Monday, 29 February 2016

“Schizophrenia” does not exist. Discuss.

With a title like "“Schizophrenia” does not exist", the opinion piece by Jim van Os [1] (open-access) was bound to attract some attention and comment (indeed, several). As per other examples where diagnostic labels have been questioned (see here) the response to such viewpoints typically falls into one of two categories: (a) the person or persons making the suggestion just want to make a name for themselves (and how better than to stir up a bit of controversy) or (b) the person or persons making the claim have a valid point.

In the case of the viewpoint posited by van Os, and without trying to offend too many people, I'm tending towards the latter option because I think he has a point. Read onwards and I'll try and explain why.

The crux of the suggestion is that in these days of increasing pluralisation of diagnostic labels (see here for another example) and realisation that individual behavioural or psychiatric labels rarely occur unaccompanied (see here) the idea that there is a discrete condition called schizophrenia is fast losing 'evidence-based' backing. His descriptions of how DSM-5 classifies schizophrenia and the various diagnostic classifications that patients may 'move in and out of', harks back to some of the reasons why the RDoC (Research Domain Criteria) initiative was first suggested and continues to gather momentum.

As per other entries on this blog acknowledging the idea of the more plural 'schizophrenias' (see here) and even a 'bipolar - schizoaffective - schizophrenia spectrum' (see here), van Os suggests a more wide-ranging term to supplant schizophrenia: psychosis spectrum syndrome. This label, it is suggested, takes account of the "extreme heterogeneity, both between and within people, in psychopathology, treatment response, and outcome." van Os also suggests that the creation of such a spectrum is a way to "forget about “devastating” schizophrenia as the only category that matters and start doing justice to the broad and heterogeneous psychosis spectrum syndrome that really exists."

I don't believe we're going to see a dramatic migration towards psychosis spectrum syndrome as a replacement for the singular schizophrenia term very quickly. Much like what goes on behind other conditions/labels, change is often a slow process in medicine and convincing people who might have their own reasons for sticking with the label schizophrenia (e.g. identity, management options, etc.) will prove difficult. That we already have a similarly worded term, [unspecified] schizophrenia spectrum disorder in the current manifestation of DSM is an additional point of complication to make.

Still, I can see the benefits of taking a wider approach to the categorisation of symptoms in this area of psychiatry. Indeed, if one considers the data on schizophrenia spectrum disorder appearing alongside 22q11.2 deletion syndrome for example (see here) you get a flavour for how many routes there may be taking someone towards clinically significant symptoms. That 'treatment response' may also guide the appreciation of a wider spectrum definition encompassing schizophrenia (see here for example), one could foresee a time when a specific place on the psychosis spectrum is given to patients and the trial-and-error of symptom management potentially becomes a thing of the past with the right patient work-up. That is also assuming some accuracy in [some of] the management options put forward [2]...

That all being said, in agreement with this article by Allen Frances on a related topic, I think we also have to be a little careful not to be too broad in our brush strokes on spectrum generalisations.

Music: War and Low Rider.


[1] Os van J. "Schizophrenia" does not exist. BMJ. 2016 Feb 2;352:i375.

[2] Jauhar S. et al. Cognitive-behavioural therapy for the symptoms of schizophrenia: systematic review and meta-analysis with examination of potential bias. Br J Psychiatry. 2014 Jan;204(1):20-9.

---------- Os, J. (2016). “Schizophrenia” does not exist BMJ DOI: 10.1136/bmj.i375