“Schizophrenia” does not exist
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“Schizophrenia” does not exist
BMJ 2016; 352 doi: http://dx.doi.org/10.1136/bmj.i375 (Published 02 February 2016) Cite this as: BMJ 2016;352:i375- Jim van Os, full professor and chair, Department of Psychiatry and Psychology, Maastricht University Medical Centre, PO Box 616, 6200 MD Maastricht, Netherlands
In
March 2015 a group of academics, patients, and relatives published an
opinion piece in a national newspaper in the Netherlands, proposing that
we drop the “essentially contested”1
term “schizophrenia,” with its connotation of hopeless chronic brain
disease, and replace it with something like “psychosis spectrum
syndrome.”2
We launched two websites (www.schizofreniebestaatniet.nl/english/ and www.psychosenet.nl)
aimed at informing the public about the nature of psychotic illness and
helping patients deal with pervasive, unscientifically pessimistic,
organic views of their symptoms. The timing was no coincidence.
Several
recent papers by different authors have called for modernised
psychiatric nomenclature, particularly regarding the term
“schizophrenia.”3 4 5 6 Japan and South Korea have already abandoned this term.
Current classifications
The classification of mental disorders, as laid down in ICD-10 (International Classification of Diseases, 10th revision) and DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, fifth edition), is complicated, particularly psychotic illness.
Currently,
psychotic illness is classified among myriad categories, including
schizophrenia, schizophreniform disorder, schizoaffective disorder,
delusional disorder, brief psychotic disorder, depression/bipolar
disorder with psychotic features, substance induced psychotic disorder,
and psychotic disorder not otherwise classified. Categories such as
these do not represent diagnoses of discrete diseases, because these
remain unknown; rather, they describe how symptoms can cluster, to allow
grouping of patients.
This elegant solution allows
clinicians to say, for example, “You have symptoms of psychosis and
mania, and we classify that as schizoaffective disorder. If your
psychotic symptoms disappear we may reclassify it as bipolar disorder.
If, on the other hand, your mania symptoms disappear and your psychosis
becomes chronic, we may re-diagnose it as schizophrenia.
“That
is how our classification system works. We don’t know enough to
diagnose real diseases, so we use a system of symptom based
classification. The DSM-5 does this differently than ICD-10—but that
does not matter, because it’s only a classification.”
If
everybody agreed to use the terminology in ICD-10 and DSM-5 in this
fashion, there would be no problem. However, this is not what is
generally communicated, particularly regarding the most important
category of psychotic illness: schizophrenia.
The
American Psychiatric Association, which publishes the DSM, on its
website describes schizophrenia as “a chronic brain disorder,” and
academic journals describe it as a “debilitating neurological disorder,”7 a “devastating, highly heritable brain disorder,”8 or a “brain disorder with predominantly genetic risk factors.”9
Current language suggests discrete disease
This
language is highly suggestive of a distinct, genetic brain disease.
Strangely, no such language is used for other categories of psychotic
illness (schizophreniform disorder, schizoaffective disorder, delusional
disorder, brief psychotic disorder, and so on). In fact, even though
they constitute 70% of psychotic illness morbidity (only 30% of people
with psychotic illness have symptoms that meet the criteria for
schizophrenia),10
these other categories tend be ignored in the academic literature (see
box) and on websites of professional bodies. They are certainly not
referred to as brain disorders or similar. It’s as if they don’t exist.
What
remains is the paradox that 30% of psychotic illness morbidity is
portrayed as a discrete brain disease; the other 70% of the morbidity is
communicated only in classification manuals.
Psychosis susceptibility syndrome
Scientific
evidence indicates that the different psychotic categories can be
viewed as part of the same spectrum syndrome, with a lifetime prevalence
of 3.5%,10
of which “schizophrenia” represents the minority (less than a third)
with the poorest outcome, on average. However, people with this
psychosis spectrum syndrome—or, as patients have recently suggested,
psychosis susceptibility syndrome6—display extreme heterogeneity, both between and within people, in psychopathology, treatment response, and outcome.
The
best way to inform the public and provide patients with diagnoses,
therefore, is 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.
ICD-11 should remove the term “schizophrenia.”
Number of PubMed hits with specific diagnostic categories in the title (November 2015)
- Schizophrenia: 51 675
- Schizoaffective disorder: 1170
- Schizophreniform disorder: 216
- Delusional disorder: 212
- Brief psychotic disorder: 17
- Psychotic disorder (not otherwise specified): 5
- Bipolar disorder with psychotic features: 1201
- Depression with psychotic features: 409
- Substance induced psychotic disorder: 28
Notes
Cite this as: BMJ 2016;352:i375
Footnotes
- Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: in the past five years, the Maastricht University psychiatric research fund that I manage has received unrestricted investigator led research grants or recompense for presenting research from Servier, Janssen-Cilag, and Lundbeck, companies that have an interest in the treatment of psychosis.
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