Derived simply from the Greek work chronos, meaning time, the label ‘chronic’ denotes an illness of long duration or one of frequent recurrence. However, when chronic is paired with schizophrenia, as in ‘this person is a chronic schizophrenic’, the connotation becomes an expectation of deterioration, defect, or deficit states (Cutting, 1983). These perceptions about schizophrenia have pervaded and guided clinical judgements (Feighner et al, 1972; American Psychiatric Association, 1980, 1987), treatment programming (Bachrach, 1979; Lamb, 1981; Strauss & Glazer, 1982), policy formulation (Greenblatt, 1978; Talbott, 1979), and decisions about priority for funding (Kraft, 1981). These perceptions have also stripped hopes of recovery from patients and their families (Chamberlin, 1979; Lovejoy, 1984). Further, the use of phrases such as ‘deinstitutionalisation of chronic mental patients’ glosses over the large heterogeneity of patient types, courses of illness and recovery, and the actual shifts in composition and migrations of groups of patients within society (Lamb, 1979; Leighton, 1982; Harding & Ashikaga, 1982).

Two critically important areas of research are the long-term course of illness and predictors of outcome in chronic schizophrenia. Although these two areas have been actively investigated throughout the 20th century, there is still a lack of agreement about even basic features of the long-term outcome of schizophrenia as well as a lack of validating evidence for putative predictors of outcome. Determining the long-term outcome of schizophrenia has implications for the pathophysiology and public health policy of this illness. For example, a course of illness that is marked by progressive deterioration may suggest a degenerative disease process, whereas a course that remains stable or improves over time may be more consistent with non-degenerative hypotheses such as neurodevelopmental, infectious, or toxic processes. In terms of public health policy, the allocation of resources related to issues such as community-based versus hospital-based care will be heavily influenced by knowledge of the level of chronicity and impairment associated with schizophrenia throughout the lifetime of affected individuals. Validation of predictors of outcome will have immediate clinical relevance, as well as providing support for pathophysiological hypotheses.

Kraepelin's assumption that affective psychoses always have a ‘good‘ outcome was found to be untrue — it could not differentiate affective from schizophrenic disorders. Long-term investigations have shown that a relevant proportion of affective disorders have an ‘unfavourable outcome’ (Angst, 1987; Marneros & Deister, 1990; Marneros et al, 1990b), while some schizophrenic disorders can have a good prognosis (Bleuler, 1972; Ciompi & Müller, 1976; Huber et al, 1979; Möller & von Zerssen, 1986; Marneros et al, 1989a, 1990b, 1991b).

It is accepted that schizophrenia runs in families, but whether this relates to genetic or psychosocial transmission is an unanswered question. Kendler (1988) has articulated four testable hypotheses: (a) a general liability to any psychiatric illness (b) a liability to schizotypal functioning — oddness, suspiciousness etc. (c) a liability to broadly defined schizophrenic psychosis, or any functional, non-affective psychosis and (d) a specific liability to narrowly defined schizophrenia, e.g. using DSM-III-R criteria (American Psychiatric Association, 1987). Kendler suggests that neither hypothesis (a) nor (d) is correct, and that the familial predisposition is neither completely non-specific nor highly specific; available results strongly support the second hypothesis and also provide some support in favour of the third.

Converging lines of evidence suggest that attentional dysfunctions are indicators of a biological susceptibility to some forms of schizophrenia. More specifically, following the criteria outlined by Holzman (1983), impaired attention can be considered a potential biological marker because of the: (a) well replicated association between schizophrenia and attentional dysfunctions in patients, both when in episode and in remission (Nuechterlein & Dawson, 1984); (b) evidence that attentional problems can be detected in unaffected first-degree adult relatives of schizophrenic patients (Wood & Cook, 1979; Keefe et al, 1989, Steinhauer et al, 1991) (c) reports from a number of high-risk studies that attentional deficits pre-date clinical symptoms by many years (Rutschmann et al, 1977; Nuechterlein, 1983; Cornblatt & Erlenmeyer-Kimling, 1985; Mirsky et al, 1986; Erlenmeyer-Kimling & Cornblatt, 1987b; Mirsky, 1988) and (4) preliminary results suggesting that attention per se is genetically transmitted (Cornblatt et al, 1988).

Psychiatric disorders are psychopathologically characterised by signs and symptoms. Although diagnosis and classification rely heavily on the patient's report of subjectively experienced symptoms, the assessment of the underlying psychopathological process can be impaired by the patient's distorted self-image, his cognitive abnormalities, and his limited capacity to express himself verbally. Non-verbal behaviour, however, lends itself to objective and generalisable assessments: it can be reliably and accurately observed and measured, and although subject to cultural influence, it is the infant's most elementary form of self-expression (Gaebel, 1990). In addition, it plays a major role in interpersonal communication, which is disturbed in all psychiatric disorders. Therefore, the analysis of non-verbal behavioural dysfunction offers an important approach to the complex biopsychosocial framework of mental disorders.

Various associations have been reported in the literature between severe mental disorders, particularly schizophrenia, and other diseases; the demonstrated association of two (or more) diseases would be of great theoretical and practical importance. If two (or more) diseases occur in the same individual significantly more often than would be expected by chance, the same aetiological factors may be involved, or one disease may be pathogenic to the other, or one condition may be a hitherto unrecognised manifestation of the other, or the patient — as a sequela of one disease — may be exposed to risk factors for the other. In addition to the scientific importance of such discoveries, knowledge of this kind may be useful for the furtherance of public-health programmes, for the organisation of services, and for the prevention of illness.

