The consensus definition of remission in schizophrenia defines
a state in which patients have experienced an improvement in core signs and
symptoms to the extent that any remaining symptoms are of such low intensity that
they no longer interfere significantly with behavior and are below the threshold
typically utilized in justifying an initial diagnosis of schizophrenia.1
The operationalisation of this definition consists of two elements:
the absence or low intensity of eight core symptoms of
schizophrenia (severity criterion) and the maintenance of this
state for a minimum of 6 months (time criterion). The consensus
definition is aimed at facilitating research on the course of illness,
at improving the comparability of studies and at helping clinicians
The definition has been used in several studies of
schizophrenia, exploring cognitive ability and antipsychotic
medication,3,4and is validated by several studies using functional
outcome, symptom severity, need for care and/or quality of life as
outcome measures.5–9However, these outcome measures are
validation using self-report measures of actual functioning (e.g.
time spent with others and in goal-directed activities) and real-life
experiences is lacking. We therefore aimed to validate the
remission criterion using a momentary assessment strategy
investigating symptom level and functioning in patients with
schizophrenia spectrum disorders. We investigated positive
symptoms, negative symptoms and functional outcome in the
flow of daily life in patients meeting the severity criterion of the
symptomatic remission definition, patients not meeting that
criterion and a healthy comparison group, the last allowing a
comparison with a ‘normal’ level of functioning.
The sample consisted of 191 patients diagnosed with schizo-
phrenia spectrum disorders and a control group of 168 healthy
individuals. Data for this study were pooled from three previous
Experience Sampling Method (ESM) studies.10–12
criteria for all studies were age 18–65 years and sufficient
command of the Dutch language to understand and complete
the questionnaires. Exclusion criteria were brain disease and
history of head injury with loss of consciousness. Control
participants were excluded if presenting with a lifetime history
of psychotic or affective disorder or a family history of psychotic
disorder. In all three studies, patients were recruited from mental
health facilities in the south of The Netherlands and in Flanders,
Belgium. A full description of this procedure is given in the earlier
studies of the three study samples.11–13Interview data and clinical
record data were used to complete the Operational Criteria
Checklist for Psychotic Illness yielding DSM-III-R and DSM-IV
diagnoses in two of the study samples,11,12or the Comprehensive
Assessment of Symptoms and History,14
diagnoses in one study sample.13The ESM questionnaires were
set up identically in terms of mood, symptoms and context to
enable pooling of the data. Written informed consent, conforming
to local ethics committee guidelines, was obtained from all
participants. Participants were compensated with a voucher of
e25 (or equivalent).
Experience Sampling Method
The ESM, a structured self-assessment technique, was used to collect
data in the natural flow of daily life.15,16Participants received a
Symptomatic remission in psychosis and real-life
M. Oorschot, T. Lataster, V. Thewissen, M. Lardinois, J. van Os, P. A. E. G. Delespaul
and I. Myin-Germeys
In 2005 Andreasen proposed criteria for remission in
schizophrenia. It is unclear whether these criteria reflect
symptom reduction and improved social functioning in daily
To investigate whether criteria for symptomatic remission
reflect symptom reduction and improved functioning in real
life, comparing patients meeting remission criteria, patients
not meeting these criteria and healthy controls.
The Experience Sampling Method (ESM), a structured diary
technique, was used to explore real-life symptoms and
functioning in 177 patients with (remitted and non-remitted)
schizophrenia spectrum disorders and 148 controls.
Of 177 patients, 70 met criteria for symptomatic remission.
These patients reported significantly fewer positive and
negative symptoms and better mood states compared with
patients not in remission. Furthermore, patients in remission
spent more time in goal-directed activities and had less
preference for being alone when they were with others.
However, the patient groups did not differ on time spent in
social company and doing nothing, and both the remission
and non-remission groups had lower scores on functional
outcome measures compared with the control group.
The study provides an ecological validation for the
symptomatic remission criteria, showing that patients who
met the criteria reported fewer positive symptoms, better
mood states and partial recovery of reward experience
compared with those not in remission. However, remission
status was not related to functional recovery, suggesting that
the current focus on symptomatic remission may reflect an
overly restricted goal.
