Файл: An.Atlas.of.Schizophrenia.eBook-EEn.pdf

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Figure 1.20

A series of self-portraits by Bryan Charnley which vividly illustrate his experiences as he came off

medication. His descent into paranoia, hallucinations and depression is graphically depicted and explained with
reference to his diary entries. Sadly the series ended with his death from suicide. Figures reproduced with kind
permission of Mr Terence Charnley

Self-portrait 11–16 April 1991

April 20: ‘Very paranoid...The person
upstairs is reading my mind and speaking
back to me in a sort of ego crucifixion...The
large rabbit ear is because I am confused
and extremely sensitive to human voices,
like a wild animal.’

May 6: has turned himself into a
dartboard. ‘I feel like a target for people’s
cruel remarks. What is going on? I have
sweet talked a girl to suicide because I
had no tongue, no real tongue and could
only flatter.’

May 23: ‘The blue is there because I feel
depressed, through cutting back on the
antidepressants...the wavy lines are
because just as I feel I am safe, a voice
from the street guts me emotionally by its
ESP of my conditions...I am so pleased that
I have been able to express such a purely
mental concept as thought-broadcasting by
the simple device of turning the brain into
a mouth.’

May 18: acutely disturbed. ‘My mind seems
to be thought-broadcasting very severely
and it is beyond my will to do anything
about it...I have summed this up by painting
my brain as an enormous mouth.’

April 29: Bryan has turmoil in his mind.
The features in his portrait have become
fragmented. He feels lonely and exposed,
as on a stage. ‘A strange spiritual force is
making me feel I should not smoke or I
will incur a disaster.’

June 27 (left): This is Bryan’s most complex
picture. He feels he is ‘closing in’ on the
essential image of schizophrenia. He feels
transparent. ‘I make crazy attempts at some sort
of control over what has become an impossible
situation (the man with the control stick). My
brain, my ego is transfixed by nails as the Christ
who could not move freely on the cross without
severe pain. So I find I cannot think without
feelings of pain.’ The red muzzled beast
symbolizes silent anger. ‘My senses are being
bent by fear into hallucinations.’

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REFERENCES

1.

Haslam J. Illustrations of Madness. London, 1810

2.

Kraepelin E. Psychiatrie: Ein Lehruch fur Studierende

und Arzte, 5th edn. Leipzig, Germany: JA Barth,
1896

3

Kraepelin E. Psychiatrie: Ein Lehruch fur Studierende
und Arzte, 6th edn. Leipzig, Germany: JA Barth,
1899

4.

Kraepelin E. Dementia Praecox and Paraphrenia
[1919]. Robertson GM, ed; Barclay RM, trans. New
York, NY: Robert E. Kreiger, 1971

5.

Bleuler E. Dementia Praecox or the Group of
Schizophrenias. Madison, CT: International Univer-
sities Press, 1950

6.

Schneider K. Clinical Psychopathology. Hamilton
MW, trans. London, UK: Grune and Stratton, 1959

7.

World Health Organization.

Report of the

International Pilot Study of Schizophrenia. Geneva:
WHO, 1979

8.

American Psychiatric Association. Diagnostic and
Statistical Manual, 4th Edition Revised (DSM–IV).
Washington, DC: APA, 1994

9.

World Health Organisation.

The International

Classification of Diseases, 10th Edition (ICD–10).
Geneva: WHO, 1992

10.

Jones P, Rodgers B, Murray R, et al. Child
development risk factors for adult schizophrenia in
the British 1946 birth cohort. Lancet 1994;344:
1398–1402

11.

Ciompi L. Catamnestic long-term study of the
course of life and aging in schizophrenia. Schizophr
Bull 1980;6:606–18

12.

Ciompi L. The natural history of schizophrenia in
the long term. Br J Psychiatry 1980;136:413–20

13.

Bleuler M. The long-term course of schizophrenic
psychoses. Psychol Med 1974;4:244–54

14.

Bland RC, Orn H. 14-year outcome in early
schizophrenia. Acta Psychiatr Scand 1978;58:327–38

15.

Salokangas RK. Prognostic implications of the sex of
schizophrenic patients. Br J Psychiatry 1983;142:
145–51

16.

Shepherd M, Watt D, Falloon I, et al. The natural
history of schizophrenia: a five-year follow-up study
of outcome prediction in a representative sample of
schizophrenics.

Psychol Med Monogr

1989;15

(Suppl.):1–46

17.

Frangou S, Murray RM. Schizophrenia. London:
Martin Dunitz, 1997

18.

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

19.

Johnstone EC, Frith CD, Crow TJ, et al. The
Northwick Park ‘Functional’ psychoses study:
diagnosis and outcome. Psychol Med 1992;22:331–46

20.

Johnstone EC, Crow TJ, Frith CD, Owens DG. The
Northwick Park ‘Functional’ psychoses study:
diagnosis and treatment response. Lancet  1988;
2:119–25

21.

