The Schizophrenia Prognosis

In summary,  fewer than 20 percent of patients with a first episode of schizophrenia have a good prognosis. That means that fewer than 20 out of every 100 schizophrenia patients are likely to marry, have children, and keep a job - behaviors that most consider central to having a normal,  productive life.

Unfortunately, the majority of people with schizophrenia experience multiple episodes of the illness. 

For these individuals, keeping a job and interacting with other people is often overwhelming. Approximately one-half of schizophrenia patients become so impaired that their social and occupational functioning is severely limited. These patients usually never marry, and they are unable to work or go to school. They may spend a lot of time in a psychiatric hospital or under the care of a mental health professional.  All schizophrenia patients benefit from a supportive family network and an attentive treatment team.

Pain Insensitivity and Schizophrenia

Physical pain serves a very useful purpose.  When our bodies
are in pain,  it signals to us that we may be sick or in danger.
Perhaps you’ve run the shower too hot and entered it only to
have to step back from the scorching spray.  In this case,  the
minor pain you feel from the hot water tells you to stand back
and turn the temperature down in order to avoid being burned.

Although   many   patients   with   schizophrenia   experience
physical pain just as you do,  some patients appear to have an
especially   high   tolerance   for   painful   stimuli.  Emil   Krapelin,
the Austrian physician who was one of the first to identify what
is now known as schizophrenia,  observed that “the patients
often become less sensitive to bodily discomfort;  they endure
uncomfortable   positions,  pricks   of   a   needle,  injuries,  with-
out thinking much about it.”  Indeed,  recent observations
from physicians include case reports describing patients with
schizophrenia   who   experienced   serious   physical   problems
but reported little accompanying pain.  Such reports include
a   patient   who   suffered   a   perforated   bowel   and   reported
little pain and tenderness during examination,  a patient who
experienced a ruptured appendix,  and a patient who broke
his ankle.

An   even   more   intriguing   observation   emerged   from   the
research of Professor Jill Hooley and her colleagues at Harvard

Professor Hooley invited two groups of participants
into her laboratory.  The first group included relatives of individu-
als with schizophrenia.  The second group included individuals
who reported no family history of mental illness. The participants
were asked to place a pressure algometer,  a device with a small
weight,  onto the middle finger.  The participants indicated when
they first began to feel pain and removed the weight when they
could no longer withstand the discomfort.  Several of the relatives
of schizophrenia patients reported a higher pain tolerance than
the control participants with no family history of mental illness.

Thus far,  researchers do not know why some individuals with
schizophrenia experience less pain than people without schizo-
phrenia. Nor do we understand why some relatives of schizophre-
nia patients have a higher tolerance for pain than people with no
history of mental illness in their families.  Some basic research
suggests that some brain areas that are implicated in schizo-
phrenia are also implicated in pain perception,  although the
specific association remains unclear.  The relationship between
pain and schizophrenia is a fascinating new avenue for research
that might reveal useful information about the disorder.

Are there any features that indicate what course of illness a particular patient will experience? Although it is difficult to predict with any accuracy what any one patient will experience, researchers have identified several features that appear to be associated with a poor prognosis in schizophrenia in general.

Male patients who have never married, developed schizophrenia symptoms suddenly, and spend much of the first two years of their illness psychotic appear to have a more serious course of schizophrenia. Indeed, it appears that the best predictor of long-term functioning is the percentage of time a patient spent experiencing psychotic symptoms in the early years of his or her illness.

Age or Gender?

Schizophrenia is just as common in men and women,  but the
severity of the disease differs between the two genders.  Males,
on average,  suffer from more severe schizophrenic symptoms
and are more seriously disabled than females.  Women with
schizophrenia   are   more   likely   to   marry   and   have   families
and to live independently than men.  At first glance,  it seems
there must be something about males—their physiology,  their
development,  or their social environment—that makes them
vulnerable to a more severe form of the disease.  Could there
be another explanation for the greater number of more seriously
ill males?

Males,  on average,  also show their first symptoms of schizo-
phrenia   at   an   earlier   age   than   females.  Men   typically   are
affected by the disease starting in their late teens or early
twenties,  while women are more likely to first show signs of the
disease 10 years later,  in their late twenties or early thirties.

Perhaps early onset of the disease,  not “maleness,”  leads to
more severe illness.  If this was true,  males who did not
develop the disease until their late twenties or thirties would be less
disabled than men who had symptoms early,  and females with
early symptoms would be just as severely affected as males
with early symptoms.

To answer this question,  researchers have studied whether
the severity of symptoms is related to age of onset,  looking at
males and females separately. 

They have found that,  in fact,
severity of schizophrenia is related to the age at which symp-
toms first appear,  not specifically the gender of the patient.
Both males and females with earlier onset of symptoms are
more severely affected than either males or females with late
onset of symptoms.  Symptoms earlier in life disrupt education
and development of social connections.  Perhaps women with
schizophrenia are more likely to marry,  start careers,  and have
independent lives because,  on average,  they have 10 more
years to complete their education and establish relationships
before their symptoms appear.  To further our understanding
about schizophrenia,  it is important to sort out the unique
effects of age and gender on the course of the illness.

Most patients develop schizophrenia symptoms in early adulthood. The typical course of the illness, however, suggests that,  by the time patients reach middle and late adulthood, psychotic symptoms are on the decline. Thus, as schizophrenia patients reach their fifties and sixties, they tend to experience fewer positive symptoms of the illness.

Cognitive symptoms, however, such as problems with concentration and memory, appear to become more pronounced. Although some cognitive deterioration is common as people age, it is more severe in schizophrenia patients.

Researchers have identified three stages of schizophrenia: the prodromal stage, the acute stage, and the residual stage.

The course of the illness differs among patients. Some patients experience only one episode of acute schizophrenia, whereas others cycle rapidly between episodes. Treatment with antipsychotic medications is usually necessary to alleviate schizophrenia symptoms in the acute stage. The next section looks at the causes of schizophrenia.

Heather Barnett Veague, Ph.D.
Heather Barnett Veague attended the University of California, Los Angeles, and received her Ph.D. in psychology from Harvard University in 2004. She is the author of several journal articles investigating information processing and the self in borderline personality disorder. Currently, she is the Director of Clinical Research for the Laboratory of Adolescent Sciences at Vassar College. Dr. Veague lives in Stockbridge, Massachusetts, with her husband and children.


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