Declaration of interest
The British Journal of Psychiatry (2012)
201, 215–220. doi: 10.1192/bjp.bp.111.104414
pre-programmed digital wristwatch and ten self-assessment
forms collated in a booklet for each day. Ten times a day on six
consecutive days the watch emitted a signal at unpredictable
moments between 07.30h and 22.30h. After each ‘beep’
participants were to fill out one of the forms, rating emotional
experience, symptoms and context on seven-point Likert scales
and answering open-ended questions. The ESM procedure was
explained in a briefing session, in which all participants completed
a practice form, were instructed to complete their reports
immediately after the beep and to register the time at which they
completed the questionnaire. During the sampling period,
research staff contacted participants to assess whether they were
complying with the instructions. In a debriefing session
participants were interviewed to be sure that they had complied
with the instruction. Reports were assumed to be valid when
participants responded to the beep within 15min, and their data
were only included in the analyses when they provided valid
responses for at least a third of the emitted beeps.17Previous
studies have demonstrated the feasibility, validity and reliability
of ESM in general and patient populations.16,18The following
variables were derived from the ESM questionnaires.
Positive symptom assessment
Hallucinations were measured using the items ‘I hear voices’ and
‘I see phenomena’. Delusional intensity was measured using three
items (‘I’m suspicious’, ‘I can’t get rid of my thoughts’ and ‘I fear
losing control’; Cronbach’s a=0.66). The validity of the delusion
and hallucination items had been previously demonstrated.19,20
All items were rated on a Likert scale ranging from 1 (not at
all) to 7 (very).
Negative symptom assessment
Flattened emotional experience
Emotional experience was assessed with eight mood adjectives
(e.g. ‘I feel anxious’) rated on seven-point Likert scales. The items
‘insecure’, ‘lonely’, ‘anxious’, ‘sad’ and ‘guilty’ constituted negative
affect (Cronbach’s a=0.83). The mean score of the items
‘cheerful’, ‘relaxed’ and ‘satisfied’ constituted positive affect
Anhedonia was defined as lack of emotional reward after pleasant
events, with emotional reward conceptualised as the change in
positive affect after pleasant events compared with that after
neutral events.21In order to assess anhedonia, participants were
asked to report the most important event that had happened
between the current and the previous beep. Subsequently, the
participant rated this event on a seven-point bipolar scale (73
very unpleasant, 0 neutral, 3 very pleasant), providing a subjective
measure of event pleasantness. Observations including events
appraised as slightly pleasant (1), pleasant (2), very pleasant (3)
and neutral (0) were included in the analyses. The neutral events
were set as the reference category. The effect of subjective
(positive) event pleasantness on positive affect was calculated,
with lower positive affect reactions indicating more anhedonia.
Real-life social functioning was conceptualised using self-report
information regarding participants’ social context and the
appraisal thereof. Participants were asked to report whether they
were alone; if not, they had to report how much they would prefer
to be alone (‘I’d rather be alone’) and to indicate the actual level of
interaction using the item ‘We are interacting’, both rated on a
seven-point Likert scale (1 not at all, 7 very). We investigated time
spent alone, level of interaction and preference for being alone
while with others. We furthermore measured the level of social
anhedonia, which was defined as lack of emotional reward from
being in the company of others, with emotional reward
conceptualised as the change in positive affect when with others
compared with being alone.22We also investigated the change in
negative affect when with others compared with being alone in
order to examine the possible negative effects of social company
on emotional experience.
