Longitudinal Studies of Schizophrenic Patients · Poliklinik Bonn, Sigmund-Freud-Strasse 25, D-5300 Bonn 1, F.R.G. VOL 6, NO. 4, 1980 593 investigations in the world literature. However,

592 Longitudinal Studies ofSchizophrenic Patients

by Gerd Huber, Gisela Gross,Relnhold Schiittler, andMaria Linz

translated by SiegfriedClemens

AbstractA sample of 502 schizophrenic pa-tients, who had been admitted to theUniversity Psychiatric Clinic between1945 and 1959, was systematicallyfollowed up between 1967 and 1973.The same well-defined diagnosticcriteria were used throughout thestudy. At the time of the last foDowup,the average duration of illness was 22.4years. Twenty-two percent of thepatients showed complete psycho-pathological remissions, 43 percenthad noncharacteristic types of remis-sion, and 35 percent suffered fromcharacteristic schizophrenic deficiencysyndromes. Psychopathological out-come in the patients studied wasassessed in relationship to such factorsas duration of illness, social remission,family history of schizophrenia, pri-mary personality, educational level,social class, age at onset, and presenceof precipitating factors. It is concludedthat prognostic predictions are possibleonly when several factors with a simi-lar influence on long-term outcomeoccur in combination and when factorswith a contrary prognostic influenceare absent. Even under these circum-stances, the individual course is by nomeans certain. The hypothesis thatpresenting symptomatology can beused to differentiate between trueschizophrenias and schizophreniformpsychoses is not supported.

Research investigating the course ofschizophrenia is still in its infancy.This surprising discovery was madeby M. Bleuler in 1972. Until just ashort time ago, there were hardly anylife-long studies of schizophrenia withresults that would even approach gen-eral applicability. Studies that in-cluded long-term outpatients whowere no longer under a doctor's carewere virtually nonexistent. Not untilthis past decade were studies presentedthat could be considered as generally

valid and representative for the schizo-phrenias. Among these were investiga-tions by M. Bleuler, Gompi andMuller, and those of our own team(Bleuler 1972; Bleuler et al. 1976;Gompi and Muller 1976; Huber, Gross,and Schiittler 1979). The data collectedby M. Bleuler in studies of patients fromZurich and our own studies of theBonn population were compared, andthe results were summarized (Bleuleret al. 1976).

Below we briefly report on some ofthe results of the Bonn investigation.This study began with 758 schizo-phrenic patients who had been ad-mitted as inpatients to the UniversityPsychiatric Clinic of Bonn between1945 and 1959. Of these, 502 patientscould be personally followed up,usually in their home environments,between 1967 and 1973. During theperiod of the followup catamnesis, 87percent of them lived at home in theirresidential communities. Among the435 probands who were not perma-nently hospitalized, two-thirds had notbeen under a doctor's care for an ex-tended period at the last followup. De-tails of the study have been presentedin a monograph (Huber, Gross, andSchuttler 1979).

Diagnostic Concepts andSample Characteristics

M. Bleuler, C. Muller, H. Mitsuda,and others have emphasized the differ-ences in the diagnostic criteria forschizophrenia. In view of the variety ofmethods, different selection criteria ofprobands, and insufficient reportingof methodological details, it is virtuallyimpossible to make accurate com-parisons among the results of different

Reprint requests should be sent to Prof.Dr. Gerd Huber at Univ.-Nervenklinik undPoliklinik Bonn, Sigmund-Freud-Strasse25, D-5300 Bonn 1, F.R.G.

VOL 6, NO. 4, 1980 593

investigations in the world literature.However, a comparison of the criteriaused by M. Bleuler and ourselves todiagnose the Zurich and Bonn pro-bands, respectively, convinced us thatthere was complete agreement in thediagnoses for schizophrenia (Bleuler etal. 1976). The applicability of courseinvestigations relies heavily on the un-ambiguous definition of the schizo-phrenia concept on which they arebased. Diagnoses must be made in-dependently of outcome assessments.As Bleuler has remarked, long-termstudies investigating prognosis aremeaninglessif an unfavorable^>uteomeis used as an obligatory criterion forthe diagnosis of schizophrenia, and afavorable outcome as an exclusionarycriterion. Our findings agree withthose of Bleuler and Muller, in that nosymptoms or syndromes at the time ofonset could be used to predict, withany certainty whatever, the differenti-ation between malignant or benign,process or nonprocess, genuine orpseudo-schizophrenic, and schizo-phrenic or schizophrenif orm psy-choses. This point is important withrespect to the studies by various schoolsand authors who regard schizophreniaswith favorable, outcomes as indepen-dent disease types, labeling them asschizophreniform psychoses, schizo-affective psychoses, reactive psychoses,atypical psychoses, or cycloidal psy-choses (Langfeldt 1956; Leonhard 1966;Angst and Penis 1968; Weitbrecht1973; Mitsuda 1974; Mitsuda andFukuda 1974; Huber 1976b; Huber,Gross, and Schiittler 1976).

The concept of schizophrenia ap-plied in the Heidelberg and Wieslochstudy (Huber 1957,1961,1966) wasused in the present investigation. Diag-noses were based upon the criteria ofK. Schneider and M. Bleuler. Thus, weincluded schizophrenic psychoses withcomplete remissions that would havebeen excluded by some others: for ex-

ample, by Leonhard, who would havecalled them cycloidal psychoses; byMitsuda and Fukuda, who would havecalled them atypical psychoses; and byLangfeldt and Astrup, who would havecalled them schizophreniform orpsychogenic psychoses. The diagnosiswas supported by first-rank symptomsin 77 percent of the cases, and by sec-ond-rank symptoms and so-calledsymptoms of expression (as per K.Schneider 1976) in 23 percent of thecases. The schizophrenics who showedfirst-rank symptoms had a significantlyless favorable prognosis than thosewho did not^Sixty-seven percentofthe 502 subjects from Bonn becameprobands upon their first hospitaliza-tion. This portion of the sample is con-sidered to have a more favorable prog-nosis—although not significantly so—than the remainder of the probands(Huber, Gross, and Schuttler 1979).

Of the original sample of 758 pa-tients, 142 patients died (4.9 percent bysuicide) before the followup examina-tions were carried out. For the remain-ing probands, only indirect catamneseswere possible (26 cases), a followup ex-amination was refused (48 cases), orthe probands could not be located (34cases). Six cases with symptoms ofschizophrenia were ultimately shownto be suffering from identifiable braindiseases (see table 1). The separateanalysis of probands not personally

inspected in followup examinationssupports the assumption that the 502patients included in the Bonn mainsample are adequately representativeof a population of patients with atleast one hospitalization for schizo-phrenia. In general, there was no par-ticular support for the assumption thatthe long-term prognosis for the sub-group of probands who refused to sub-mit to followup examination (12 per-cent) was any less favorable than thatof the main group. "Refusal of fol-lowup examination" correlates posi-tively with such factors as "aboveaverage intelligence, ""belonging to _upper social strata," and "abnormalprimary personality."