Loebel AD, Lieberman JA, Alvir JM, et al. Duration
of psychosis and outcome in first-episode schizo-
phrenia. Am J Psychiatry 1992;149:1183–8

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CHAPTER 

2

Epidemiology and risk factors

The incidence of schizophrenia in industrialized
countries is in the region of 10–70 new cases per 
100000 population per year

1

, and the lifetime risk

is 0.5–1%. The geographical distribution of
schizophrenia is not random: recent studies have
shown that there is an increased first-onset rate in
people born or brought up in inner cities (

Figure

2.1

)

2

. There is also a significant socioeconomic

gradient, with an increased prevalence in the
lower socioeconomic classes. ‘Social drift’, both in
social class, and into deprived areas of the inner
cities, may account for part of this, but specific

environmental risk factors (e.g. overcrowding,
drug abuse) may also be operating.

The onset of the disease is characteristically

between the ages of 20 and 39 years, but may
occur before puberty or be delayed until the
seventh or eighth decade. The peak age of onset  is
20–28 years for men and 26–32 years for women

1

(

Figure 2.2

). The overall sex incidence is equal if

broad diagnostic criteria are used, but there is
some evidence for an excess in men if more
stringent diagnostic criteria, weighted towards the
more severe end of the diagnostic spectrum, are

Figure 2.1

Adjusted relative risk of schizo-

phrenia in Denmark according to place of
birth, with rural area used as the reference
category (*). Data from reference 2

0

Relative risk (95% Cl)

Capital

Suburb of capital

Provincial city

Provincial town

Rural area*

Greenland

Other countries

Unknown

1

2

3

4

5

6

7

RELATIVE RISK OF SCHIZOPHRENIA  

ACCORDING TO PLACE OF BIRTH

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Figure 2.3 

This graph is based on a

population cohort of 1.75 million
people from the civil registration
system in Denmark. The data
points and vertical bars show the
relative risks and 95% confidence
intervals, respectively, with the
month of birth analyzed as a
categorical variable. The curve
shows the relative risk as a fitted
sine function of the month of birth
(the reference category is
December). Figure reproduced
with permission from Mortensen
PB, Pedersen CB, Westergaard T, 

et

al. 

Effects of family history and

place and season of birth on the
risk of schizophrenia. 

N Engl J Med

1.4

1.3

1.2

1.1

1.0

0.9

0.8

0.7

0.6

Relative risk

Month of birth

January

February

Ma

rch

April

May June

July

August

September

October

November

December

RELATIVE RISK OF SCHIZOPHRENIA  

ACCORDING TO MONTH OF BIRTH

Figure 2.2 

This graph shows the

incidence rate per 100 000 popu-
lation for broadly defined schizo-
phrenia in an inner city area of
London (Camberwell). Although
the overall rate is similar in males
and females, mean onset in women
is slightly later. Figure reproduced
with permission from Castle E,
Wessely S, Der G, Murray RM. The
incidence of operationally defined
schizophrenia in Camberwell
1965–84. 

Br J Psychiatry

1991;159:790–4

60

50

40

30

20

76+

10

0

Rates per 100

 000 population

Males

Females

Age at onset (years)

66–75

56–65

46–55

36–45

26–35

16–25

0–15

INCIDENCE OF SCHIZOPHRENIA BY GENDER

©2002 CRC Press LLC

applied. The prevalence of schizophrenia is consi-
derably higher in the unmarried of both sexes.
There is a small excess of patients born during the
late winter and early spring months in both north-
ern and southern hemispheres (and a less well-
known decrement in late summer (

Figure 2.3

)

2

.

People with schizophrenia have a twofold

increase in age-standardized mortality rates, and
are more likely to suffer from poor physical
health. Much of the increased mortality occurs in
the first few years after initial admission or diagn-
osis. Contributing factors early in the course
include suicide, with later factors, such as cardio-
vascular disorders, due in part to the poor lifestyle
of many patients, with heavy cigarette smoking
and obesity being common.

THE RISK FACTOR MODEL OF
SCHIZOPHRENIA

It is often said that schizophrenia is a disease of
unknown etiology. This is no longer true. Schizo-
phrenia is like other complex disorders such as
ischemic heart disease, which have no single cause
but are subject to a number of factors that
increase the risk of the disorder. Some of the risk
factors for schizophrenia are summarized in

Figure 2.4

. Schizophrenia, however, differs from

disorders such as ischemic heart disease in that we
do not understand the pathogenic mechanisms
linking the risk factors to the illness, i.e. we do not
understand how the causes ‘cause’ schizophrenia.

Figure 2.4 

Causality over the life course. Risk factors for schizophrenia occur both early and late in

the life course, and interact with each other in a complex fashion

Psychosis

Childhood 

vulnerability

Early causes

(genetic, obstetric

complications)

Late causes

(life events,

drug abuse)

Dysplastic

networks

Cognitive

impairment

Social difficulties

BIRTH ADOLESCENCE

THE DEVELOPMENTAL RISK FACTOR MODEL