In order to assess activity level, participants were asked to report
what they were doing. These activities were coded and divided in
‘doing nothing’ v. ‘doing something’, and ‘goal-directed activities’
(e.g. household chores, study/work) v. ‘not goal-directed activities’
(e.g. watching television, taking a walk). Subjective activity level
was measured using the item ‘I’m active’ rated on a seven-point
Interview-based information on symptom severity was assessed
with the Positive and Negative Syndrome Scale (PANSS),23a
semi-structured interview rating positive (7 items), negative (7
items) and general (16 items) symptoms. Each item was scored
on a scale ranging from 1 (absent) to 7 (extreme). Assessment
was done by a trained research assistant within a week after the
sampling period. Remission status was defined as a score of 3 or
below on the following PANSS items: delusions, unusual thought
content, hallucinatory behaviour, conceptual disorganisation,
mannerism/posturing, blunted affect, passive/apathetic social
withdrawal and lack of spontaneity and flow of conversation.
Participants were divided in three groups (0 control group, 1
remission group, 2 non-remission group).
Multilevel linear modelling techniques were used to examine the
associations between remission status and outcome measures.
Multilevel or hierarchical linear modelling techniques are a variant
of the more often used unilevel linear regression analyses and are
ideally suited for the analysis of ESM data consisting of multiple
observations in one person, creating two levels of analysis (ESM
beep level and participant level). Data were analysed with the
XTREG module in Stata version 10.0 on Windows. Effect sizes
from predictors in the multilevel model were expressed as B,
representing the fixed regression coefficient. In all analyses we
investigated the effect of group on the dependent variable. Gender
and age were included a priori as confounders in all regression
Analyses ofpositive symptoms
hallucinatory or delusional intensity as dependent variable and
group as independent variable. Flattened emotional experience
was analysed with level of positive or negative affect as dependent
variable and group as independent variable. Anhedonia was
investigated first with the number of positive events as dependent
variable and group as independent variable, and second in a
random regression model with positive affect as dependent
variable and event pleasantness, group and the interaction
between these as independent variables. We included negative
affect intensity and number of observations as covariates in the
analyses. From these models, effect sizes of event pleasantness,
stratified by group, were calculated by applying and testing the
Oorschot et al
Remission and functioning in psychosis
appropriate linear combinations using the Stata LINCOM
command. Main effects and interactions were assessed by Wald
tests. Social functioning was analysed with percentage of moments
alone, level of interaction and preference for being alone as
dependent variablesand group
Differences in the effect of being in the company of others on
emotional experience were investigated fitting multilevel random
regression models with positive or negative affect as dependent
variable and group, social context (0 not alone, 1 alone) and their
interaction as independent variables. Activity level was analysed
with percentage of moments spent in goal-directed activities and
subjective activity level as dependent variables and group as
Of the recruited participants, 3 patients (having mania with
psychotic features as their main diagnosis) and 17 persons from
the control group (with a lifetime history of depression) were
excluded from the analyses. Furthermore, 9 patients (3 in
remission) and 3 control group members were excluded because
of insufficient number of valid ESM observations (fewer than
20) and 2 patients were excluded because of missing data on the
PANSS. The final sample therefore comprised 177 patients (70
in remission) and 148 controls. Additional information regarding
sociodemographic characteristics and ESM reports is summarised
in Table 1. Mean scores on the dependent and independent
variables are summarised in Table 2.
Patients who were not in remission reported significantly higher
levels of hallucinatory and delusional intensity compared with
both the remission group and the control group (Table 3). Patients
in remission scored more highly on delusional intensity compared
with the control group (Table 3).
Both patient groups reported significantly lower positive affect
and higher negative affect compared with controls. However, the
Demographic and clinical characteristics
Age, years: mean (s.d.) 34.4 (10.7)30.3 (10.1) 36.5 (12.3)
Male, n (%)
Diagnosis, n (%)a,b
Other psychotic disorder
Education, n (%)b
PANSS score, total (s.d.)a
80 (75) 44 (63)56 (38)
Number of valid reports per person, mean394248
PANSS, Positive and Negative Syndrome Scale.
a. Control group is excluded from the analysis.
b. Because of rounding, percentages may not exactly total 100%.
Group scores on the dependent and independent variables
Positive symptoms, mean (s.d.)
Negative symptoms, mean (s.d.)
Number of positive events, mean
Percentage of time spent alone, mean
Level of interaction, mean (s.d.)
Preference for being alone, mean (s.d.)
