Hostname: page-component-758b78586c-qzq9q Total loading time: 0 Render date: 2023-11-29T03:29:31.642Z Has data issue: false Feature Flags: { "corePageComponentGetUserInfoFromSharedSession": true, "coreDisableEcommerce": false, "useRatesEcommerce": true } hasContentIssue false

The metamorphosis of schizophrenia: from chronicity to vulnerability

Published online by Cambridge University Press:  09 July 2009

Joseph Zubin*
Biometrics Research, Veterans Administration Medical Center, Pittsburgh, Department of Psychiatry, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, USA
Jay Magaziner
Biometrics Research, Veterans Administration Medical Center, Pittsburgh, Department of Psychiatry, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, USA
Stuart R. Steinhauer
Biometrics Research, Veterans Administration Medical Center, Pittsburgh, Department of Psychiatry, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, USA
1Address for correspondence: Dr J. Zubin, Biometrics Research, 151R, Veterans Administration Medical Center, Highland Drive, Pittsburgh, PA 15206, USA.


On the evidence of long-term follow-up studies of cohorts of patients in Europe the outcome of schizophrenia appears to be changing from chronicity to an episodic course with a more favourable outlook. While the reasons for this change are unclear it is suggested that schizophrenia is characterized essentially by a state of vulnerability to the disorder. This vulnerability may or may not give rise to an episode of illness, depending on the incidence of triggering life event stressors and on the moderating influences of social networks, ecological factors, and premorbid personality. The traditional view of schizophrenia as an essentially chronic condition reflects not so much the natural history of the disorder as iatrogenic influences, lack of satisfactory extra-mural care, the accumulation of a relatively small proportion of truly chronic illnesses and the failure to recognize the termination of an episode of illness in patients with poor premorbid personalities. Evidence for the episodic nature of schizophrenia is presented.

Research Article
Copyright © Cambridge University Press 1983

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)


