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©2002 CRC Press LLC

Figure 1.14 

Cordron, by Gilbert Price. This patient was admitted at the age of 22 years. His extreme shyness and

eccentric behavior culminated in his arrest for ‘suspicious’ conduct. Neologisms, elaborated into complex
descriptive systems of pictures, chimneys and other objects, dominated his psychopathology. Reproduced with kind
permission of the Bethlem Royal Hospital Archives and Museum, Beckenham, Kent, UK


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©2002 CRC Press LLC

Poverty of speech

Restriction in the amount

of spontaneous speech and in the information
contained in speech (alogia).

Flattening of affect

Restriction in the

experience and expression of emotion.

Anhedonia–asociality 

Inability to experience

pleasure, few social contacts and social with-
drawal.

Avolition-apathy

Reduced drive, energy

and interest.

Attentional impairment

Inattentiveness at

work and interview.

NEGATIVE SYMPTOMS

Figure 1.15  

Cats, by Louis Wain (1860–1939). Wain was a British artist who became famous for his drawings of cats. He

was a patient at the Bethlem Hospital in the 1920s. Paintings such as these, which are suggestive of disorganization, visual
perceptual disturbances and abnormalities of affect, have been taken as illustrative of his psychological decline, although
more recent scholarship suggests that they were not out of keeping with contemporary design practice. Reproduced with kind
permission of the Bethlem Royal Hospital Archives and Museum, Beckenham, Kent, UK

THE CHRONIC ILLNESS

Eventually, even without treatment, the acute
symptoms of schizophrenia usually resolve.
Unfortunately this does not always mean that the
patient will fully recover. Over 50% of patients
diagnosed as suffering from schizophrenia will
show evidence of a significant degree of negative
symptomatology. Furthermore, in chronic schizo-
phrenia, positive symptoms also frequently
remain, although they tend not to predominate.

Negative symptoms may also be seen in the

acute episode, and their onset can often precede
(as one form of ‘schizophrenic prodrome’) the
development of typical positive symptoms.
Negative symptoms are multifactorial in origin.
Primary negative symptoms may be difficult to
distinguish from those secondary to florid positive


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©2002 CRC Press LLC

and are the most important cause of long-term
disability.

COURSE AND OUTCOME OF
SCHIZOPHRENIA

The in-patient psychiatric population has fallen
dramatically since the 1950s in Western countries,
when effective antipsychotic drug treatments first
became available (

Figure 1.17

). However, the

outcome of schizophrenia, even with treatment,
remains variable (

Figure 1.18

 and 

Table 1.1

)

11–17

.

Longitudinally, the typical course of chronic

schizophrenia is described in 

Figure 1.19

18

.

Schizophrenia also carries a high mortality. Rates
of suicide in follow-up studies vary from about 2%

psychotic symptomatology, while others may
represent side-effects of antipsychotic drugs. It is
often difficult to differentiate between the
negative symptoms of schizophrenia and the
symptoms of a depressive illness. Depression is
common in schizophrenia, and often becomes
evident as the acute episode resolves.

True primary negative symptoms are often

described as ‘deficit’ symptoms. Their frequency is
markedly increased in chronic schizophrenia and
is related to poor prognosis, poor response to
antipsychotic drugs, poor premorbid adjustment,
cognitive impairment and structural brain
abnormalities (sometimes called ‘type 2’ schizo-
phrenia). These symptoms are not easy to treat,
are often very distressing to families and carers,

Figure 1.16 

Broach shizophrene, by Bryan Charnley. Bryan Charnley illustrated the experience of psychosis in many

striking artworks, including a series of self-portraits painted as he came off medication (see 

Figure 1.20

). Reproduced

with kind permission of the Bethlem Royal Hospital Archives and Museum, Beckenham, Kent, UK


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©2002 CRC Press LLC

Figure 1.18

Course of schizo-

phrenia. Four typical patterns
in the course of schizophrenia
are described by Shepherd and
colleagues

16

who followed up

a cohort of patients with an
operational (CATEGO-defined)
diagnosis of schizophrenia who
were admitted to a UK hospital
over an 18-month period.
Figure reproduced with
permission from Shepherd M,
Watt D, Falloon I, 

et al.

