heidelberg-New
on
I973 criteria
1941
Allgemeine
Mayer-Gross
schizophrenia:
1968 survey
Based
1913
Psychiatr
Copenhagen/London.
78:429-441.
S: Prognostic
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1956 [Acta
P: Schtzophrenia
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9:227-232,
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Barth,
J Gen Psycho1 121: 133 143, 1972
York-London,
A: Classification
97:332.
1939
Lawton
1972 of
in
in schizophrenia.
G: The Schizophreniform
Catamnestic gaard,
Krankenund Thieme,
Leipzig,
prognosis
Copenhagen,
Geistess-
Stuttgart.
(ed):
Schizophrenic Cancro
schizophrenen
Lichte
Familiengeschrchten.
Janssen,
E: Psychiatric.
Langfeldt
examinations,
Bleuler
chiatrie
Kraepelin
Stand
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Am J Psychiatry
Geistess-
7-82
Compr
status.
1941
der Gegenwart York,
Prognostic
1940
Psychiatr
der schizophrenen
Berlin-Heidelberg-New
BS:
The importance
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Schizophrener
Beziehungen.
Einzeldarst.
Bleuler
Gottlieb hebephrenia.
I
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GE:
Prospective
remtssion.
51X.1964
Arch
prediction Gen
Psychiatry
01
0
VER THE COURSE of many years, a vast amount of material has been brought together documenting the development of schizophrenia. Milestones in these efforts are the contributions of Mayer-Gross, M. Bleuler, Langfeldt, and Vaillant, which, though worthy of acknowledgment, need not be summarized here. For a long time, the mainstream of attention focused on the question of whether Kraepelin’s original opinion had retained its validity. Kraepelin, of course, maintained that “dementia praecox” had an absolutely unfavorable prognosis and, over the years, would lead to a special dementia or to a defective condition. With the gradual discovery that schizophrenic developments indeed exist which do not invariably lead to a severe terminal state, psychiatry began to examine the question of whether a distinction would have to be made between schizophrenias per se, in the narrower sense, and other forms of psychoses. Linked to the assumption that there exists a “core group” of schizophrenias characterized by an unfavorable course was the hypothesis that schizophrenia pursues a course whose process is-ultimately-organicahy determined. And, though its nature is as yet unknown, it will sooner or later be clarified. It is interesting to note that E. Bleuler, the father of the concept of schizophrenia. never spoke of a process, although he, too, had no doubt that in the final analysis the genesis of schizophrenia was organic. When we survey the innumerable studies available today on the catamnesis of schizophrenia, we cannot but observe that, depending on the author’s basic conception, the material has been differentially selected and its interpretation approached in the same manner. Repeatedly, one senses the attempt to exclude from the diagnosis of schizophrenia those cases which did not conform with the model pattern of the “unfavorable course.” All along we have taken a firm stance against this blending of diagnostics and course typology. In our opinion it is inappropriate to formulate a disease entity that is based only on the principle of incurability. In the entirety of medical sciences, such a procedure has never been applied. On this point we are in accord with M. Bleuler, with whose magnificent work on schizophrenia the audience is assumed to be familiar. Moreover, Mosher et al., of the National Institute of Mental Health, have arrived at similar conclusions. In a review article from 1972, this group explicitly pointed out the difficulty of comparability of diagnostic criteria, noting that the symptoms described in the literature as typical often depend on the theoretical stance of the researcher. “While past history is useful in differentiating extreme types (e.g., good from poor From rhe Hospiral De Cer_v. Psychiatric Clinic of Lausanne Vniversit.v. Lausanne. Switzerland. Miiller, M.D.: Director and Chairman, Hospiral De Cecv. Clinique Psychiatrique Vniversitaire. Lausanne. Switzerland; Luc Ciompi, M.D.: Associate Prqfessor and Head Physician. PsJ,chiafric Clinic of Lausanne Vniversit_v. Lausanne. Sti,ir:erland. Reprint requests should be addressed IO Professor C. Miiller. Direcror and Chairman. Hospital De
Christian
Cery. Clinique Psychiatrique Vniversitaire. 1008 Prilly. Swit-_erland. c 1916 hy Grune & Strarton. Inc. Comprehensive Psychiatry, Vol. 17, No. 3 IMay/Junel. 1976
387
388
MijLLER
AND CIOMPI
premorbid patients) it fails to characterize adequately the majority of schizophrenic patients who fall midway along the process-reactive-continuum. As a diagnostic tool, prognosis too seems inadequate-affected as it is by the uncertain influences of intervention efforts.” This problem complex is cited in these introductory remarks because of its importance for an understanding of our subsequent presentation, a study of the lifelong course of schizophrenia. As basic material, we selected a larger number of hospitalized patients who had been unequivocally diagnosed as schizophrenic. Having access to the archives of the Clinic of Lausanne, these date were processed within the framework of the larger study, “Enqutte de Lausanne.” The composition of this material deserves a brief explanation. Ever since E. Bleuler, Swiss psychiatry has known a certain “unite de doctrine” with regard to the