Typology of SchizophrenicResidual Syndromes

The average course of illness, up to thetime of the last followup investigation,was 22.4.years, including the prodro-mal period insofar as it was known. Inthe last followup, we found the distri-bution of psychopathological out-comes shown in table 2. These arebased on the typology of schizophrenicresidual syndromes that we establishedin 1961, and have since modified anumber of times (Huber 1961,1966,1968,1976a, 1976b; Huber, Gross, andSchuttler 1979). As can be seen in

Table 1. Original sample of 758 cases

Original group of patients

Personal followup examinations (main sample)DeceasedIndirect catamneses from relativesRefused catamnesesUndiscoverableSymptomatic schizophrenias

n

Males

209641517162

323

Females

293781131184

435

Total

5021422648346

758

594 SCHIZOPHRENIA BULLETIN

table 2, 22 percent of the probandswere in a state of complete remission—the same percentage M. Bleuler (1972)included in his outcome category"phasic course with recovery." An im-portant component of our typology ofresidual syndromes is the pure defectstate without psychotic symptomato-logy (the so-called "reiner Defekt"). Theconcept of a pure defect state is some-what similar to Janzarik's (1959)"dynamic insufficiency" or Conrad's(1958) "reduction of the psychic ener-getic potential." Although the pure de-fect residual state is categorized in table2 as "noncharacteristic" (because it nolonger takes a characteristically schizo-phrenic form), it is in fact the mostcommon outcome—accounting for 40percent of cases. The other noncharac-teristic outcome type, "structural de-formity without psychosis" (odd,original characters) is relatively rare,seen in only 3 percent of cases. The re-maining 35 percent of the sample wascategorized as "characteristic" out-come types. Most common amongthese were the mixed residues (16 per-

cent) and the typically schizophrenicdefect psychoses (11 percent). Thechronic pure psychoses and the "struc-tural deformities with psychosis," re-spectively, constituted only 4 percentand 3 percent of the sample.

Basic Disorders

The clinical picture of the pure defectstates is made up of numerous symp-toms of diminished capacity that arenot identifiably "schizophrenic"; thatis, by dynamic and cognitive defi-ciencies that are experienced and de-scribed by the patient himself (Huberand Penin 1968; Huber 1976W). Thesedeficiencies, which we refer to as "basicdisorders," are pervasive, appearingat different phases of illness. Sullwold(1977) has described them as part ofthe onset of illness, whereas we haveobserved the same phenomena in thepostpsychotic pure residual states(Huber 1961, 1966, 1973). We havebeen exploring the concepts of basicdisorders, prodromal and postpsy-chotic basic states ("Basisstadium"),

Table 2. Types of remission after average duration of illness of 22.4years

Types of remission

Complete remission

Pure residual syndromes

Structural deformitywithout psychosis

Mixed residualsyndromes

Typically schizophrenicdefect psychosis

Chronic pure psychosis

Structural deformitywith psychosis

n = 502

11122.1 %202 ""I40.2% I,

153.0 %J83 ->|

16.5%54

10.8%21

4.2%16

3.2%^

Groups of types of remission

111 = 22.1%Complete remissions

217 = 43.2%Noncharacteristicresidual syndromes

174 = 34.7%** Characteristic

residual syndromes

and pure residual syndromes since1961, and we have tested these con-cepts in the Bonn study.

Table 3 lists the most characteristicsymptoms of basic disorders, whichwere derived from self-descriptionsprovided by the patients in pure (202cases) and mixed residual states (83cases). Recurring symptoms includecognitive disturbances (such as thoughtand memory disorders); exhaustion;general disturbances of well-being; lossof drive, energy, endurance, and pa-tience; cenesthesia; and exaggeratedimpressionability—a category thatcorresponds to the lowering of thethreshold of tolerance for nonspecificstress (Huber 1966; 1976c; Wing 1976).

Table 3. Characteristicsymptoms of patients withpure residual syndromes

Cognitive disturbancesPhysical and mental exhaustionDisturbances of general well-being

and efficiencyLoss of drive, energy, endurance,

etc.Cenesthetic disordersExaggerated impressionabilityReduced threshold of tolerance to

nonspecific stressHypersensitivity to noise and

weatherSleep disturbancesVegetative and sensorial dis-

turbancesDecrease of initiativeLoss of naivety, compulsion to

reflectionTendency to subdepresslve moodsDisorders of "In-Erscheinung-

Treten" (aesthetic symptoms)Loss of liveliness and directnessInability to be pleased, "GefOhl der

Gefuhllosigkeit"Increased need for sleepReduced capacity for adaptation

VOL 6, NO. 4, 1980 595

In 75 percent of schizophrenics withpure or mixed residual states, the"pure defect" becomes evident inthe first 3 years of illness. Psychotropicmedication seems to have little effecton the nonpsychotic symptomatologyof pure defect states. The performanceof patients with pure residual syn-dromes on psychological tests deviatedsignificantly from normal, and indeedfindings obtained in these patients didnot differ appreciably from those inpatients with organic brain disease(Hasse-Sander et al. 1971; Huber,Gross, and Schiittler 1979). It is possi-ble that the^>oor psychological testperformance of patients with pureresidual syndromes may reflect under-lying deficits in the collection and pro-cessing of information (Broen 1969;Huber 1976c, 1976d; Sullwold 1977).Echoencephalographic findings re-vealed a significantly greater medianvalue of the transverse diameter of thethird ventricle in patients with pureresidual syndromes as compared to pa-tients in complete remission (Schtittler,Huber, and Gross 1974).

Long-term Prognosis

The long-term prognosis is indepen-dent of the duration of the disease(table 4). The distribution of the varioustypes of remission (from most favor-able to least favorable outcomes) doesnot vary significantly within the fourdifferent course-duration groups (i.e.,patients ill 9-14 years, 15-19 years,20-29 years, and 30-59 years, respec-tively). Complete remissions and non-characteristic residual states both occurat approximately the same rate in pa-tients whose durations of illness rangefrom short to long. The most unfavor-able outcomes (i.e., the characteristicresidual states) occur with almost equalfrequency in the last three course-duration groups (15-19, 20-29, and30-59 years' duration). However, the

Table 4. Duration of illness and long-term psychopathologicalprognosis

CoursedurationOn years)

9-14

15-19

20-29

30-59

Completeremission

2227.8%

4025.6%

3818.6%

1117.5%

Non-characteristic

residualsyndromes

3949.4%

5635.9%

9345.6%

2946.0%

Characteristicresidual

syndromes

1822.8%

6038.5%

7335.8%

2336T5%

n = 502

7915.7%156

31.1%20440.6%

6312.5%

x2 10.6 (6 c//) = nonsignificant.

shortest courses (9-14 years) tend to beassociated with more favorable out-come, and there are some data to indi-cate that psychopharmacologicaltreatments are responsible for thebetter prognosis in this group.

