PROGNOSTIC FACTORS IN SCHIZOPHRENIA

WERNER SIMON, M.D., D ROBERT D. WLRT, PH.D.2

European psychiatry, under the strong METHOD

influence of Kraepelin(4), employs con- In this investigation, personality, histori-
ceptual and methodological differences from cal and demographic data of 80 consecutive
those used in the United States, in the diag- first hospital admission patients with clearly
nosis, symptomatology, treatment and prog- established diagnoses of schizophrenia were
nosis of schizophrenia. The rate for lasting studied. In addition, the following 4 social
social recovery has been quoted as approxi- history variables, taken from a factor ana-
mately 40% by various American and Euro- lytic study by Beck and Nunnally( 1), were
pean investigators. Several factors have employed: 1. Parental rejection ; 2. Absence
been considered by Langfeldt(5, 6) as in- of consistent parental figures; 3. Parental
dicating a favorable prognosis in schizo- indifference or inadequacy; and 4. Parental
phrenia. Among these are: an emotionally over-protection. Each of these factors was
and intellectually well-developed pre-psy- rated for 5 traits having the highest factor
chotic personality; demonstrable precipitat- loadings. Twelve prognostic factors, report-
ing factors; acute onset; affective admix- ed in the literature as having validity, were
ture; and favorable environment before and used. These were taken from studies by
after the onset of the disorder. Investiga- Pascal, et al.(7), and by Schofield, et al.(8,
tions of the natural history of schizophrenia 9), and include the following factors:
in this country by Hastings, et al.(3), have
shown that 60% of all patients spent over TABLE 1
half of their initial post-hospitalization in- PROGNOSTIC FACTORS

terval in a mental institution or experienced 1. Affective Expression.

severe adjustment difficulties which neces- 2. Orientation.
3. Direction of Aggression.
sitated continuous care by their families.
4. Type of Onset.
Long-term follow-up studies by Staudt and 5. Duration of Illness.
Zubin( 12) have failed to show better results 6. Precipitating Stress.
for the treated over the untreated in terms of 7. Marital Status.
recovery and improvement, with the re- 8. School Deportment.
9. Marital Adjustment.
covery rate remaining around 35 to 40%, al-
10. Presence of previous episodes.
though the treated groups stay in the hos-
11. Adjustment to the hospital.
pital is definitely shortened and the death 12. Presence of ideas of reference.
rate is lower in this group. It has been
claimed by Donnelly and Zeller(2) that The most (15) and least improved (13)
the best remission rates are achieved in dis- patients were compared clinically and
orders which are episodic and self-limiting statistically during hospitalization and the
in time, either remitting spontaneously or most (26) and least improved (25) were
responding to therapy. Schofield and Balian similarly studied 1 year following hospital-
(8, 9) have shown presumed etiologic fac- ization, to determine which factors were
tors to be about as common in normals as in prognostic of hospital course, and which
were related to longer term adjustment.
patients diagnosed schizophrenic. If better
prognostic indicators were available, results RESULTS
of differential therapies could be evaluated
At the time of discharge from the hospital,
more adequately( 10, 11, 13).
3 of the prognostic factors showed discrimi-
1 Read at the 116th annual meeting of The
nation between those who improved and
American Psychiatric Association, Atlantic City, those who did not. We found that exag-
N. J., May 9-13, 1960. gerated expression of affect, rapid onset of
2 VA Hospital, Minneapolis 17, Minn. symptoms, and a brief rather than an cx-