The idea of a triggering effect in schizophrenia emphasises the role of life events as precipitating factors which act on an individual's specific predisposition towards the illness (Wing, 1978).

A vulnerability/stress framework for schizophrenia is one means by which the strong evidence for genetic and other biological factors in schizophrenia can be combined in a useful way with persistent evidence that stressful environments may play a role in precipitating psychotic episodes (Gottesman & Shields, 1972; Zubin & Spring, 1977; Nuechterlein & Dawson, 1984; Nuechterlein, 1987; Ciompi, 1989). Within a large longitudinal study of the early course of schizophrenia, we have been attempting to examine several possible ways in which both psychobiological vulnerability factors in the patient (Dawson & Nuechterlein, 1987; Nuechterlein et al, 1991) and external environmental stressors (Ventura et al, 1989) individually and jointly influence the course of schizophrenia. At the Second International Symposium on Schizophrenia in Bern, we focused on two promising mediating factors in schizophrenia — those involving persistent information-processing abnormalities and stress-triggered autonomic arousal (Nuechterlein et al, 1989). We focus here on recent analyses that relate to current controversies in the literature on interpersonal attitudes that are typically called expressed emotion (EE) — socio-environmental attributes that have been statistically associated with psychotic relapse in schizophrenia.

Numerous studies have examined whether certain specific attributes of intrafamilial attitudes and relationships are related to the onset and course of schizophrenia. A frequent underlying assumption of this research has been that these attributes interact with a biological predisposition to the disorder, raising or lowering the probability of its expression or of recurrences, once the initial onset has appeared. Previous work within a longitudinal study of disturbed adolescents indicated that a number of qualities in parents were associated with an increased risk for schizophrenia spectrum disorder, particularly deviant communication and negative affective attitudes and interaction behaviour (Goldstein, 1987). In assessing the quality of communication, the construct and operational definition of communication deviance (CD) as elucidated by Wynne et al (1976) were used. With regard to affective attitudes, the operational definition of high expressed emotion (EE), developed by Brown et al (1972) and by Vaughn & Leff (1976), was used, while affective interactive behaviour was coded using the affective style system of Doane et al (1981).

Research in the field of interpersonal behaviour is widely recognised as an important key to understanding the nature of mental illness. In schizophrenic patients especially, deviant social interaction has been proved to be associated with pathological behaviour (see Bellack et al, 1989). Numerous studies have revealed that affective attitudes expressed towards the patient by a relative during hospital admission for an episode of schizophrenia (high expressed emotion (EE)) are predictive of the short-term course of the disorder (Leff & Vaughn, 1985; Jenkins et al, 1986; Nuechterlein et al, 1986; Mintz et al, 1987).

The analysis of schizophrenic persons' attempts at coping with their disease has developed into a fertile research area over the last few years. Results are expected that may lead to a better understanding of specific psychopathological phenomena, and hopes are raised for improvements in specific therapeutic programmes (cf. Böker & Brenner, 1983; Wiedl & Schöttner, 1989a). Previous studies have shown that schizophrenics use many different strategies to cope with their disease. Sometimes conflicting results deal with the frequency of specific ways of coping, their orientation to specific symptoms or strains, their relationship to the course of the disease and the nosological classification of the patients, and finally, with their suitability or usefulness (cf. Wiedl & Schöttner, 1989b). Altogether, these investigations have contributed to correcting the image of the schizophrenic as a person who is passive and helpless against his/her illness, and have expanded the scope of knowledge in psychiatry and clinical psychology (cf. Strauss, 1989a,b).

It is important to know how people with a schizophrenic disorder experience their cognitive vulnerability and how that experience affects their daily lives. Rehabilitation, as we understand it, has the aim of stimulating patients to make the best use of their residual capacities, especially in dealing with social complexity. Unfortunately, the rehabilitation approach in psychiatry still lacks a firm scientific basis. Strong links need to be developed between the practice of rehabilitation and theories of basic cognitive and behavioural dysfunction in schizophrenic patients (Watts & Bennett, 1983). It is a prerequisite that the subjective experiences of patients are included in this endeavour: schizophrenia is an ‘I am’ illness (Estroff, 1989).

One purpose of cognitive-behaviour therapy is to provide patients with a ‘psychological model’ of their illness; this would enable them to become aware of, and thereby gain insight into the ways that the symptoms and behavioural deviances they exhibit, and the circumstances of the onset of illness are actually related to their previous experience and social learning (for overview see Hawton et al, 1989). This concept provides a basis for gaining greater insight into special therapeutic interventions, and should help patients to develop their own lifetime methods of coping with problems.

The discovery of neuroleptics some 40 years ago brought about a revolution in the treatment of schizophrenia. Until then, schizophrenic patients were primarily treated with various forms of coma and shock therapy, and many were permanently confined in psychiatric hospitals. With the availability of neuroleptic medication, however, hospital stays have become considerably shorter and many patients can be returned home for out-patient care. In addition, psychosocial therapy for schizophrenic psychoses could not have been effective without the protective effect of neuroleptics.