The overall pattern of our findingsconfirms the results of previous long-term studies from Zurich and Heidel-berg. Based on these studies, schizo-phrenia does not seem to be a diseaseof slow, progressive deterioration.Even in the second and third decadesof illness, there is still potential forfull or partial recovery (Bleuler 1972;Huber 1961,1966,1968,1969).

No significant relationship is foundbetween age at the last followup andsocial and psychopathological remis-sion in the Bonn sample.

Social prognosis at the last followupis shown in table 5, which distinguishesfive levels of social remission. Socialrecovery is achieved when the pro-bands are fully employed at theirprevious occupational level (social re-mission degree 0) or fully employedbelow their previous occupationallevel (1). The level of recovery offemale patients who previously workedas housewives was estimated according

to analogous criteria. Fifty-six percentof the probands are socially recovered;that is, fully employed. Of these, abouta third are employed below, and two-thirds are employed at their pre-vious occupational level. Social prog-nosis is somewhat better for women,60 percent of whom are consideredsocially recovered as compared to 51percent of men.

Social and psychopathological long-term remission are highly significantlycorrelated (table 6). Ninety-nine per-cent of the probands with total psy-chopathological remission are alsosocially recovered. The differentiationbetween characteristic and nonchar-acteristic residual states is also mean-ingful. Sixty percent of the non-characteristic residues have sociallyrecovered, as compared to only 25 per-cent of the characteristic residues. Therather high rate of social recovery inthe total sample—56 percent—is all themore remarkable when one considersthat only 13 percent of these patientsparticipated in any outpatient rehabili-tation program.

Duration of the stability of the psy-chopathological remission and qualityof the social remission correlate posi-


Table 5. Social remission in men and women

Degree of social remission Males Females Total

0—Fully employed at previous occupationallevel

1—Fully employed below previous level

2—Limited ability to work

3—Incapable of earning a living

4—Completely incapable of working

7234.5%

3416.3%

3114.8%

5224.9%

209.6%209

12141.6%

5418.6%

6622.7%

3110.7%

196.5%291

19338.6%

8817.6%

9719.4%

8316.5%

397.8%

500

Table 6. Social remission and psychopathological long-termprognosis

Degree ofsocial remission

0—Fully employed atprevious occupa-tional level

1—Fully employed be-low previous level

2—Limited ability towork

3—Incapable of earn-ing a livingv

4—Completely inca-pable of working

Completere-

mission

10797.3%

21.8%—

10.9%—

Non-characteristic

residualsyndromes

6530.0%

6429.5%

4922.6%

3516.1%

41.8%


syndromes

2112.1%

2212.7%

4827.7%

4727.2%

3520.2%

n = 500

19338.6%

8817.6%

9719.4%

8316.5%

397.8%

x2 = 278.1 (8d/), P < 001.

tively. Among the patients with 10 ormore years of stable remission (53 per-cent), 51 percent are fully employed attheir previous occupational levels, butonly 24 percent of those patients withless than 10 years of stable remissionare similarly employed. Up to age 50the stability of the remission remainsindependent of age. Only after that is itpossible, as it was in the Lausanne

study (Gompi and Muller 1976), torecognize a stabilizing effect due to age.

In order to characterize the entirecourse, we established course typesthat consider both the kind of course("Verlaufsweise") and the psychopath-ological outcome. In 22 percent of thecases, course of illness was phasic, in48 percent it progressed in surges("Schiibe"), and in only 21 percent was

it sluggish ("einfach-geradlinig"). Pa-tients with no more than five episodesthroughout their entire course pre-dominate (75 percent).

When type of course and psycho-pathological outcome were consideredtogether, 73 course types could beempirically identified, which we wereable to reduce to 12 by combining re-lated types. These types, classified ac-cording to rate of social recovery, aredesignated as Course Types I throughXn (table 7).

In monophasic Course Type I, onesingle psychotic phase, lasting on anaverage of 17 months, is followed bycomplete remission. PolyphasicType II, averaging five psychoticepisodes, also ends in permanent re-covery. These are the two most prog-nostically "favorable" types, andthey account for 22 percent of patients.Course Type III includes psychosesthat appear predominantly chronicfrom the beginning and persist con-tinuously as paranoid-hallucinatorypsychoses until the late catamnesis, butwithout any substantial disturbance ofperformance or adaptation to realityand a surprisingly high rate of socialrecovery (91 percent). Type IV leadsto predominantly mild pure residualstates (Huber, Gross, and Schiittler1979) with but a single surge ("Schub").The average duration of this first andonly psychotic manifestation inType IV is shorter, lasting only 10months, than is the case with mono-phasic Type I. This refutes the hypoth-esis that pure deficiency syndromes arethe necessary psychic-reactive conse-quences of a longer lasting psychoticexperience. Type V progressesprimarily in phases, and then insurges ("Schuben") to pure residues.Type VI progresses in surges andends in pure residues with a second(positive) bend. This second (positive)bend, with remission from a chronicpsychosis to a pure residual state.

VOL 6, NO. 4, 1980 597

Table 7. Frequency and rates of social remission in 12 types ofcourse

Types of course

FavorableI: Monophasic

II: Polyphaslc

Relatively favorableIII: Chronic pure psychoses

IV; With one manifestation to pure residues

V: Phasic- "schubfOrmig"1 to pure residues

VI: "SchubfSrmlg" with second, positivebend to pure residues

Relatively unfavorableVII: "Schubf&rmig" or simple to structural

deformitiesVIII: Simple to pure residues

IX: "SchubfOrmig" to pure residues

UnfavorableX: "Schubformig" to mixed residues

XI: Simple to mixed residues

XIII: "SchubfOrmig" or simple to typicallyschizophrenic defect psychoses

Frequency(n = 502)

5010.0%

6112.1%

214.2%316.2%50

10.0%295.8%

316.2%275.4%65

12.9%

489.6%367.2%53

10.5%

Socialremission

50100%59

96.7%

1990.5%

258a6%

3570.0%

1965.5%

1651.6%

1348.1%

2944.6%

1225.0%

38.3%

11.9%

1 Course In surges or shifts.

may occur at any time from the 5thto the 30th year of illness. Types IIIthrough VI comprise the "relativelyfavorable" prognostic group.