887
888 PROGNOSTIC FACTORS IN SCHIZOPHRENIA [April

tended period between the acute onset and were markedly psychotic, who evidenced
hospitalization, are all prognostically favor- defective functional intelligence, who were
able indicators at a statistically significant dilapidated, regressed, and apparently dull
level. Insidious onset, accompanied by in affect. They exhibited a relative blunting
blunted emotional life, and a period of years of emotions and had an insidious onset of
between the first symptoms and the first illness with a poor work history. Their early
treatment efforts were found to be prognos- background was characterized by family
tically unfavorable signs. discord or isolation from parental influence.
Nearly all the patients in both groups One year after hospital discharge, all
were oriented at the time of their admission improved patients expressed some religious
to the hospital. Most expressed aggressive affiliation, whereas half of those having no
feelings outward rather than toward them- affiliation were in the unimproved group.
selves; most had experienced only mild Patients who maintained their improved
precipitating stress; and most had some his- status a year after hospital treatment were
tory of previous episodes of disturbed be- individuals who tended to express their
havior, not diagnosed as schizophrenia, aggressive impulses, rather than turning
however. In nearly all categories differences them inward; who had an acute onset of
were in the expected directions, even schizophrenia, which had a duration of a
though most were slight. month or less prior to hospitalization; who
We found no reliable differences for such were married and had a good marital adjust-
demographic data as age, ordinal position in ment; who did not have a history of
the family, number of siblings, educational previous episodes of severe emotional dis-
level, religion, socio-economic status, num- turbance; and were management problems
ber of children, and incidence of mental while hospitalized. The patients rated as
illness in the family. unimproved at the time of the follow-up
Only 2 items among the social history were men whose histories showed an insidi-
factors differentiated the groups at ad- ous onset of illness, developing over a
mission, and thus predicted from their social period of 2 years or more; who were not
histories the outcome of hospital treatment. hospitalized until several years following
These were: Absence of consistent paren- onset of symptoms; who were single; and
tal figures, which predicted poor treatment who showed some evidence of periods of
response, and Mothers would do anything emotional disorder in earlier life.
for the child, which heralded favorable Since the statistical analyses showed few
outcome. Other factors which showed a clear prognostic or social factors to be
trend toward distinguishing the back- significant in differentiating improved from
grounds of the patients, indicate that more unimproved schizophrenics, we attempted a
of the improved patients came from homes clinical comparison of the 7 most improved
in which mothers struck out in anger, rather and the 9 patients least improved, utilizing
than maintaining constructive discipline; detailed social histories. On the basis of this
and more of the unimproved patients lacked comparison, 13 behavior variables, both
any real parental figure or lived with par- favorable and unfavorable, were found to
ents whose discord left the family in a differentiate good and poor prognosis in
turmoil and whose fathers were promis- schizophrenia. These are listed in Table 2.
cuous and debauched. These findings sug- Items 5, 6 and 7 were characteristic of
gest the importance of the presence of par- every one of the poorest outcome patients.
ents in the home, and that consistent dis- The other items were far more frequent in
cipline is less important than protection, patients with poor follow-up ratings than in
family stability, and positive relations be- those with good outcome. The 3 items
tween the parents. characteristic for good prognosis were
In comparing patients who improved found in all of the best outcome patients and
during a course of hospital treatment with in none of those with poor follow-up ratings.
those who did not, we found several distin- In addition, a number of similarities
guishing characteristics. Patients who did appeared, which we believe are diagnostic
not improve were men who at admission or predictive of a schizophrenic disorder,
1961 1 WERNER SIMON, AND ROBERT D. WIRT 889

TABLE 2 symptoms. During and after adolescence

BEHAVIOR DIFFERENTIATING GOOD AND they tried to break away from home. Some
Poon PROGNOSIS IN SCHIZOPHRENIA took jobs, some went into service early, and
Poor Prognosis some also ran away from home. This often
1. No behavior problem in school or at coincided with an attempted change of in-
home. terest pattern from that set by the father. In
2. Lack of socialization during childhood all cases these efforts failed and the patients
(poor relations with both peers and sib- returned home; many were troubled with
lings). feelings of guilt and self-blame for their
3. Threatened (without cause) by parents non-achievement. Usually the onset of
as a form of discipline. schizophrenia was displayed in acute para-
4. Poor heterosexual relationships through-
noid behavior either in service or shortly
out life (no interest in girls; fear of
after discharge. After service they generally
girls).
showed increased apathy and lack of striv-
5. Few interests during adolescence and
early adult life. ing, marked weight loss, few interests, and
6. Poor work history throughout life. surrender to schizophrenic thinking.
7. Inability to express aggression through- Families of these patients were character-
out life. ized by fathers described as heavy drinkers
8. Possible organic involvement (instru- and harsh disciplinarians. The mothers also
mental and/or premature birth; infec- were described as strict, seemingly unhappy
tious process; head injury, etc.). most of their lives and complained of poor
9. Inability to express feelings (difficult health. Patients rated as unimproved fre-
to get to know). quently had schizoid tendencies most of
10. Fears associated with school and/or their lives, while the more improved pa-
peer relationships.
tients were more likely to have shown some
Good Prognosis:
greater rebelliousness during adolescence.
1. Some specific traumatic episodes which
might have precipitated onset. The more improved patients suffered some
2. Good work history during childhood and reaction to interpersonal threat (e.g., the
adolescence. death of a parent) during adolescence,
3. Marriage (with or without conflict). while the unimproved patients were likely
to have had similar experiences much earlier
in life.
and which were common to both improved
and unimproved groups. Common among DISCUSSION
both extremes in improvement rate was a
Our data regarding prognostic factors
history of over-ambition. As children and
failed to support most of the findings of
adolescents many had an ego ideal with
Pascal and his co-workers(7). Our findings,
whom they attempted to identify. This was
however, do confirm some of the factors
usually a father whose achievement the sons
listed by Langfeldt(5, 6) as indicating a fa-
could never match. If the father was a
vorable prognosis in schizophrenia. Lang-
physician or a bricklayer, their sons who
feldt has pointed out that precipitating fac-
also became physicians or bricklayers were
never quite successful or skillful. Prior to tors are as a rule lacking in typical cases of
schizophrenia, but that in atypical, schizo-
adolescence many of these patients had
phreniform conditions psychogenic traumas
made a single important achievement, such
are frequently observed. He emphasizes
as winning a trophy or becoming the local
that such atypical schizophrenias should be
athletic hero. Throughout life these men
grouped and classified as schizophreniform
were identified in the community as persons
psychoses, and he recalls his personal ob-
who had achieved some special distinction
servation that half of the patients diagnosed
in early life, a distinction they could never
recapture. Most of the patients were de- as having schizophrenia in the United States
scribed as shy and withdrawn while chil- would be classified differently in Europe.
dren. They were considered sensitive and Langfeldt believes that research in schizo-
fragile by their families. Many of them suf- phrenia should be concerned predominantly
fered from a variety of psychosomatic with process schizophrenia, and that it has
890 PROGNOSTiC FACTORS IN SCHIZOPHRENIA [April