definition of schizophrenia. In Lausanne, also, from 19 11 onward, diagnoses were based on his criteria. Our old case histories are amazingly detailed and contain well-documented information on the admitting condition at the time of hospitalization, on the subsequent course, patient’s premorbid personality, and his familial and socioprofessional situation. Added to this advantage of a thorough documentation is the favorable circumstance that, during the past 60 years, the Swiss population has remained markedly stable. Being spared wars, as was its good fortune, there were few migratory movements. When one adds that the municipal archives and population control have always been wellmaintained, this amounts to virtually ideal conditions for tracing a maximum number of former patients, even after so long a period of time. Thus, we proceeded along the following lines. From 1963 onward, we attempted systematically to contact all former clinic-patients who, at that time, were age 65 or over, i.e., the age groups 1873-1897. By far, the majority of these patients were admitted to our clinic between the years 1920 and 1940, since it was then the only psychiatric hospital for the population under study. Of a total of 5661 patients, 1642 had been diagnosed as schizophrenic. We obtained catamnestic information from 1586 of these formerly schizophrenic patients, 1239 of whom had deceased by the time of the follow-up investigation. Of these surviving 347 patients at the time of the catamnestic study, 8 could not be reached, 35 refused the examination, and in 16 cases, the original diagnosis could not be confirmed. Thus, 288 persons in our study remained available for thoroughgoing individual foIIow-up. As a rde, this consisted of a visit to the patient’s home, lasting from 1 to 3 hr. In each instance, the examination was conducted by a trained psychiatrist. Besides studying the old case history, there was a semistructured interview, and after the follow-up examination, a new record was compiled which included a report of several pages plus a completed questionnaire of approximately 90 items. One may infer, therefore, that our basic data represented all of the more severe cases of schizophrenia in our population-at least so far as the age group 1873-1897 is concerned-which had led to hospitalization. Let us now examine the distribution of age and sex in the subjects of our study and the period of time we were enabled to work with them. At the time of admission to hospital, i.e., at the very beginning of observation, the mean age was 33.2 years for the male and 41.3 for the female patients. At the time of our followup study the average age was 75.2 years for the males, and 75.8 for the females. Thus, the average span of catamnesis for both sexes totaled 36.8 years.
ANAMNESTIC
FACTORS
AND
SCHIZOPHRENIA
389
Except for a study by Lawton, this is the longest catamnestic period known in the literature today. It should be noted, moreover, that our study deals with schizophrenics who had long ago been discharged from hospital care. We believe that, from both the theoretical and practical standpoints, it would be impossible to visualize a population of schizophrenics that would afford a longer observation period for statistical evaluation. Considering the limits imposed by genera1 life expectancy, we have pretty well reached the maximum feasible observation period. We would surmise, therefore, that with respect to length of the observation period, our findings are valid. Whereas in the case of investigations by other authors, the objection can always be raised that a longer observation period might yet have led to changes in the type of course, this element of doubt is ruled out in our study. In contrast with other authors, the determining factor for us in accepting the diagnosis of schizophrenia was not the course which, at the time of the initial hospitalization, was unknown, but the severe psychopathologic picture presented during the onset of the illness. Herewith, our concept of schizophrenia differs from that of the Americans, whose concept is often very broad with a tendency “to diagnose practically all non-organic psychoses as schizophrenia” (Stephens, 1969), as well as from that of the Scandinavians who, depending on the course, speak of a schizophrenic “core group” as distinguished from a schizophreniform reactive psychosis. It is beyond the scope of the present study to discuss the relationships between those patients who have been followed-up and those who are deceased. This question has been examined elsewhere, particularly with reference to the extent to which those surviving can be regarded as “representative.” Nor is it possible here to consider the interesting problems of increased mortality among schizophrenics. However, let us direct our attention more specifically toward our theme, i.e., the influence of premorbid factors as they affect the course of schizophrenia. In analyzing the course of schizophrenia we have distinguished five different aspects: (1) overall development of schizophrenia (favorable, unfavorable, uncertain), (2) “terminal state” (favorable, unfavorable, uncertain), (3) presence of an organic psychosyndrome (favorable, unfavorable, uncertain), (4) social adaptation (favorable, unfavorable, uncertain), and (5) overall state of mental health (favorable, unfavorable, uncertain). The first question we asked ourselves was whether significant differences