[Psychiatric handicap--precursor or social sequelae of schizophrenia?]

Having finalized the ICD 10, the WHO is now preparing a new version of the "International Classification of Impairments, Disabilities and Handicaps" (ICIDH). At present this threefold scheme is designed to classify the consequences of mental illness. Impairment is defined as either a loss of function or a damage to structure. Disability is the resulting limitation in performance. The restriction in the ability to fulfill social roles is known as role handicap. These three aspects conceptualised in strict sequence have thus far been understood only in terms of the result of the illness. The planned review of the ICIDH will most likely consist of substituting this rather rigid scheme by a more flexible one. This will allow for feedback mechanism between the different levels. Premorbid disabilities/handicaps as possible risk factors for the development of mental illness may even be taken into consideration. The analyses within the Mannheim ABC schizophrenia study have convincingly shown that social disability and role handicaps are present in a high percentage of patients (57%) prior to the onset of the first psychotic symptom. On an average they begin about two to four years before the first hospitalisation and one to three years prior to the first psychotic symptom. While the correlation between social disability and positive symptoms is not significant, disability and negative symptoms are closely related. In addition to this only part of this correlation can be explained as a conceptual overlap (i.e. the SANS subscales Avolition and Anhedonia have items comparable to the Disability Assessment Schedule). In fact, we found comparably high correlations between affective blunting and alogia and social disability as well. Patients with early disability not only have an overall unfavourable course of negative symptoms but negative symptoms are shown to be useful predictors for social disability three years after the first hospitalisation.