Course Types VII through IX arecharacterized by "relatively unfavor-able" prognoses. The social recoveryrate for this group ranges from 45 to52 percent. Type VII ends in structuraldeformities with or without psychoses.Type VIII follows a simple course topure residues, with a second (positive)

bend in over half the cases. Type IXprogresses in several surges to pureresidues. In the "prognostically un-favorable" group, including Types X,XI, and XII, the social recovery rate is25 percent in Type X, 8 percent inType XI, and 2 percent in Type XH.Type X progresses in several surges,and Type XI in a simple course tomixed residues. The highly unfavor-able Type XII progresses to typicallyschizophrenic defect psychoses. In 38

percent of the patients of Type XII, thisdefect psychosis developed in the first3 years of illness. A rate of 4 percent of502 of such "schizophrenic catastro-phes" (Mauz 1930) is lower than thevalues encountered by Bleuler (5 to 14percent) in 1941.

For the individual prognosis, it isimportant to note that 3.4 percent ofprobands, after having had a-completeor a partial remission to a pure residualstate, went on to develop a typicalschizophrenic defect psychosis. Even inpatients who have seemingly made acomplete recovery and who have beenfree ofpsycrTSsisfor alengperioaHupto 30 years!), the most unfavorableoutcome imaginable is still possible. In15 percent of the probands, after com-plete remission of the first psychoticepisodes, there are still later manifesta-tions of noncharacteristic (three-quarters) or characteristic (one-quarter)residual syndromes. The chances forrehabilitation are reduced by the ir-reversible components of partially re-mitting and chronic schizophrenias,that is, by "structural deformation"and by "pure defect" and their inter-ference with productive-psychoticsymptoms (Huber 1976a, 1976b;Huber, Gross, and Schuttler 1979;Janzarik 1968). The prognosticallyfavorable Types I, II, and III arefree of the components of "pure de-fect" and/or "structural deformation"that play a role in creating the "endstates" (Bleuler 1941) of the increas-ingly unfavorable Types IV throughXII. Whereas structural deformities areusually resistant to therapy, the symp-toms of "pure defect" can be favorablyinfluenced by profiled thymoleptics(Huber 1976a). The four groups ofprognostically favorable, relativelyfavorable, relatively unfavorable, andunfavorable course types each embraceabout one-quarter of all schizophrenicillnesses. The proportion of men tendsto be lower in the relatively favorable


group, while the men predominatesignificantly in the relatively unfavor-able group.

An attempt was made in the Bonnstudy to correlate long-term prognosiswith a number of factors that havebeen studied in past investigations.

Sex Differences. The long-term prog-nosis tended to be more favorable forwomen than for men, but the onlysignificant difference was in social re-covery. Some data suggest that womenare more frequent among schizophren-ics than men, as is known to be true inmanic-depressive psychosis. Of the3,767 schizophrenic patients hospi-talized in the three psychiatric facilitiesin Bonn from 1945 through 1959, 64percent were women and only 36 per-cent men. Social factors are not suf-ficient to explain this difference. Anadditional finding was that the age ofonset was lower for men than forwomen. Among 2,991 schizophrenicpatients, 70 percent of the men, ascompared to 47 percent of the women,had onset of illness before age 30. Inthe fourth and fifth decades of life, andafter age 50, significantly more womenthan men became ill (Huber, Gross, andSchuttlerl979).

Family History of Functional Psychosis.The presence or absence of secondarycases of schizophrenia or manic-de-pressive psychosis among the relativesof probands is not related to long-termprognosis. The only exceptions are maleprobands with secondary cases ofschizophrenia in the immediate family;in this subgroup, the rate of completeremissions is significantly lower. In the46 probands who have two or moresecondary cases of schizophrenia intheir families, the long-term prognosisis significantly more favorable than thatfor the rest of the sample because ofthe low rate (17 percent) of characteris-tic residues (table 8).

Table 8. Long-term psychopathologlcal prognosis in subgroupwith positive family history of schizophrenia (two or moresecondary cases)

Subjects

Nonchar- Charac-acterlstic terlstlc

Complete residual residualremission syndromes syndromes n = 480

Two or moresecondarycases ofschizophrenia

Rest of thesample

919.6%

10123.3%

2963.6%

17841.0%

817.4%

15535.7%

469.6%

43490.4%

x2 = 9.1 (2df),P < .01.

Birth Order. Only children are rela-tively rare (8 percent) among the Bonnprobands. First- and last-born childrenoccur with about the same frequency(24 and 22 percent, respectively). Mid-dle-born children are the most common(34 percent). There are no significantbirth-order effects on long-term prog-nosis.

Primary Personality. Patients with anonaberrant, syntonic (adaptable),socially competent primary personality(37 percent) and, especially, patientswith a markedly abnormal (psycho-pathic) primary personality (11 percent)differ significantly from the overallsample (table 9). Among the markedlyabnormal primary personalities, com-plete remissions are absent, and theleast favorable outcomes—the charac-teristic residues—are relatively fre-quent at 48 percent. The influence ofthe primary personality on long-termprognosis is more pronounced amongwomen than among men. A sensitive-inhibited personality structure is signif-icantly more favorable than a schizoid

Scholastic Achievement. We catego-rized probands into three general

groups: elementary school failures (10percent), average elementary schoolachievers (54 percent), and probandswith advanced education (35 percent).Elementary school failure is prognosti-cally unfavorable, and advanced edu-cation is usually favorable (table 10).Among the elementary school failures,characteristic residues are markedlymore frequent (50 percent) and com-plete remissions rarer than among pro-bands with advanced education. Incontrast to the finding reported forprimary personality, scholastic achieve-ment (and so also that of the premorbidintelligence level) has greater prognosticimportance for men than for women.The favorable influence of above-average intelligence is less pronouncedthan the negative effect of scholasticfailure. Among probands with ad-vanced education, improved prognosisis noted only in elementary pupilswith above-average achievement(about a 10 percent level), whereas pa-tients with high school or collegetraining cannot be distinguished fromthe average of the total sample. Halfof the university graduates are fullyemployed at their former occupationallevels, but the other half are sociallynonrecovered, since no university

VOL 6, NO. 4, 1980 599

Table 9. Primary personality and long-term psychopathologlcalprognosis

Primarypersonality

Normal

Slightlyabnormal

Markedlyabnormal

r2 = 20.6 (4 df), p

Completeremission

5129.0%

5722.9%

—

< 0.01.