The

natural history of schizo-
phrenia: a five-year follow-up
study of outcome prediction in
a representative sample of
schizophrenics. 

Psychol Med

Monogr

1989;15 (Suppl.):1–46

One episode
no impairment.

Several episodes with no
or minimal impairment.

Impairment after the first
episode with occasional
exacerbations of symptoms.
No return to normality.

Impairment increasing with
each exacerbation of
symptoms. No return  
to normality.

13%

30%

10%

47%

1

2

3

4

FIVE-YEAR FOLLOW-UP OF 102 PATIENTS  

WITH SCHIZOPHRENIA

160 000

140 000

120 000

100 000

80 000

60 000

40 000

20 000

0

1845

A

verage annual occupied

psychiatric hospital beds

185518651875188518951905191519251935194519551965197519851995

CHANGES IN THE IN-PATIENT PSYCHIATRIC  

POPULATION OF ENGLAND & WALES

Figure 1.17 

There was a steady

increase in the in-patient mental
hospital population in England and
Wales during the hundred years from
1860. This was due to a combination
of factors, including increased
urbanization and changes in mental
health legislation. The sharp decline
in this population coincided with the
introduction of effective antipsych-
otic medication, together with
changes in health policy and
legislation 


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©2002 CRC Press LLC

to 10% and the overall rate of suicide in schizo-
phrenia is estimated to be in the region of 10%
(

Figure 1.20

).

FACTORS AFFECTING PROGNOSIS

Certain clinical features are associated with a poor
prognosis: early or insidious onset, male sex,
negative symptoms

19,20 

(

Figure 1.8

), lack of a

prominent affective component or clear precip-
itants, family history of schizophrenia, poor
premorbid personality, low IQ, low social class,
social isolation, and significant past psychiatric
history.

Several studies have demonstrated an

association between longer duration of untreated
illness and poorer outcome. For example, Loebel
and colleagues

21

found that a longer duration of

both psychotic and prodromal symptoms prior
to treatment was associated with a lesser likeli-
hood of remission. The longer the duration of
pretreatment psychotic symptoms, the longer
the time to remission. These data suggest that
early detection and intervention in schizo-
phrenia may be important in minimizing
subsequent disability.

Figure 1.19 

Breier and colleagues

18

among others have

suggested that, despite the heterogeneity of schizophrenia,
a model of a common course of illness can be derived.
Based on evidence from their own studies and other long-
term follow-up studies they describe an earlier
deteriorating phase usually lasting some 5 years. During
this time there is a deterioration from premorbid levels of
functioning, often characterized by frank psychotic
relapses. After this phase much less fluctuation can be
expected and the illness enters a ‘stabilization’ or ‘plateau’
phase. This period may continue into the fifth decade,
when there is a third ‘improving’ phase for many patients.
Figure reproduced with permission from Breier A,
Schreiber JL, Dyer J, Pickar D. National Institute of Mental
Health longitudinal study of chronic schizophrenia.
Prognosis and predictors of outcome. 

Arch Gen Psychiatry

1991;48:239–46

10

Years

Deteriorating

Course

20 30 40 50 60 70

Stable Improving

COURSE OF SCHIZOPHRENIA 

(THEORETICAL MODEL)

Years of 

follow-up 

37

23

14

8

5

Number of

patients

289

208

90

161

49

Good clinical

outcome (%)

27

20

26

26

22

Poor clinical

outcome (%)

42

24

37

24

35

Social recovery

(%)

39

51

65

69

45

Study

Ciompi 1980

11,12

Bleuler 1978

13

Bland & Orne 1978

14

Salokangas 1983

15

Shepherd et al., 1989

16

Table 1.1  Summary of long-term clinical outcome studies in schizophrenia.

Table reproduced with permission from Frangou S, Murray RM. 

Schizophrenia

. London: Martin Dunitz, 1997