Percentage of time spent doing nothing, mean
Percentage of time spent in goal-directed activities, mean
Activity level, mean (s.d.)
Oorschot et al
two patient groups differed significantly from each other, with
those in remission reporting higher positive affect and lower
negative affect compared with the non-remission group. Both
patient groups also reported significantly fewer positive events
compared with controls, with patients in remission reporting
more positive events than the non-remission group (Table 3). A
significant interaction effect between event pleasantness and group
in the model of positive affect was found (w2(2)=8.30, P=0.02),
indicating that the groups differed in the level of positive affect
reported after pleasant events. Analyses stratified by group
revealed that event pleasantness and positive affect are positively
associated in all groups (control group B=0.09, 95% CI 0.07–
0.11, P50.001; remission group B=0.14, 95% CI 0.11–0.18,
P50.001; non-remission group B=0.10, 95% CI 0.07–0.12,
P50.001). Patients in the remission group, however, displayed a
larger increase in positive affect after pleasant events compared
with the non-remission group (w2(1)=4.57, P=0.03) and controls
(w2(1)=8.15, P=0.004), whereas the non-remission and control
groups did not differ from each other (w2(1)=0.26, P=0.61).
Patients spent significantly more time alone than control group
participants, but the two patient groups did not significantly differ
in the amount of time they spent with others (Table 3). In the
company of others, the groups did not significantly differ in the
intensity of interaction they reported. Patients, however, displayed
a greater preference for being alone when with others compared
with controls, and this preference for being alone was lower in
the remission group than the non-remission group (Table 3).
No significant interaction effect between social company and
group was found in the model of positive affect (w2(2)=0.92,
P=0.63). Positive affect was decreased in all participants when
they were alone (B=70.13, 95% CI 70.16 to 70.10, P50.001).
However, a significant interaction effect between social company
and group was found in the model of negative affect
(w2(2)=11.92, P=0.003). Analyses stratified by group revealed
that being alone was associated with significant increased negative
affect in patients (remission group B=0.08, 95% CI 0.03 to 0.12,
P=0.001; non-remission group B=0.11, 95% CI 0.07 to 0.14,
P50.001;remission v. non-remission groups w2(1)=0.90,
P=0.34) but not in the control group (B=0.02, 95% CI
70.004 to 0.05, P=0.09).
No difference was found in the subjectively experienced activity
level between the three groups. However, both patient groups
spent more time doing nothing and were less often involved in
goal-directed activities compared with the control group. The
remission group patients were more involved in goal-directed
activities than patients not in remission (Table 3).
Our findings provide ecological validation for the symptomatic
remission criteria, showing that patients who met the severity
criterion reported fewer positive symptoms, better mood states
and increased hedonic capacity compared with patients with
non-remitted disorder. Remission status, however, was not related
to clear improvements in real-life functioning, since both
remission and non-remission groups scored lower on our
measures of functional outcome compared with controls. Subtle
differences between the patient groups in this domain were
present, however: patients in remission were found to spend more
preference for being alone when with others compared with the
activities and showedless
Positive and negative symptoms
Patients in remission showed reduced levels of hallucinations and
delusional intensity compared with patients who were not. This is
not surprising, since positive symptoms are relatively clearly
defined and are directly reflected in the ESM measures of positive
symptoms. The higher delusional intensity in patients in
remission compared with the control group is in line with the
remission criteria, which do not require symptoms to be
completely absent. In contrast to the positive symptoms, negative
symptom consensus items cannot be directly measured using
ESM. Correct operationalisation of negative symptoms is further
complicated by the current debate on traditional definitions and
Comparison of symptoms and functioning in the two patient groups
Non-remission groupRemission group
Non-remission v. remission
0.75 to 1.20
0.28 to 0.61
0.71 to 1.04
70.21 to 0.29
70.19 to 0.18
0.04 to 0.41
Number of positive events
0.870.72 to 1.04
71.23 to 70.78
710.97 to 75.57
0.31 0.12 to 0.49
70.69 to 70.18
77.21 to 71.14
Time spent alone
Level of interaction
Preference for being alone
Time spent doing nothing
Time spent in goal-directed activities
0.06 0.006 to 0.11
70.63 to 0.15
0.45 to 0.97
0.06 to 0.10
70.33 to 70.25
70.23 to 0.35
70.001 to 0.12
70.32 to 0.42
70.04 to 0.55
0.05 to 0.10
70.27 to 70.18
70.41 to 0.24
a. Regression coefficient indicates the difference in symptoms and functioning in the patient groups compared with the control group. Gender and age are included as confounders
in the model.