Non-characteristic

residualsyndromes

7542.6%109

43.8%27

51.9%


syndromes

5028.4%

8333.3%

2548.1%

n = 477

17636.9%249

52.2%52

10.9%

Table 10. Scholastic achievement (premorbld level of Intelligence)and long-term psychopathological prognosis

Scholasticachievement

Elementaryschool failures

Average ele-mentary schoolachievers

Advancededucation

Completeremission

611.5%

6323.1%

4223.7%

Non-characteristic

residualsyndromes

2038.5%111

40.7%

8648.6%


syndromes

2650.0%

9936.3%

4927.7%

n = 502

5210.4%27354.4%

17735.3%

X2 = 11.1 (4df),P < 025.

graduate is fully employed below hisprevious occupational level.

Disrupted Family Relationships. Dis-rupted family relationships (as reflec-ted in broken homes, up to age 16) areapparent in 27.4 percent of the cases.This factor has no significant influenceon long-term development, but aninteresting sex difference is noted. Fe-male patients from disrupted familiesduring childhood tend toward a lessfavorable long-term prognosis, but themales toward a more favorable one.

This finding supports M. Bleuler's(1972) conclusion that disrupted familyrelationships more clearly influencethe disease course in women than inmen. •*-

Social Standing. Since Hollingsheadand Redlich published their study in1958, there has been a feeling of cer-tainty that schizophrenics come fromthe lower socioeconomic levels of so-ciety. In our opinion, investigationsaddressing this question must differ-entiate among the social level of the

patient's parents, the highest sociallevel achieved by the proband pre-morbidly, and the proband's sociallevel after a short or long duration ofillness. The Bonn study distinguishesbetween these three categories. In de-fining criteria of the socioeconomicstatus, we held to the analysis of socialstrata in West Germany by Janowitz(1958). The essential formal criterion ismembership in certain occupationalgroups.

First, we consider the proband'ssocial background, that is, the level ofhis parental family. As can be seen intable Il7for the entire populaHonofBonn's three psychiatric hospitals(University Psychiatric Clinic, RhenishState Hospital, and a private clinic),41.7 percent belong to the lower levels,42.7 percent to the lower-middle level,and 15.6 percent to the upper-middlelevel. In comparison with the totalpopulation of the Federal Republic ofGermany (according to Janowitz), thelower social levels might be under-represented, while the upper-middlelevels might be overrepresented. Therewas no difference in the distribution ofclasses between the patients of theUniversity Psychiatric Clinic and theRhenish State Hospital, but a largerproportion of patients admitted to theprivate clinic were from the upper-middle stratum.

A comparison of the social back-grounds (table 11) with the highestsocial levels attained premorbidly(table 12) reveals that intergenerationalmobility, which shows an increase inthe lower levels from 42 to 50 percentand a drop in the middle levels from 58to 50 percent, is relatively minimal.Likewise, the distribution of premorbidsocial levels among those patients wholater became schizophrenic hardly de-viates from that of the average popula-tion of the German Federal Republic,with the exception of the figures formembers of the upper-middle class,


Table 11. Social class of parents of schizophrenic patients in threehospital samples

Social classof parents

Lower classes

Lowermiddle class

Uppermiddle class

n

Universityclinic

21743.8%209

42.1%70

14.1%496

Statehospital

82043.6%795

42.2%26514.2%

1,880

Privateclinic

2113.0%

7949.0%

6138.0%161

n

1,05841.7%1,08342.7%

39615.6%2,537

FederalRepublic

ofGermany

51.9%

38.6%

4.6%

Table 12. Highest social class achieved before onset of illness byschizophrenic patients in three hospital samples

Premorbldsocial class

Lower classes

Lowermiddle class

Uppermiddle class

n

Universityclinic

25551.2%198

40.0%428.5%

495

Statehospital

1,21453.0%855

37.0%24010.0%

2,309

Privateclinic

179.9%90

52.6%64

37.5%171

n

1,48650.0%

1,14338.4%34611.6%

2,975

FederalRepublic

ofGermany

51.9%

38.6%

4.6%

which still remain somewhat higher.Only a comparison of the social back-ground and of the premorbid levelswith the social levels of the 502 pro-bands in the study sample at the timeof the lastfollowup (table 13) revealsa clear shift toward the lower strata. Inthe lower bottom level, we note an in-crease from 12 to 23.5 percent frompremorbid levels to those at the time ofcatamnesis; the reverse is true for thelower middle levels, which show a de-crease from 40 to 33 percent.

All told, we find that after an aver-age of 22.4 years' duration of illness,the distribution is unequal, in favor of

the lower bottom social level. Sincesuch inequality is not noted premorbidlyor among the parents, it is most easilyexplained, in the context of a drifthypothesis, as a consequence of thedisease. As a result of social incompe-tence, related either directly or indirectlyto their disease, schizophrenic pa-tients drift increasingly toward socio-economically lower population groups(Huber, Gross, and Schuttler 1979).

Furthermore, neither the patient'sfamily background nor his premorbidsocial status significantly influences hissocial or psychopathological long-termdevelopment.

Precipitating Factors in the InitialPsychotic Episode. We attempted toidentify precipitants that had precededthe onset of an initial episode of psy-chosis by no more than 4 weeks (table14). In 25 percent of cases, psycho-logical precipitants (e.g., loss of a closerelative, professional conflicts) ap-peared to have been important. Noreally typical—much less specific—psychological precipitants could bepinpointed, however. The types ofprecipitants also did not seem to belinked to a characteristic premorbidpersonality type. Nine percent of initialpsychotic episodes were apparentlyprecipitated by somatic factors (e.g.,illnesses accompanied by fever, sur-gery, physical excesses and exhaustion,alcoholic intoxication, accidents, andsleep deprivation). Generational pro-cesses (e.g., childbirth) were implicatedin the onset of psychosis in 5 percent ofpatients. However, in the majority ofcases—61 percent—no clear-cut pre-cipitating factors could be identified.There were no significant differencesin long-term prognosis among thefour subgroups (table 14).