Achté, K. A. (1967). On prognosis and rehabilitation in schizophrenia and paranoid psychoses. Acta Psychiatrica et Neurologica Scandinavica Supplement 125, 33.Google Scholar
Altman, I. (1975). The Environment and Social Behavior. Brooks/Cole Publishing Co.: Monterey, CA.Google Scholar
American Psychiatric Association (1980). Diagnostic and Statistical Manual – III (DSM–III). APA: Washington, D.C.Google Scholar
Andreasen, N. C. (1982). Negative symptoms in schizophrenia: definition and reliability. Archives of General Psychiatry 39, 784788.Google Scholar
Andreasen, N. C. & Olsen, S. A. (1982). Negative vs. positive schizophrenia: definition and validation. Archives of General Psychiatry 39, 789794.Google Scholar
Andreasen, N. C., Olsen, S. A., Dennert, J. W. & Smith, M. R. (1982). Ventricular enlargement in schizophrenia: relationship to positive and negative symptoms. American Journal of Psychiatry 139, 297302.Google Scholar
Berkman, L. & Syme, S. (1979). Social networks, host resistance and mortality: a nine-year follow-up study of Alameda County residents. American Journal of Epidemiology 109(2), 186204.Google Scholar
Bleuler, M. (1941). Krankheitsverlauf, Persönlichkeit und Verwandtschaft Schizophrener und ihre gegenseitigen Beziehungen. Thieme: Leipzig. (Disease Course, Personality and Kinship of Schizophrenics and their Mutual Relationships. Cited by Bleuler (1978).)Google Scholar
Bleuler, M. (1978). The Schizophrenic Disorders: Long-term Patient and Family Studies (transl. Clemens, S. M.). Yale University Press: New Haven. (Translation of Die Schizophrenen Geistesstörungen im Lichte: Langjahriger Kranken- und Familiengeschichten. Georg Thieme Verlag: Stuttgart. 1972.)Google Scholar
Brenner, M. H. (1973). Mental Illness and the Economy. Harvard University Press: Cambridge, Mass.Google Scholar
Brown, G. W., Birley, J. L. T. & Wing, J. K. (1972). The influences of family life on the course of schizophrenic disorders: a replication. British Journal of Psychiatry 121, 241258.Google Scholar
Brown, G. W., Ní Bhrolchaín, M. & Harris, T. (1975). Social class and psychiatric disturbances among women in an urban population. Sociology 9, 225254.Google Scholar
Brown, G. W., Preisman, R. C., Anderson, M. D., Nixon, R. K., Isbister, J. L. & Price, H. A. (1981). Memory performance of chemical workers exposed to polybrominated biphenyls. Science 212, 14131415.Google Scholar
Cassel, J. (1976). The contribution of the social environment to host resistance. American Journal of Epidemiology 104, 107123.Google Scholar
Ciompi, L. (1980). The natural history of schizophrenia in the long term. British Journal of Psychiatry 136, 413420.Google Scholar
Cooper, J. E., Kendell, R. E., Gurland, B. J., Sharpe, L., Copeland, J. R. M. & Simon, R. (1972). Psychiatric Diagnosis in New York and London: A Comparative Study of Mental Hospital Admissions. Maudsley Monograph No. 20 Oxford University Press: London.Google Scholar
Crow, T. J. (1980). Discussion: positive and negative schizophrenic symptoms and the role of dopamine. British Journal of Psychiatry 137, 383386.Google Scholar
Crow, T. J. (1981). Riposte: positive and negative schizophrenic symptoms and the role of dopamine. British Journal of Psychiatry 139, 251254.Google Scholar
Dohrenwend, B. P. & Dohrenwend, B. S. (1969). Social Status and Psychological Disorder. John Wiley & Sons: New York.Google Scholar
Eaton, W. W. (1978). Life events, social supports and psychiatric symptoms: a reanalysis of the New Haven data. Journal of Health and Social Behavior 19, 230234.Google Scholar
Essen-Möller, E. & Hagnell, O. (1975). ‘Normal’ and ‘regional’ traits of personality according to Sjöbring: re-ratings and prognostic implications. Neuropsychobiology 1, 146154.Google Scholar
Essen-Möller, E., Larsson, H., Uddenberg, C. E. & White, G. (1956). Individual traits and morbidity in a Swedish rural population. Acta Psychiatrica et Neurologica Scandinavica Supplement 100, 1160.Google Scholar
Feldman, P. G., Ricks, N. L. & Baker, E. L. (1980). Neuropsychological effects of industrial toxins: a review. American Journal of Industrial Medicine 1, 211227.Google Scholar
Galle, O. R., Gove, W. R. & McPherson, J. M. (1972). Population density and pathology: what are the relations for man? Science 176, 2330.Google Scholar
Gerard, D. & Houston, L. (1953). Family setting and the social ecology of schizophrenia. Psychiatric Quarterly 27, 90101.Google Scholar
Glass, D., Singer, J. & Pennebaker, J. (1977). Behavioral and physiological effects of uncontrollable environmental events. In Perspectives on Environment and Behavior (ed. Stokols, D.), pp. 131151. Plenum Press: New York.Google Scholar
Gottesman, I. I. & Shields, J. (1976). A critical review of recent adoption, twin, and family studies of schizophrenia: behavioral genetics perspectives. Schizophrenia Bulletin 2, 360401.Google Scholar