could be observed between the sexes. On the basis of our computations, the answer was negative for all five of our developmental aspects. Nor did the added assessment of the relationship between (A) sex and (B) the “extremely favorable” and “extremely unfavorable” development show any different result. Thus, the sex factor appears in no way to have influenced the long-term development of our subjects-extending even as far as old age. Furthermore, we analyzed the relationship between long-term course and familial conditions in our subjects’ childhood. Here, understandably, we could apply only rough criteria, and in a number of cases, the question had to remain open. Nevertheless, we found that in 70 patients (24.2%) the childhood situation had been severely disturbed in the sense of “broken home” through death of one or both parents, divorce, institutionalization, etc. This figure seems relatively high. By means of far more differentiated and reliable investigations, however, M. Bleuler was able to observe that, on the average, the loss of parents and childhood
MULLER
390
AND
CIOMPI
situations of the “broken home” type are only slightly more frequent among schizophrenics than in the total population, and even less frequent than in certain other psychic illnesses (e.g., alcoholism). Moreover, it must be taken into account that the influence of events, such as the loss of parents, depends on the overall internal and external situation. In other words, it may have a relieving effect as well as traumatizing. As was to be expected, therefore, our statistical computations confirmed that for the five course aspects under consideration, no significant correlations exist with the disturbed childhood conditions mentioned. With respect to long-term development extending into the old age of our subjects, childhood conditions appear to be of no consequence. What, then, is the relationship of the premorbid personality with respect to long-term development? On the basis of the personality characteristics reported in the old case histories, we constructed two different scales: (A) (B) (C) (D)
Schizoid personalities Other types of abnormal personality traits Inconspicuous (not deviating from norm) Uncertain
126cases 53 cases 50cases 60cases
= = = =
43.6% 18.4% 17.3% 20.8%
These figures differ from those of M. Bleuler by a greater proportion of nonschizoid personality disturbances and by a lesser percentage of prepsychotically nondeviant subjects. The second scale we employed was based on the descriptive adjectives occurring in the original personality descriptions: (A) Scrupulous-anxious-dysphoric-uncommunicative personalities (B) Impulsive-irritable-excitable-choleric-sensitive (C) Dependent, infantile hysteriform, demonstrative (D) Other abnormal traits (E) Nondeviant, syntonous, well-balanced, cheerful, active (F) Uncertain
71 cases 33 cases 13 cases 38cases 40 cases 49 cases
= = = = = =
24.6% 11.4% 4.5% 13.1% 13.8% 32.5%
Both scales were adjusted with relationship to the five evolutionary aspects previously mentioned. From a statistical standpoint, this now yielded clearly significant correlations. For both scales, we found more favorable evolutionary tendencies in the nondeviant premorbid personalities as compared to all others, notably for all five evolutionary factors with the single exception of psycho-organic change. By contrast, differences in course tendencies could be shown within the group of abnormal premorbid personalities. Specifically, the schizoid personalities were not marked by exceptionally poor developmental tendencies. Hence, premorbid personality disturbances indiscriminately worsen the prognosis, while their lack improves it. These findings in themselves are not new. Authors such as Gottlieb, Chase and Silverman, Vaillant, Cancro, and recently also M. Bleuler, had already arrived at similar results. New, however, is the disclosure that the relationship between premorbid personality and course of the disease applies not only to earlier stages, but continues into senescence. Thus, our investigations seem to confirm that factors are laid down in the prepsychotic personality structure which
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decisively codetermine psychic development during the entire course of life. We are aware, naturally, that with regard to the concept, prepsychotic personality. nothing has yet been said about its origins. Intelligence and Education in Relation to the Course ofthe Disease In ten subjects we found an intelligence that had originally been above average, in 183, average intelligence, and in 26, an intelligence below average. Twentyseven of our subjects were clearly mentally retarded, and in 43, the intelligence at the time of onset of the illness could not be determined with certainty. Correlated with the evolution was the well-known fact that the “terminal states” in oligophrenics often bore a more severe stamp than in the remaining subjects. The overall evolution of the schizophrenic disturbance, however, is not significantly influenced by a deficiency in intelligence. In the small group of persons whose intelligence was above average, neither a particularly favorable nor a particularly unfavorable evolutionary tendency was found. To summarize, therefore, it may be said that intelligence is only very loosely related to the course of schizophrenia. Neither is a significant correlation to be found in the