Precipitating Factors in PsychoticRelapses. In 29 percent of cases, psy-chotic relapses were associated withpsychological precipitants. The long-term prognosis for this subgroup issignificantly more favorable (only 24percent developed characteristic resid-ual syndromes). Psychotic relapsesprecipitated by generational processes,especially postpartum psychoses, arealso prognostically favorable. How-ever, our data do not support a separatenosological category for the schizo-phrenic postpartum psychoses, sincethe long-term prognosis of patientswhose initial psychotic episodes oc-curred during the postpartum perioddoes not differ significantly from thatfor the rest of the sample. Neitherinitial episodes nor subsequent episodes

VOL 6, NO. 4, 1980 601

Table 13. Social class of parents, highest premorbid social class,and social class at the last foilowup

Social Class

Lowerlow class

Upperlow class

Lowermiddle class

Uppermiddle class

n

Class ofparents

326.5%185

37.3%209

42.1%70

14.1%496

Bonn main sample

Premorbidclass

5911.9%196

39.6%198

40.0%428.5%

495

Class atcatamnesls

11223.5%164

34.4%159

33.3%428.8%477

FederalRepublic

ofGermany

38.5%

13.3%

38.6%

4.6%

Table 14. Precipitating factors In the initial psychotic episode andlong-term prognosis

Type ofprecipitant

Somatic

Psychological

Generationalprocesses

No clear-cutreleasingprecipitants

Completeremission

920.0%

3326.6%

726.9%

6220.6%

Nonchar-acterlstlcresidual

syndromes

1840.0%

6048.4%

1142.3%126

41.9%

Charac-teristicresidual

syndromes

1840.0%

3125.0%

830.8%113

37.5%

n = 496

459.1%124

25.0%265.2%301

60.7%

x2 = 7.2 (6 df), nonsignificant.

of psychoses precipitated by somaticfactors are significantly related to long-term prognosis. (See table 15.)

Multiple Episodes With Clear-cutPrecipitants. Releasing of more thanone episode occurs significantly moreoften among women than among men.Of the Bonn sample of 502 patients, 98had two or more psychotic episodes

with identifiable precipitants. As canbe seen in table 16, the long-term prog-nosis for this subgroup is significantlymore favorable than that for the rest ofthe sample. Only 16 percent of patientswith multiple releasings of psychoticepisodes show an unfavorable out-come; that is, go on to develop charac-teristic residual syndromes.

Among the cases with psychological

precipitants, acute, subjectively severelife events predominate, providing somesupport for the hypothesis of a non-specific stress effect on a latent ba-sically somatic process (Gross, Huber,and Schiittler 1971). The precipitatingfactors are nonspecific somatic orpsychic "triggers" that, in many cases,seem to represent necessary—but notsufficient—conditions for the develop-ment of the psychotic episode. TheBonn findings provide support for theassumption of Langfeldt and othersthat clear-cut psychological precipi-tants may be regarded as signs of afavorable^rognosis^ However, the dif-ferences are too small to form the basisfor a nosologically independent con-cept of true "psychogenic psychoses"(see Astrup 1974; Huber 1969, 1976b;Huber, Gross, and Schuttler 1976).

Age of Onset. Among the2,991 patientsin the overall Bonn sample, age of on-set is most commonly (39 percent) inthe third decade of life, followed bythe fourth decade (26 percent), thesecond decade (17 percent), and thefifth decade (14 percent). Only 14 per-cent of patients become ill after age 50.The age of onset has no significantprognostic value, as table 17 shows forthe study sample of 502 patients. Thisis valid for the early- as well as for thelate-onset schizophrenias. Despite thevarious peculiarities in primary per-sonality, symptomatology, and out-come (Huber, Gross, and Schuttler1975fc, 1979), the late-onset schizo-phrenias are no more deserving ofspecial nosological classification thanare the postpartum psychoses, thereactive schizophrenias, or—in the areaof the cyclothymias—the so-called in-volutional depressions (Angst andPerrisl968).

Prodromes and Outpost Syndromes("Vorpostensyndrome"). Noncharac-teristic prodromes, which lead to initial


Table 15. Precipltants of psychotic relapses and long-termprognosis

Type ofprecipitant

Somatic

Psychological

Generationalprocesses

No clear-cutprecipitants

v2 = 30.1 (6 df), P <

Completeremission

26.9%23

21.2%5

41.7%32

14.2%

.001.

Nonchar-acteristicresidual

syndromes

1862.1%

5954.6%

758.3%

8838.9%


syndromes

931.0%

2624.1 %

—

10646.9%

n = 375i

297.7%108

28.8%12

3.2%226

60.3%

Table 16. Long-term prognosis in schizophrenic patients with 2 ormore psychotic episodes

Repeatedepisodes

Rest ofthe sample

v2 = 20.9 (2 dt), p <

Completeremission

2222.4%

8922.0%

.001.

Nonchar-acteri8ticresidual

syndromes

6061.2%157

38.9%


syndromes

1616.3%158

39.1%

n = 502

9819.5%40480.5%

psychotic episodes after an averagecourse of 3.2 years, occur in 37 percentof the sample. Phenomenologically,these prodromes are, by and large,identical to the pure residues, the re-versible asthenic basic states, and thefree-standing outpost syndromes thatprecede the prodromes or the initialpsychotic manifestations by an aver-age of 10.2 years. Outpost syndromes,which were observed in 15 percentof cases, are noncharacteristic (e.g.,asthenic) episodes that completely re-

mit after a duration of 3 days to 4years. However, the occurrence ofprodromes does not correlate with theprogression to pure residues. Pureresidues often develop without any ofthe noncharacteristic precursors. Thisis illustrated, among others, in CourseType V, which leads to pure residues(see table 7), but begins in only 12 per-cent of cases with a prodrome. Thetype of course that progresses to a"pure defect" state does not alwayssignal its coming in the noncharacter-

istic prodromes and outpost syn-dromes that sometimes precede thepsychoses.

There are clear differences betweenthe brief prodromes and the long-termprodromes that last over 2 years. Thelonger the prodrome persists, the rarerare complete psychopathologicalremissions. Long-term prodromes cor-relate positively with the developmentof pure and mixed residues, that is, ofdeficiency syndromes that are ex-clusively or predominantly determinedby symptoms of irreversible reductionof psychic energetic potential.

Onset of Illness. The long-term prog-nosis in acute-onset psychoses issignificantly more favorable (only 24percent characteristic residues),whereas the reverse is true in insidious-onset psychoses (58 percent character-istic residues). Acuteness of onset cor-relates with the primary personality.In cases of abnormal primary per-sonalities, insidious onsets are morefrequent than in cases of nonaberrantor slightly aberrant primary person-alities.

Psychopathological Pictures. The mostcommon initial psychotic manifesta-tions are paranoid-hallucinatory (37percent) and paranoid (17 percent).Hebephrenic (11 percent), depressiveor depressive-cenesthetic (combined 9percent), cenesthetic (7 percent), andcatatonic (5 percent) symptom pic-tures are seen more rarely. Catatonicand cenesthetic-depressive initial psy-chopathological syndromes are prog-nostically favorable, but hebephrenicsymptoms (especially in women) areunfavorable. While pure paranoid ini-tial syndromes prove to be prognosti-cally neutral, the paranoid-hallucina-tory onset syndromes are unfavorable(though the difference is not signifi-cant). Initial cenesthetic and depressive-cenesthetic syndromes lead more fre-

VOL 6, NO. 4, 1980 603

Table 17. The age at the onset of illness (first psychotic mani-festation) and long-term psychopathological prognosis

Age at onsetof diseaseOn years)

5-14

15-19

20-29

30-39

40-49

50 and more

Completeremission

541.7%

2623.4%

3719.9%

2217.9%

1630.2%

529.4%


syndromes

216.7%

4641.4%

9148.9%

5443.9%

1935.8%

529.4%


syndromes

541.7%

3935.1%

5831.2%

4738.2%

1834.0%

741.2%

n = 502

122.4%111

22.1%186

37.1%123

24.5%53

10.6%17

3.4%

x2 = 11.9 (10 dl), nonsignificant.

quently to noncharacteristic residues,and more rarely to characteristic resi-dues. This finding is more pronouncedin men and supports earlier findings inmale cenesthetic schizophrenics who,as a rule, develop pure residues andonly rarely typical schizophrenic de-fect-psychoses (Huber 1971).