Remission and functioning in psychosis
the nature of such symptoms.24However, the study shows
increased intensity of negative affect, which is indicative of the
absence of flattened affective experience. This is in line with a
growing number of studies showing the absence of flattened
emotional experience in patients with schizophrenia, despite the
fact that flattened emotional expression is present.25Anhedonia
is not measured using the PANSS and thus is not included in the
consensus definition of remission. Nevertheless, our data reveal
that hedonic capacity is improved in patients in remission.
Hedonic capacity, or emotional reward experience, is proposed
to be a critical factor underlying deficits in motivation and real-
life functioning in schizophrenia, although studies of hedonic
capacity in schizophrenia have inconsistent results.26
The increase in reward experience should be investigated in
more depth since it may be one of the crucial mechanisms
involved in recovery. Studies of reward experience and illness
course or treatment effects in schizophrenia are surprisingly
scarce. Several ESM studies in depression, however, showed
changes in positive emotions and reward experience to be a
predictor of treatment response to antidepressants.27,28In our
study, patients in remission reported both more pleasant events
in their daily life and increased emotional reward from these
pleasant events. These concepts are likely to be interrelated, with
increased reward experience predicting increased motivation to
search for positive experiences and the combination of more
pleasant experiences and more emotional reward from such
experiences working synergistically in their effect on mood.
Increased reward experience or hedonic capacity might therefore
be one of the keys to recovery after a psychotic episode and should
be further investigated.
The study shows that symptomatic remission is not the same as
functional recovery; although patients in remission reported
reduced symptom levels, real-life functioning did not clearly
improve and this group still scored worse than controls on most
measures of such functioning. This is in line with other studies,29
and with the focus of the remission criteria consensus group
which was on symptomatic rather than functional remission.
However, the consensus group decided on these specific symptom
severity thresholds since they were assumed not to interfere
significantly with day-to-day functioning, whereas our results
suggest that functioning in patients with remitted disorder is still
impaired. These impairments are not necessarily related to
increased delusionality levels, but may be related to lower mood
or other non-measured factors such as cognitive dysfunction.30
Moreover, many patients have never achieved certain social,
educational or vocational milestones and functional impairments
in the remission group could therefore just be a continuation of
poor premorbid functioning.31
Measuring real-world functioning
In order to better understand the process of functional recovery,
however, sophisticated measures of everyday functioning in
schizophrenia are necessary. It is now generally accepted that
symptomatic remission is too restricted a goal and that treatment
should aim at functional remission.1,7Awidely accepted definition
of functional remission is still lacking. Generally, functional
remission is considered a multidimensional concept which is
broader than symptomatic remission and implies good social
and occupational functioning.31,32A review of measures of social
functioning in schizophrenia indicated that the most frequently
used scales were the Global Assessment of Functioning Scale, the
Global Assessment Scale and the Social Functioning Scale.33The
first two measures, however, are both single-item, clinician-rated
assessments of functioning, and the third is a self-report measure
with a 3-month reference period. The ESM may be a useful
addition to these measures of real-world functioning, since it is
a self-report measure which is sensitive to small changes in
behaviour, focuses on functioning in the realm of daily life and
allows investigation of subjective appraisal of activities. In contrast
to the traditional scales measuring real-life functioning, ESM
allows investigation not only of functional outcome but also of
the underlying processes and thus provides useful information
for treatment and rehabilitation. Computerised ESM using mobile
telephones, personal digital assistants or dedicated devices is a
rapidly growing field in psychiatry research,34,35and makes
implementation of momentary assessment easier to achieve in
clinical practice, since it minimises the effort and time required
from both patient (filling in answers to the questions) and
clinician (transcribing and analysing the data).