Gove, W. R. & Hughes, M. (1980). Re-examining the ecological fallacy: a study in which aggregate data are critical in investigating the pathological effects of living alone. Social Forces 58, 11571177.Google Scholar
Hagnell, O. (1966). A Prospective Study of the Incidence of Mental Disorder. Svenska Bokforlaget Norstedts.Google Scholar
Hammer, M., Makiesky-Barrow, S. & Gutwirth, L. (1978). Social networks and schizophrenia. Schizophrenia Bulletin 4, 525545.Google Scholar
Hare, E. H. (1956 a). Mental illness and social conditions in Bristol. Journal of Mental Science 102, 349357.Google Scholar
Hare, E. H. (1956 b). Family setting and the urban distribution of schizophrenia. Journal of Mental Science 102, 753760.Google Scholar
Hare, E. H. (1974). The changing content of psychiatric illness. Journal of Psychosomatic Research 18, 283289.Google Scholar
Henderson, S., Byrne, D. G., Duncan-Jones, P., Scott, R. & Adcock, S. (1980). Social relationships, adversity and neurosis: A study of associations in a general population sample. British Journal of Psychiatry 136, 574583.Google Scholar
Holmes, T. H. & Rahe, R. H. (1967). The Social Readjustment Rating Scale. Journal of Psychosomatic Research 11, 213218.Google Scholar
Huber, G., Gross, G., Schuttler, R. & Linz, M. (1980). Longitudinal studies of schizophrenic patients. Schizophrenia Bulletin 6,592605.Google Scholar
Jackson, J. H. (1931). Selected Writings (ed. Taylor, J.). Hodder & Stoughton: London. (Quoted by Andreasen, N. C. et al. 1982.)Google Scholar
Johnstone, E. C., Crow, T. J., Frith, C. D., Husband, J. & Creel, L. (1976). Cerebral ventricular size and cognitive impairment in chronic schizophrenia. Lancet ii, 924926.Google Scholar
Kohn, M. (1973). Social class and schizophrenia: a critical review and a reformulation. Schizophrenia Bulletin 17, 6079.Google Scholar
Kramer, M. (1978). Population changes and schizophrenia, 1970–1985. In The Nature of Schizophrenia: New Approaches to Research and Treatment (ed. Wynne, L. C., Cromwell, R. L. and Matthysse, S.), pp. 545571. John Wiley & Sons: New York.Google Scholar
Kreisman, D. (1970). Social interaction and intimacy in preschizophrenic adolescents. In The Psychopathology of Adolescence (ed. Zubin, J. and Freedman, A. M.), pp. 299318. Grune and Stratton: New York.Google Scholar
Leckman, J. F., Bowers, M. B. Jr & Sturges, J. S. (1981). Relationship between estimated premorbid adjustment and CSF homovanillic acid and 5-hydroxyindoleacetic acid levels. American Journal of Psychiatry 138, 472477.Google Scholar
Leff, J. (1978). Social and psychological causes of the acute attack. In Schizophrenia: Towards a New Synthesis (ed. Wing, J. K.). pp. 139166. Academic Press: New York.Google Scholar
Leff, J. & Vaughn, C. (1981). The role of maintenance therapy and relatives' expressed emotion in relapse of schizophrenia: a two-year follow-up. British Journal of Psychiatry 139, 102104.Google Scholar
Magaziner, J. (1980). Density, living alone, age and psychopathology in the urban environment. Unpublished doctoral dissertation: The University of Chicago.Google Scholar
Mintz, N. & Schwartz, D. (1964). Urban ecology and psychosis. International Journal of Psychiatry 10, 101118.Google Scholar
Myers, J. K., Lindenthal, J. & Pepper, M. (1974). Social class, life events and psychiatric symptoms: a longitudinal study. In Stressful Life Events (ed. Dohrenwend, B. S. and Dohrenwend, B. P.), pp. 191205. John Wiley & Sons: New York.Google Scholar
Neale, J. M. & Oltmanns, T. F. (1980). Schizophrenia. pp. 362388. John Wiley & Sons: New York.Google Scholar
Paul, G. L. & Lentz, R. J. (1977). Psychosocial Treatment of Chronic Mental Patients: Milieu versus Social Learning Programs. Harvard University Press: Cambridge, Mass.Google Scholar
Pollin, W. & Stabenau, J. R. (1968). Biological, psychological and historical differences in a series of monozygotic twins discordant for schizophrenia. In The Transmission of Schizophrenia (ed. Rosenthal, D. and Kety, S. S.), pp. 317332. Pergamon Press: Oxford.Google Scholar
Pollin, W., Stabenau, J. R., Mosher, L. & Turpin, J. (1966). Life history differences in identical twins discordant for schizophrenia. American Journal of Orthospychiatry 36, 492509.Google Scholar
Proshansky, H., Nelson-Shulman, Y. & Kaminoff, R. (1978). The role of physical settings in life crisis experiences. In Stress and Anxiety, Vol. 6 (ed. Sarason, I. and Spielberger, C.), pp. 125. John Wiley & Sons: New York.Google Scholar
Rosenberg, G. S. (1970). The Worker Grows Old. Jossey-Bass: San Francisco.Google Scholar
Rosow, I. (1967). Social Integration of the Aged. Free Press: New York.Google Scholar