Initial Psychopathological Symptoms.Of 31 individual symptoms, only threeoccur in over half the patients duringthe first 6 months, and these are schizo-phrenic disturbances of affect orcommunication, central-vegetative dis-turbances, and delusional ideas. First-rank symptoms and likewise catatonicdisturbances are present in the first 6months in less than one-fourth of thepatients. In the long-term course,among the first-rank symptoms, egodisturbances occur in 51 percent, delu-sional perceptions in 42 percent,acoustic hallucinations in 40 percent,and bodily influence experiences in 39percent. Among the second-ranksymptoms, the most frequent are

delusional ideas (86 percent), self-rela-tionships (75 percent), and second-rank acoustic hallucinations (75 per-cent). We tested whether the presenceor absence of certain symptoms in thefirst 6 months would influence thelong-term prognosis. Among the prog-nostically favorable symptoms arecatatonic hypersymptoms, endo-genous-depressive moods, depersonali-zation, and delusional misidentifica-tion of persons.The only prognosticallyunfavorable initial symptom thatachieves significance is first-rankacoustic hallucinations. Second-rankacoustic hallucinations, bodily in-fluence experiences, and schizophrenicego disturbances also tend to be un-favorable. Delusional perceptions,optical hallucinations, and—contraryto expectations—formal thought dis-turbances (loosening of association,interruption of thought, and more orless noncharacteristic disturbances inthinking) tend toward a more favorableoutcome. The long-term prognosis ofthe small subgroup (18 percent) of

schizophrenics without formal thoughtdisturbances is not significantly differ-ent from that of the rest of thesample group. Thus, the presence offormal thought disturbances in schizo-phrenic psychoses does not appear tobe a useful criterion to distinguish be-tween, for example, the "true schizo-phrenias" and the "schizoaffectivepsychoses" (Huber, Gross, andSchuttlerl979).

Therapeutic Factors. The subgroup(43 percent) of patients who were nottreated during their initial psychoticepisodes (table 18) have significantlyworse remissions than patients whowere initially treated (with electrocon-vulsive or psychophannacologicaltherapy, or with combinations of thesetwo). In the overall course, only 7 per-cent remained untreated. For these,too, the long-term prognosis is lessfavorable, although not significantlyso, than that for the total sample.Certain findings from the Bonn studyattest to a favorable influence on thelong-term prognosis of therapy, andespecially of psychopharmacotherapy.Thus, for example, patients who be-came ill from 1951 through 1959 (whenpsychopharmacological treatment be-came increasingly available) have asignificantly better prognosis than pa-tients who became ill before 1951. Pa-tients who were initially hospitalizedand treated within 1 year after onset(including prodromes) have a highlysignificantly better long-term prognosisthan do patients who did not receivetheir first treatment until later.

Individual Prognosis. Predictions arepossible only when several factors thathave a similar influence on the long-term prognosis occur in combination,and when factors with a contrary prog-nostic influence are absent. Even underthese circumstances, the individualcourse is by no means certain. More-


Table 18. Treatment of the first psychotic manifestation and long-term psychopathological prognosis in the Bonn main sample

Treated

Untreated

X2= 13.5(2d/),p

Completeremission

8027.9%

3114.6%

< .01.


syndromes

11941.5%

9645.1 %


syndromes

8830.7%

8640.4%

n = 500

28757.4%21342.6%

over, at the onset of illness, no reason-ably reliable prognosis for the individ-ual patient is possible. The hypothe-sis that presenting symptomatologycan be used to differentiate betweentrue schizophrenias and schizophreni-fonn (or schizoaffective) psychosescannot be supported by current findings(see Bleuler 1972; Huber, Gross, andSchuttler 1979).

References

Angst, ]., and Perris, C. Zur Nosologieendogener Depressionen. Vergleichder Ergebnisse zweier Untersuchun-gen. Archiv fur Psychiatrie undNervenkrankheiten, 210:373-386,1968.

Astrup, C. Long-term prognosis ofthe functional psychoses. In: Mitsuda,H., and Fukuda, T., eds. BiologicalMechanisms of Schizophrenia andSchizophrenia-like Psychoses. Tokyo:Igaku Shoin Company, Ltd., 1974.pp. 120-125.

Bleuler, M. Krankheitsverlauf, Per-sbnlichkeit und VerwandtschaftSchizophrener und ihre gegenseitigenBeziehungen. Leipzig: Georg Thieme,1941.

Bleuler, M. Die schizophrenen Gei-stesstbrungen im Lichte langjahriger

Kranken- und Familiengeschichten.Stuttgart: Georg Thieme, 1972.

Bleuler, M.; Huber, G.; Gross, G.; andSchuttler, R. Der langfristige Verlaufschizophrener Psychosen. Gemein-same Ergebnisse zweier Unter-suchungen. Nervenarzt, 47:477-481,1976.

Broen, W.E. Schizophrenia: Researchand Theory. New York: AcademicPress, Inc., 1969.

Ciompi, L., and Mflller, C. Lebens-weg und Alter der Schizophrenen.Eine katamnestische Langzeitstudie bisins Senium. Monographien aus demGesamtgebiete der Psychiatrie. Bd.12. Berlin: Springer/Verlag, 1976.

Conrad, K. Die beginnende Schizo-phrenie. Versuch einer Gestaltanalysedes Wahns. Stuttgart: Georg Thieme,1958.

Gross, G.,- Huber, G.; and Schflttler,R. Peristatische Faktoren im Beginnund Verlauf schizophrener Erkran-kungen. Archiv fur Psychiatrie undNervenkrankheiten, 215:1-7, 1971.

Hasse-Sander, I.; Huber, G.; Gross,G.; and SchGttler, R. Testpsycho-logisch-psychopathologische Un-tersuchungen bei schizophrenenResidualsyndromen. In: Huber, G.,ed. Atiologie der Schizophrenien.

