[Incidence of the deficit form in refractory schizophrenia]

The treatment and management of schizophrenic patients "resistant" to neuroleptics is one of the major problem areas in current psychiatry, as is deficitary (non-productive) schizophrenia, which is considered to be the least curable clinical form of the disease. What is the scope of these definitions? The majority of definitions amalgamate affective blunting, social withdrawal, poverty of ideas and speech when describing the deficitary clinical picture. Even though there are differences between authors such as Andreasen and Kay, the consensus opinion holds that there is impoverished emotional range and diminished spontaneous movement. The term "resistance" refers to resistance to neuroleptic treatments. Kane, for example, stipulates that 3 antipsychotic treatments at effective doses and prescribed for an adequate length of time must have proved to be ineffective before the patient can be termed "treatment-resistant". Based on studies, 5 to 20% of these patients are also intolerant of neuroleptics, in particular of their extrapyramidal effects, which induce Parkinson's syndrome, akathisia and tardive dyskinesia. The sedative and extrapyramidal effects of neuroleptics may incidentally augment the negative symptoms (Möller, 1993). Currently there is no scientific method of predicting the likely profile of responders and non-responders to neuroleptics. Collaborative studies carried out by the National Institute of Mental Health (Cole et al., 1964, 1966) on the response to neuroleptics in the acute phase of schizophrenia showed that 3% of patients were worsened, 22% marginally improved and 69% greatly improved by treatment. Recognition of negative forms in resistant schizophrenia also requires distinction between depressive features which develop during the course of schizophrenia. Symptoms such as anhedonia, apathy, social withdrawal and poverty of speed which are typical of depressive illness are also considered to be schizophrenic symptoms (Maier et al., 1990). It is currently accepted that 10 to 25% of schizophrenic patients may be considered as non-responders to antipsychotic treatments. When evaluating this response not only the disappearance of positive and negative symptoms, but also the ability to function socially and professionally and the number of hospitalizations must be taken into account (Strauss and Carpenter, 1972), (Brenner, 1990). It is highly appropriate to evaluate the beneficial effects of treatments on positive and negative symptoms. Johnstone et al. (1978) verified the hypothesis that the traditional neuroleptics were less effective against negative symptoms. Kay and Opler (1987) showed that improvement in these symptoms took longer to become established. The negative symptoms which characterize type II schizophrenia described by Crow (1980, 1985) are considered to be non-responders to treatment. However, authors such as Goldberg (1985) and Meltzer et al. (1986) in the French tradition have dismissed this argument. Studies on the evaluation of treatment currently tend to make a sharp distinction between negative and positive poles. In all cases, biological treatment is rarely adequate and it is essential to combine it with psychosocial therapy. Information from patient and family on the type of illness involved and on the different types of assistance which can be provided, as much medical as purely social, invariably proves useful.