Shapiro, R. & Shader, R. (1979). Selective review of previous follow-up studies of schizophrenia and other psychoses. In Schizophrenia: An International Follow-up Study, World Health Organization, Geneva, pp. 1143. John Wiley & Sons: New York.Google Scholar
Sjöbring, H. (1963). La personnalité: Structure et développement. Paris: Doin. (Reprinted (1973) as: Personality structure and development, a model and its application. Acta Psychiatrica Scandinavica Supplement 244, transl. E. Essen-Möller.)Google Scholar
Sokolovsky, J., Cohen, C., Berger, D. & Geiger, J. (1978). Personal networks of ex-mental patients in a Manhattan S.R.O. Hotel. Human Organization 37, 515.Google Scholar
Spitzer, R. L., Endicott, J. & Robins, E. (1975). Research Diagnostic Criteria for a Selected Group of Functional Disorders (2nd edn). Biometrics Research Unit, New York State Psychiatric Institute: New York.Google Scholar
Spring, B. & Coons, H. (1982). Stress as a precursor of schizophrenia. In Psychological Stress and Psychopathology (ed. Neufeld, R. W. J.), pp. 1354. McGraw-Hill: New York.Google Scholar
Spring, B. & Zubin, J. (1978). Attention and information processing as indicators of vulnerability to schizophrenic episodes. In The Nature of Schizophrenia: New Approaches to Research and Treatment (ed. Wynne, L. C., Cromwell, R. and Matthysse, S.), pp. 366375. John Wiley & Sons: New York.Google Scholar
Staudt, V. & Zubin, J. (1957). A biometric evaluation of the somatotherapies in schizophrenia. Psychological Bulletin 54, 171196.Google Scholar
Strauss, J. S., Carpenter, W. T. & Bartko, J. J. (1974). The diagnosis and understanding of schizophrenia: III. Speculation on the processes that underlie schizophrenic symptoms and signs. Schizophrenia Bulletin 11, 6169.Google Scholar
Torrey, E. F. (1980). Schizophrenia and Civilization. Jason Aronson: New York.Google Scholar
United Nations Environment Program and the World Health Organization (1980). Environmental health criteria 12: Noise. Reviewed by Miller, A. R. In American Journal of Industrial Medicine 1, 229232.Google Scholar
Watt, N. F., Grubb, T. W. & Erlenmeyer-Kimling, L. (1982). Social, emotional, and intellectual behavior at school among children at high risk for schizophrenia. Journal of Abnormal Psychology 50, 171181.Google Scholar
Wechsler, H. & Pugh, T. F. (1967). Fit of individual and community characteristics and rates of psychiatric hospitalization. American Journal of Sociology 73(2), 331338.Google Scholar
Weinberger, D. R., Torrey, E. F., Neophytides, A. N. & Wyatt, R. J. (1979). Lateral cerebral ventricular enlargement in chronic schizophrenia. Archives of General Psychiatry 36, 735739.Google Scholar
Weinberger, D. R., Cannon-Spoor, E., Potkin, S. G. & Wyatt, R. J. (1980). Poor premorbid adjustment and CT scan abnormalities in chronic schizophrenia. American Journal of Psychiatry 137, 14101413.Google Scholar
Wing, J. K. (1966). Five year outcome in early schizophrenia. Proceedings of the Royal Society of Medicine 59, 1718.Google Scholar
Wing, J. K. (1978 a). Clinical concepts of schizophrenia. In Schizophrenia – Towards a New Synthesis (ed. Wing, J. K.), pp. 130. Academic Press: London.Google Scholar
Wing, J. K. (1978 b). Social influences on the course of schizophrenia. In The Nature of Schizophrenia: New Approaches to Research and Treatment (ed. Wynne, L. C., Cromwell, R. L. and Matthysse, S.), pp. 599616. John Wiley & Sons: New York.Google Scholar
Wing, J. K. (1980). Social psychiatry in the United Kingdom: the approach to schizophrenia. Schizophrenia Bulletin 6, 556565.Google Scholar
Wing, J. K., Cooper, J. E. & Sartorius, N. (1974). The Measurement and Classification of Psychiatric Symptoms. Cambridge University Press: Cambridge.Google Scholar
World Health Organization (1979). Schizophrenia – An International Follow-up Study. John Wiley & Sons: New York.Google Scholar
Zubin, J. (1965). Psychopathology and the social sciences. In Perspectives in Social Psychology (ed. Klineberg, O. and Christie, R.), pp. 189207. Holt, Rinehart and Winston: New York.Google Scholar
Zubin, J. (1972). Scientific models for psychopathology in the '70s. Seminar Psychiatry 4, 283296.Google Scholar
Zubin, J. & Burdock, E. I. (1965). The revolution in psychopathology and its implications for public health. Acta Psychiatrica Scandinavica 41, 348359.Google Scholar
Zubin, J. & Spring, B. (1977). Vulnerability: a new view of schizophrenia. Journal of Abnormal Psychology 86, 103126.Google Scholar
Zubin, J. & Steinhauer, S. (1981). How to break the logjam in schizophrenia: A look beyond genetics. Journal of Nervous and Mental Disease 169, 477492.Google Scholar
Zubin, J., Sutton, S., Salzinger, K., Salzinger, S., Burdock, E. I. & Peretz, D. (1961). A biometric approach to prognosis in schizophrenia. In Comparative Epidemiology in the Mental Disorders (ed. Hoch, P. H. and Zubin, J.), pp. 143203. Grune & Stratton: New York.Google Scholar