Bestandsaufnahme und Zukunftsper-spektiven. Stuttgart: Schattauer, 1971.pp. 215-220.

Hollingshead, A.B., and Redlich, F.C.Social Class and Mental Illness. NewYork: John Wiley & Sons, Inc., 1958.

Huber, G. Pneumencephalographischeund psychopathologische Bilder beiendogenen Psychosen. Monographienaus dem Gesamtgebiete der Psychiatrieund Neurologic. Berlin: Springer/Verlag, 1957.

Huber, G. Chronische Schizophrenic.Synopsis klinischer und neuroradio-logischer Untersuchungen an de-fektschizophrenen Anstaltspatienten.Einzeldarstellungen aus der theo-retischen und Klinischen Medizin.Heidelberg: Dr. Huthig, 1961.

Huber, G. Reine Defektsyndromeund Basisstadien endogener Psy-chosen. Fortschritte der Neurologie,Psychiatrie und ihrer Grenzgebiete,34:409-426, 1966.

Huber, G. Verlaufsprobleme schizo-phrener Erkrankungen. SchweizerArchiv fur Neurologie, Neuro-chirurgie und Psychiatrie, 101:346-368,1968.Huber, G., ed. Schizophrenic undZyklothymie. Ergebnisse und Prob-leme. Stuttgart: Georg Thieme, 1969.

Huber, G. Die coenasthetischeSchizophrenic als ein Pragnanztypschizophrener Erkrankungen. ActaPsychiatrica Scandinavica, 47:349-362, 1971.

Huber, G., ed. Verlauf und Ausgangschizophrener Erkrankungen. Stutt-gart: Schattauer, 1973.

Huber, G. Psychiatrie. SystematischerLehrtext fur Studenten und Ante.2 Aufl. Stuttgart: Schattauer, 1976o.

Huber, G. Schizophrenic—nosolo-gjsche und dtiologische Aspekte. In:Grinschgl, G., ed. Referateband des16. Neuropsychiatrischen Sym-

VOL 6, NO. 4, 1980 605

posiums in Pula. Graz: Kuratoriumder Neuropsychiatrischen Symposienin Pula, 1976b.Huber, G., ed. Therapie, Rehabili-tation und Pravention schizophrenerErkrankungen. Stuttgart: Schattauer,1976c.

Huber, G. Indizien fur die Soma-tosehypothese bei den Schizophrenien.Fortschritte der Neurologie, Psychia-trie und ihrer Grenzgebiete. 44:77-94,

Huber, G.; Gross, G.; and Schuttler,R. A long-term foUow-up study ofschizophrenia: 'Psychiatric course andprognosis. Acta Psychiatrica Scandi-navica, 52:49-57, 1975a.

Huber, G.; Gross, G.; and Schuttler,R. SpStschizophrenie. Archiv furPsychiatrie und Nervenkrankheiten,221:53-66, 1975b.Huber, G.; Gross, G.; and Sdiuttkr,R. Nosologie der SchizophrenicMunchener, Medizinische Wochen-schrift, 118:1663-1668, 1976.Huber, G.; Gross, G.; and Schuttler,R. Schizophrenie. Verlaufs- undsozialpsychiatrische Langzeitunter-suchungen an den 1945 his 1959 inBonn hospitalisierten schizophrenenKranken. Monographien aus demGesamtgebiete der Psychiatrie. Bd.21. Berlin: Springer/Verlag, 1979.Huber, G., and Penin, H. Klinisch-elektroencephalographische Korrela-tionsuntersuchungen bei Schizo-phrenen. Forschritte der Neurologie,Psychiatrie und ihrer Grenzgebiete,36:641-659, 1968.

Janowitz, M. Soziale Schichtung undMobilitat in Westdeutschland. KobierZeitschrift fUr Soziologie und Sozial-psychologie, 10:1-38, 1958.Janzarik, W. Dynamische Grundkon-stellationen in endogenen Psychosen.Berlin: Springer/Verlag, 1959.

Janzarik, W. Schizophrene Verlaufe.Berlin: Springer/Verlag, 1968.

Langfeldt, G. The prognosis in schizo-phrenia. Acta Psychiatrica Scandi-navica, Supplement 110:7-66, 1956.Leonhard, K. Aufteilung der endo-genen Psychosen. 3. Aufl. Berlin:Akademie-Verlag, 1966.

Mauz, F. Die Prognostik der endo-genen Psychosen. Leipzig: GeorgThieme, 1930.

Mitsuda, H. Clinical Genetics in Psy-chiatry. Problems in NosologicalClassification. Kyoto: Bunko-shaCompany Ltd., 1974.Mitsuda, H., and Fukuda, T., eds.Biological Mechanisms of Schizo-phrenia and Schizophrenia-likePsychoses. Tokyo: Igaku Shoin Com-pany Ltd., 1974.

Schneider, K. Klinische Psycho-pathologie. 11. Aufl. Stuttgart: GeorgThieme, 1976.

Schuttler, R.; Huber, G.; and Gross,G. Psychopathologische Remission-stypen und echoencephalographischerBefund am 3. Ventrikel. Archiv furPsychiatrie und Nervenkrankheiten,218:251-264, 1974.

Sulhvold, L. Symptome schizophrenerErkrankungen. Uncharakteristische

Basisstdrungen. Monographien ausdem Gesamtgebiete der Psychiatrie.Bd. 13. Berlin: Springer/Verlag, 1977.

Weitbrecht, H.J. Psychiatrie imGrundriss. 3. Aufl. Berlin: Springer/Verlag, 1973.

Wing, J.K. Eine praktische Grundlagefur die Soziotherapie bei Schizo-phrenie. In: Huber, G., ed. Therapie,'Rehabilitation und Pravention schizo-phrener Erkrankungen. Stuttgart:Schattauer, 1976. pp. 31-54.

The Authors

Gerd Huber, M.D., is Professor andDirector, University PsychiatricClinic and Policlinic; Gisela Gross,M.D., is Professor and Chairman,Department for "Verlaufspsychiatrie";Reinhold Schuttler, M.D., is Professorand Chairman, Department for "SocialPsychiatry"; and Maria Linz is Re-search Assistant, University Psy-chiatric Clinic, Bonn, F.R.G.

The Translator

Siegfried Clemens is Technical In-formation Specialist, National Clear-inghouse for Mental HealthInformation, National Institute ofMental Health, Alcohol, Drug Abuse,and Mental Health Administration,RockviUe, MD.

Documents

Longitudinal Studies of Schizophrenic Patients · Poliklinik Bonn, Sigmund-Freud-Strasse 25, D-5300 Bonn 1, F.R.G. VOL 6, NO. 4, 1980 593 investigations in the world literature. However,