Several methodological issues should be taken into account. First,
as in other studies,5,7,8,36we had no information on the 6-month
time criterion. A longer period of symptomatic remission could
result in improvement in functional outcome. However, we
investigated functional outcome in a subset of 25 patients with
remitted disorder for whom we did have time criterion data (16
fulfilling the 6-month criterion). These pilot results (not shown)
indicated that functional recovery remains equally if not more
problematic over time in patients fulfilling both the symptomatic
and time criteria. Second, compliance with the research protocol is
a crucial element of this research method. Some authors have cast
doubt on compliance in paper-and-pencil ESM studies and
preferred the use of electronic devices.37However, two studies in
which paper-and-pencil diary and electronic diary data were
compliance rates with the time protocol and demonstrated that
both methods yielded data comparable in terms of both
psychometric features and research findings.38,39Third, in line
with other studies by our group,10–12,19participants who made a
valid response to at least a third of the beeps were included in
the analyses. Although this criterion might seem liberal compared
with criteria used in studies applying more regular methods such
as questionnaires and interviews, the absence of data is inherent to
the ESM in which we study the daily life of participants while
encouraging them not to adapt their activities to the research
method. Moreover, the mean number of valid beeps in this study
was two-thirds of the total number of beeps. We do not have
evidence of systematic differences between groups on missed
beeps, except for patients missing the first beep of the day more
often than controls, which might be related to differences in
sleeping pattern.17Fourth, we used a scientific definition of
remission and functioning, whereas patients have developed an
experience-based approach to remission and recovery. Patient-
based definitions of recovery generally refer to a unique and
personal process in which people are able to participate fully in
their communities and live a fulfilling and productive life despite
a disability.40Fifth, we included a control group of healthy
individuals. One could argue that this group is not feasible as a
control since its members also differ on all demographic variables;
however, we chose to include this group to reflect a ‘normal’ level
of functioning in society. Sixth, we pooled data from three
different studies, which might induce systematic differences within
the data-set; however, we feel that it is justified and necessary to
pool data to increase power and find subtle effects, as is common
Oorschot et al
practice in genetic studies. Furthermore, the diary structure was
similar in all three studies and none of the data had been used
previously to study remission or a related concept.
M. Oorschot, MSc, T. Lataster, PhD, Department of Psychiatry and
Neuropsychology, Maastricht University, The Netherlands; V. Thewissen, PhD,
Department of Psychiatry and Neuropsychology, Maastricht University, and Faculty
of Psychology, Open University of the Netherlands, Heerlen; M. Lardinois, PhD,
Department of Psychiatry and Neuropsychology, Maastricht University;
J. van Os, PhD, Department of Psychiatry and Neuropsychology, Maastricht
University, The Netherlands, and Department of Psychosis Studies, Institute of
Psychiatry, King’s College London, UK; P. A. E. G. Delespaul, PhD, Department
of Psychiatry and Neuropsychology, Maastricht University, The Netherlands;
I. Myin-Germeys, PhD, Department of Psychiatry and Neuropsychology, Maastricht
University, The Netherlands, and School of Psychological Sciences, University of
Correspondence: Dr Inez Myin-Germeys, Department of Psychiatry and
Neuropsychology, Maastricht University, PO Box 616 (VIJV), 6200 MD Maastricht,
The Netherlands. Email: email@example.com
First received 10 Oct 2011, final revision 12 Feb 2012, accepted 3 Apr 2012
I.M.-G. was supported by a 2006 NARSAD Young Investigator Award and by a Dutch
Medical Research Council (Vidi) grant.
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10.1192/bjp.bp.111.104414Access the most recent version at DOI: Download full-text
M. Oorschot, T. Lataster, V. Thewissen, M. Lardinois, J. van Os, P. A. E. G. Delespaul and I.
Symptomatic remission in psychosis and real-life functioning
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