been quite detrimental to the progress of proved patients, produced 13 behavior vari-
psychiatry to let the whole dementia prae- ables, both favorable and unfavorable,
cox idea be absorbed by the collective which differentiated good and poor prog-
designation of schizophrenia. nosis.
Our clinical appraisal of the histories of In addition, the data give empirical sup-
the most improved and the least improved port for some theories of etiology in schizo-
patients showed a number of characteristics phrenia.
typical of both extremes. These findings BIBLIOGRAPHY
reveal that schizoid personality traits were
1. Beck, S. J., and Nunnally, J. C.: J. Psy-
evident from early life. A few social influ-
chiat. Social Work, 22: 123, 1953.
ences appeared to have favorable prognostic 2. Donnelly, J., and Zeller, W.: J. Clin. &
value; chiefly an adequate work history, Experim. Psychopath., 17: 180, 1956.
some effort at heterosexual adjustment, and 3. Hastings, D. W., Hathaway, S. R., and
the presence of precipitating stress. These Bell, D.: Univ. Minn. Hosp. Bull., 23: 149,
factors suggest that the distinction between 1951.
improved and unimproved patients may be 4. Kraepelin, E.: Textbook of Psychiatry.
based on a fundamental difference between Edinburgh: E. & S. Livingstone, 1919.
reactive and process forms of schizophrenia, 5. Langfeldt, G.: Acta Psychiat. & Neurol.
Scandin., Suppl. 110, 1956.
and support the view of those who hold that
6. Langfeldt, G.: Am. J. Psychiat., 116:
such a diagnostic distinction has merit.
537, 1959.
7. Pascal, G. R., et at.: J. Consult. Psychol.,
SUMMARY
17: 163, 1953.
Four social history and 12 prognostic 8. Schofield, W., et al. : J. Consult. Psychol.,
factors, reported in the literature to have 18: 155, 1954.
statistical validity, were studied in this 9. Schofield, W., and Balian, L.: J. Abn. &
investigation. In addition, personality, his- Soc. Psychol., 59: 216, 1959.
torical and demographic data of 80 consecu- 10. Simon, W., et a),.: Am. J. Psychiat.,
tive first hospital admission patients were 114: 1077, 1958.
11. Simon, W., and Wirt, R. D.: In Pro-
compared clinically and statistically during
gress in Psychotherapy, Vol. 5. New York:
and 1 year following hospitalization.
Grune & Stratton, 1960.
Some factors were prognostic of hospital 12. Staudt, V. M., and Zubin, J.: Psychol.
course, while others were related to longer Bull., 54: 171, 1957.
term adjustment. 13. Wirt, R. D., and Simon, W.: Differen-
A clinical comparison utilizing detailed tial Treatment and Prognosis in Schizophrenia.
social histories of the most and least im- Springfield: Charles C Thomas, 1959.