relationship between education and the course of the disease. Prqfessional Training, Occupationai Activities. and Adaptation We subdivided our subjects into four groups depending on whether they had received complete, incomplete, or no professional training prior to the onset of their illness, or whether the data on these factors were uncertain. Here, we found a loose correlation with the evolution of the disease: late social adaptation was significantly better in patients who, at one time, had completed a professional training. With regard to professional level and occupational activities, the correlation with the subsequent course is minimal. The general evolutionary tendency lies in the direction of somewhat better developmental chances in the case of persons with higher qualified occupations, and less favorable chances in those who are less qualified. This is particularly true among subjects who were already professionally inactive at the time of the onset of their illness. Finally we have observed that premorbid, inadequate occupational adaptation correlates with urzfavorable evolution; adequate adaptation with favorable longterm developments. Early>Socio-Familial Adaptation and Long-Term Evolution Here, again, we classified the subjects of our follow-up study into four groups: bad, mediocre, unequivocally good, and “uncertain” socio-familial adaptation. We learned that the overall course of the schizophrenic illness and severity of the terminal stages-coupled with the social adaptation and general mental health in old age-are significantly and invariably, in the same sense, related to the sociofamjbal adaptation as it at one time existed. Had that adaptation been inadequate, then ordinarily, we find a tendency toward an unfavorable development. If the adaptation was good, the long-term development was also favorable. For the most part these correlations were even high!,~sign$cant. With regard to marital status we were able to confirm observations made by
MtiLLER
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AND CIOMPI
other authors: a larger number of single persons was found among schizophrenics at the time of onset of the illness in comparison with the total population. We found no certain relationship, however, between the earlier marital status and the development of schizophrenia. Social adaptation at the time of the follow-up study was shown to be significantly better in the case of those who were married at the time of the onset of illness than among single individuals. Thus, the married state, in the initial phases of the iIIness, seems to provide an indication, from the Iongrange viewpoint, for better social adaptation. This, however, contains no further prognostic value regarding the evolution of the illness.
DISCUSSION
For now we shall leave this exploration of the relationships between our several anamnestic variables and the course of the disease. Nor shall we take up the question of the relationship between the earliest schizophrenic symptomatology and later development; this question will be discussed within a different context. Instead, let us try to assess our findings and to view our data in larger perspective. Those variables for which we discovered no significant relationship with longterm development included (1) sex, (2) childhood situation, (3) intelligence, and (4) education. According to investigations by other authors, in particular Bleuler, we may still add heredity and body constitution. We have also tested these two variables in our material, arriving at similarly negative findings. In the preceding presentation, no detailed reference was made to these variables because the figures were relatively inconclusive. However, there can be no doubt about Bleuler’s results in this respect. Among the variables that can be verified anemnestically, and which show a positive correlation in either a favorable or unfavorable sense with the evolution, we have found, in the decreasing order of their importance, (1) premorbid sociofamilial adaptation, (2) premorbid occupational adaptation, (3) premorbid personality, (4) marital status, (5) professional education, and (6) occupational activities. Upon closer examination, we see that the overall course of schizophrenia and its terminal stages are intimately and significantly related first of all to the premorbid personality and secondly to the socio-familial and occupational adaptation that existed at the time of onset. This leads us to surmise that the evolution of schizophrenia depends on factors reaching deeply into the original personality structure. Hence, we are far removed from the assumption that a “schizophrenic process” develops in a premorbidly normal personality and from there on runs its regular course. It is a different question, however, how this premorbid personality structure and the capacity for socio-familial or occupational adaptation needs to be interpreted. Does it ultimately, or predominantly, depend on the effects of the early family milieu, or is this an echo of the ego weakness postulated by the pioneers of psychoanalysis? At this point, we have arrived at the boundaries of that which can be clarified through catamnestic work. Further progress will assuredly be achieved through prospective investigations. These may help us to arrive at a better understanding of the relationships between origins and evolution.
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