The slow death of the concept of schizophrenia and the painful birth of the psychosis spectrum

Abstract

The concept of schizophrenia only covers the 30% poor outcome fraction of a much broader multidimensional psychotic syndrome, yet paradoxically has become the dominant prism through which everything ‘psychotic’ is observed, even affective states with mild psychosis labelled ‘ultra-high risk’ (for schizophrenia). The inability of psychiatry to frame psychosis as multidimensional syndromal variation of largely unpredictable course and outcome – within and between individuals – hampers research and recovery-oriented practice. ‘Psychosis’ remains firmly associated with ‘schizophrenia’, as evidenced by a vigorous stream of high-impact but non-replicable attempts to ‘reverse-engineer’ the hypothesized biological disease entity, using case–control paradigms that cannot distinguish between risk for illness onset and risk for poor outcome. In this paper, the main issues surrounding the concept of schizophrenia are described. We tentatively conclude that with the advent of broad spectrum phenotypes covering autism and addiction in DSM5, the prospect for introducing a psychosis spectrum disorder – and modernizing psychiatry – appears to be within reach.

What is the risk‐benefit ratio of long‐term antipsychotic treatment in people with schizophrenia?

“…While the diagnosis of schizophrenia has been associated with poor outcome and need for long‐term antipsychotic treatment, the heterogeneity in response and illness course has resulted in calls to broaden the view towards a psychosis syndrome with variable outcome patterns. Some studies suggest that a minority of patients could potentially discontinue antipsychotic treatment without risk of relapse.…”

30 Years on: How the Neurodevelopmental Hypothesis of Schizophrenia Morphed Into the Developmental Risk Factor Model of Psychosis

“…74 Such a model has to take into account evidence which has become available and indicates that schizophrenia is not a discrete disease entity but rather the severe end of a broader multidimensional psychosis spectrum. 75 Numerous studies indicate that there exists a continuum of subclinical psychotic symptoms, often associated with subtle cognitive deficits, 76 extending into the general population and that the same factors that influence risk of schizophrenia also influence the prevalence of minor psychotic symptoms in the general population. [75][76][77] Thus, liability to psychosis is distributed in the same way as liability to hypertension or obesity.…”

“…75 Numerous studies indicate that there exists a continuum of subclinical psychotic symptoms, often associated with subtle cognitive deficits, 76 extending into the general population and that the same factors that influence risk of schizophrenia also influence the prevalence of minor psychotic symptoms in the general population. [75][76][77] Thus, liability to psychosis is distributed in the same way as liability to hypertension or obesity. If an individual's blood pressure is persistently above a certain arbitrary level (90 mmHg in many countries), they are considered hypertensive; if the hypertension is not readily responsive to treatment, they may be further diagnosed as having severe or malignant hypertension.…”

Authors’ reply: Psychosis Spectrum Disorder is a clinical diagnosis

“…(4) We never suggested extending the boundaries of PSD to include psychotic experiences and beyond in clinical practice. On the contrary, we questioned the validity of the ultra-high-risk-cum-transition paradigm attributing special value to positive psychotic experiences rather than embracing the full range of person-specific psychopathology in identifying at-risk population -in other words, the 'pre-schizophrenia' group (van Os & Guloksuz, 2017). However, we do conclude that psychotic experiences, similar to any other subtle expression of psychopathology domains (e.g.…”