PubMed2002
OBJECTIVE: In this study, we explore the onset of psychotic episodes in schizophrenia. Patients with schizophrenia have sometimes reported specific life-events at the period of onset. For example: "It started on my 22nd birthday. From that day onward, my life was colored with extremes of happiness and tragedies", or "It was when I was playing with a cat in the park of S temple that I realized suddenly that my 'I'-ness had completely changed." In each case, patients referred to a specific event as a critical moment when the meaning of selfness and the surrounding world had changed. Interestingly, these moments were reported repeatedly throughout the history of their illnesses. We termed these clinical phenomena "Recurrent retrieval of the core episode referred to as the onset of schizophrenia" and investigated their psychopathologic implication. METHOD: The autobiographical memory of nine schizophrenic patients with "Recurrent retrieval of the core episode referred to as the onset of schizophrenia" was investigated. Four representative cases are described in detail. Samples of subjective statements were collected from medical records and analyzed. RESULTS: 1) Form and content of the statement: Patients clearly referred to a specific moment in their life. They usually reported that their image of self or the world had completely changed. The content of their reports were always about the same theme. 2) Chronological pattern of the repetition: Although the reported life event occurred just before onset, the reminiscence usually occurred not only at the beginning of the refractory period but also at the beginning of the recovery period. Patients did not report such events when they were stable. In the refractory period, distinct symptoms of schizophrenia were observed after the reminiscence. In the recovery period, the reminiscence was accompanied by minor physical symptoms, such as fever elevation or gastrointestinal dysfunction. 3) Subjective characteristics of repetitive reminiscence: In the refractory period, patients relived the onset of schizophrenia by reporting it reminiscently. They were excited, in a state of high-tension, or feeling oppressed. In contrast, in the recovery period, they reported the critical moment in an emotionally stable state, and even recollected it with humor. They were able to maintain some emotional distance from the reminiscence. 4) Predictive factor on prognosis: Reminiscence in the recovery period predicted a good prognosis. Seven of nine such cases were in remission. Two patients with whom the reminiscence was observed only in the refractory period were chronically ill. Therefore, two patterns of repetitive reminiscence of the critical moment should be discriminated. DISCUSSION: 1. The statements of patients were developed on the possibility that the critical event had not happened. Therefore, it can be postulated that their statements reconstructed a temporality open to any possible future: the moment just before the critical event might not have happened. The proper temporality associated with repetitive reminiscence should be distinguished from that of repetition of a traumatic memory in post-traumatic stress disorder. 2. From a therapeutic viewpoint, it is important to know to whom the discourse of the patient was addressed. In the refractory period, patients reported the repetitive reminiscence to anyone in a non-discriminating fashion. In contrast, in the recovery period, their discourse on the reminiscence was directed to a particular person with whom they were in close contact. The structure of the latter discourse was similar to that of neurotic patients in that they both demand acceptance from others. That is, the discourse structure of our patients was drastically changed in the recovery period. Reconstruction of the critical moment found in the recovery period was accomplished by the patient's discourse directed to another person, one from whom they could realize self-acceptance.